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Key Features
1.
2.
3.
4.
Preoperative assessment
Minor nail surgical procedures require a careful medical and
medication history, bacterial and mycology studies if infection is
suspected, and imaging (X-ray or MRI) of the affected digit if a
subungual tumor is possible. Preoperative screening should take
place before the larger nail surgery procedures that require regional
anesthesia or intravenous sedation. Depending on the patients
age and medical history, the anesthesiologist will decide the
preoperative assessment that is needed. Particular attention
should be focused on distal neurovascular compromise (peripheral
arteriopathy, Raynauds phenomenon, diabetes), hemostasis
(coagulopathy), and drug intake that may interfere with anesthetic
drugs or coagulation (beta-blockers, phenothiazines, anticoagulants,
aspirin, nonsteroidal anti-inflammatory drugs and blood thinners)
as well as allergies (anesthetic drugs, latex, antibiotics). Perioperative monitoring and drug control of high-risk patients is
especially important for diabetics, the immunocompromised, and
subjects on anticoagulants. Although no evidence supports this
practice,3 some practitioners recommend an antibiotic injection
before incision for operations that carry a higher risk of postoperative infection (osteitis, foot surgery4); we use preoperative
antibiotic prophylaxis for patients whose mucous cysts have
drained preoperatively.
Surgical Setting
Nail avulsions, biopsies, and simple excisions are safely performed
in the dermatologists ofce under the same conditions as basic skin
surgery procedures. Prepping is usually done with povidone iodine
or a 0.5% chlorhexidinealcohol preparation. Draping is conventional. We recommend that advanced nail surgery be performed
in a surgical facility that meets orthopedic surgery standards. We
generally advise surgical scrubbing of the patients hand with a
povidone iodine or chlorhexidine-impregnated surgical scrub, or
soaking of the patients foot in an antiseptic solution. Preparation
and draping of the extremity prior to advanced nail surgery is
standardized as for any orthopedic surgical procedure.
Pain Management
Pain control requires perioperative interventions. The perioperative period extends from the preoperative day through the
operation and into the postoperative recovery period. Preoperative
measures include nonsteroidal anti-inflammatory medications and
anxiolysis if necessary. Anesthetic creams prior to distal digital
anesthesia may be valuable for children. The use of nerve blocks
with long-acting anesthetics bupivacaine (Marcaine), and
ropivacaine (Naropin) enhances postoperative analgesia for up to
24 hours after the surgery. The presence of an anesthesiologist is
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Preoperative anxiolysis
Preoperative anxiolysis is not mandatory but offers numerous
advantages. Benzodiazepines are the most widely used medication
for anxiety relief; midazolam (Versed) is favored because of its
higher potency and shorter duration. Short-acting midazolam
offers hypnotic, anxiolytic, and anterograde amnestic properties,
which are advantageous because patients often do not remember
the pain, associated with local nerve blocks.
Anesthesia/sedation
LOCAL AND REGIONAL ANESTHESIA Depending on the
procedure, and on personal preference, there is a choice of distal,
proximal, or transthecal digital anesthesia, as well as a variety
of regional blocks. Simple nail surgeries require only distal or
proximal digital blocks.
DISTAL NAIL BLOCKS Distal digital anesthesias (Fig. 23.1)
can be performed in different ways: distal digital block or distal
digital anesthesia through the proximal nail fold and through the
hyponychium. Plain 2% lidocaine is preferred but 1% also may
also be used. Although lidocaine with epinephrine is safe for digital
anesthesia,5,6 it is not useful because exsanguination is necessary
and sufcient. Very slow injections beginning with a dermal papule
are necessary to minimize pain. A dental syringe and a 30-gauge
needle are useful for this purpose; a 2 mL Luer lock and syringe are
also adequate.
Distal digital block (wing block): Offers an immediate and
total nail unit anesthesia; the needle is inserted 2 to 3 mm
proximal to the junction of the proximal and lateral nail
fold. A dermal papule of anesthetic is done at the dorsal
level, the needle is then directed vertically and the injection
carried out along the lateral aspect of the digit. We inject
0.5 mL of anesthetic. The opposite side of the digit is
anesthetized in the same way.
