Microsurgical toe-to-hand transplantation remains a valuable reconstructive option for severe, mutilated hand injuries ever since its inception in the 1960s, allowing composite replacement of amputated digits through a single-stage procedure with minimal donor morbidity. Increased experience over the past 40 years has allowed establishment of certain principles that yield consistent results with optimal functional and esthetic outcomes. This article critically examines the latest innovations and refinements in the continual pursuit of excellence for microsurgical toe-to-hand transplantation.