Vascularized nail flap vs. free nail graft

Summary With recent improvements in microvascular surgery, the vascularized nail flap procedure has had considerable success. On the other hand, free nail graft without microvascular anastomoses is still used but little has been published to make a comparison between these two procedures. Thus, it is not known which is the better procedure. In the past, hand nail defects in 12 patients have been reconstructed by the free nail graft procedure and in four patients by vascularized nail flap procedure. In this article, the free nail graft is compared with the vascularized nail flap and the merits and demerits of both techniques are presented. Requests for reprints: T. Endo, M.D.     

Avulsion injuries of the nail bed do not need nail bed graft

From 1985 to 1992, 12 cases of severe avulsion injuries of the nail bed were treated by allowing the nail bed to regenerate naturally, without a nail bed graft irrespective of the extent of nail bed loss. This involved simply covering the residual nail bed with the nail splint for a period of approximately 6 weeks or until the nail bed was observed to be fully regenerated. The patients were then followed up until full nail growth. It was observed that the nail bed regenerated spontaneously, followed by a normal nail growth identical to the contralateral uninjured nail.Proper coverage of the nail bed protected the culture milieu conducive to natural nail bed regeneration, and nail bed grafting was not necessary irrespective of the extent of tissue loss.     

The microvasculature of the nail bed, nail matrix, and nail fold of a normal human fingertip

The organization of the microvasculature of the dorsal human fingertip based on a vascular corrosion cast was examined using a stereoscopic microscope. The variations of the superficial capillary network of the 3 specialized areas of skin of the dorsal fingertip (the nail bed, the nail matrix, and the nail fold) are described. In the nail bed numerous capillary loops were observed arising from a deeper regular arrangement of sagittally aligned, parallel rows of vessels. The size and direction of inclination of the capillary loops varied, getting longer and more inclined to the nail bed distally, with the longest capillary loops seen at the hyponychium. There were no capillary loops at the nail matrix region, but there was a single, layered, rectangular plexus of capillaries in the plane of the nail matrix. This extended distally to sagittally stretched coils of vessels that straightened out as the nail matrix enters the nail bed region. At the edge of the proximal nail fold the capillary loops looked like fine bristles and were approximately 3 times shorter than those found on the nail bed and hyponychium. This study provides a baseline for future work in understanding the changes in the microvasculature of the dorsal fingertip due to injury or pathology.     

Heritable nail diseases

Heritable nail diseases are associated with a great variety of inherited diseases and syndromes. Well over 60 HEDs and numerous other inherited nail abnormalities are known to exist. A classification system of these disorders, as well as the specific nail change found in each, has been presented. Table 1 has been included to correlate many of the nail disorders with their corresponding inherited disease or syndrome. Clinically, inherited nail diseases may appear to be of questionable importance. In cases of primary presentation or poor historical background, however, these subtle nail changes may prove useful in arriving at or substantiating a diagnosis.     

Similarities between a conjoined nail and the palmar nail syndrome

The congenital palmar nail syndrome consists of a triad of palmar nail, absent finger flexion and abnormalities of the distal phalanx. There are two main theories about the pathogenesis of this syndrome: the ancestral reversion theory and the duplication theory. In this paper, similarities between a conjoined nail in conjoined twins and the palmar nail syndrome are described to support the duplication theory.     

外伤性指甲缺损的修复

目的：介绍吻合血管的趾瓣移植与游离趾甲移植修复外伤性指甲缺损的疗效。方法：为11例指甲缺损者采用趾甲移植进行修复，根据受区指端软组织的条件，其中5例为吻合血管的趾甲瓣移植，6例为不吻合血管的游离趾甲移植，结果：移植后趾甲全部成活，术后随访1－3年（平均16个月），9例术后移植指甲外形良好，2例不吻合血管的游离趾甲移植者指甲轻度萎缩变形。结论：趾甲移植是修复外伤性指甲缺损的有效方法。     

