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POST-TRAUMATIC NAIL

UNIT RECONSTRUCTION

Christian Dumontier
Service de Chirurgie de la Main, Chirurgie Plastique, Reconstructrice et Esthétique, Nice

With the help of Dr Sylvie Carmès
5 QUESTIONS

Why restoring a nail ?

What are the structures to be repaired ?

How frequent are those injuries ?

How to repair them ?

For which results ?
1 S T Q U E S T I O N : W H Y D O PAT I E N T S
WA N T A N O R M A L N A I L ? A N D
W H AT I S A N O R M A L N A I L ?
THE NAIL UNIT

The nail is the privilege of man and superior
primates

It is part of the evolution of species and an
adaptation to a highly precise pinch

It is a distinct organ whose anatomy and
physiology are different from the fingers
NAIL UNIT FUNCTIONS

Useful to scratch or to defend ourselves

Thermal exchanges

Mechanical protection for the dorsum of the
finger

Esthetic +++

Functional +++: it increases pulp sensibility
by a counter pressure effect as it is the only
rigid structure of the fingertip
A MORE COMPLEX SYMBOLISM

In the movie «doubt», father Flynn keeps his nails long
and clean. This is a metaphor that you can do what
ever you want if you don't get caught. You have to do it
"clean". This references to the child molestation.

Later in the movie, Meryl Streep's character tells him to
cut his nails. She symbolically tells him to stop
molesting the children.
A MORE COMPLEX SYMBOLISM

To see nails in your dreams, indicates
much toil and small recompense.
To deal in nails, shows that you will
engage in honorable work, even if it be
lowly.
To see rusty or broken nails, indicates
sickness and failure in business.
Picasso kept a long little fingernail for
mixing paints, Turkish men commonly
keep such a nail for opening cigarette
wrappers. The fingernails cover the fingers just as the Mercy Seat
covered the Ark of the Covenant (arche d’alliance). 
2 N D Q U E S T I O N : W H AT A R E T H E
S T R U C T U R E S I N V O LV E D I N T H I S
PA RT I C U L A R N A I L D Y S T R O P H Y ?
WHAT IS THE ANATOMY
OF THE NAIL UNIT ?
A BONY SUPPORT
AND ITS ADJACENT LIGAMENTOUS
STRUCTURES

A proximal fibrous nucleus with the mixing of fibers
from the extensor, the flexor, the collateral ligament

Appareil extenseur

Ligament inter-osseux

latéral de Flint

Ligament hyponichial
AND ITS ADJACENT LIGAMENTOUS
STRUCTURES

A proximal fibrous nucleus with the mixing of fibers from the extensor, the
flexor, the collateral ligament

Of which arose the Flint’s ligament

And the Proximal stabilizing ligament of Guéro
AND ITS ADJACENT LIGAMENTOUS
STRUCTURES

A proximal fibrous nucleus with the mixing of fibers from the extensor, the
flexor, the collateral ligament

Of which arose the Flint’s ligament

And the Proximal stabilizing ligament of Guéro

Plus the hyponychial ligament

No hypodermic tissue
THE NAIL PLATE

The peryonychium:

All the tissues located under the nail place

The paronychium:

All the tissues located over the nail plate
THE PERYONYCHIUM

Nail matrix (germinal)

Nail bed (sterile)

Hyponychium
THE NAIL MATRIX

Starts proximal, 1,4 mm +/- 0,6 mm
from the insertion of the extensor
tendon

Extends up to the lunula (not always
visible)

Also cover the proximal part of the
nail plate
THE NAIL MATRIX

Only structure able to produce the nail plate +++

Cannot be replace by another tissue +++

It thickens the nail plate by adding new cellular
layers
THE NAIL BED

Highly specialized structure responsible:

For the adhesion of the nail plate

Longitudinal ridges mixing with the
underlying surface of the nail plate

For the nail plate shape

May sometimes be replace by another
tissue
THE HYPONYCHIUM

The distal part of the nail bed where
the nail plate looses its adherence +++

Its loss (distal amputations; pulp flaps) is
responsible for a painful nail plate adhesion

Mechanical barrier + immunologic
function (rich in polynuclear cells)
THE PARONYCHIUM

