Radial artery superficial palmar branch free flap versus toe pulp free flap for finger pulp reconstruction: a narrative review

Finger pulp reconstruction remains a challenging aspect of hand surgery and requires a careful balance between functional restoration and donor-site morbidity. Among the various microsurgical options, radial artery superficial palmar branch (RASP) and toe pulp free flaps have emerged as the two most widely used techniques, each offering distinct advantages. This narrative review comprehensively compares these two microsurgical approaches for finger pulp reconstruction. The RASP free flap harvested from the thenar region provides glabrous palmar tissue with an excellent color match, minimal donor-site morbidity, and the advantage of single-field surgery. However, it lacks the specialized architecture of native finger pulp. In contrast, the toe pulp free flap offers anatomically identical tissue with superior sensory recovery (two-point discrimination, 4-7 mm vs. 6-12 mm for the RASP free flap) and exceptional durability, representing true "like-with-like" reconstruction. Nevertheless, it requires longer operative times and carries significant donor-site morbidity, affecting gait. The selection of these techniques should be individualized based on the defect characteristics, functional demands, and patient factors. The RASP free flap is an excellent first-line option for most defects where standard functional recovery is sufficient, whereas toe pulp transfer remains the gold standard for patients requiring maximal sensory discrimination. Future research should prioritize high-quality comparative studies to evaluate the outcomes of various finger pulp reconstruction techniques.