Nail Surgery

Contents: Surgical anatomy of the nail apparatus * Instrumentation * General considerations * Anesthesia of the nail apparatus * Surgery of the nail plate * Surgery of the proximal nail fold * Surgery of the nail bed * Surgery of the lateral nail folds * Surgery of the distal fold * Surgery of the matrix * Surgery of the whole nail unit * Surgery of the bony phalanx * Surgery of the distal interphalangeal joint * Acute trauma of the nail unit * Cosmetic nail surgery for congenital nail abnormalities With over 500 color and black-and-white illustrations

Bertrand Richert, MD, PhD Clinical Professor, University of Liège and Consultant Dermatologist, Université Libre de Bruxelles, Belgium Second Vice President of the Council for Nail Disorders Former Secretary of the European Nail Society Author of L’ongle : de la clinique au traitement (2002; second edition, 2008), 50 cas de pathologie unguéale (2005), and a DVD on Basic Nail Surgery (2007)

Nilton Di Chiacchio, MD Head of Dermatology Clinic, Hospital do Servidor Público Municipal de São Paulo, Brazil Former Vice President of the Brazilian Society of Dermatologic Surgery His previous publications include Doenças das Unhas (2007)

Eckart Haneke, MD, PhD Department of Dermatology, University of Berne, Switzerland Dermatology Practice Dermaticum, Freiburg, Germany Centro de Dermatología Epidermis, Porto, Portugal and Department of Dermatology, Academic Hospital, University of Ghent, Belgium Former President, European Society for Dermatological Surgery Former President, International Society for Dermatologic Surgery Former President, European Society for Cosmetic and Aesthetic Dermatology His previous publications include Nail Surgery (2000), Diseases of the Nails and their Management (2001), Text Atlas of Nail Disorders (third edition, 2003), Onychomycosis (second edition, 2006), and The Nail in Differential Diagnosis (2007) Published in association with the Journal of Dermatological Treatment

Telephone House, 69-77 Paul Street, London EC2A 4LQ, UK 52 Vanderbilt Avenue, New York, NY 10017, USA

www.informahealthcare.com

Cover design by Florence Richert ([email protected])

Richert • Di Chiacchio • Haneke

This text is a master-class for those wishing to perform nail surgery – a comprehensive practical guide to all types of nail surgery, including some cosmetic procedures, with clear descriptions of each stage involved and of any complications and how to deal with them.

Bertrand Richert Nilton DI Chiacchio Eckart Haneke

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Nail Surgery

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Nail Surgery

Edited by Bertrand Richert, MD, PhD Clinical Professor University of Liège and Consultant Dermatologist Université Libre de Bruxelles, Belgium Nilton Di Chiacchio, MD Head of Dermatology Clinic Hospital do Servidor Público Municipal de São Paulo Brazil Eckart Haneke, MD, PhD Department of Dermatology University of Berne, Switzerland Dermatology Practice Dermaticum, Freiburg, Germany Centro de Dermatología Epidermis, Porto, Portugal, and Department of Dermatology, Academic Hospital, University of Ghent, Belgium

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This edition published in 2010 by Informa Healthcare, Telephone House, 69-77 Paul Street, London EC2A 4LQ, UK. Simultaneously published in the USA by Informa Healthcare, 52 Vanderbilt Avenue, 7th Floor, New York, NY 10017, USA. Informa Healthcare is a trading division of Informa UK Ltd. Registered Office: 37–41 Mortimer Street, London W1T 3JH, UK. Registered in England and Wales number 1072954. # 2011 Informa Healthcare, except as otherwise indicated No claim to original U.S. Government works Reprinted material is quoted with permission. Although every effort has been made to ensure that all owners of copyright material have been acknowledged in this publication, we would be glad to acknowledge in subsequent reprints or editions any omissions brought to our attention. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, unless with the prior written permission of the publisher or in accordance with the provisions of the Copyright, Designs and Patents Act 1988 or under the terms of any licence permitting limited copying issued by the Copyright Licensing Agency, 90 Tottenham Court Road, London W1P 0LP, UK, or the Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, USA (http://www.copyright.com/ or telephone 978-750-8400). Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. This book contains information from reputable sources and although reasonable efforts have been made to publish accurate information, the publisher makes no warranties (either express or implied) as to the accuracy or fitness for a particular purpose of the information or advice contained herein. The publisher wishes to make it clear that any views or opinions expressed in this book by individual authors or contributors are their personal views and opinions and do not necessarily reflect the views/opinions of the publisher. Any information or guidance contained in this book is intended for use solely by medical professionals strictly as a supplement to the medical professional’s own judgement, knowledge of the patient’s medical history, relevant manufacturer’s instructions and the appropriate best practice guidelines. Because of the rapid advances in medical science, any information or advice on dosages, procedures, or diagnoses should be independently verified. This book does not indicate whether a particular treatment is appropriate or suitable for a particular individual. Ultimately it is the sole responsibility of the medical professional to make his or her own professional judgements, so as appropriately to advise and treat patients. Save for death or personal injury caused by the publisher’s negligence and to the fullest extent otherwise permitted by law, neither the publisher nor any person engaged or employed by the publisher shall be responsible or liable for any loss, injury or damage caused to any person or property arising in any way from the use of this book. A CIP record for this book is available from the British Library. ISBN-13: 9780415472333 Orders may be sent to: Informa Healthcare, Sheepen Place, Colchester, Essex CO3 3LP, UK Telephone: +44 (0)20 7017 5540 Email: [email protected] Website: http://informahealthcarebooks.com/ For corporate sales please contact: [email protected] For foreign rights please contact: [email protected] For reprint permissions please contact: [email protected] Typeset by MPS Limited, a Macmillan Company Printed and bound in India

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This is to pay fond homage to Dr. Robert Baran, who assumed the role of father and mentor for me and to whom dermatology owes a complete new discipline: onychology. Also, in recognition to my mother for her constant and unconditional support and love all over the years. To thank Josette, for her fruitful and constant collaboration and her profound friendship. To Dionyssios, for his patience and understanding. Bertrand Richert.

This book is dedicated to my lovely wife and best friend Rosely, to my daughter Ana Carolina, and to my son Nilton, whose love, patience, and understanding have been my strength and source of inspiration. You have all been the stimulus of my work. This could not have been achieved without your encouragement and support throughout these endless months. Nilton Di Chiacchio.

I dedicate this work to my beloved wife Elisabeth, who continuously helped and supported me, and to the memory of my father, my first teacher in dermatology. Eckart Haneke.

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Preface

For more than 20 years, the three of us have experienced daily nail surgery. We thought that designing a tutorial book with a step-by-step approach would be of great value both for beginners and skilled dermatologic surgeons repelled by nail procedures. We composed this book not according to the pathology but to the site of the surgical procedure. Thus, the reader will encounter surgery of the nail bed, of the matrix, of the proximal nail fold, etc. The first chapters, crucial before any further reading, are devoted to the anatomy of the nail apparatus, the anesthetic procedures, and specific instrumentation. One whole chapter covers all the prerequisites before embarking on surgery such as the preoperative consultation, the surgical field prep, the dressings, management of postoperative pain, etc. Each chapter is organized in the same way, following the same framework: a short overview of the area involved, the specific instrumentation, the most adequate type of anesthesia, the procedure itself—step by step— with corresponding illustrations (both high-resolution macrophotographs and schematic drawings), and then the handling of postoperative pain, postoperative care, potential complications, and their management. Each procedure is rated in three grades according to the difficulty of the surgical procedure. The same rating is applied to postoperative pain. This textbook is directed to demystify and dispel the fears and inhibitions of the physician and the skin surgeon facing surgical procedures of the nail apparatus. Sa˜o Paulo, June 2009, and Athens, June 2010

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Contents

(Surgical procedures in italics) Preface

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1. Surgical anatomy of the nail apparatus Eckart Haneke Basic anatomy 1 Advanced anatomy 4 Microscopic anatomy 7 2. Instrumentation 11 Bertrand Richert Basic equipment 11 Advanced equipment

