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 FIG.
28-06. Dissecting through the edges of the groin flap, initial reconstruction
is performed with simultaneous transplantation of bilateral second toes,
with arterial inflow provided to both toes through the dorsal radial artery
at the wrist, digital nerves to the transferred toes are anastomosed to
branches of the median and ulnar nerves in the palm.
FIG. 28-07. The toe metatarsals have been slotted into the recipient metacarpals to restore length and the MP joints, as shown on x ray.
 FIG. 28-08. Arm flap is next to hand. Toe transplantation is followed 18 months later by web space widening and resurfacing with a lateral arm flap.
 FIG. 28-09. The hypothenar area was resurfaced with a lateral arm flap to provide sensate stable cover. (see Chapter 8, case 6)
 FIG. 28-10. The patient has developed independent flexion of each digit and has completed his plastic surgical training, including a fellowship in microsurgery, and is now in private practice. This case illustrates the team approach utilizing multiple microvascular transplants simultaneously and in sequence.
CASE 3
A 20-year-old man injured his dominant hand in a wood-chipping machine, with loss of all fingers and the ulnar half of his hand.
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 FIG. 28-11. Initial injury following debridement and stabilization with an external fixator.
 FIG. 28-12. The nonreplantable parts.
 FIG. 28-13. First-stage reconstruction of the ulnar side of the hand was planned using simultaneous microvascular transplants from the hip and chest. DCIA donor area.
 FIG. 28-14. Latissimus donor area.
 FIG. 28-15. The DCIA flap was fixed to the radius and revascularized the end of the ulnar artery in the proximal wrist.
 FIG. 28-16. The latissimus was wrapped around the bone graft and revascularized by an end-to-side repair to the dorsal radial vessels.
 FIG. 28-17. Completion of the first step reconstruction. Thumb extension.
 FIG. 28-18. Thumb flexion.
 FIG. 28-19. A. X ray of DCIA in place.
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