Proximal nail wall/fold

Lateral nail walls/folds
PROXIMAL NAIL FOLD

Cutaneous structure that encircles the
nail plate

The cuticle is the seal that closes the
nail fold

It is responsible for the shape of the
nail plate
LATERAL NAIL FOLDS

Encircle the nail plate

Are responsible for both
its shape and orientation
THE NAIL PLATE

Supple structure made of three layers of
keratynocytes

0,5 mm of thickness, made of 20% of water,

Double convexity (longitudinal and
transverse) ➤ esthetic and functional
harmony

Its shape depends from the integrity of the
underlying structures and paronychium
CLINICAL CONSEQUENCES

• The nail plate is so supple that it is often intact in nail
trauma

• It has to be removed to see and repair the lesions +++
THE NAIL PLATE
Is only produced by the nail
matrix ++++
Tablette
Is non-adherent in the matrix Matrice unguéale Lit unguéal

zone

Is highly adherent in the nail
bed zone

The hyponychial zone is the
place where the nail plate looses
its adherence
NAIL PLATE SHAPE
DEPENDS OF

The bony support

The nail bed

The nail folds
CLINICAL CONSEQUENCES

• You cannot have a normal nail over an abnormal bone
• Bone loss = hook-nail
• Large phalanx = racket nails
• Malunion = ungueal dystrophia
• Arthrosis = pincer nail…
PHYSIOLOGY

Normal nail growth is of 1,9 to 4,4 mm/month, a
mean of 0,3 mm/jour
Two months for the nail plate to exit from the proximal fold,
and 6 months for a complete nail regrowth

As the first nail is always irregular, clinical results
cannot be judged before one year
PHYSIOLOGY
Factors that increase nail Factors that decrease nail
growth growth

Long fingers > 20 years

After nail plate avulsion During night

Pregnancy In immobilized patients,
denutrition
Onychophagia
After an infection
In warm countries

Those factors cannot be modified by the surgeon
AFTER A TRAUMA

Nail plate growth stops for 3 weeks,
proximal part thickens

Then nail growth speeds up for 50 days
(the plate becomes thinner)

Then it slows for 30 days

Which led to the constitution of a Beau’s
line which moves with the nail
VASCULARIZATION
A. superficielle

A. distale

A. proximale

A. collatérale palmaire

The nail unit is highly vascularized and healing is
usually not a problem

The same applies for venous or lymphatic drainage
INNERVATION

Very rich

Usually nerves follow the vessels

Nail surgery is very painful +++
3 R D Q U E S T I O N : W H AT A R E T H E
T R A U M AT I C L E S I O N S O F T H E
FINGERNAILS ?
EPIDEMIOLOGY OF NAIL
TRAUMA

Epidemiological study (187 cases in 2 years)

Associated lesions

Pulp: 26,7%

Distal phalanx Fx: 15,5%

Pulp lesion + Fx: 26,2%

Another lesion on the finger/hand: 11,8%

Almost 70% of associated lesions !
EPIDEMIOLOGY OF NAIL TRAUMA

Crushing mechanism +++

50% of lesions were in the distal part of the nail unit
4 T H Q U E S T I O N : H O W T O R E PA I R I T ?
WHAT DO WE NEED ?

Small instruments

A freer elevator

Loupes

Small sutures (PDS 6/0, non-colored)

A new nail to cover your repair
THE MAIN LESIONS

Hook-nail deformity

Hyponychial loss

Nail folds injuries

Nail bed injuries

Nail matrix injuries

Absence of nail
Loss of the supportive tissues

Hook-nail deformity
Volar inclination of the nail is secondary to:
Bone loss
Pulp retraction/loss
Treatment can only be surgical
Possible surgical techniques

Many techniques have been
published ?
With very few cases and short
follow-up usually

Low level of evidence !
Proposed techniques
✓ Retrocession flap (Dufourmentel)
✓ Excision of nail bed (Kumar)
Supply with soft- ✓ Hetero-digital flap (Atasoy)
✓ Island flap (Gilbert, Tubiana)
tissue
✓ Composite graft from the toe (Buback)
✓ Microvascular transfer (Morrison)

✓ Free bone graft (Tubiana, Gilbert)
Bony support ✓ Vascularized bone (Saffar, Gargollo)
✓ Phalangeal osteotomy (Shepard)
✓ Microsurgical transfer (Morrison)
Retrocession flap : Dufourmentel 1963