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3. General considerations 16 Bertrand Richert Preoperative assessment and preparation of the patient Discontinuation of systemic treatments 17 Disinfection of the surgical field 18 Dressings 18 Postoperative pain management 19 Dressing removal and replacement 21 Postoperative long-term paresthesia 21 4. Anesthesia of the nail apparatus 24 Bertrand Richert Anesthetic products 24 Material 25 Procedures 25 Proximal digital block 25 Distal digital block (wing block) 26 Matricial block 27 Transthecal digital block 27 Hyponychial block 28 Tips 28 Reducing pain from the needle prick 28 Reducing pain from infusion of the anesthetic Complications and management 29 5. Surgery of the nail plate 31 Bertrand Richert Nail plate biopsy 31 Nail plate avulsion 31 Total nail avulsion: Distal approach

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Total nail avulsion: Proximal approach 34 Total nail avulsion with plate replacement 36 Trap door avulsion 36 Curled nail avulsion 37 Partial nail avulsion 38 Partial nail avulsion with plate replacement 39 Proximal 39 Longitudinal 40 6. Surgery of the proximal nail fold 42 Eckart Haneke, Bertrand Richert, and Nilton Di Chiacchio Acute paronychia 42 Chronic paronychia 43 Crescent excision 46 Eponychial flap 47 Acquired fibrokeratoma 49 Tumor of the PNF 50 7. Surgery of the nail bed 55 Bertrand Richert, Eckart Haneke, and Nilton Di Chiacchio Nail bed biopsy 55 Tumors of the nail bed 59 Longitudinal erythronychia 59 Pyogenic granuloma 62 Keratoacanthoma 64 Fibroma/Fibrokeratoma 66 Superficial acral fibromyxoma 69 Glomus tumor 70 Bowen’s disease 72 Heloma—Onychoclavus 74 Pachyonychia congenita 75 Extension of the nail bed for large defects 76 Secondary intention healing for large defects 78 Nail bed grafting 80 8. Surgery of the lateral nail folds 85 Bertrand Richert Hypertrophic lip 85 Ingrowing nail with hypertrophic lateral walls 87 Vandenbos’ procedure 87 Super U 88 Noe¨l’s procedure 88 Howard-Dubois’ procedure 89 Horn of the lateral sulcus 90 Fibrokeratoma 91 Bowen’s disease, epidermoid carcinoma, and squamous cell carcinoma Implantation cyst 95 9. Surgery of the distal fold 97 Bertrand Richert Distal embedding 97 Howard-Dubois’ procedure 98 Shaving procedure 99 Tumors of the distal fold 100

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CONTENTS

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10. Surgery of the matrix 103 Nilton Di Chiacchio, Bertrand Richert, and Eckart Haneke Partial matricectomy 103 Narrowing the matrix 103 With surgery 103 With chemocautery 106 With laser 108 With radiosurgery 109 Removal of a spicule 110 Shortening the matrix 112 Total matricectomy 112 Matrix transplantation 115 Tumors of the matrix 118 Onychomatricoma 118 Intraungual fibrokeratoma 120 Submatricial glomus tumor 121 Submatricial myxoid pseudocyst 122 Excision of longitudinal melanonychia 124 With punch excision 124 With elliptical excision 126 With crescent excision 128 With tangential excision 129 11. Surgery of the whole nail unit 133 Eckart Haneke, Bertrand Richert, and Nilton Di Chiacchio Lateral longitudinal biopsy 133 Ungueodermal flap for congenital malalignment of the great toenail Removal of the whole nail unit 137 Closure with secondary intention healing 139 Closure with a graft 140 Closure by reversed dermal flap 143 Cross-finger flap 144 12. Surgery of the bony phalanx 149 Eckart Haneke, Nilton Di Chiacchio, and Bertrand Richert Exostosis and osteochondroma 149 Chondroma 152 Enchondroma 153 Inclusion cyst 155 Osteoid osteoma 155 Pincer nail 157 Selective matrix horn resection 159 Matrix horn resection plus nail bed plasty 159 13. Surgery of the distal interphalangeal joint Bertrand Richert Myxoid pseudocyst (ganglion cyst) 165

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14. Acute trauma of the nail unit 171 Eckart Haneke and Bertrand Richert Subungual hematoma 171 Other lacerating and crush lesions of the nail apparatus

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15. Cosmetic nail surgery for congenital nail abnormalities Bertrand Richert Congenital malalignment of the great toenail 177 Trapezoidal nails 177 Racquet nails 178 Vertical implantation of the fifth toenail 180 Duplication of the fifth toenail 181

Index

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177

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Surgical anatomy of the nail apparatus Eckart Haneke

BASIC ANATOMY The nail apparatus is an integral part of one of the most important organs, the tip of the digit. It forms a functional unit with the digital pulp, which is extremely richly innervated and serves as the most important tactile tool, with the bone of the terminal phalanx, which gives support to the pulp and carries the nail, with the distal interphalangeal joint with its tendons and ligaments, and with all the nerves, especially sensory nerves and receptors, and blood vessels supplying the distal phalanx. In fact, almost all ectodermal and mesodermal tissues can be found in the nail apparatus: skin, connective tissue, bone, joint, synovial membrane, ligaments, tendons, tendon sheaths, arteries, veins, lymphatic vessels, glomus bodies, nerves, specialized nervous end organs, fat, etc. They are interrelated in a unique fashion (1). In-depth knowledge of the anatomy of the nail apparatus and distal phalanx is a prerequisite for sound nail surgery. The nail apparatus consists of three different epithelial structures (1–4): l l

l

Matrix with nail plate being its product Nail bed that firmly attaches the plate to the underlying connective tissue and bone Paronychium that acts as a frame for the nail plate.

In addition, distal joint and the bone are part of the nail organ. Matrix The nail matrix is the germinative part of the nail organ. It is solely responsible for the production of the nail plate, which is commonly called “the nail.” The matrix is situated on the proximal dorsal aspect of the distal phalanx and just distal to the interphalangeal joint. It is mostly covered by the proximal nail fold (PNF). Seen from dorsal, it is a band with parallel margins that are convex distally; thus, its lateral corners are more proximal than the center. This is of utmost importance when performing a lateral longitudinal nail biopsy or a wedge excision for an ingrown nail. Only its most distal portion, the

lunula, is visible as a whitish half-moon shaped structure situated between the free margin of the PNF and the pink nail bed (Fig. 1A–C). In normal fingernails, the lunula is visible only in the thumb and middle finger. Pushing the cuticle and PNF back makes it visible in the other fingers too and causes an apparently longer nail. The dermis of the matrix is a relatively loose connective tissue layer of up to 1 mm in thickness and overlies the very distal fibers of the extensor tendon insertion (Fig. 1B). There is very little subdermal fat in the matrix. In the matrix epithelium, melanocytes are present (5,6), which are normally inactive in fairskinned individuals, but may be activated by certain events such as repeated friction, photochemotherapy with ultraviolet A (PUVA) treatment, and cytotoxic agents. The density of the melanocytes per mm2 is the same in both the proximal and distal matrix. In the proximal matrix, the melanocytes are mostly dormant. In the distal matrix, two compartments are identified: a dormant and a functionally differentiated compartment. This is the reason why longitudinal melanonychia much more frequently originates in the distal matrix (7,8). Nail Bed The nail bed, also called sterile matrix by some hand surgeons as it does not produce nail substance, is the distal continuation of the matrix. It is seen as the pink area that spreads from the distal lunula border till the hyponychium. It very firmly adheres to the nail plate. Its pink color is thought to derive from the unique structure of the dermoepithelial interface, which is made up of parallel epithelial rete ridges and papillary body ridges. The latter contain three to five capillaries one above the other that run longitudinally virtually all along the length of the nail bed (Fig. 2A and B). The parallel arrangement of the rete ridges is clearly seen when the nail plate is cautiously removed from the bed. The longitudinal arrangement of the capillaries is the reason for the so-called splinter hemorrhages, small narrow brownish streaks under the nail because of thrombosis of some distance of a capillary (Fig. 2B). The distal border of

