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.     

Thin split-thickness toenail bed grafts for avulsed nail bed defects

Avulsed defect of a fingernail bed is a common injury in acute hand trauma. Insufficient management for this type of nail bed avulsion often leads to an irregular and nonadherent nail. The use of thin split-thickness sterile matrix graft from the great toe for immediate replacement of a nail bed defect can regain a smooth, adherent, and normal-looking nail. Between May of 1998 and December of 2001, we used thin split-thickness toenail bed grafts in 13 fingers of 12 patients with avulsed defects of the nail bed. The end results of this technique were excellent and no deformities occurred in the graft donor area. Thin split-thickness toenail bed graft is a good choice for the treatment of acute nail bed avulsion.     

Fingertip reconstruction with flaps and nail bed grafts

We retrospectively reviewed the cases of 14 fingertips reconstructed with a combination of local or regional flaps and nail bed grafts, some of which were placed wholly or partially over a de-epithelialized flap. Most of the fingertips sustained a crushing injury and were reconstructed at the time of the injury. Soft tissue coverage was provided by palmar V-Y flaps in 6 cases, thenar flaps in 4, lateral V-Y flaps in 2, a Moberg flap in 1, and a cross-finger flap in 1. Split toenail bed grafts were used in 6 cases, full-thickness nail bed grafts from the amputated part in 6, and split nail bed grafts from the injured digit in 2. There was 1 partial graft loss and 1 partial flap loss. The remaining cases had completely successful grafts and good soft tissue healing. Subsequent nail growth and adherence were good in all but the 1 digit requiring secondary composite grafting.     

Nail grafts for reconstruction

Monkey digits were used experimentally to demonstrate the pathologic anatomy of nail deformities and the results of treatment using full and partial thickness nail matrix grafts. Seventy-five human nail deformities were evaluated and treated. In both the experimental and clinical groups, microscopic hypertrophy of the superficial epithelial elements underlying the deformed nail existed. A follow-up of treatment of nail deformities indicated that nail matrix grafts, both full and partial thickness, are beneficial when the defect involves the sterile matrix and the proximal nail fold.     

自体真皮移植修复甲床缺损的临床初步研究

目的 观察自体真皮移植术修复甲床缺损的临床效果及可行性.方法 2009年8月至2010年6月,对24例外伤性甲床缺损,随机分成A、B两组,每组12例.甲床缺损面积为2mm×4 mm～5 mm×8 mm.A组采用自体真皮移植术修复,B组采用自体甲床移植术修复.术后随访观察两组指甲生长情况.结果 术后2周拆除加压包后,A组有1例出现部分坏死,经换药后愈合;余23例创面全部愈合.随访时间为3～12个月,术后3个月患指指甲均能长出覆盖甲床,A组3例、B组1例新生指甲不平滑,外观欠佳.A组供皮区无病例发生并发症;B组供趾甲床不平滑2例,外观欠佳.24例患指均无疼痛,捏持和握力不受影响.结论 自体真皮移植术疗效满意,取材方便,对供区影响小,可作为传统自体甲床移植的替代治疗方案.     

Nail bed injuries and deformities of nail

Nail bed injuries are common and management of these requires good knowledge of the nail bed anatomy. Proper management of these injuries will ensure good healing and prevent late deformities. When loss occurs it is challenging to reconstruct which can be done by grafts or microsurgical reconstruction to restore aesthetic appearance of fingers.     

Securing meshed split-thickness skin grafts with 2-octylcyanoacrylate.

Meshed split-thickness skin grafts (STSGs) secured with 2-octylcyanoacrylate (2-OCA) were compared with meshed STSGs secured by suture and bolster (S&B). The 2 techniques were compared for graft survival, foreign-body giant cell response, inflammatory response, appearance, texture, and application time. Sixteen 2.5 x 2. 5 cm meshed STSGs were harvested from the dorsa of 2 pigs for a total of 32 grafts. On each pig 8 grafts were sprayed with 2-OCA, and the other 8 were secured with S&B. Evaluations were performed on postoperative days 14, 24, 48, and 56. Biopsy specimens were obtained on postoperative days 14 and 56. There were no significant differences in percent survival, foreign-body giant cell response, inflammatory response, and appearance between control and study grafts. The average time to apply the 2-OCA onto a graft was 3 seconds, compared with 8 minutes for S&B application. 2-OCA provides a quick and reliable means of securing meshed STSGs and would be especially useful in areas where it is difficult to use S&B, such as total maxillectomy defects.     