Distal anesthesia through the proximal nail fold (PNF): This
is useful for anesthesia of the PNF, matrix and the proximal
bed. The needle is inserted in the middle of the PNF; a
dermal papule of anesthesia is carried out before penetrating
the proximal nail plate and the matrix where most of the
injection takes place. We inject 0.5 to 1 mL of anesthetic
very slowly. We observe the lunula and nail bed blanching,
which roughly indicates the territory of anesthesia.
Distal anesthesia through the hyponychium: This is done
more rarely because it is more painful. The territory of
anesthesia may include the hyponychium, the bed, and
most of the matrix. The needle is inserted in the lateral
hyponychial area (to avoid the prominent distal phalangeal
ungueal process) and directed horizontally in the nail bed
while the anesthetic is injected. Here also, blanching
roughly indicates the territory of anesthesia, which may
include the hyponychium, the bed, and most of the matrix.
Distal anesthesia is helpful because it takes effect almost immediately. Because the major digital vessels and nerves are not
transected, these techniques carry a low risk of neurovascular
compromise. The subungual space is limited and nonexpandable.
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Preoperative sedation
Although the average patient does well with preoperative
anxiolysis associated with regional anesthesia, patients undergoing
advanced surgical procedures may require deeper conscious intravenous sedation (an anesthesiologist is required).
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Instruments
FIGURE 232. Transthecal digital anesthesia injection sites.
Operative technique
Operative measures to alleviate postoperative pain include wound
tension control. Wound tension should be kept as minimal as
possible. Undermining should be done when necessary and the
wound should be closed with a limited number of stitches to
facilitate drainage. Openings should be made in the nail plate: at
the base, the extremity, or laterally to ensure drainage.
Postoperative analgesia
Postoperative measures rely on a pharmacological intervention.
The analgesic should be chosen according to the anticipated level
of pain (Table 23.1) and should be given at regular intervals
depending on the drug elimination half-life and before the
reappearance of the pain. Adaptation of analgesic strength levels
and doses is necessary. In the absence of sedation, the physician
should not hesitate to repeat the initial dose or to increase the
analgesic level to achieve satisfactory pain relief.
Pain levels associated with nail surgery are variable. In our
experience, surgical techniques that induce an intense level of pain
are laterolongitudinal excisions; large nail bed, nail unit, or skin
flaps; and total nail unit removal. Simple excisions and biopsies are
moderately painful whereas avulsions and segmental matricectomies
generate a low level of pain.
Initial drug choice depends on the expected level of pain. Step 1
refers to a low to moderate level of pain for which acetaminophen
INTENSE
Avulsion
Phenolization
Biopsy
Shave excision
Fusiform longitudinal
excision
Lateral longitudinal
excision
Flaps
Nail unit graft
270
MODERATE
LOW
X
X
X
X
X
X
X
X
Most instruments used for nail surgery are not specic, including
magnifying loupes and delicate instruments such as those used in
plastic surgery. Adequate magnication is essential, Heine or
Zeiss binocular loupes that magnify 2.5 to 3.5 times at 13 to
16 inches are adequate.
Delicate forceps are necessary to avoid crushing the small tissue
specimens; delicate Adson models with one by two teeth or
Castroviejo forceps are optimal. Double-prong Guthrie retractors
are used for proximal nail fold retraction or nail bed/matrix tissue
flaps. A delicate needle holder is required to secure ne suture
material. Nail plate avulsions may necessitate some specic tools
such as nail elevators, nail nippers or nail splitters. Lempert
elevators 2- and 3-mm large (Fig. 23.3) are useful to perform
partial avulsions for lateral matrix segmental phenolization. Their
extremity is slightly bent to conform to the nail bed shape (see
Fig. 23.3). The larger freer septum elevator is used for larger hemior total nail plate avulsions. When missing, the smooth side of the
jaw of an opened Halstead or Mosquito forceps or the thin lateral
external side of a blunt-tipped Stevens scissors may replace this
instrument.
Straight 5-inch nail nippers may be used to section the nail plate
during distal avulsions; double-action nail nippers are invaluable
in cutting thick toenails, our preferred model is the Ruskin bonecutting forceps. The English anvil-action nail splitter (Fig. 23.4) is
helpful for laterolongitudinal toenail avulsions. The lower blade of
the instrument has a flat and smooth undersurface that glides
along the nail bed atraumatically. As the anvil-like upper surface of
the lower blade slides under the nail plate, the inferior cutting edge
of the upper blade is placed over the nail plate. The spring action
of the instrument allows it to cut through the thickest nail plate
with ease.
