You are on page 1of 113

POST-TRAUMATIC NAIL

UNIT RECONSTRUCTION

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

With the help of Dr Sylvie Carmès


r

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


primate

It is part of the evolution of species and an


adaptation to a highly precise pinc

It is a distinct organ whose anatomy and


physiology are different from the ngers
s

fi
h

NAIL UNIT FUNCTIONS

Useful to scratch or to defend ourselve

Thermal exchange

Mechanical protection for the dorsum of the


nge

Esthetic +++

Functional +++: it increases pulp sensibility


by a counter pressure effect as it is the only
rigid structure of the ngertip
fi
r

fi
s

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 ngernail for
mixing paints, Turkish men commonly
keep such a nail for opening cigarette
wrappers. The ngernails cover the ngers just as the Mercy Seat
covered the Ark of the Covenant (arche d’alliance). 
fi
.

fi
fi
.

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 brous nucleus with the mixing of bers


from the extensor, the exor, the collateral ligament

Appareil extenseur

Ligament inter-osseux

latéral de Flint

Ligament hyponichial
fi
fl
fi
AND ITS ADJACENT LIGAMENTOUS
STRUCTURES

A proximal brous nucleus with the mixing of bers from the extensor, the
exor, the collateral ligamen

Of which arose the Flint’s ligamen

And the Proximal stabilizing ligament of Guéro


fl
fi
t

fi
t

AND ITS ADJACENT LIGAMENTOUS


STRUCTURES

A proximal brous nucleus with the mixing of bers from the extensor, the
exor, the collateral ligamen

Of which arose the Flint’s ligamen

And the Proximal stabilizing ligament of Guér

Plus the hyponychial ligamen

No hypodermic tissue
fl
fi
t

fi
THE NAIL PLATE

The peryonychium

All the tissues located under the nail plac

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
tendo

Extends up to the lunula (not always


visible

Also cover the proximal part of the


nail plate
n

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 plat

Longitudinal ridges mixing with the


underlying surface of the nail plat

For the nail plate shap

May sometimes be replace by another


tissue
e

THE HYPONYCHIUM

The distal part of the nail bed where


the nail plate looses its adherence ++

Its loss (distal amputations; pulp aps) is


responsible for a painful nail plate adhesio

Mechanical barrier + immunologic


function (rich in polynuclear cells)
fl
n

THE PARONYCHIUM

Proximal nail wall/fol

Lateral nail walls/folds


d

PROXIMAL NAIL FOLD

Cutaneous structure that encircles the


nail plat

The cuticle is the seal that closes the


nail fol

It is responsible for the shape of the


nail plate
d

LATERAL NAIL FOLDS

Encircle the nail plat

Are responsible for both


its shape and orientation
e

THE NAIL PLATE

Supple structure made of three layers of


keratynocyte

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

Double convexity (longitudinal and


transverse) ➤ esthetic and functional
harmon

Its shape depends from the integrity of the


underlying structures and paronychium
y

CLINICAL CONSEQUENCES

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


traum

• It has to be removed to see and repair the lesions +++


a

THE NAIL PLATE


Is only produced by the nail
matrix +++
Tablette
Is non-adherent in the matrix Matrice unguéale Lit unguéal

zon

Is highly adherent in the nail


bed zon

The hyponychial zone is the


place where the nail plate looses
its adherence
e

NAIL PLATE SHAPE


DEPENDS OF

The bony suppor

The nail be

The nail folds


d

CLINICAL CONSEQUENCES

• You cannot have a normal nail over an abnormal bone


• Bone loss = hook-nai
• Large phalanx = racket nail
• Malunion = ungueal dystrophi
• Arthrosis = pincer nail…
l

PHYSIOLOGY

Normal nail growth is of 1,9 to 4,4 mm/month, a


mean of 0,3 mm/jou
Two months for the nail plate to exit from the proximal fold,
and 6 months for a complete nail regrowt

As the rst nail is always irregular, clinical results


cannot be judged before one year
fi
r

PHYSIOLOGY
Factors that increase nail Factors that decrease nail
growth growth

Long nger > 20 year

After nail plate avulsio During nigh

Pregnanc In immobilized patients,


denutritio
Onychophagi
After an infection
In warm countrie

Those factors cannot be modi ed by the surgeon


fi
s

fi
AFTER A TRAUMA

Nail plate growth stops for 3 weeks,


proximal part thicken

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
s

VASCULARIZATION
A. super cielle

A. distale

A. proximale

A. collatérale palmaire

The nail unit is highly vascularized and healing is


usually not a proble

The same applies for venous or lymphatic drainage


fi
m

INNERVATION

Very ric

Usually nerves follow the vessel

Nail surgery is very painful +++


h

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 lesion

Pulp: 26,7%

Distal phalanx Fx: 15,5

Pulp lesion + Fx: 26,2

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

Almost 70% of associated lesions !


