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 FIG. 28-19. B. The second-stage reconstruction was performed four months later, using the second toe from each foot. These toes were transplanted into the DCIA bone graft. Long vein grafts and nerve grafts were used to revascularize and innervate the toes.
 FIG. 28-19. C. Result 2 years after injury. A wide web space has been created between the thumb and two ulnar digits.
 FIG. 28-19. D. Strong three-finger pulp-to-pulp pinch has been restored.
 FIG. 28-19. E. The patient has returned to writing with his dominant reconstructed right hand.
FIG. 28-19. F. The donor areas on the left foot are no problem, and the patient is again practicing karate and other sports.
CASE 4
A man sustained a bilateral degloving injury from a hot metal roller.
 FIG. 28-20. Preoperative view of the left hand with multiple carpal fractures, disruption of the median nerve and radial artery, avulsion of the finger flexors, and multiple finger injuries.
 FIG. 28-21. The right hand suffered severe dorsal degloving with exposed bone and extensor tendon.
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 FIG. 28-22. Postoperative follow-up at 1 year. Reconstruction was performed 72 hours after injury with simultaneous transplantation of a serratus flap to the left wrist and a myocutaneous latissimus flap to the right hand, both from the same donor site. The median nerve was repaired during the same operation with sural nerve grafts. The stump of the avulsed radial artery was used to supply arterial inflow to the serratus flap to the right hand. The patient has improving sensation in all fingers, and is using his hands in all daily activities with adequate pinch and grasp. Flexion.
 FIG. 28-23. Extension.
 FIG. 28-24. Lateral view of right hand in flexion.
CASE 5
An army officer suffered a devastating bilateral hand injury while unsuccessfully attempting to disarm an explosive. Initial wound closure was completed with skin grafts following extensive debridement.
 FIG. 28-25. Preoperative view of both hands 18 months after blast injury. All metacarpal joints have been destroyed in the left hand, although thenar and hypothenar muscles are innervated.
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