Curved and blunt tipped scissors such as Stevens or Graddle
are convenient to section thin nail plate. Nail-pulling forceps
are seldom used because regular Halstead or Mosquito forceps
or regular needle holders with teeth do their job efciently. A
bone curette is essential for matricectomies. We use them after
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Sutures
We prefer suturing all nail unit wounds to minimize scarring.
Nonetheless, some basic nail surgical procedures do not require
sutures; these include biopsies or excisions with diameter 3 mm.
When skin approximation is needed, we use Ethicon sutures
(Johnson & Johnson). Coated Vicryl rapide (polyglactin 910)
suture offers short-term wound support (710 days) and avoids the
need for suture removal, which is often feared by nail surgery
patients. Drawbacks are essentially a reduced tensile strength that
is markedly visible when trans nail plate suturing is needed.
We routinely used 4-0 (toenails) and 5-0 (ngernails) for laterolongitudinal excisions and to approximate proximal and lateral
nail folds.
Nail epithelium approximation is performed with absorbable
sutures. Undyed (clear) coated Vicryl (polyglactin 910) suture or
PDS II (polydioxanone) synthetic absorbable suture are preferred
for nail bed and nail matrix approximations. We use 6-0 for matrix
suturing and 5-0 for nail bed. Vicryl is preferred for its ease of
knot tying, knot security, and knot sliding capabilities. Surgeons
preferring monolament sutures choose the PDS II because of its
pliability and extended wound support.
Digital tourniquet
When the procedure is performed under local digital anesthesia,
a digital tourniquet is placed at the base of the nger.12 Digital
tourniquets have been condemned on the basis of excessive
pressure applied on the neurovascular bundles. It has been shown
that rubber band and Penrose drain deliver high and unreliable
pressure.13 A sterile rubber glove nger whose tip has been removed
may be stretched over the digit.13 It has been shown that a rolled
rubber glove whose size is equal to the patients glove size delivers
a reliable pressure under 500 mmHg.13 The main disadvantage of
the gloves nger technique is that the tourniquet can inadvertently
be left in place at the end of surgery. When performing ngernail
surgery, the use of a whole surgical glove offers (Fig. 23.5) a safer
and reproducible digit exsanguination while providing a sterile
surgical eld. The whole glove cannot be forgotten during the
dressing at the end of the procedure. When the gloves nger technique is used, we recommend securing a hemostat to the rubber
band in order to prevent any accident; we also ask our nurse to
control the tourniquet removal at the end of the procedure.
Pneumatic tourniquet
When the patient has a digital infection or a distal vascular
compromise (atherosclerosis, diabetes or Raynauds phenomenon),
a proximal pneumatic tourniquet is preferred. An awake patient
will tolerate a pneumatic tourniquet for about 30 minutes; a
forearm tourniquet is also adequate and may be better tolerated.14
Longer procedures need adequate regional block or general
anesthesia.
Postoperative Dressings
We use a nonadherent dressing coated with petrolatum emulsion
(Adaptic) associated with an ointment or a cream that keeps the
wound from drying and provides a good microenvironment for
wound healing15 (silver sulfadiazine, bacitracin, or mupirocin ointments). The rst dressing is made with a sufcient number of large
gauzes to absorb bleeding, which is always noticeable. A loose
23
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FIGURE 237.
Onychomatricoma. Matrix
approach exposes the
multidigitated tumor.
272
explained and lifted up, the surgery performed and the nail plate
positioned back in place and secured to the lateral nail folds.
A proximal approach is rarely needed (distal nail plate destruction or absence, nail bed tumefaction, distal nail thickening) once
the proximal nail fold has been detached from the nail plate as
seen previously, the elevator is gently pushed more proximally to
come into contact with the most proximal part of the nail plate,
the instrument is then reoriented downward to slide on its under
surface, the instrument is then pushed in the direction of the
hyponychium, detaching the nail plate from its nail bed attachment. This proximal technique is more difcult to perform and
more traumatic than the distal technique.
A nail-pulling forceps, a standard Halstead hemostat, or the
needle holder may be used to grasp and avulse the detached nail
plate, the undersurface of which should be inspected.
PARTIAL NAIL PLATE AVULSIONS17 Partial nail plate avulsion
is a versatile procedure that may be performed in many different
ways (Fig. 23.9).
