This woman had lost the ulnar half of her thumb pulp plus tissue from the first web space. (From Hall, E.J., and Buncke, H. J.: Microsurgical techniques to reconstruct irreparable nerve loss. Orthop Clin North Am 12:381, 1981.)

FIG. 5-19. The first web space has been opened and the ulnar side of the thumb tissue defect recreated. A template of the defect has been made.

FIG. 5-20. The template is next to the donor area on the foot.

FIG. 5-21. The tissues from the foot first web space and dorsalis pedis island have been mobilized.

FIG. 5-22. The first web space of the hand has been opened, and the sensory island flap from the toe has resurfaced the ulnar half of the thumb.

FIG. 5-23. The patient has restoration of sensation and normal cover to the ulnar pinch of the thumb.

CASE 4

These photographs illustrate a nasal reconstruction performed on a teenage boy who had total destruction of his nose after radiation therapy for a vascular lesion during early childhood.

FIG. 5-24. Three previous nasal reconstructions, two Tagliacozzian arm flaps, and one sternocleidomastoid flap had failed.

FIG. 5-25. Total nasal reconstruction using the dorsalis pedis flap with underlying second metatarsal bone for L-shaped support is planned. Template of the skin paddle is cut out of rubber sheeting to permit three-dimensional moulding.

FIG. 5-26. The dorsalis pedis flap and second metatarsal have been elevated on a long proximal pedicle.

FIG. 5-27. The flap is transplanted to the face and the long vascular pedicle tunneled across the forehead for anastomosis to the superficial temporal vessels.

FIG. 5-28. X ray shows the bony fixation of vascularized second metatarsal to nasal bone remnant.

FIG. 5-29. Postoperative follow-up at 4 years. Although the flap is not a perfect color match, contour and projection have remained.

FIG. 5-30. Side view.

CASE 5

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