Hard palate mucosal grafts for defects of the nail bed

The authors present 2 children in whom a hard palate mucosal graft was used for a defect of the nail bed after resecting subungual exostosis. After the tumor was resected with the overriding nail bed, hard palate mucosa without periosteum was grafted to the nail bed defect. In both patients the graft took completely, and within 2 weeks after the operation the patients were able to enjoy activities of daily life, including athletic movement, without any symptoms. Nail growth was uneventful and was complete in 4 or 5 months after the operation without any complications. The authors think that a hard palate mucosal graft is a valid choice for a defect of the nail bed, and the mucosa does not need to be harvested with periosteum. The grafting of hard palate mucosa without periosteum to a defect of the nail bed contributes to a shorter healing time, resulting in a reduction in the period of restriction of movement in activities of daily life, and this is a great advantage in children.     

甲后皱襞U形切除扩大甲床术的临床应用

指尖损伤伴甲床缺损、指骨外露时,无论行残端修整或皮瓣修复,甲床面积都将缩小,直接影响指甲的外形。自2005年来,本院采用甲后皱襞U形切除扩大甲床术治疗甲床远端缺损108例,效果满意,现报道如下。     

Histomorphometric analysis of intraoral split-thickness skin grafts.

Transposition of split-thickness skin grafts from the anterior thigh to the oral cavity is an ideal method for reconstruction of selected defects following major oncologic ablative surgery. This alternative potentially allows for tongue mobility, deglutition, and articulation superior to that obtained with bulky adynamic myocutaneous flaps. We have examined the adaptive responses of split-thickness skin grafts to the intraoral environment with biopsies from 10 patients 11 to 90 months following oral cavity reconstruction. Histologic examination of intraoral skin grafts shows preservation of the cytoarchitecture of the epidermis, an absence or atrophy of skin appendages, and a statistically significant thinning of the keratin layer. A "junctional zone" between the normal oral cavity mucosa and the skin graft was identified. This zone is characterized by an abrupt transition from keratinized stratified squamous epithelium with a prominent granular layer, to nonkeratinized stratified squamous epithelium lacking a granular layer. This study clearly demonstrates that split-thickness skin, when transposed to the oral cavity, maintains the epidermal phenotype and does not assume the histologic characteristics of mucosa.     

Fingertip reconstruction by nail bed grafting using thenar flap

Ideally, treatment for fingertip injury should involve the least pain possible, using durable and sensate skin with due consideration to aesthetic aspects. This paper presents two cases of fingertip reconstruction through the use of thenar flaps and nail bed grafts. In either case, injury had been due to fingertip crushing and reconstruction was conducted immediately thereafter. A full-thickness nail bed with hyponychium and perionychium from the severed part was used for dorsal reconstruction and thenar flaps for finger pulp reconstruction. In both cases, the grafting was quite satisfactory and good soft-tissue healing was observed. Subsequent nail growth and adherence were good. The outcome was pleasing to both patients. Thus, the presented method may be considered quite satisfactory from aesthetic and functional recovery standpoints.     

Nail bed injuries

The nail bed injury is common in mechanized societies. Appropriate early care is essential to good postsurgical results. The timing and techniques of this care are described.     

En block forehead reconstruction with split-thickness cranial bone

This report demonstrates the utility of split-thickness cranial grafts harvested by craniotomy in the reconstruction of the entire forehead in an en bloc fashion. The technique allows a cosmetic recontouring of large surfaces of the cranial vault in particular, with little or no need for multiple extracranial grafts. Computer imaging and three-dimensional graphic reconstruction lend themselves well to preoperative planning.     

部分甲体甲床甲母质切除甲沟成形术治疗嵌甲型甲沟炎256例

目的:探讨一种利用甲侧襞皮瓣改变甲体与甲沟的位置结构,从而彻底治愈嵌甲型甲沟炎的手术方法。方法:切除部分甲体、甲床及甲母质,并利用甲侧襞皮瓣成形甲床、甲沟、甲侧襞联合结构。结果:本院2010年1月～2011年6月对256例嵌甲患者,足趾255例、手指1例,共376侧嵌甲进行甲沟成形手术,随访6月～2年,取得满意效果。结论:本手术从根本上彻底解决了嵌甲的病因,手术并发症少,复发率极低。     

Free vascularized nail grafts

A considerable amount of literature has been written on microneurovascular surgery for the reconstruction of partial defects in fingers, but little has been published on reconstruction to replace lost fingernails. We report on two clinical cases in which a free vascularized nail graft and a “double onychocutaneous flap” were used successfully. We suggest that the free vascularized nail graft is a superiormethod in reconstruction to treat fingernail loss or deformity.