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Figure 2 (A) Transverse section through the nail bed showing that nail bed capillaries are arranged one above the other. (B) Dorsal view on the nail bed demonstrating the longitudinal arrangement of the capillaries and the mechanism of splinter hemorrhage development.

rization (10). The nail bed of fair-skinned persons contains very few melanocytes (11). The nail bed is richly innervated and contains a number of glomus bodies, specialized arteriovenous shunt organs implicated in acral temperature regulation. Hyponychium The hyponychium is the transition of the nail bed to the distal groove. Its function is to seal the nail bed from the free skin and environment, but also to allow the nail plate to separate from the nail bed. It forms a granular layer in contrast to nail bed and matrix epithelium. The hyponychial attachment is seen through the nail as the onychodermal band (9,10) (Fig. 3). Figure 1 (A) Schematic illustration of the nail. (B) Dorsooblique view of the nail apparatus. Abbreviations: DP, distal phalanx; HO, hyponychium; L, Iunula; M, matrix; NB, nail bed; PNF, proximal nail fold. (C) Sagittal section of the nail apparatus. 1. Distal groove, 2. hyponychium, 3. nail bed, 4. distal border of the lunula, 5. cuticle, 6. proximal matrix, 7. distal matrix, 8. free edge, 9. lateral nail fold, 10. proximal nail fold.

the nail bed is the onychodermal band, which is seen as a 1- to 1.5-mm transverse band (9). This is of a dark pink in light-skinned and brown in darkly pigmented individuals, but its color may vary with different diseases and compression that influence the vascula-

Proximal and Lateral Nail Folds The nail folds that ensheath the nail unit on three sides are proximal and lateral (Fig. 4). The lateral nail folds (LNFs) merge with the proximal (posterior or dorsal) fold (PNF). The latter covers and protects most of the matrix and the newly formed nail plate. The pocket formed by the PNF is called the proximal nail groove. Its most proximal part is named the culde-sac. The dorsal aspect of the PNF is covered with skin that has a thin dermis, almost no fat and lacks hair follicles and sebaceous glands, but has some

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Figure 5 Comparison of the shape of a finger- and toenail. Abbreviations: L, lunula; M, matrix. Figure 3 Schematic illustration of the hyponychium. Abbreviations: ODB, onychodermal band; FM, free nail plate margin; DG, distal groove.

Figure 4 Proximal and lateral nail folds ensheathing the nail plate on three sides.

sweat glands in its most proximal portion. The ventral surface of the PNF has a thin flattened epidermis without any skin appendages. The free margin of the PNF forms an acute angle, which is the prerequisite for the formation of the cuticle. The LNFs are rolls flattening distally to merge with the hyponychium. They are often very pronounced in the lesser toes and sometimes the big toes rendering these subjects prone to develop ingrowing nails. The lateral grooves are flat indentations framing the lateral nail margins and providing an abutment for the nail, for which they have a specialized connective tissue arrangement. Nail Plate The nail plate, commonly called “the nail,” is a platelike keratinous structure, which is exclusively formed by the matrix. It has a transverse curvature that varies inter- and intraindividually. It is relatively

flat in the middle finger and thumb, as well as in many persons also in the lesser toes 2 to 4. However, particularly in the toes there is a great variability, and it is a common experience that those individuals having a more pronounced transverse curvature of their toenails tend to have more problems, particularly with ingrowing nails. The nails also have a slight convex longitudinal curvature, which is more pronounced in clubbed nails. When the nail bed is longer than the terminal phalangeal bone, it tends to grow a bit over the tip of the toe, thus causing a much more pronounced longitudinal curvature, a socalled hook nail. This is also the case in pterygium unguis inversum. Koilonychia, or spoon nails, are defined by a concave longitudinal curvature. It is physiological in the big toenails of newborns. The longitudinal curvature is probably due to the fact that the proximal matrix proliferates slightly faster than the distal one, which causes the dorsal layer of the nail plate to virtually overgrow the deep one. There is a considerable variation in the shape and size of the finger- and toenails (Fig. 5). The great toe has the biggest nail, then the thumb, middle, index, ring, and little finger. The lesser toes have smaller nails with the little toe often only forming a tiny one. The toenails are rather wider than long. The thumbnail is almost as wide as long, whereas the other fingernails are clearly longer than wide. Pushing the cuticle and free margin of the PNF back makes the fingernails appear longer. Blood and Lymph Vessels The distal phalanx of the digit is mainly nourished by the paired volar digital arteries, which divide into the proper artery and thinner obliquely dorsally running branch proximal of the distal interphalangeal joint. The latter meets the superficial arcade that mainly derives from the proper artery. Two more subungual arcades derive from the cruciate artery

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Figure 6 Vascularization of the nail apparatus. Note that the three rich arcades arise from the digital artery. Figure 7

Hand innervation.

Figure 8

Innervation of the digital distal phalanxes.

that originates from the merging of the lateral and medial proper arteries (Fig. 6). The draining venous system is much less abundant. There are many arteriovenous anastomoses in the distal digit, from simple shunts to the complex glomus bodies. Relatively little is known about the lymphatic drainage of the distal phalanx. Nerves In the hand, the median nerve supplies the volar surface of the thumb, index, and middle fingers as well as the radial half of the ring finger, the ulnar nerve, the ulnar half of the ring finger, and the entire little finger, whereas the radial nerve supplies only the proximal half of the dorsal aspect of the digits I through III and the radial half of the dorsal aspect of the proximal half of the ring finger. Thus, a block of the median nerve anesthetizes the first 3½ fingernails, and an ulnar block, the rest of the fingernails (Fig. 7). Paired volar and dorsal nerves run at the sides of the flexor tendon and with the dorsal neurovascular bundle. There is no unanimity as to which digits have which type of innervation of their tips; it is generally assumed that the index, middle, and ring fingertips get their innervation from the palmar digital nerves whereas the thumb, little finger, as well as the toe tips are innervated by the dorsal nerves (Fig. 8). However, systemic research is still lacking. This is, however, important for the understanding of the transthecal block anesthesia. ADVANCED ANATOMY As mentioned earlier, the nail is part of one of the most versatile tools and sensory organs of the human being. Even though looking like a simple plate of

horn surrounded on three sides by the nail folds and having a free distal margin, it is a sophisticated organ that supports the sensory functions of the fingertip, protects it, and is an invaluable adjunct for dexterity. Certain surgeries require an in-depth knowledge of all the details of the nail’s anatomy (1,12). The intimate relationship of the nail, fingertip, and joint with all its ligaments, tendons, and capsule has only recently been studied in more detail (13,14). The skeletal component (Fig. 9) of the distal phalanx is made up of the terminal phalangeal bone and the distal interphalangeal joint. The phalanx has a widened proximal base, a tapered shaft, and a head, which in the distal phalanx is mainly the horseshoe-shaped processus unguicularis. Whereas the latter has a rough surface for anchoring the connective tissue of the distal nail bed, the dorsal

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Figure 9

X ray of a normal distal bony phalanx.

surface of the bone is smooth and gently concave from proximal to distal. At the distal end, there is the corona unguicularis or the spines of the ungual process. At the sides of the base of the terminal phalanx, there are tuberosities that are the proximal insertion points of the lateral interosseous ligaments, the distal insertions of which are the most proximallateral extensions of the corona unguicularis. These interosseous ligaments protect the neurovascular supply for the nail bed (Fig. 10). In principle, the distal phalanx of fingers and toes are similar, but the toe phalanges are shorter and have a wider base and head. The shape and size of the bone

Figure 10 Ligamentary structure of the nail apparatus and tendons. Schematic illustration of the extensor and flexor tendons. (A) Dorsal view. (B) Lateral view. Abbreviations: bdp, base of the distal phalanx; cu, corona unguicularis; dleet, dorsolateral expansion of the extensor digiti tendon; et, extensor digiti tendon; ft, flexor tendon; iol, interosseous ligament; mp, middle phalanx.