DISTAL AVULSIONS Distal avulsions are used for the distal nail
bed and hyponychial surgical approach. They may be central,
lateral, or concern the distal half of the nail plate. Distal and
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FIGURE 2310.
Junctional nevus. Proximal
matrix exposed, showing
the longitudinally oriented
pigmented lesion.
Distal
avulsions
Longitudinal
avulsions
Proximal
avulsions
Central
avulsion
FIGURE 239. Partial nail plate avulsion is a versatile procedure that may be
performed in many different ways.
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proximal nail fold and the nail plate, and then between the nail
plate and the distal nail matrix laterally from the lateral nail sulcus
at the level of the lunula. The nail plate is partially cut transversally
with a Stevens scissor and lifted up to perform the surgery (it may
be a proximal hemi-avulsion or a proximal quarter avulsion). After
the surgery, the nail plate is either removed or positioned back in
place (in this case a 2-mm transversal recut may be needed).
LONGITUDINAL AVULSIONS Longitudinal avulsions may be
used to expose nail bed or matrix in their lateral or central aspect
(Fig. 23.12). It is possible to avulse from 15 to 80% of the lateral
nail plate (Figs 23.12 and 23.13). The procedure is the same as
described in total nail avulsion but limited to a narrow strip of
nail plate. The nail plate is sectioned with a Stevens scissor when
the nail plate is thin (digit), with an English nail splitter for a
toenail, or an anvil-action nail nipper for thick toenails. The nail
plate is then removed with a Mosquito hemostat or a nail-pulling
forceps.
CIRCULAR AVULSIONS Circular avulsions may be used for
localized procedures of the central nail bed or distal matrix. This
technique is useful to evacuate hematomas or remove foreign
bodies such as metallic splinter or gravel that may have penetrated
the nail plate. It may be used as nail bed or matrix approach before
a 3-mm biopsy punch.
A 5-mm circular punch is used to drill the nail plate, which is
removed as a lid.
Partial nail plate avulsion is a versatile procedure that may be
performed in many different ways.
FIGURE 2312.
(A) Longitudinal avulsion
to approach lateral nail
bed (B) post-traumatic
nail bed pyogenic
granuloma is uncovered.
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275
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FIGURE 2317.
A shallow vertical incision
is made with an eleven
blade to circumscribe the
lesion that will be shaved.
276
Biopsies
Indications20
Nail biopsy is useful for the diagnosis and treatment of various nail
diseases as well as for the prevention of potentially harmful or
disguring conditions. Nail unit biopsy is an integral part of the
dermatologists armamentarium. Nail biopsy is indicated when
careful medical history, clinical examination, and appropriate
diagnostic tests (e.g. mycology, standard X-ray, MRI) fail to
establish a precise diagnosis. The nail biopsy can be performed by
a variety of techniques depending on the type and/or the nail unit
localization. Any specic part of the nail unit (matrix, nail bed,
bone, nail folds, pulp) may be sampled; nail semiology (Table 23.2)
should dictate the preferred biopsy site. A nail unit biopsy that
is performed using the nail surgery standards described in this
chapter will not be very painful or leave unsightly scars; it should
be performed wisely, as often as necessary.
A monodactylous onychopathy should always be suspected of
being a tumor and sampled when a denite origin is not recognized.
The most frequent reasons to sample the nail unit are nail unit
tumors (melanoma, squamous cell carcinoma, pyogenic granuloma,
osteochondroma), inflammatory nail diseases (functional
melanonychia, lichen planus, psoriasis), and onychomycosis.
Localization
Nail semiology should be analyzed as critically as possible to
sample the correct anatomical zone that is suspected of being at the
origin of the symptomatology. When the origin is equivocal the
whole nail unit may be sampled (lateral longitudinal biopsy).
NAIL BED Onycholysis, subungual hyperkeratosis, tumefaction,
ulceration, tumor, pigmented macules, partial colored streaks,
distal ssure, pain and distal nail plate destruction may indicate a
nail bed origin.
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MATRIX
Onycholysis
Subungual hyperkeratosis
Ulceration
Pachyonychia
Dyschromia:
macular
longitudinal
Onychomadesis
Nail surface alterations
Trachyonychia
Fissure
Pits
Onychorrhexis
Longitudinal nail groove
Transversal nail groove
Nail destruction
Dorsal pterygion
Paronychia
Tumor
Ingrown nail
Acropachy
Pain
X
X
X
X
Total
X
X
X
X
Deep/full thickness
X
X
X
X
X
X
X
X
X
X
NAIL BED
X
X
X
X
X
X
X
Partial
NAIL PLATE
BONE
X
X
X
X
X
X
X
X
Total
X
X
X
X
Supercial
X
X
X
X
X
Distal
X
X
X
X
X
X
X
X
X
X
X
X
X
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NAIL FOLDS Chronic paronychia, pain, and nail fold skin alterations may indicate a nail fold origin.
