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UNIT RECONSTRUCTION
Christian Dumontie
Service de Chirurgie de la Main, Chirurgie Plastique, Reconstructrice et Esthétique, Nice
5 QUESTIONS
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
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Thermal exchange
Esthetic +++
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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
Appareil extenseur
Ligament inter-osseux
latéral de Flint
Ligament hyponichial
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AND ITS ADJACENT LIGAMENTOUS
STRUCTURES
A proximal brous nucleus with the mixing of bers from the extensor, the
exor, the collateral ligamen
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A proximal brous nucleus with the mixing of bers from the extensor, the
exor, the collateral ligamen
No hypodermic tissue
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THE NAIL PLATE
The peryonychium
The paronychium
THE PERYONYCHIUM
Hyponychium
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THE HYPONYCHIUM
THE PARONYCHIUM
CLINICAL CONSEQUENCES
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The nail be
CLINICAL CONSEQUENCES
PHYSIOLOGY
PHYSIOLOGY
Factors that increase nail Factors that decrease nail
growth growth
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AFTER A TRAUMA
VASCULARIZATION
A. super cielle
A. distale
A. proximale
A. collatérale palmaire
INNERVATION
Very ric
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
Associated lesion
Pulp: 26,7%
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Crushing mechanism ++
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
Hook-nail deformit
Hyponychial los
Absence of nail
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Hook-nail deformity
Volar inclination of the nail is secondary to:
Bone loss
Pulp retraction/loss
Treatment can only be surgical
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)
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Foucher’s variation
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11/16 cases, 50% good results
Quality of results was correlated to
the importance of bone loss
Interesting in case of scarring pulp
Island ap
Texte
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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
Cross nger ap
Bony reconstruction ?
Microsurgical transfers
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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, ...)
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HYPONYCHIAL LOSS
Very frequen
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
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Two tricks: graft the donor site + nail bed graft on the
inferior part of the nail fold +++
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Some examples
Split-thickness graft of a nail wall
for treatment of a pterygium
NAIL BED
RECONSTRUCTION
NAIL BED INJURIES
Onycholysi
Splints, groove
DONOR SITE
The great to
TECHNIQUE
Oversized graf
1 yr
2 years
Distal onycholysis
treated with nail bed
graft
RESULTS OF NAIL BED GRAFTS
3 yrs
4 published series (< 10 cas
AN EXCEPTION
A desepidermized pulp ap
can be used: a volar ap which
distal part is desepidermized
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8 Months
RESULTS OF
DESEPIDERMIZED FLAPS
NAIL MATRIX
DESTRUCTION
We need some matrix
tissues !
NAIL MATRIX DESTRUCTION
TWO POSSIBILITIES
Double treatment
3 years
ABSENCE
OF NAIL
Do we need one ?
ABSENCE OF NAIL
Stump amputatio
Skin graft
Nail prosthesi
SKIN GRAFTS
NAIL SUBSTITUTES
Now abandone
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Hook-nail
ARTERIALIZED VENOUS NAIL FLAP
SOME
ENDING
REMARKS
AFTER 24 YEARS INTERESTING IN NAILS
SO TO AVOID NAIL
DYSTROPHIES
Preventio
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1 month results
Example of a desepidermized Atasoy’s ap to
reconstruct a distal nail bed loss: easy and suf cient
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DO NOT FORGET