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Correction of Pincer-Nail

Deformities With Autograft or
Homograft Dermis: Modified
Surgical Technique
Elvin G. Zook, MD, Charles P. Chalekson, MD, Richard E. Brown, MD,
Michael W. Neumeister, MD, Springfield, IL

The pincer-nail deformity is characterized by an excessively curved and distorted nail across the
transverse dimension. Forty-nine sides (paronychial folds) were dissected off the distal phalanx
periosteum with scissors and/or a small elevator. The dermis was placed between the paronychial
fold and the plalanx to flatten the germinal and sterile matrix. Direct comparison of autograft
dermis to homograft dermis did not show any significant differences in postcorrection appearance
of the nail or relief of symptoms. Surgical time averaged 22 minutes less in those patients having
reconstruction on both sides of one nail with homograft dermis. (J Hand Surg 2005;30A:400 – 403.
Copyright © 2005 by the American Society for Surgery of the Hand.)
Key words: Pincer, dermal homograft (Alloderm), trumpet, nail.

The deformity of the pincer nail is an excessive
curvature in the transverse dimension of the nail plate
(Fig. 1). This deformity increases toward the distal
end of the nail, leading to pinching, curling, and
distortion of the underlying soft tissue, resulting frequently in pain.1 The deformity has been attributed to
both hereditary and acquired sources including psoriasis, trauma, developmental abnormalities, beta
blockers, allergic reactions, epidermal cysts, subungal exostosis, osteoarthritis, and ill-fitting shoes.2– 8
Numerous methods have been described for correct-

ing this nail deformity including nail plate removal,
partial nail bed ablation, or total nail bed ablation
(chemical and surgical).1,2,8 –10 Few studies have attempted to reconstruct the nail bed while preserving
the entire nail matrix. Preserving width is important
on the fingers for functional and aesthetic reasons.
We have described previously correction of the pincer nail using autograft dermis with good results.11
We present a modification of this method using dermal homograft (Alloderm; Lifecell, Branchburg, NJ)
for reconstruction and compare long-term results
with our dermal autograft–treated patients.

From the Southern Illinois University School of Medicine, Plastic Surgery Institute, and Southern Illinois University, Springfield Surgical
Associates, Springfield, IL.
Received April 16, 2004; accepted in revised form September 23,
2004.
No benefits in any form have been received or will be received from
a commercial party related directly or indirectly to the subject of this
article.
Reprint requests: Dr Elvin G. Zook, Southern Illinois University,
School of Medicine, PO Box 19653, Springfield, IL 62794-9653.
Copyright © 2005 by the American Society for Surgery of the Hand
0363-5023/05/30A02-0025$30.00/0
doi:10.1016/j.jhsa.2004.09.005

Technique

400

The Journal of Hand Surgery

Surgical reconstruction was performed under digital
block anesthesia and a finger tourniquet. The deformed nail plate was removed from the underlying
bed and discarded (Fig. 2). An oblique incision was
made distal to the hyponychium in line with the most
lateral aspect of the nail bed. Through the small
hyponychial incisions (Fig. 3) 1 or both sides of the
deformed paronychium are elevated off the distal
phalanx with fine scissors and/or a small elevator to

Zook et al / Correction of Pincer Nail Deformities

401

Figure 1. A dorsal and end-on view of a pincer (trumpet) nail
treated with autograft dermis.
Figure 5. Dermal graft prepared for placement inside the
tunnel.

Figure 2. Removal of the nail with small elevator and the
removed nail plate.

Figure 6. Passing of the graft (distal to proximal) through the
tunnel with use of a nylon suture.

Figure 3. Oblique incision at the edge of the nail laterally
distal to the hyponychium.

Figure 7. Application of reinforced silicone sheeting to protect nail bed after surgery.

Figure 4. Elevation of the nail bed off the distal phalanx with
creation of a tunnel for the graft.

correct unilateral or bilateral deformities. Dissection
is carried proximal, freeing the germinal matrix to
create a tunnel between the nail bed and the underlying phalanx (Fig. 4). Both the sterile and germinal
matrixes are elevated in this manner. A small inci-

402

The Journal of Hand Surgery / Vol. 30A No. 2 March 2005

Table 1. Pincer-Nail Reconstruction Using
Homologous and Autologous Dermis Showing
Number of Sides Corrected With Idiopathic and
Traumatic Causes
Cause

Homologous
Dermis

Autologous
Dermis

Total

Idiopathic (17 digits)
Traumatic (8 digits)
Total

18
12
30

15
4
19

33
16
49

Figure 8. The corrected nail (left) and uninvolved nail (dorsal) and end-on view of patient in Figure 1.