Foucher’s variation
11/16 cases, 50% good results
Quality of results was correlated to
the importance of bone loss
Interesting in case of scarring pulp

Dumontier et al, 1989
Island flap

Texte
Limited results due
to undersizing of
the pulp with
secondary
retraction
28 patients, 1/3 excellent,
1/3 good, 1/3 fair
Results were correlated to
bone loss, the cutting edge
being 50% bone loss
It is important to over-
estimate the skin loss to
prevent recurrence due to
secondary flap retraction

Dumontier et al, 1995
Cross finger flap

Poor quality of the skin flap
Less logical than an island flap if bone loss is limited, or
a microvascular transfer is bone loss is important
7 cases reported in children (Strick, JHS(E) 2004) with
5 good and 2 fair results
Bony reconstruction ?

Free non-vascularized bone graft
absorbs in adults. I have no
experience in children
Phalangeal osteotomy could be
considered only if bone loss is
limited.
Microsurgical transfers

1980 MORRISON wrap-around flap

1980 FOUCHER wrap-around modified

1988 KOSHIBA free arterialized nail flap

1990 NAKAYAMA arterialized venous nail

1996 ENDO short pedicled-arterialized nail flap

1997 HIRASE modified twisted-toe flap transfer
Example
(adult)
Best treatment relies on prevention:
reconstruction in emergency of the supportive
structures of the nail plate
Surgical indications for hook-
nail deformity

Depends of :
Bone loss: < 50% (soft-tissue), > 50% consider
microsurgery if:
Pulp loss
Thumb (> finger)
Local vascularity (Age +++, smoker)
Functional needs (Musicians, ...)
HYPONYCHIAL LOSS

Very frequent

After distal pulp loss
(i.e. fingertip
amputation w/wo
reconstruction with a
flap)
HYPONYCHIAL LOSS

Patient complains of
pain when pulling on
their pulp or when
trying to cut their nails
HYPONYCHIAL LOSS

Treatment is easy:
remove the distal scar at
the end of the nail bed

And place a small skin
graft on which the nail
cannot adhere
A SIMPLE AND AEFFICIENT TECHNIQUE- NO
SERIES PUBLISHED
NAIL FOLD
INJURIES
LATERAL NAIL FOLD
RECONSTRUCTION

Loss of lateral nail fold induces nail malrotation
deformity and/or painful pinch and/or ingrowing
nail

Lateral skin flaps is the only solution

But few are available
PROXIMAL NAIL FOLD
RECONSTRUCTION

Many skin flaps designed for burn injuries

Two tricks: graft the donor site + nail bed graft on the
inferior part of the nail fold +++
Some examples
Split-thickness graft of a nail wall
for treatment of a pterygium
NAIL BED
RECONSTRUCTION
NAIL BED INJURIES

Scars or loss of nail bed will lead to
adhesion problems

Onycholysis

Splints, grooves

Nail fragility (onychoschyzy)

The nail plate will loose its adherence
and/or its shape and/or its orientation
NAIL BED FLAPS

If nail bed loss is limited (2-3 mm):

Laterally: resect the proximal matrix and shorten
nail width
NAIL BED FLAPS

If nail bed loss is limited (2-3 mm):

Centrally: Undermine the nail bed from the phalanx
and bring the two edges together. If necessary, a
contra incision can be made at the junction of the lateral
nail wall and nail bed
NAIL BED DESTRUCTION

If the nail bed can sometimes be replace by another
tissue in emergency

It can only be replace by a nail bed graft for
reconstruction

The same nail :Very limited possibilities

The great toe
DONOR SITE

The great toe

The blade must be seen during
removal (< 300 µ)

Take care of the nail convexity

25% sequelae at the donor site
TECHNIQUE

Oversized graft

Some sutures (6/0 to 8/0)

Use the nail plate/substitute
to mold the repair
1 yr

2 years
Distal onycholysis
treated with nail bed
graft
RESULTS OF NAIL BED GRAFTS

3 yrs
4 published series (< 10 cas)

60-70% good results

Failures were due to:

Unknown (secondary) infection

Associated matrix involvement
AN EXCEPTION

If only the distal part of the
nail bed is destroyed AND a
pulp reconstruction needed