fi
%

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 instrument

A freer elevato

Loupe

Small sutures (PDS 6/0, non-colored

A new nail to cover your repair


s

THE MAIN LESIONS

Hook-nail deformit

Hyponychial los

Nail folds injurie

Nail bed injurie

Nail matrix injurie

Absence of nail
s

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 ap (Dufourmentel)
✓ Excision of nail bed (Kumar)
Supply with soft-
✓ Hetero-digital ap (Atasoy)
✓ Island ap (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)

fl
fl
fl

Retrocession ap : Dufourmentel 1963

Foucher’s variation
fl
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 ap

Texte
fl
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 ap retraction

Dumontier et al, 1995


fl

Cross nger ap

Poor quality of the skin ap


Less logical than an island ap 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
fi
fl
fl
fl

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 ap

1980 FOUCHER wrap-around modi ed

1988 KOSHIBA free arterialized nail ap

1990 NAKAYAMA arterialized venous nail

1996 ENDO short pedicled-arterialized nail ap

1997 HIRASE modi ed twisted-toe ap transfer


fi
fl
fl

fi
fl

fl

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 (> nger)
Local vascularity (Age +++, smoker)
Functional needs (Musicians, ...)

fi

HYPONYCHIAL LOSS

Very frequen

After distal pulp loss


(i.e. ngertip
amputation w/wo
reconstruction with a
ap)
fl
fi
t

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 be

And place a small skin


graft on which the nail
cannot adhere
d

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
nai

Lateral skin aps is the only solutio

But few are available


l

fl
n

PROXIMAL NAIL FOLD


RECONSTRUCTION

Many skin aps designed for burn injurie

Two tricks: graft the donor site + nail bed graft on the
inferior part of the nail fold +++
fl
s

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 problem

Onycholysi

Splints, groove

Nail fragility (onychoschyzy

The nail plate will loose its adherence


and/or its shape and/or its orientation
s

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 emergenc

It can only be replace by a nail bed graft for


reconstructio

The same nail :Very limited possibilitie

The great toe


n

DONOR SITE

The great to

The blade must be seen during


removal (< 300 µ

Take care of the nail convexit

25% sequelae at the donor site


e

TECHNIQUE

Oversized graf

Some sutures (6/0 to 8/0

Use the nail plate/substitute


to mold the repair
t

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 result

Failures were due to

Unknown (secondary) infectio

Associated matrix involvement


s

AN EXCEPTION

If only the distal part of the


nail bed is destroyed AND a
pulp reconstruction neede

A desepidermized pulp ap
can be used: a volar ap which
distal part is desepidermized
fl
fl
d

8 Months
RESULTS OF
DESEPIDERMIZED FLAPS

Dumontier, ACPE 1992; 37: 553-55

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

Adhesion to 90% of the nail bed surfac

Simple and easy technique which allows for pulp


coverage, protection of the phalanx and reconstruction
of the nail bed in a single procedure
9

NAIL MATRIX
DESTRUCTION
We need some matrix
tissues !
NAIL MATRIX DESTRUCTION

A nail matrix loss (or a scar)


cannot produce nail plat

The nail plate will present


either a ridge or will be
devided in two parts
e

NAIL MATRIX DESTRUCTION

If the scar also concerns the


proximal nail fold, one will observe
a pterygiu

The maximum nail matrix loss


giving no sequelae is around 3 mm
m

TWO POSSIBILITIES

Limited, central nail matrix los

Translational aps (same as


described for nail bed losses

Large matrix los

Partial nail matrix grafts


fl
s

NAIL MATRIX LOSS AND


PTERYGIUM

Double treatment

Nail matrix reconstructio

Excision + suture if limited loss (2-3 mm

Partial nail matrix graf

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 nai

Stump amputatio

Skin graft

Nail prosthesi

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


s

SKIN GRAFTS

Mostly used for nail tumor

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
s

NAIL SUBSTITUTES

Described in the 70’s, now abandone


Creation of a pounch in which an arti cal 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
fi
d

MAKING A NEW NAIL

With bone loss ➾


vascularized pulp or toe
transfe

w/o bone loss ➾ non-


vascularized nail unit
graft (or toenail graft)
r

NON VASCULARIZED NAIL UNIT GRAFT

According to Flint, partial nail matrix


always fai

Shepard reported of 8 cases of «en bloc»


nail unit graf

Sellah (2000) reported of 14 cases without


late resorbtion and 11 good result

We have done three cases


l

Limitations: toenail does not have the same shape or length


PEDICLED NAIL TRANSFERS

On-top plasty technique (using a nger-bank

Now abandone

3 (old) series only: Butler, 1964; Krishna and Pelly,


1982; Papavassiliou, 1969
d

fi
)

MICROSUGICAL NAIL TRANSFER

1980: Wrap-around and modi ed wrap-


around ap (Morrison & Foucher

1988: Free arterialized nail ap (Koshiba

1990: Arterialized venous nail ap


(Nakayama

1996: Short pedicled-arterialized nail ap


(Endo

1997: modi ed twisted-toe ap (Hirase)


)

fl
fi
)

fl
fl
fi
fl
)

fl
)

MICROVASCULAR NAIL TRANSFER

Either a long or a short pedicl

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 technique

In my experience, fair results and failures are not rar

We can improve patient, rarely can we give them a


normal nail

SO TO AVOID NAIL
DYSTROPHIES

Preventio

Quality of the rst treatment:

Respect the nail uni

Do immediate reconstruction when needed


n

fi
t

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 ap to
reconstruct a distal nail bed loss: easy and suf cient
fl
fi
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

You might also like