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largely determine the shape and size of the nail. An abnormal terminal bony phalanx will always result in an abnormal nail (15). This is seen in racket fingers that have a short terminal phalanx because of premature ossification of the epiphysis, which leads to a short and wide nail. Acral hypervascularization in neuropathic acro-osteolysis may lead to enlargement of the terminal phalanx and an enlarged nail. The terminal phalanx gets its structural support plus mobility from its unique and complex structure of ligaments, tendons, joint capsule, flexor sheath, fasciae, and retinacula. The distal interphalangeal joint is a hinged synovial joint (16). The base of the terminal phalanx has two shallow concavities and an intervening ridge, into which the bicondylar surface of the head of the middle phalanx fits. The joint is laterally stabilized by lateral ligaments and also by lateral branches of both the extensor and flexor tendons (Fig. 1B). The flexor and extensor tendons insert on the ventral and dorsal aspect of the base of the terminal phalanx, respectively (Fig. 1B). The extensor tendon not only has a bony insertion but also attaches to the nail matrix by a sheetlike superficial lamina, which divides further into fibers that run along the undersurface of the matrix and into the PNF (Fig. 1B). Between the superficial and deep lamina under the matrix, there is a richly vascularized fat pad (17,18). The collateral ligaments form dorsal expansions blending into the lateral matrix and nail bed connective tissue (19). It was thought that hypertrophy of the lateral dorsal expansion in the big toe might be the cause of congenital malalignment of the great toenail. The dorsal expansion of the collateral ligaments and the interosseous ligaments gives rise to a special distal expression of Cleland’s ligament that anchors in the lateral skin of the distal phalanx (16) (Fig. 10). The matrix produces the nail plate (Fig. 11). It is also called germinative or intermediate matrix as it is

Figure 11 nail plate.

Nail matrix. Abbreviations: L, lunula; M, matrix; NP,

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Figure 13 Figure 12 Nail matrix and nail plate layers: the proximal matrix synthesizes the superficial nail plate; the distal (intermediate) matrix produces the bulk of the nail plate. The nail bed is responsible for just a thin layer of subungual keratin.

the sole component producing nail plate substance. It reaches from the depth of the proximal groove— sometimes just a tiny bit also turning around to the roof of the cul-de-sac—to the distal border of the lunula, which is seen as a half-moon-like structure just before the free margin of the PNF. In sagittal sections, the matrix epithelium has an undulating border with the matrix connective tissue, and its proximal end often forms an acute angle (Figs. 12 and 15). As outlined earlier, the matrix is fixed by extensions of the extensor tendon and dorsal expansions of the collateral ligaments. The distance of the proximal tip of the matrix epithelium from the insertion of the extensor tendon is about 0.8 mm. The matrix has a whitish to pale blue-gray color, which is thought to be due to the light scattering of the nucleated cells of the matrix’ onychogenous zone. This is seen after nail avulsion both in the remaining matrix as well as the avulsed nail plate, to which usually the upper third to half of the matrix epithelium adheres. The color difference between the lunula and nail bed also remains when the nail bed vessels are compressed and the nail bed is pale. The matrix has about double the proliferation rate of that of the surrounding epidermis, but only about one-third of that of hair follicle bulbs (Haneke, personal data, 1995). The proliferation rate slowly decreases with age (20). The nail bed, also called the distal or sterile matrix, is the distal continuation of the matrix. Its border to the matrix is abrupt clinically, but usually also clearly discerned histologically. Its epithelium is very thin and resembles that of a catagen hair follicle sheath with cells enlarging toward the surface and

Hair and nail relationship.

undergoing keratinization without a granular layer (Fig. 13). The thin keratin layer produced by the nail bed (Fig. 12) epithelium is just enough to allow the forward movement of the nail plate without shearing off its attachment. Why the attachment of the nail bed epithelium to the nail plate is so firm in contrast to the matrix epithelium is not known. The nail bed does not produce nail plate substance (21–25). However, some authors claim that the nail bed adds to the ventral part of the nail plate (26,27). The nail bed extends to the onychodermal band, which is part of the hyponychium complex (Fig. 3). Its color is rosepink because of the many capillaries running in several layers one above the other from proximal to distal in the unique rete ridges of the nail bed corium. The nail bed is said to have derived from the matrix (28), but has a much lower proliferation rate. However, it has no directed growth in contrast to the matrix (see “Extension of the Nail Bed,” pp. 76–78). The nail plate is a sheet of hard keratin continuously produced during the entire lifetime. It is durable, chemically resistant, and partially translucent. It is curved transversely and gently curved longitudinally. Its proximal and distal margins are parallel to the lunula border, thus it is extending more proximally in its lateral margins. The thin dorsal layer of the nail plate has a smooth shiny surface. It is made up of many strongly flattened onychocytes with considerable intercellular adhesion structures. The intermediate layer is much thicker, but its cells are less flattened than those of the superficial layer. The ventral layer is mainly nail bed (onycholemmal) keratin (Fig. 12). All layers can be distinguished also by their distinctive birefringence in polarized light and particular staining patterns with Giemsa stain. The nail plate serves several functions, of which protection and enhancement of the sensory functions of the fingertip are the most important. It aids in manual dexterity and allows picking up flat

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Figure 14 Formation of the cuticle. The cuticle results from eponychium (ventral aspect of the proximal nail wall, PNW) and the stratum corneum of the dorsal aspect of the PNW. Abbreviations: NP, nail plate, TC, true cuticle, FC, false cuticle.

objects from a plane surface. It permits scratching, scraping, and buttoning. The middle fingernail of the dominant hand of a young adult grows approximately 3 mm/mo. The nails of the shorter fingers grow comparatively slower and the toenails grow about one-third to one-half. As outlined in section “Basic Anatomy,” the nail is surrounded on three sides by the proximal and the lateral nail folds. Whereas the lateral nail folds are just flat connective tissue rolls that usually flatten distally, the PNF is a skin fold overlying much of the matrix (Fig. 13). Seen from dorsal, its free margin is concave distally. In vertical sections, it has an acute angle at the extremity of which a specialized keratin formation is seen, the cuticle (Fig. 14). It has a unique sealing function and when no longer present, foreign bodies, dirt, and microorganisms can enter

Figure 15

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the space under the PNF. This may lead to acute to chronic paronychia. This, in turn, causes the free margin of the PNF to swell and loose its acute angle. Once this is lost the undersurface of the PNF looses much of its adherence to the growing nail plate and the cuticle gets lost spontaneously. The cuticle is divided into two parts: the true cuticle is attached to the underlying newly formed nail and produced by the deep portion of the ventral surface, whereas the false cuticle is formed by the horny layers of the dorsal roof and the distal third of the ventral surface of the PNF (Fig. 14). The transition from the nail bed to the distal groove is called the hyponychium. Comparable to the cuticle, it has a sealing function for the nail bed epithelium, and injury from sharp cleaning instruments may therefore cause detachment of the nail plate from the distal portion of the nail bed with consecutive microbial colonization and infection. MICROSCOPIC ANATOMY The different epithelial components of the nail organ also have different histological patterns. The dorsal surface of the PNF has normal, but thin epidermis with flat rete pegs. There are a few small eccrine glands in the proximal part of the PNF, but no hair follicles and sebaceous glands. The undersurface of the PNF has very thin orthokeratotic epidermis with a granular layer. The keratin is attached to the nail plate and pulled out with the growing nail (Fig. 15A). From the depth of the proximal groove, the horny layer can be easily identified. Approximately at its distal third, it separates with the outer part remaining attached to the nail plate as the true cuticle and the inner layer forming the free or false cuticle.

Microscopic anatomy of (A) the matrix and (B) the proximal nail fold.