As the inferior part of the proximal nail fold represents the most
proximal part of the matrix, trachyonychia, transverse depressions
(Beaus lines and longitudinal nail groove) may have a proximal
nail fold origin.
Lateral nail fold tumors may also induce onycholysis or
onychomadesis.
NAIL PLATE Supercial or deep chromonychia may indicate a
nail plate origin (supercial or deep fungal chromonychia); in this
case the nail plate itself is colored. Apparent nail plate coloration
may be secondary to onycholysis (apparent chromonychia)
pointing to a nail bed process (glomus tumor, pyogenic granuloma,
felon, foreign body).
BONY PHALANX Acropachy, ingrowing nail, paronychia,
onycholysis, nail bed or matrix tumor, and pain may be the
symptoms of bone tumors and cysts, as well as of cartilaginous
outgrowth.
NAIL UNIT It is not uncommon for inflammatory nail diseases or
tumoral processes to have multiple anatomic localizations. On the
other hand, it is not always possible to localize precisely the origin
of a lesion. In these cases, a nail unit biopsy may be indicated.
Laterolongitudinal biopsy or excision is often used when the
pathology is lateralized.21
Techniques
20
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Pulp
FUSIFORM EXCISIONS Fusiform biopsies/excisions may be
oriented transversally near the hyponychium or sagittally when
localized in the ventral area.
CRESCENT-SHAPED WEDGE EXCISION (DUBOIS TECHNIQUE)22 This technique has been suggested to correct distal nail
plate embedding when medical treatment (dorsoventral pulpar
massaging, acrylic nail) is not successful. We have never had to use
this procedure because the cases of distal nail plate embedding that
we have seen were easily corrected with medical advices.
A sh-mouth incision is carried out 5 mm distal and parallel to
the distal groove. A transversal fusiform excision 3 to 5 mm wide
is performed. Undermining of the whole nail unit is realized over
the bony phalanx. The defect is closed with 4-0 Vicryl rapide.
Matrix
LONGITUDINAL MATRIX EXCISION23 (Fig. 23.23) Most
authors recommend excising lesions with transversal incisions in
the matrix area.24 Unfortunately, nail matrix pigmentations and
tumors at the origin of longitudinal melanonychia are longitudinally oriented so that transversal excision is not feasible. In
fact, a 3-mm longitudinal melanoncyhia results in a rectangular
pigmented macule that is 3 mm in the transversal axis and 5 mm in
the sagittal axis. Even very small lesions cannot be easily excised
with transversally oriented incisions. We have used longitudinal
fusiform excisions in the matrix for 10 years without any signicant postoperative nail dystrophy (slight focal, longitudinal nail
plate thinning may be observed postoperatively).
The proximal nail matrix is exposed, a longitudinal elliptical
excision of the lesion is done and incisions are done deep to the
bone. It is possible to excise lesions up to 4 mm on the larger nails
(thumbnail, big toenail); undermining is done for lesions larger
than 3 mm. The smallest lesions (up to 2 mm) may be closed
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The tiny specimen should be transferred flat to a piece of cardboard, e.g. a piece from the cardboard suture packing. Supercial
excisions of this type heal with minimal scarring, i.e. longitudinal
erythronychia or supercial nail plate longitudinal thinning.
SURGICAL MATRICECTOMY AND OTHER DESTRUCTIVE
TECHNIQUES Total nail matrix destruction is rarely needed to
correct onychogryphosis.
SURGICAL MATRICECTOMY This surgical technique is difcult to perform and induces a longer walking impediment than
the other procedures (phenolization, CO2 laser photocoagulation
and cauterization. Surgical matrix dissection should include the
proximal and distal matrix, the lateral matrix horns, as well as the
undersurface of the proximal nail fold.
The proximal nail plate is avulsed and the matrix exposed. The
area to be excised is outlined with a shallow (2-mm deep) incision,
and the epithelium is dissected from the distal part of the lunula
to the matrix horns. The epithelium of the undersurface of the
proximal nail fold is also removed. The proximal nail fold is
positioned back in place after completion of surgery. Healing by
secondary intention is obtained after 4 to 8 weeks.