Distal replantation,nail bed,and nail problems in musicians

Nails enhance pulp sensibility, increase pulp stability and are necessary for fine prehension. A finger without a nail will compromise a musician's career if the finger involved is necessary to play a note (strings, keyboards) or hold a position (winds). Salvage of the nail is then a very important part of any surgical procedure in musicians with distal finger trauma. Surgical techniques will depend on the level and type of nail injury. Replantation is by far the best technique in distal finger amputation but, when not feasible, reposition-flap repair may be used. In isolated nail lesions, sutures, split-thickness nail bed graft, or nail matrix flaps are used according to the level and severity of the lesion.     

Comparison of nail bed repair versus nail trephination for subungual hematomas in children

Fifty-three fingers in 52 children were divided into 2 groups, operative and nonoperative, after fingernail crush injury. Criteria for inclusion into the study were an intact nail and nail margin with subungual hematoma and no previous nail abnormality. The length of the follow-up period averaged longer than 2 years for each group. Twenty-six fingers in 26 children were treated by nail removal, exploration, and repair of nail bed lacerations (operative group). Twenty-seven fingers in 26 children were treated by evacuation of hematoma by nail trephination without nail removal in 11 fingers and by observation in the other 16 fingers (nonoperative group). In the operative group, transient abnormalities (nail depression or hypertrophy), which resolved by 4 months, occurred in 3 patients. In the group treated by simple decompression, there were no complications except for 1 transient nail depression at 3 months. The average cost to the operative group was $1,263 compared with $283 to the trephination group. Although formal nail bed reconstruction has been advocated for hematomas larger than 25%, we found no notable difference in outcome between the 2 groups regardless of hematoma size, presence of fracture, injury mechanism, or age. Charges, however, were 4 times greater for the operative group. Based on the results of this study, we do not feel that nail removal and nail bed exploration is indicated or justified for children with subungual hematoma and an intact nail and nail margin.     

断层甲床移植治疗甲床缺损

目的：研究断层甲床移植治疗甲床缺损的临床效果。方法对2004年2月-2005年1月收治的8例甲床缺损患者进行断层甲床移植手术,并进行术后随访。结果除1例出现甲畸形,2例伴有渗液外,其余病例均恢复正常。结论对不伴有生发基质损伤的甲床缺损,断层甲床移植术具有很好的疗效,且简便易行,适于推广。     

Surgical nail procedures

As the so-called "non-surgical" nail procedures grow more and more aggressive and invasive in nature, the cold steel matrixectomy becomes an increasingly viable alternative. Many chemical and thermal matrixectomies are performed under poor aseptic conditions, increasing the risk of wound infection. With chemical matrixectomy, regulation of the level of tissue destruction is uncontrolled and often results in bone injury. The combination of these two elements can result in delayed diagnosis and recognition of osteomyelitis. When a practitioner is faced with a challenging ingrown, dystrophic, or mycotic nail, surgical nail removal should be considered the preferred technique. Etiologic variants of nail deformity, such as hypertrophied ungual labia, subungual exostosis, traumatized nail, and prominent underlying bony condyles, are well managed by the two procedure modifications presented. Advantages in asepsis, quicker wound healing, low reoccurrence rates, and good postoperative cosmesis make surgical nail removal a good choice. The difficulty of the technique and the danger of bone infection have frightened many practitioners away from the cold steel nail procedure. The preferred phenol technique or "p and a" may be simpler to perform, but it yields an unpredictable result. The constant draining and erythema of a phenolized nail may mask an underlying infection. This is one reason why cold steel nails are the preferred technique for nail removal in a diabetic patient. Complications makes cold steel a necessary addition to the surgeons armamentarium. We have presented a brief clarification and historical overview of the four most important contributors to surgical nail removal. These four techniques (Winograd, Frost, Zadik, and Kaplan) have been interwined into the two modifications commonly used today. By following the step-by-step surgical method presented and adding the reader's own successful techniques, a good surgical result can be easily achieved.     