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The matrix begins where the undersurface of the PNFs ends (Figs. 12 and 15B); this appears to be slightly variable, as in some digits it may extend just a tiny bit into the undersurface of the PNF. The matrix epithelium is relatively broad and has an undulating border to the connective tissue in longitudinal sections, but densely arranged slender rete ridges in transverse sections (Fig. 15B). The basal cells of the matrix are small, cuboid, and basophilic and arranged in a parallel manner. They retain this aspect for approximately 40% of the thickness of the matrix epithelium before they gradually flatten and become more eosinophilic. This is the onychogenic or keratogenic zone that abruptly becomes involucrin positive (Fig. 16). The cell nuclei decrease in size and together with the eosinophilic cytoplasm keratinize abruptly, although under certain conditions nuclear remnants may be seen in the deep layer of the nail plate. There is no granular layer. Avulsed nail plates usually have most of the eosinophilic keratogenic zone attached to their undersurface. The matrix

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connective tissue is made up of densely packed fine collagen fibers. In the depth of the matrix dermis, there are some small fat cell lobules, blood vessels, glomus bodies, and nerves (Figs. 17 and 18). The nail bed has a thin epithelium with characteristic longitudinally arranged rete ridges. The epithelium has a basal layer of cuboid basophilic cells that gradually increase in size when they move upward but do not really flatten and thus resemble the inner root sheath catagen cells of the hair follicle (hence the term “onycholemm”). They do not form a granular layer but keratinize directly and only produce a very thin orthokeratotic layer, called the ventral nail (Fig. 19). In longitudinal section, the interface between the epithelium and the dermis appears to be flat, but in transverse sections, equally long, narrow rete ridges are seen. In them run capillaries, three to five above each other, in longitudinal direction. They are the reason for the socalled splinter hemorrhages seen so frequently under the nail (Fig. 2B). The dermis of the nail bed consists

Figure 16 Microscopic anatomy of the nail apparatus, immunohistochemical demonstration of involucrin. (A) Matrix. (B) Transition of matrix to nail bed. (C) Nail bed. (D) Nail bed and fingertip skin.

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Figure 20 Histological section through the hyponychium. Source: Courtesy of J. Andre´, Brussels, Belgium. Figure 17

Figure 18

Neural structures in subungual connective tissue.

Matrix connective tissue with Vater-Pacini body.

Figure 19 Histological section through the nail bed. Source: Courtesy of J. Andre´, Brussels, Belgium.

of dense collagen with vessels, glomus bodies, and nerves. The hyponychium is the transition of the nail bed to the digital pulp. A narrow zone of epithelium with granular layer and a certain epithelial thickening is seen at the distal end of the nail (Fig. 20). Then the epithelium forms a shallow groove that is mainly filled with keratin until the typical ridged skin of the pulp begins. This contains Meissner taste buds as well as, in the depth in the specialized finger pad fat, Vater-Pacini bodies. The nail produces special keratins, which may be mutated in certain diseases such as pachyonychia congenita. Keratins 1 and 10 are expressed in the suprabasal layers of the PNF and the volar skin of the fingertip. Keratins 5 and 14 are expressed in the basal layer of the skin, matrix, nail bed, and hyponychium. The nail bed produces keratins 6a and 16 as well as 6b and 17, whereas the hard keratin Ha 1 is produced by the matrix, which also expresses K 17 (29–31). The matrix stem cells are located in the center of the matrix (32). The nail plate is a light red–stained plate of flattened onychocytes in hematoxylin-eosin stains. Particularly in its proximal deep part, remnants of the matrix keratinocyte nuclei may be seen, usually as dark red spots, sometimes as dark blue spots. Giemsa stains often show a variable staining pattern from light red to blue, apparently reflecting slight biochemical changes. PAS shows the borders of the onychocytes (Fig. 21) and is the routine stain for the histopathological diagnosis of onychomycosis. Polarized light shows a bright birefringence along the direction of the keratin fibers. In longitudinal nail biopsies, the keratin fibers of the matrix epithelium run continuously into the nail plate in an oblique upward direction toward the free end of the nail.

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Figure 21 Histological section of the nail plate at the level of the nail bed.

This pattern of the keratin fibers is the reason why the proximal approach of nail avulsion is the least traumatizing. REFERENCES 1. Morgan AM, Baran R, Haneke E. Anatomy of the nail unit in relation to the distal digit. In: Krull EA, Zook EG, Baran R, et al. Nail Surgery. A Text and Atlas. Philadelphia: Lippincott Williams & Wilkins, 2001:1–28. 2. Fleckman P, Allen C. Surgical anatomy of the nail unit. Dermatol Surg 2001; 27:257–260. 3. Haneke E. Surgical anatomy of the nail apparatus. Dermatol Clin 2006; 24:291–296. 4. De Berker DAR, Andre´ J, Baran R. Nail biology and nail science. Int J Cosm Sci 2007; 29:241–275. 5. Higashi N. Melanocytes of nail matrix and nail pigmentation. Arch Dermatol 1968; 97:570–574. 6. Higashi N, Saito T. Horizontal distribution of the DOPA-positive melanocytes in the nail matrix. J Invest Dermatol 1969; 53:163–165. 7. Tosti A, Cameli N, Piraccini BM, et al. Characterization of nail matrix melanocytes with anti-PEP1, anti-PEP8, TMH-1, and HMB-45 antibodies. J Am Acad Dermatol 1994; 31:193–196. 8. Perrin C, Michiels JF, Pisani A, et al. Anatomic distribution of melanocytes in normal nail unit: an immunohistochemical investigation. Am J Dermatopathol 1997; 19:462–467. 9. Terry RB. The onychodermal band in health and disease. Lancet 1955; 1:179–181. 10. Sonnex TS, Griffiths WAD, Nicol WJ. The nature and significance of the transverse white band of human nails. Semin Dermatol 1991; 10:12–16. 11. de Berker D, Dawber RPR, Thody A, et al. Melanocytes are absent from normal nail bed; the basis of a clinical dictum. Br J Dermatol 1996; 134:564.

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12. Haneke E. Nail surgery: indications and outcome. Exp Rev Dermatol 2006; 1:93–104. 13. McGonagle D, Lories RJ, Tan AL, et al. The concept of a “synovio-entheseal complex” and its implications for understanding joint inflammation and damage in psoriatic arthritis and beyond. Arthritis Rheum 2007; 56:2482–2491. 14. McGonagle D, Tan AL, Benjamin M. The biomechanical link between skin and joint disease in psoriasis and psoriatic arthritis: what every dermatologist needs to know. Ann Rheum Dis 2008; 67:1–4. 15. Baran R, Juhlin L. Bone dependent nail formation. Br J Dermatol 1986; 114:371–375. 16. Gigis PI, Kuczynski K. The distal interphalangeal joint of human fingers. J Hand Surg 1982; 7:76–182. 17. McGonagle D, Tan AL, Benjamin M. The nail as a musculoskeletal appendage—implications for an improved understanding of the link between psoriasis and arthritis. Dermatology 2009; 218:97–102. 18. McGonagle D, Benjamin M, Tan AL. The pathogenesis of psoriatic arthritis and associated nail disease: not autoimmune after all? Curr Opin Rheumatol 2009; 21:340–347. 19. Gue´ro S, Guichard S, Fraitag SR. Ligamentary structure of the base of the nail. Surg Radiol Anat 1994; 16:47–52. 20. Raguz JM, Haneke E. Analyse der Proliferationsaktivita¨t der Nagelmatrixzellen mit der AgNOR-Methode. Hautarzt 1997; 48(suppl 1):S62. 21. Samman PD. The human toenail: its genesis and blood supply. Br J Dermatol 1959; 71:296–302. 22. Samman PD. The ventral nail. Arch Dermatol 1961; 84:192–195. 23. Zaias N, Alvarez J. The formation for the primate nail plate. An autoradiographic study in squirrel monkey. J Invest Dermatol 1968; 51:120–136. 24. Achten G, Parent D. The normal and pathologic nail. Int J Dermatol 1983; 22:556–564. 25. Fleckman P. Anatomy and physiology of the nail. Dermatol Clin 1985; 3:337–381. 26. Johnson M, Comaish JS, Shuster S. Nail is produced by the normal nail bed: a controversy resolved. Br J Dermatol 1991; 125:27–29. 27. Johnson M, Shuster S. Continuous formation nail along the bed. Br J Dermatol 1993; 128:277–280. 28. Gonzalez-Serva A. Structure and function. In: Scher RK, Daniel CR III, eds. Nails: Therapy, Diagnosis, Surgery. 2nd ed. Philadelphia: WB Saunders, 1997:11–30. 29. Kitahara T, Ogawa H. Cultured nail keratinocytes express hard keratins characteristic of nail and hair in vivo. Arch Dermatol Res 1992; 284:253–256. 30. Picardo M, Tosti A, Marchese C, et al. Characterization of cultured nail matrix cells. J Am Acad Dermatol 1994; 30:434–440. 31. De Berker D, Wojnarowska F, Sviland L, et al. Keratin expression in the normal nail unit: markers of regional differentiation. Br J Dermatol 2000; 142:89–96. 32. Ko¨rver J. Quantitative visualisation of epidermal cell populations; a study in healthy and psoriatic skin and its appendages. Ph.D. thesis, Nijmegen, Netherlands, May 27, 2009.