A desepidermized pulp flap
can be used: a volar flap which
distal part is desepidermized
8 Months
RESULTS OF
DESEPIDERMIZED FLAPS

Dumontier, ACPE 1992; 37: 553-559

12 cases : 2 excellents, 7 good, 2 fair & 1 poor

Adhesion to 90% of the nail bed surface

Simple and easy technique which allows for pulp
coverage, protection of the phalanx and reconstruction
of the nail bed in a single procedure
NAIL MATRIX
DESTRUCTION
We need some matrix
tissues !
NAIL MATRIX DESTRUCTION

A nail matrix loss (or a scar)
cannot produce nail plate

The nail plate will present
either a ridge or will be
devided in two parts
NAIL MATRIX DESTRUCTION

If the scar also concerns the
proximal nail fold, one will observe
a pterygium

The maximum nail matrix loss
giving no sequelae is around 3 mm
TWO POSSIBILITIES

Limited, central nail matrix loss

Translational flaps (same as
described for nail bed losses)

Large matrix loss

Partial nail matrix grafts
NAIL MATRIX LOSS AND
PTERYGIUM

Double treatment:

Nail matrix reconstruction

Excision + suture if limited loss (2-3 mm)

Partial nail matrix graft

Plus nail fold reconstruction with a split thickness
nail bed graft under the fold
3 years
ABSENCE
OF NAIL

Do we need one ?
ABSENCE OF NAIL

Don’t want to make a nail

Stump amputation

Skin grafts

Nail prosthesis

Try to make a new nail ? Find another one elsewhere !
SKIN GRAFTS

Mostly used for nail tumors

In our series of ≈ 30 cases, the graft thickens with
time, does not ulcerate, pulp sensibility was normal
and cosmetic results considered good
5 years
NAIL SUBSTITUTES

Described in the 70’s, now abandoned
Creation of a pounch in which an artifical nail was placed and either
stuck (early failure) or screwed (sepsis and loosening)

The only alternative is the use of esthetic prosthesis
which always hide the pulp
MAKING A NEW NAIL

With bone loss ➾
vascularized pulp or toe
transfer

w/o bone loss ➾ non-
vascularized nail unit
graft (or toenail graft)
NON VASCULARIZED NAIL UNIT GRAFT

According to Flint, partial nail matrix
always fail

Shepard reported of 8 cases of «en bloc»
nail unit graft

Sellah (2000) reported of 14 cases without
late resorbtion and 11 good results

We have done three cases
Limitations: toenail does not have the same shape or length
PEDICLED NAIL TRANSFERS

On-top plasty technique (using a finger-bank)

Now abandoned

3 (old) series only: Butler, 1964; Krishna and Pelly,
1982; Papavassiliou, 1969
MICROSUGICAL NAIL TRANSFER

1980: Wrap-around and modified wrap-
around flap (Morrison & Foucher)

1988: Free arterialized nail flap (Koshiba)

1990: Arterialized venous nail flap
(Nakayama)

1996: Short pedicled-arterialized nail flap
(Endo)

1997: modified twisted-toe flap (Hirase)
MICROVASCULAR NAIL TRANSFER

Either a long or a short pedicle

Either nail, nail + bone or
complete toe transfer
Hook-nail
ARTERIALIZED VENOUS NAIL FLAP
SOME
ENDING
REMARKS
AFTER 24 YEARS INTERESTING IN NAILS

Most of the reported techniques have short follow-
up,

No real series published for most techniques

In my experience, fair results and failures are not rare

We can improve patient, rarely can we give them a
normal nail
SO TO AVOID NAIL
DYSTROPHIES

Prevention

Quality of the first treatment:

Respect the nail unit

Do immediate reconstruction when needed
All those patients have been treated in a Hand unit !
RESPECT THE NAIL UNIT
Initial repair

1 month results
Example of a desepidermized Atasoy’s flap to
reconstruct a distal nail bed loss: easy and sufficient
DO NOT FORGET

Prosthesis that gives a beautiful cosmetic results !
SOME REFERENCES

• Diseases of the nails and their
management, Baran, Dawber, (Blackwell,
1994)

• L’ongle, Dumontier, (Elsevier, 2000)

• Nail surgery, Krull, Zook, Baran, Haneke,
(Lippincott, 2001)
Many thanks to Pr BASSETTO and the
Italian Society for your invitation

Thanks for your
attention