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 FIG. 20-46. The patient was initially taken to the operating room for debridement and stabilization with an external fixator and K wires. Dorsal view.
 FIG. 20-47. Palmar view.
 FIG. 20-48. X ray of temporary stabilization.
 FIG. 20-49. Four days later, a simultaneous DCIA bone graft and rectus muscle transplant were planned, through the same incision.
 FIG. 20-50. Iliac graft bone block, vascularized.
 FIG. 20-51. Block next to wound.
 FIG. 20-52. Bone block in place, DCIA vessels anastomosed to dorsal radial artery and vena comitantes.
 FIG. 20-53. X ray shows good metacarpal alignment and stabilization. Dorsal view.
 FIG. 20-54. Side view.
 FIG. 20-55. A free rectus muscle was used to cover the vascularized bone graft and extensive wound. Muscle next to wound.
 FIG. 20-56. Muscle in place, revascularized to same dorsal radial vessel through branches of the DCIA (internal shunt).
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 FIG. 20-57. Meshed skin graft over muscle.
 FIG. 20-58. The following day, venous congestion was noted in the muscle. Re-exploration revealed a thrombosed venous repair, which was excised and redone.
 FIG. 20-59. The flap survived, but the split-thickness skin graft was partially lost, requiring regrafting.
 FIG. 20-60. Long-term follow-up. Radial view.
 FIG. 20-61. Dorsal view. Extension.
 FIG. 20-62. Flexion.
 FIG. 20-63. Palmar view. This complex case illustrates the value of immediate bony reconstitution and vascularized wound closure with multiple transplant and internal shunts between the transplants.
CASE 7
A 59-year-old man underwent a left maxillectomy and enucleation of the left eye in September, 1987, for squamous cell carcinoma of the left maxillary sinus. He presented with trismus, regurgitation of food, and difficulty in speaking, especially when his denture was not in position. He also complained of purulent drainage from his left nostril.
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