Vascularized Pulp Island Nail Flap in The Treatment of Macrodactyly of Toe

Background

Macrodactyly of toe is rare congenital finger anomaly which manifests isolated digit
overgrowth affecting all tissues types. The goal of surgical reduction for macrodactyly is to
achieve functional and cosmetically appealing. A variety of surgical techniques exists to
reconstruct rather than amputate affected digits primarily. Free nail graft combined with
shortening of the toe have been used by Sabapathy et al to reconstruct the toe and preserving
nail, however, blood flow cannot be retained through the grafted nail in free nail grafting and
is likely to result in atrophy or deformation of the nail. In intention to maintain intake of
graft the author was attempt to perform vascularized pulp island nail flap.

Patient and Method

19-year old female was reffered to plastic surgery department because overgrowth of right
toe since birth. She had difficulty in finding proper footwear and frequent of nail ingrown.
Radiographic findings revealed enlargement of the phalanges proximal and distal in right first
toe only. On this case performed phalangeal osteotomy and debulking of soft tissue with help
of tourniquet control. The skin was fashioned as needed to obtain appropriate closure. To
preserve the nail, vascularized pulp island nail flap was performed. Care was taken during
dissection to preserve all connection between medial side of the blood vessel, nerve and the
nail complex.

Result

At early post operative evaluation, the vascular status of the nail flap was excellent
monitored by observation of color and capillary refill of the dorsal skin. The incision wound
edge was close firmly and has good tension. The size of right toe reduced approximately 15%
of the circumference and 30% of the length. By the end of 2nd weeks, ranges of motion and
sensation were evaluated and it was the same as before surgery.

Conclusion

The vascularized pulp island nail flap has advantages on increasing the safety of nail grafting
also preserve functional and cosmetically appealing. However, the excellent results obtained
in the present case are partially attributable to the relatively low severity of the abnormality.