Advanced nail surgery

Six techniques not yet widely known or used in the dermatologic surgery of the nails are briefly described. Small-to-medium-sized tumours of the proximal nail fold (PNF) can be excised and the defect repaired with advancement or rotation flaps. A superficial biopsy technique of the matrix for the diagnosis of longitudinal brown streaks in the nail, which allows rapid histological diagnosis of the melanocyte focus to be performed, is described here. Because the excision is very shallow and leaves the morphogenetic connective tissue of the matrix intact, the defect heals without scarring. Laterally positioned nail tumours can be excised in the manner of a wide lateral longitudinal nail biopsy. The defect repair is performed with a bipedicled flap from the lateral aspect of the distal phalanx. Malignant tumours of the nail organ often require its complete ablation. These defects can be covered by a full-thickness skin graft, reversed dermal graft, or cross-finger flap. The surgical correction of a split nail is often difficult. The cicatricial tissue of the matrix and PNF have to be excised and the re-attachment of these wounds prevented. The matrix defect has to be excised and sutured or covered with a free matrix graft taken either from the neighbouring area or from the big toe nail.     

Matricectomy and nail ablation

Matricectomy refers to the complete extirpation of the nail matrix, resulting in permanent nail loss. Usually however, matricectomy is only partial, restricted to one or both lateral horns of the matrix. Nail ablation is the definitive removal of the entire nail organ. The most important common denominator in the successful matricectomy is the total removal or destruction of the matrix tissue. Matricectomy may be indicated for the management of onychauxis, onychogryphosis, congenital nail dystrophies, and chronic painful nail, such as recalcitrant ingrown toenail or split within the medial or lateral one-third of the nail.     

Microvascular nail transfer

A composite of nail and its skin appendages can be transferred for the foot to the hand by microvascular anastomosis. For technical reasons, the most suitable donor nail is from the big toe, and this most closely approximates the thumb nail. A finite portion of hemipulp must be included with the transfer to ensure adequate vascularization. Nail size can be reduced by resection of the edges of the germinal matrix so as to match the donor defects. For finger nail reconstruction, it is usually more practical to transfer the whole of the tip of the second or third toe to replace the whole of the tip of the finger. The indications of nail reconstruction by this technique are relatively rare and are predominantly cosmetic.     

The repair of nail deformities with the nonvascularized nail bed graft: indications and results

Twenty-four cases of nonvascularized nail bed grafting to correct nail deformities were reviewed. The highest success rate in improving the appearance of the deformed nail, 86%, was achieved when the split-thickness nail bed graft of sterile matrix was used to correct a nail deformity caused by a sterile matrix injury; the same procedure used to correct a nail deformity caused by a germinal matrix injury had a 0% success rate. Donor site morbidity occurred in 25% of split-thickness nail bed grafts and 100% of full-thickness nail bed grafts. The split-thickness nail bed graft of sterile matrix, if used in properly selected patients, will consistently improve the appearance of the deformed nail.     

应用第二套供血系统的全指甲再造术

目的探讨对手指指甲缺损或畸形进行精细重建的技术。方法对2003年12月-2004年6月在我院应用显微外科技术治疗的9例指甲（13指）缺损患者进行回顾性分析。所有患者均利用第二套供血系统以携带最小量组织进行切取包括趾甲、甲床、甲下皮、甲周膜在内的复合组织及其营养动脉、静脉和神经，与受区进行趾-指动脉、静脉、神经的吻合，完成单一全趾甲复合组织移植再造指甲。结果所有再造指甲均顺利成活，外形十分满意，接近原手指指甲的效果，供区的外观和功能无明显影响。结论应用第二套供血系统的全指甲单位再造术，可获得理想的治疗效果。     