PHENOLIZATION The phenol technique is the easiest method.
Total nail avulsion is performed and the full-strength phenol
applied meticulously over the entire matrix; this procedure should
be repeated three to four times until surface blackening is observed;
a total phenol application time of 60 seconds is necessary for
adequately matrix destruction.
CARBON DIOXIDE LASER PHOTOCOAGULATION A
carbon dioxide laser may be used in a defocused mode to vaporize
the matrix epithelium after reflection of the proximal fold and
proximal nail plate avulsion; care must be taken to treat the under
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FIGURE 2323. (A) Single longitudinal melanonychia, histology disclosed a junctional nevus; (B) proximal matrix exposed, showing the longitudinally oriented pigmented
lesion; (C) longitudinally excised specimen; (D) the longitudinal wound sutured with 6-0 absorbable material; (E) the longitudinal wound is closed with absorbable material;
(F) postoperative result showing slight longitudinal nail plate thinning.
surface of the proximal fold and the lateral horns. Healing takes
place by secondary intention.
CAUTERIZATION Radiosurgery (Ellman surgitron) and electrocautery are other alternatives. Specically designed electrodes have
been commercialized for this purpose (insulated matrix electrode
set, ref H9, Ellman Corporation). Proximal nail plate avulsion is
performed before electrosurgical coagulation of the matrix area,
Nail bed
LONGITUDINAL EXCISION Fusiform longitudinal excision is
used to biopsy or excise nail bed lesions. The nail plate is elevated
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FIGURE 2324. (A) Nail matrix tumor; (B) a fusiform biopsy performed after nail plate avulsion showing an orange tumor, histology diagnosed a giant cell tumor of the
tendon sheath; (C) the wound is sutured with absorbable material.
Hyponychium
Hyponychial lesions may be removed with an A to T flap (see p.
289, A-T advancement flap).
Nail unit
LATEROLONGITUDINAL EXCISION AND SELECTIVE
DESTRUCTIVE TECHNIQUES
LATEROLONGITUDINAL EXCISION (Fig. 23.27) This
procedure is useful to biopsy21 or remove lateral nail matrix
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FIGURE 2325. (A) Shallow vertical incision circumscribing the lesion to be excised; (B and C) the blade is tangentially oriented and the lesion is supercially shaved off;
(D) the thinnest slice that can be made reaches the reticular dermis.
Key Features
* The width of the excision cannot exceed 40% of the nail plate width
* Curettage of the nail matrix horns should be meticulous to avoid
postoperative nail spicule growth
* Postoperative pain is always noticeable after this intervention; it should be
anticipated and prevented. Adequate postoperative analgesia should be
provided to the patient
* Postoperative nail aspect is very good; the rectitude of the normally
rounded angle between the cuticle and the lateral nail fold is slightly
noticeable
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C
FIGURE 2326. (A) Toenail longitudinal melanonychia
suspected to be frictional; (B) nail matrix is exposed;
(C) nail matrix specimen; (D) a shallow, vertical incision
is made with an eleven blade to circumscribe the lesion
that will be shaved; (E) nail fold is sutured with 5-0
absorbable material.
large 3-mm (toenails) curved elevator.23 The lateral nail bed and
matrix are carefully dried with a piece of gauze introduced along
the lateral nail bed and under the proximal nail fold. This procedure, repeated from time to time during the operation, ensures a
perfectly dried surgical eld warranting phenol efcacy. The
inferior (concave) side of the 3-mm large Lempert elevator is
soaked in full-strength phenol (88%); any excess is absorbed on a
piece of gauze. The tiny phenol layer covering the inferior part of
the elevator is applied to the lateral matrix, ventral part of the
proximal nail fold, and corresponding nail bed. When a pyogenic
granuloma is associated, a drop of phenol is also applied over the
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FIGURE 2327. (A) Laterolongitudinal excision (LLE) incision lines; (B) transection of the nail plate is done with a regular 15 blade that is progressively advanced in a
sawing motion and the wedge of tissue is removed over the bony phalanx; (C) suturing is realized with 5-0 absorbable sutures; (D) slight postoperative cuticular retraction.