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Instrumentation Bertrand Richert

Very few specific instruments are needed for nail surgery: l

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An elevator is mandatory to avulse the nail atraumatically by gently detaching the nail plate from the bed and proximal nail fold. Several elevators are available (Fig. 1A,B): the Freer septum elevator is probably the most widely used with its round and smooth tip at each extremity and its curved shape perfectly adapted to the longitudinal shape of the nail; the Lempert elevator is a narrower variant with a less curved extremity and the Locke elevator is a narrower and flat variant (1); the dura mater elevator may also be used, as it has a smooth narrow rounded tip but its long bendable extremity makes it not easy to handle. Instruments from other specialties may be used: the dental spatula is shorter, easy to handle, has an extremity of intermediate size (3 mm), with sharp corners and adapted angle. When none of these instruments is available, the jaw of thin blunt-tipped curved scissors may be supportive. Nippers are also of utmost importance for cutting the nail plate. Of course, for cutting thin nails (like in children or diseased thinned nails) straight scissors will do. For cutting thick nails, the dual action nail nipper (Fig. 2A) is invaluable: it has nicely adapted beveled jaws and its four hinges will allow cutting the thickest pachyonychia. This nipper may also be used for cutting bone exostosis when a bone rongeur is not available. The English nail splitter (Fig. 2B) is very unique with its anvil-like lower jaw. Its upper surface slides under the nail plate while the upper jaw has an inferior cutting edge allowing to cut thick nails. Various sizes are available. The main drawback of this instrument is that the thickness of the lower jaw always induces a lateral onycholysis ahead of the cutting line. Straight nail nippers (Fig. 2C) are probably the most adequate for cutting a nail of normal thickness: they have sharp cutting jaws, thin beveled extremities, and a flat undersurface. They allow cutting of the nail without almost no extra lateral onycholysis.

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A tourniquet is required in most instances as the surgical field needs to remain bloodless, especially when performing matrix cauterization. Several options are available. The most widely used is the Penrose drain that is wrapped around the base of the digit and whose two ends are clamped together with a sturdy hemostat. This is especially adapted for toenail surgery. It has been shown that this technique delivers high and unreliable pressure (2) and is not recommended for digits. For fingernail surgery, it is best to use a sterile glove, half a size smaller than the adequate size. After anesthesia and full disinfection of the hand with plain alcohol, the glove is donned by the surgeon under full aseptic conditions. The affected glove fingertip is pierced with some sharp instrument (Fig. 3A) and rolled back to the base of the proximal phalanx (Fig. 3B). This technique exsanguinates the digit and delivers a reliable pressure under 500 mmHg. The remainder of the glove will serve as a sterile field. It also provides the safest tourniquet technique as the whole glove cannot be forgotten at the end of the procedure. If a too large glove has been used or if the glove fingertip has been too largely cut, the plastic ring rolled at the base of the finger may not be tight enough and bleeding may still occur. In such instances, the pressure from the plastic ring may be increased using a hemostat that is hold in place by folding back the most proximal part of the glove (3) (Fig. 3C). This procedure may dramatically increase the pressure and should be avoided. It may be applied for very few minutes, for example during chemical cauterization of the matrix in a bloodless field. For the same reason, tunable zip-ties that have been proposed as digital tourniquets should not be used (4) (Fig. 3D).

BASIC EQUIPMENT Even if nail surgery happens on a surface under 4 cm2, it will encounter both very thick and hard structures (nail plate and bone) and thin and fragile tissues (nail bed and matrix). For nail plate surgery, instruments have to be sturdy and resistant. For nail

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Figure 2 (A) Dual action nail nippers. Note the four hinges making these nippers very powerful. (B) English nail splitter. Note the anvil-like lower jaw. (C) Straight nail nipper. Note the sharp thin beveled jaws. Figure 1 (A) Elevators, general view, from left to right: dental elevator, Freer elevator, dura mater elevator. (B) Same instruments on a side view showing their distal curve.

bed and nail matrix surgery, instruments should be as delicate as possible, as one may use for fine flaps on the face. Nail surgery often starts with a nail avulsion to see what is happening under the plate.

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Figure 3 (A,B) The glove tourniquet, ensuring finger exsanguination and sterile field. (C) The glove tourniquet with increased pressure: this procedure should be strictly limited to a few minutes. This may be useful in patients under blood thinners. (D) The zip-tie tourniquet. This device is not recommended.

The nail avulsion tray (Fig. 4A) should include the following:

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l l l l

Elevator Nail nippers Sturdy hemostat

This tray is extremely useful for surgical exploration of the bed, chemical cauterization of the matrix in ingrowing nails, or before punch biopsy of the bed. A basic nail surgery tray (Fig. 4B) should include the following: l l l l

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Tourniquet Elevator Nail nippers Bard-Parker blade holder, with blades No. 15 or 15C Fine Adson toothed 2  1 forceps

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Fine straight scissors, Iris or Graddle type for cutting tissues Fine curved scissors, Iris or Graddle type for undermining Needle holder, with smooth jaws, for holding thin needles (5/0 or less) for suturing the bed and/or the matrix Needle holder, with serrated jaws, for holding larger needles (4/0 and over) for suturing the skin and through the nail Suture cutting scissors (the cheapest heavy straight scissors will do). Each surgical kit should contain various types of scissors that should be kept for their specific function: using inadequate scissors will lead to poor performance, unnecessary tissue damage, premature dulling and frequent replacement Sturdy straight hemostat, at least two. They are very useful to grasp thick nails for avulsion. Prefer those with serrated jaws without teeth at

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Figure 5 Beaver blade system (also called mini blade system) with No. 64 blade.

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Figure 4

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(A) Nail avulsion tray. (B) Basic surgery tray.

their extremity. One hemostat may be used for holding the tourniquet if a Penrose drain is used for toenail surgery Curette, excavator type (Besnier lupus or Volkmann curettes), fenestrated or not, for removing pyogenic granulomas, intraosseous keratoacanthomas, enchondromas, nail bed dermatophytomas Nonabsorbable 3/0 and 4/0 sutures Absorbable 5/0 and 6/0 sutures

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ADVANCED EQUIPMENT Some added peculiar instruments may improve the dexterity of the surgeon. l

Magnification loupes, if affordable, are a must, as it is essential to perform the most precise surgery

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as possible to avoid any postoperative nail dystrophy. Heine1 or Zeiss1 binocular loupes offer several magnifications. Surgical blades are also available with TeflonTM coating to minimize any dragging of the blade against the tissue. This allows them to slide smoothly through the tissue being cut (5). These particular blades are indicated when performing tangential matrix excision. The Beaver blades (or miniblade system) (Fig. 5) provide a range of various shaped cutting edges. The two most commonly used in dermatologic surgery are No. 64 that has a rounded tip with semicircular sharp cutting edge, and No. 67 that is similar to the No. 15C blade. No. 64 is especially useful in narrow areas such as the lateral longitudinal biopsy to free the matrix from the underlying bone: pushing the blade resting on the bone, in a straight forward motion, detaches the matrix without any difficulty. The same blade may be used to undermine the nail bed or the matrix. Skin hooks are very important when performing surgery with an assistant who can reflect the proximal nail fold and expose the whole cul-desac. They are also very useful for assessing flap movements. Instead of pulling on the edges with forceps that may occasionally harm the tissue, skin hooks are secured to the undersurface of the edges, in the deep dermis, allowing an atraumatic pull, even for a long time. The most common ones are the Gillies skin hooks (Fig. 6), with one small sharp hook, but other versions including larger or several hooks (double-prong Guthrie retractors) are available too. A bone rongeur should be available for removal of bone tumors.