断层甲床游离移植一期修复手指甲床缺损的临床研究

目的 甲床与甲板的生长来源及组织学特征,探讨断层甲床游离移植一期修复手指甲床缺损的治疗方法的可行性、安全性,综合评价术后手指功能情况.方法 通过考证甲床与甲板的基础研究方面的进展,总结我院于2003年8月～2005年8月临床应用第一足趾断层甲床游离移植治疗外伤性甲床缺损15例20指.结果 所有患者均获得随访,随访时间7～26个月,移植甲床全部成活,甲板生长平整无明显畸形,对指端软组织保护、防止指腹软组织向背侧旋转作用明显,同时保留甲板对手指的修饰作用.结论 断层甲床游离移植符合甲床与甲体生长及生发规律,甲板外形良好,尽可能的保留了甲板基本功能,手术方法操作简单,适合在基层医院开展.     

微粒甲床组织移植治疗甲床缺损

目的 探讨利用伤指剩余甲床微粒移植治疗甲床缺损.方法 对16例18指甲床缺损的患者,片状切取伤指的剩余甲床,将其切成微粒状的均匀组织植于甲床缺损处,打包加压包扎,术后2周拆线.结果 本组16例18指术后微粒甲床移植均Ⅰ期成活,其中2指中心部缺损遗留小部分指骨外露,经换药后愈合.术后随访时间为8～21个月,18指中达到优良16指(占88.9%),差2指(占11.1%).结论 微粒甲床移植解决了甲床缺损的修复材料问题.方法简单,效果理想,易于推广.     

微粒甲床组织移植治疗甲床缺损

目的 探讨利用伤指剩余甲床微粒移植治疗甲床缺损.方法 对16例18指甲床缺损的患者,片状切取伤指的剩余甲床,将其切成微粒状的均匀组织植于甲床缺损处,打包加压包扎,术后2周拆线.结果 本组16例18指术后微粒甲床移植均Ⅰ期成活,其中2指中心部缺损遗留小部分指骨外露,经换药后愈合.术后随访时间为8～21个月,18指中达到优良16指(占88.9%),差2指(占11.1%).结论 微粒甲床移植解决了甲床缺损的修复材料问题.方法简单,效果理想,易于推广.     

微粒甲床组织移植治疗甲床缺损

目的 探讨利用伤指剩余甲床微粒移植治疗甲床缺损.方法 对16例18指甲床缺损的患者,片状切取伤指的剩余甲床,将其切成微粒状的均匀组织植于甲床缺损处,打包加压包扎,术后2周拆线.结果 本组16例18指术后微粒甲床移植均Ⅰ期成活,其中2指中心部缺损遗留小部分指骨外露,经换药后愈合.术后随访时间为8～21个月,18指中达到优良16指(占88.9%),差2指(占11.1%).结论 微粒甲床移植解决了甲床缺损的修复材料问题.方法简单,效果理想,易于推广.     

Treatment of post-traumatic nail bed deformities with split-thickness nail bed grafts

INTRODUCTION: Split-thickness nail bed graft have been proposed for treatment of post-traumatic nail bed dystrophies. Only three papers reported good results in 60 to 90% of cases. We report our experience. MATERIAL AND METHODS: We reviewed 18 cases of split-thickness nail bed grafts from operative and consultation files and photographs. Evaluation was made using criteria as the nail plate shape, its adhesion on the nail bed, patient satisfaction and possible sequelae on the donor finger. RESULTANTS: Thirteen patients have been reviewed with a sufficient follow-up to assess the results. In 13 cases, the graft was taken from the hallux. The nail-bed graft was used for hallux reconstruction two times, the thumb six times, index six times, middle and ring finger one each, and the little finger two times. In every patient the graft was molded using either the patient nail or the nail plate from the donor finger. Clinical results were excellent in five cases, good in three and poor in five cases. Five failures were due to wrong indications in three cases in which matrix problem has been underestimated, and infectious failures in two cases. Fifteen per cent of our patients had some sequelae on the donor finger.