sion is made proximal to the eponychial fold and a
Bunnell needle is passed eye-first distally into the
tunnel and out through the tip incision. A 5-0 or 6-0
nylon suture is placed through the eye and graft
(approximately 5–10 ⫻ 15 mm) and the needle is
pulled proximally to bring both suture ends to the
eponychium. The graft is drawn into the tunnel,
elevating the paronychial fold, and is sutured to the
skin proximally to hold it in the tunnel (Figs. 5, 6).
Any excess graft is excised distally and the hyponychial incisions are closed with 5-0 nylon. Reinforced silicone sheeting is placed under the
eponychial fold to prevent synechiae (Fig. 7). The
autogenous dermal graft was harvested under local
anesthesia from the groin. The smallest sheet of
homologous dermis is 1 ⫻ 4 cm (0.782–1.780 inches
thick) and will correct 2 sides. Figure 8 is the postsurgical result of the patient in Figure 1. Figure 9
shows marked correction in an allograft-treated patient (Fig. 9).

Discussion
A total of 20 patients had nail reconstruction on 25
digits including 4 toes, 11 thumbs, 6 long fingers, 3
ring fingers, and 1 small finger. (Seventeen digits
were idiopathic and 8 had presumed traumatic
sources of the pincer-nail deformity) (Tables 1, 2).
Fifty-two percent of the pincer-nail deformities were
painful before surgery. All patients evaluated had

correction of the deformity and all had relief of pain
(Fig. 5). Two nail sides had minor areas of distal
nonadherence not requiring further treatment.
Comparison of autogenous dermis graft to homologous dermis graft correction did not show any noteworthy difference in nail appearance or symptomatic
relief. Surgical time for patients having bilateral correction of a single digit averaged 82 minutes with
autogenous dermis grafting (range, 70 – 100 minutes;
n ⫽ 9) and 60 minutes with homologous dermis
(range, 57–75 minutes; n ⫽ 6). The cost of 22 minutes (local anesthesia) at our institution is approximately $450.
Reconstruction using the autogenous dermis
graft method results in additional time for the graft
harvesting and carries with it a donor scar. The
surgical time difference between the 2 methods
differed by 22 minutes, which at our institution
translates into an approximate increased surgical
cost of $450. This is negated, however, by the
additional cost for the homologous product. For a
bilateral digital repair we use most frequently a 1
cm-⫻-4 – cm sheet that is associated with a hospital charge of $648 ($148 charge to the hospital).
This makes the homologous dermis technique approximately $200 more expensive to the patient.
This does not, however, take into consideration
that our study was done in a teaching university
where the donor site can be harvested and closed
simultaneously by another physician/resident,

Figure 9. (A) Presurgical pincer nail with deformity and pain. (B) Postsurgical correction with allografts (Alloderm).

Zook et al / Correction of Pincer Nail Deformities

403

Table 2. Case Listing of Nail Bed Reconstruction
Patient

Cause

Digit

Technique

Pain
(Pre/Post)

1
2
3

T
T
T
T
T
T
T
T
I
I
I
I
I
I
I
I
I
I
I
I
I
I

Th
R
R
L
Th
Toe
Toe
L
Toe
L
L
Th
Th
L
L
S
Th
Th
Th
Toe
Th
Th
Th (one
side)
Th
R

A
H
H
H
H
H
A
H
H
H
H
H
A
H
H
H
H
H
A
A
A
A

N/N
Y/N
Y/N
Y/N
N/N
Y/N
N/N
Y/N
Y/N
N/N
N/N
Y/N
Y/N
Y/N
N/N
N/N
Y/N
Y/N
Y/N
N/N
N/N
Y/N

A
A
A

N/N
N/N
N/N

4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20

I
I
I

OR Time

Correction

Follow-up Time (d)

Complications

1:35
1:07

1:15
1:40
1:20
1:20
1:19

Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y

1112
15
153
153
230
169
927
195
195
253
253
86
1131
165
279
279
363
157
221
331
14
811

N
N
N
N
N
N
N
N
N
Small nonadherence
N
N
N
N
N
N
N
N
N
N
N
Small nonadherence

1:20
1:15

Y
Y
Y

340
2084
17

N
N
N

1:00
0:44
1:10

1:25
0:57

A, autologous dermis; H, homologous dermis; I, idiopathic source; L, long finger; OR, operating room; post, postsurgery; pre, presurgery; R,
ring finger; S, small finger; T, traumatic; Th, thumb.

shortening time significantly for the autogenous
dermal method. Ultimately, however, it is our
opinion that the homologous dermis graft technique would be quicker than the autogenous dermal graft in situations where additional assistance
is not available. Additionally, the donor site morbidity, albeit slight, is eliminated if homologous
dermis is used.
The technique flattens the germinal and sterile
matrix to correct the curvature. As the nail plate
regenerates its normal contour is restored. The comparable lasting volume of homologous and autologous dermis is not well documented. In our study
they appear to last similar lengths of time. Although
both techniques work well homologous dermis has
the added advantages of decreasing surgical time and
eliminating the need for a donor site, ultimately helping to improve patient and surgeon satisfaction.

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