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15 l

Figure 6 Gillies hook. Note the size of the instrument compared to a pencil.

Any instruments proposed in the basic nail surgery set may be improved in selecting more delicate tools.

Many varieties of instruments are available, providing an overwhelming number of choices both in quality and cost of surgical instruments. Most practitioners will develop their own likes and dislikes for some instruments during their practice. Choosing the right instrument for one’s hand size and type of procedure to be performed is crucial for efficient procedures (5). However, it is no substitute for seeing, touching, and handling the instruments. At many of the larger specialty meetings, the instrument vendors will be displaying their wares where you may experience new material. These displays offer an excellent opportunity to evaluate the many instruments. Wherever possible, trial periods should be obtained before committing excessive funds to major purchases. Nothing replaces personal experience in making such selections (6). Start with good basic surgical kits and increase their size with time. It usually takes several years to be equipped fully adequately. And, of course, to ensure your instruments a great lifespan, to have them please you over several years, operating comfortably and efficiently, take care of them: proper cleaning and drying, adequate lubrication and sharpening is a must. REFERENCES

Figure 7

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Spencer suture-cutting scissors.

Spencer suture-cutting scissors (Fig. 7) are invaluable for removing stitches postoperatively without any effort and pain: the distal notch on the lower jaw is slid very easily under the suture and closing the scissors severs the stitch.

1. Abimelec P. Tips and tricks in Nail Surgery. Semin Cutan Med Surg 2009; 28:55–60. 2. Hixson FP, Shafiroff BB, Werner FW, et al. Digital tourniquets: a pressure study with clinical relevance. J Hand Surg Am 1986; 11:865–868. 3. Harrington AC, Cheyney JM, Kinslay-Scott T, et al. A novel tourniquet technique using a sterile glove and hemostat. Dermatol Surg 2004; 30:1065–1067. 4. Tang WY. A latex finger strip and nylon zip-tie combo as a tunable digital tourniquet. Dermatol Surg 2007; 33:713–715. 5. Bhatia AC, Taneja A. Surgical Instruments. In: Vidimos AT, Ammirati CT, Poblete-Lopez C, eds., Dermatologic Surgery. Philadelphia: Saunders Elsevier, 2009; 59–71. 6. Geisse JK. The dermatologic suite. Semin Dermatol 1994; 13:2–9.

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General considerations Bertrand Richert

PREOPERATIVE ASSESSMENT AND PREPARATION OF THE PATIENT Patient History A thorough and efficient preoperative evaluation is mandatory for all patients undergoing nail surgery as for any other dermatologic operation. Screening for underlying diseases, especially focusing on any cause of vascular impairment of the extremities (diabetes, Raynaud’s disease, smoking, arteriopathy, etc.), current medication and potential allergies (latex, povidone-iodine, antibiotics, pain killers of any type, anesthetics, etc.) should be performed. Management of common perioperative issues in a proactive and standardized manner, with opportunity to individualize decisions when clinical conditions indicate, is an efficient and optimal approach (1). Medical Imaging Standard X rays are not sufficiently enough performed before nail surgery. This easy noninvasive and cheap exam may reveal alterations of the bony phalanx, which may contribute to the diagnosis and guide the surgical treatment of a large number of conditions. Magnetic resonance imaging, when available with an adequate digital coil, may give a precise location of a tumor that is not clinically visible (i.e., glomus tumor) (2) (Fig. 1A,B). For some special indications, fine layer computed tomography is of great help. Ultrasound is not yet routine in preoperative diagnostics. It is very helpful to have preoperative photographs of the diseased nail (3).

Information on the Surgical Procedure The preoperative consultation should assess all aspects of the planned surgical procedure. Drawings are most eloquent. Surgical complications as well as transitory and permanent nail dystrophy should clearly be reviewed with the patient. Pain is a main concern for patients: they are mostly frightened by the anesthesia. Explanation about the procedure is of great help. If dealing with “needle phobic” patients, do not hesitate to propose anesthetics creams prior to surgery (see p. 24). They should also be reassured

about the management of postoperative pain and removal of the dressing. Information about possible long-standing postoperative dysesthesia should be given (see pp. 21–23). We offer our patients a flyer containing all preoperative information (Table 1). Information on Work Disruption It is of utmost importance to try to evaluate as accurately as possible the healing time and the impact of the surgery on the patient’s professional activity. Remember to inform the patient that the limb has to be elevated for 48 hours (it means no driving at all), so people living alone or old patients can make arrangements for accommodation of their daily life. Premedication Premedication may be useful in anxious patients. Short action molecules should be preferred: hydroxyzine, diazepines orally or sublingually, the latter being quicker. The combination of hydroxyzine 25 mg the night before operation with lorazepam sublingually one hour prior to surgery is very efficient (4). Midazolam is favored by some surgeons as it offers short-acting hypnotic, anxiolytic, and retrograde amnestic properties (3). Antibiotic Prophylaxis Antibiotic prophylaxis in dermatologic surgery is poorly understood, and data on its use are lacking. Prophylaxis is indicated for the prevention of endocarditis and prosthesis infection, as well as surgical site infection. Antibiotic prophylaxis should reflect the recommendations of recent prospective studies. Prophylactic antibiotics are only indicated for patients with high-risk cardiac conditions, and patients with prosthetic joints at high risk for joint infection. Prophylactic antibiotics are recommended when the surgical site is infected and for procedures on the lower extremities (5). Although no evidence supports this practice, some practitioners recommend prophylactic antibiotic for nail procedures that carry a higher risk of postoperative infection: poorly monitored diabetic patients and bone surgery. All

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17 Table 1 Patients

Preoperative Information Flyer Offered to Our PREOPERATIVE INFORMATION

DATE OF SURGERY: TIME: LOCATION: l l

l

l

l

l

l

Remove any trace of nail lacquer. Starting 2 days prior to surgery, bath or shower your finger/ toe twice per day and scrub it gently with povidone-iodine soap. Rinse thoroughly and tap dry. The day of surgery, soak your finger/toe in lukewarm water for 10 minutes, soap it with povidone-iodine soap, rinse, and dry. Apply a dry dressing on top. Eat normally the day of surgery. Avoid coming with an empty stomach! Bring sandals with Velcro straps or equivalent to accommodate the postoperative bulky dressing. You will not be able to put back your shoe on! You will not be able to drive back home and your insurance could be considered invalid. You must not travel back home by public transportation. Please make adequate arrangements. If the doctor prescribed you medication prior to surgery, please follow exact instructions. Should you have: – any reason to cancel or postpone your appointment – any new medication prescribed by any doctor – excessive pain and/or redness at the site of planned surgery Please call the following number:

Figure 1 (A) This lady had a very painful nail. No obvious clinical sign was noted. Standard X rays were normal. She was first referred to psychiatry. (B) MRI clearly demonstrated a glomus tumor. Surgical removal alleviated pain definitively. Source: Courtesy of Coll J. Andre´, Brussels, Belgium.

surgery procedures should be performed under full sterile conditions (6,7). For more invasive surgery, and whenever possible, surgical facilities should meet orthopedic surgery standards (3).

Preoperative Cleaning of the Surgical Site The degree of cleanliness of the digits or toes of patients on the day of surgery is sometimes amazing! It is recommended that patients who have jobs in which dirt gets under their nails soak their hand/foot in soapy water and clean them with a scrub brush for several days before surgery. Ask ladies to remove their nail lacquer (7). There is no study on the use of antiseptic soaps on the days prior to surgery to reduce bacterial carriage of the foot. DISCONTINUATION OF SYSTEMIC TREATMENTS It is important to list every medication being taken by the patient. This may reveal some underlying disease that the patient forgets to inform the physician as it is a long-standing condition and a medication has been taken for years.

