Cary Ramey has the word Carpe tattooed on the underside of his right wrist and Diem tattooed on the left. He loves extreme sports, especially mountain biking and "rock climbing without the ropes." He is in one word fearless. The life of the energetic 24-year-old from Sneed, in Northeast Alabama, almost ended two summers ago in an August car crash. Ramey was left lying on his stomach in his upside-down car; his left hand was outside the vehicle, pinned under the roof. He didn't know his thumb was crushed and half his index finger was gone. Ramey was rushed to the University of Alabama at Birmingham Hospital, but his thumb was not salvageable.

In the days immediately following the accident, Ramey didn't care that his thumb was missing; he was alive. But as time passed, he thought about an option UAB plastic surgeon James Long, M.D., had mentioned in the hospital he could get a new thumb by transplanting the second toe from one of his feet, a new twist, with fewer drawbacks, to an older procedure that transplanted a big toe.

"Before this happened, if someone had told me, 'If you ever lose your thumb, we can use one of your toes to replace it,' I probably would have said I'd never have that surgery," Ramey says. "Most people don't want a toe on their hand. After it happens, though, everything changes."

After several consultations with Long and much deliberation, Ramey decided to have the rare surgery. Long, associate professor in the Division of Plastic Surgery, transplanted the second toe from Ramey's right foot into the thumb position on his left hand in a 13-hour surgery Aug. 24 two years and nine days after Ramey had lain in the wreckage of his Subaru Baja.

Two days after surgery, even with his hand heavily wrapped, Ramey was moving his new thumb ever so slightly. One week later, Long unwrapped his left hand for the first time, giving Ramey the first glimpse of his new appendage.

"It's beyond what I imagined," Ramey says. "I can't believe how incredible everything looks and that I can move my thumb even a little bit. It's fantastic."

Ramey was even more impressed with his foot. He assumed there would be a gap between his big toe and the next; instead, he saw four toes spaced equally.

"I had no idea my foot was going to look that good," Ramey says. "I don't even have a gap. Unless you sit there and look at my toes and count them, it's hard to tell I even had one removed."

Rare surgery

Long says UAB is one of the few hospitals in the country and the only one in Alabama to perform toe-to-thumb transplants. Ramey is only the second UAB patient to have the surgery in the past two years.

The majority of publicized toe-to-thumb transplants involve the surgeon relocating the big toe to the hand. The drawbacks, Long says, are that the new thumb isn't proportioned like a regular thumb, and the lack of a big toe can affect balance significantly.
 
Though aesthetics play a role in the decision to transplant, Long prefers that not be the primary reason for the surgery.

"I always emphasize to patients that function comes before appearance," Long says. "However, when it's feasible for us to achieve both goals, we always aim for that."

For Ramey, who likes to scamper up and over boulders, removing his big toe was not an option. He favored the transplant only if it could be done using his second toe.

"Cary's goal was to return to the things he was doing before he got hurt," Long says. "He never would have been able to do them if his big toe had been used to replace his thumb."

"I was thinking more about functionality than what it would look like," Ramey says.

Transplant planning and mechanics

Long and his team used specialized angiograms of Ramey's left hand and right foot to examine the blood vessels and map the toe-to-thumb transplant. X-rays of the foot and hand enabled Long to structure the bones at the time of the transplant.

The mechanics of the transplant include joining the arteries at the original thumb position and at the donor site so that blood flow can be reestablished. This is done using vessels that typically are only about two millimeters in diameter with sutures that are less than the width of a human hair. Additionally, the bone from the foot must be stabilized onto the recipient bone of the thumb. Surgeons also must ensure adequate venous drainage, which means they have to reconstruct veins and connect them to others. Sensory nerves across the surfaces of the toe are connected to ensure sensation at the tip of the toe-thumb.

The tendons that supported the thumb are repaired and connected across the joints of its replacement to provide range of motion to the new appendage.

"It is a challenging task," Long says.

Transplanting the second toe is technically more demanding a fact that proved to be true in Ramey's case.

Long says Ramey had an unusual arterial architecture in his foot that added significant complexity.

"It probably added four hours to the surgery," Long says. "This was an interesting case because it involves all of the super-specialized disciplines that fall within the purview of plastic surgery bringing tiny nerves, arteries and veins together, fixing bones and repairing tendons. And then there exists the additional puzzle of designing the toe harvest so that it seamlessly takes its place as the new thumb."

The future is bright for limb transplantation

Long says the future of plastic surgery is in transplanting hands, faces and other body parts for patients with amputations and severe injuries due to accidents and battlefield wounds.
"This toe-to-thumb transplant surgery is fascinating to me because it is a technical proof of concept for all the surgeries we have yet to devise in the replacement of lost limbs," Long says. "As of today, we are limited by the medicine side of the equation; health problems from lifelong immunosuppression tend to offset the benefits of limb transplantation. I believe we are approaching the ability to minimize the negative effects of immunosuppression at which point the emerging field of limb transplantation will explode."

Patients like Ramey provide the key technical foundation for these future endeavors.

Ramey still has several weeks of physical therapy ahead some of which will be on his Xbox video game console. Meanwhile, he anticipates a better grasp on the handlebars of his bike and finding another rock wall to conquer.

"I can't wait," Ramey says. "I'm confident about what's to come. I think I'll be able to do all the things I did before, and it's going to be so much better."