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FIGURE 2328. (A and B) Total nail unit en bloc excision for a melanoma; (C) full thickness skin graft is in place; (D) tie-over dressing preparation; (E) FTSG a at day 10;
(F) postoperative result at 1 year.
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Pulp
V-Y ADVANCEMENT FLAPS Defects of the pulp lying close to
the hyponychium may be covered by an island flap. A unilateral,
longitudinal V-Y flap may be raised from the pulpar pad, or
bilateral transversal symmetric island flaps may be mobilized from
the skin lying at the junction of the dorsal and pulpar skin
paralleling the lateral nail sulci. These flaps have been described in
traumatology and fall beyond the scope of this chapter.34,31,36
23
of the flaps curve with the lunula. The incisions that are lying in
the semi circular lunular border are prolonged on both lateral sides
to mobilize a bilateral advancing flap.
Hyponychium
A-T ADVANCEMENT FLAP37 (Fig. 23.30) Small lesions of the
hyponychial area may heal by secondary intention. We found the
A-T flap useful to reconstruct medium sized defects of this area.
The A-T flap represents the shape of a triangular defect closed by
advancing flaps from opposite sides of the triangle.
The nail plate is lifted to visualize the lesion excised in a
triangular fashion, the base of the triangle sitting in the
hyponychium and the two sides of the triangle in the nail bed. The
incision lying in the hyponychial area is prolonged in both sides
along the distal nail groove to mobilize a bilateral flap.
Undermining is done at the level of the subcutaneous fat on the
pulpar aspect of the advancing flaps. The distal nail bed is undermined over the phalanx, mostly to facilitate suture placement.
Depending on the location of the lesion, the base limbs may vary
in length. The key suture is placed rst; it closes the advancing
edges of the two flaps together. The sides of the flaps are closed
and a three-point closure is done at the end of the procedure.
Nail unit
SCHERNBERGS TRANSLATION FLAP38 (Fig. 23.31) Central
defects, up to 5 mm wide, may be repaired by a technique described
by Schernberg and Amiel. The lesion is excised by a fusiform
central or paracentral longitudinal excision including the nail
plate, the nail bed, and the matrix. This excision extends proximally
into the proximal nail fold and distally into the pulp. The larger
half of the nail (when asymmetrical) is raised up and freed from its
hyponychial attachment distally. The pulpar incision is prolonged
laterally (3 mm from the lateral nail sulcus) on one of the lateral
aspects of the digit up to the interphalangeal level at the junction
of the dorsal and volar skin. The entire lateral nail fold is included
in the flap when the pedicle is proximal. A constant artery,
described by Flint,19 irrigates this flap, which can be advanced and
rotated so as to close the defect. The central defect is closed and
the lateral one is partially left to heal by secondary intention. The
Schernbergs flap leaves a central nail plate unsightly scar and
should only be used in selected cases.
BARAN AND BUREAUS ROTATION FLAP39 This flap has
been proposed to correct malalignment of the great toenail,
whether congenital or acquired (usually secondary to nail bed
scarring). When malaligment of the great toenail is associated with
onycholysis, the missing or scarred nail bed should be grafted rst
with a nail bed split thickness graft. A crescent-shaped excision is
performed, as in the Dubois procedure (see p. 282).22 A Burrows
triangle is designed at one end of the incision, the side of which is
indicated by the nail unit deviation. Burrows triangle excision will
authorize a nail unit rotation, making nail realignment feasible.
Grafts
Nail bed graft
Nail bed grafts are used to correct nail bed defects that cannot be
repaired by the above-mentioned techniques.
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FIGURE 2329. (A and B) Nail bed, longitudinal fusiform excision; (C) relaxing incision made longitudinally in the lateral nail sulci; (D) the entire nail bed and matrix are
undermined over the phalangeal bone; (E) only the central nail bed wound is sutured; (F) nail plate is secured with 6-0 absorbable sutures.
288
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Matrix graft
A high failure rate and unacceptable donor nail scarring explain
why nail matrix grafts have been abandoned.44
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290
Pedicled nail unit transfers, which were rst described in the late
1970s, have mostly been abandoned. Microsurgical nail unit
transfers may be used for nail unit reconstruction. A description
of this technique is beyond the scope of this book but technical
details can be found in a recent literature review.48 However, this
operation is rarely used because the donor nail unit has to be
sacriced and covered with a full-thickness graft. Furthermore, the
cosmetic quality of the results cannot be fully guaranteed.
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References
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