The severely mutilated hand is defined as the hand which has lost opposable digit function either through: a) The amputation of all four fingers proximal to the PIP joint or b) The loss of the thumb proximal to the IP joint combined with the loss of at least three fingers proximal to the PIP joint. We have outlined guidelines for the restoration of useful function and appearance to such hands utilising a variety of microsurgical toe-to-hand transfers. Specific points regarding postoperative management have been made.