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18

Should Blood Thinners Be Discontinued Before Nail Surgery? The use of blood thinners has increased dramatically in recent years among the general, and especially among the elderly, population. Antithrombotic medications may increase perioperative bleeding during cutaneous surgery. Whether to discontinue these medications before surgery is controversial. However, it has been shown that perioperative withholding of antithrombotics in cutaneous surgery may be associated with serious adverse vascular events. Continuing antithrombotics in these circumstances does not appear to significantly increase bleeding complications (8). It has been proven that discontinuation of these medications may increase the risk of cerebral and cardiovascular complications (9). Thrombotic events included strokes, cerebral emboli, myocardial infarctions, transient ischemic attacks, deep venous thromboses, pulmonary emboli, retinal artery occlusion leading to blindness, and deaths (10). Calculation of incidence yielded an estimated thrombotic risk of 1 event in 6219 operations when use of warfarin was discontinued and 1 in 21,448 when aspirin was withheld. With no documented increase in severe hemorrhagic complications during continued perioperative use of blood thinners, these data provide a compelling argument to maintain patients on medically necessary blood thinners during cutaneous operation (10). As nail surgery is mainly performed with a tourniquet, the risk of perioperative bleeding is minimal. Bleeding may occur postoperatively when the tourniquet is removed. Compressive dressing for half an hour with the limb elevated will suffice in most instances. The dressing should be changed afterward and the wound checked. If bleeding persists, it may be dramatically lessened by the injection of a load of fluid (i.e., 0.5 mL of bupivacaine) on the lateral aspect of the digit/toe that will press onto the digital proper artery.

NAIL SURGERY

application with bristles or sponges. Culture swabs were obtained from different locations: web spaces, nail folds, toe surfaces. Better reduction in bacterial carriage was obtained with alcohol scrub plus alcohol paint with bristle (only 12% of positive cultures in the nail folds) (11) and chlorhexidine scrub plus isopropyl alcohol paint (38% of positive cultures in the nail folds) (12). All other combinations had a positive culture rate over 70%. Recently, footbath with chlorhexidine gluconate (Hibitane1), 20 minutes before surgery, was recommended as it significantly reduced the intraoperative and postoperative bacterial counts (13). Brushing the nail does not decrease bacterial numbers (14). Another study mentions that incorporation of alcohol and povidone-iodine into the preoperative nail preparation may help to reduce the bacterial load (15). The most disturbing finding in these studies is that the nail remains contaminated after any of the preoperative nail preparation methods studied. This suggests that all efforts to reduce the bacterial load should be used (15) and that scrubbing with plain alcohol acts as a major factor for that. DRESSINGS In nail surgery, postoperative dressings must have three main properties: nonadherent, absorbent, and perfectly fixed. Adapted footwear is a must (Fig. 2). Nonadherent Dressing Applying large amounts of ointment (possibly containing antiseptics) covered with nonadherent dressing such as petrolatum-coated gauze (Tulle gras1, Bactigras1, Adaptic1, Jelonet1) possibly added with antiseptics (Betadine Tulle1, Fucidin Tulle1) will protect the wound from drying and will

Should Other Drugs Be Discontinued? No. DISINFECTION OF THE SURGICAL FIELD Feet, but also hands, are prone to bacterial contamination. It has been demonstrated that infection rates are higher following orthopedic procedures on the foot and ankle as compared with procedures involving other areas of the body. The difficulty of eliminating bacteria from the forefoot prior to surgery has been documented. Several studies compared the efficacy of povidone-iodine, chlorhexidine, alcohol, combination of them, and their

Figure 2 Adapted footwear is a must. Sandals with Velcro straps are best.

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Figure 3 Applying (A) large amounts of ointment and (B) a petrolatum-coated gauze will allow an easy and painless removal.

Figure 4 (A) Bulky dressing properly secured to the wrist. (B) Bulky dressing adequately secured to the ankle.

allow an easy and painless removal (Fig. 3). Telfa1 may be another option. Recently, a new category of dressing appeared on the market that is well adapted to nail surgery. It consists of a porous, semitransparent, low-adherent, flexible polyamide net coated with soft silicone (Mepitel1). It is not absorbent, but contains apertures of approximately 1 mm in diameter that allow the passage of exudate into a secondary absorbent dressing (16).

Securing the Dressing A bandage will hold together the bulky dressing. Tubular gauze or net may be used but control of the pressure on the dressing is impossible. A narrow elastic bandage (4 cm) is a more flexible form of dressing as it may apply more precise pressure over the wound. The elastic bandages are applied in a U-shaped fashion to avoid any possibility of its acting as a tourniquet. The last layers may be circular and will include wrapping around the wrist or ankle to fully secure the dressing (Fig. 4A,B). This should afford light compression that does not compromise blood flow (4).

Absorbent Dressing In nail surgery, postoperative bleeding may be noticeable, according to the type of surgery. On top of the nonadherent dressings, that are not at all absorbent, a bulky dressing made of two or three loose layers of mesh gauze will absorb bleeding and provide protection against trauma. To limit bleeding, elevation of the limb is mandatory for 48 hours.

POSTOPERATIVE PAIN MANAGEMENT Postoperative pain management relies on two points: elevation of the limb and pain killers. Immediately after surgery, we offer our patients a flyer with all

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NAIL SURGERY

Table 2 Patients

Postoperative Information Flyer Offered to Our POSTOPERATIVE INFORMATION

DATE OF REMOVAL OF DRESSING: TIME: LOCATION: 1.

2.

3.

4.

5.

The administered local anesthesia will last for X hours. To avoid any excessive pain, take one pill of paracetamol containing pain killer (drug X, Y, Z, W, no aspirin) as soon as you come home, then one pill every four hours today, one pill morning, noon, and evening tomorrow and the day after tomorrow. If pain relief is not enough add ibuprofen (A, B, C) or naproxen (D, E, F) pain killers. To avoid throbbing and any edema that may be responsible for pain, it is mandatory to keep the limb elevated (sling for a finger, footstool for a toe) for 48 hours. The dressing will be removed in 48 hours by the surgeon (or a nurse) at the place and time indicated above. If you are living very far your family doctor may take care of it. Do not forget to bring this sheet with you. Removal of the dressing is not painful. If in any case it sticks to the wound, it will be soaked in lukewarm water until is detaches spontaneously. A much smaller dressing will be placed. You will be able to wear comfortable shoes. Walking is allowed. Avoid sports for 3 to 4 weeks to allow early healing and reduce the chance of infection. If you had a treatment for ingrowing nail with phenol, oozing will persist on the lateral side of the nail for up to 6 weeks. This is normal and is not infection. The following local cares have to be done strictly

During 2 weeks: soakings of the finger/toe for 10 minutes in lukewarm water with povidone-iodine soap (red bottle). Tap dry. If you are afraid of touching your nail, use a hair dryer. Apply a line of antiseptic ointment (ointment X, Y, Z, W) on the wound. Cover with sterile dressing. After 2 weeks: replace the ointment by povidone-iodine solution (yellow bottle) and cover with a plaster until your doctor allows you to have it air-dried. Should you have: – any reason to cancel or postpone your appointment – excessive pain, redness, excessive swelling, purulent or smelly discharge, or anything that seems abnormal to you Please call the following number: If out of working hours contact:

information necessary for the postoperative care (Table 2). Elevation of the Limb Elevation of the limb will ease throbbing and facilitate healing. It will avoid edema at the surgical site that may be responsible for pain and may pull on the sutures. The patient should wear a sling if the

Figure 5 (A) Commercial sling. Always ask for it prior to surgery. Some patients had friends or members of their family that have kept one from an old trauma. (B) Customized sling using a large square scarf.

surgery involves a finger and the foot should be elevated (at the hip level, meaning horizontally) using a footstool. If a commercial sling (Fig. 5A) is not available, a large square scarf will do very well (Fig. 5B). It should be placed by the surgeon or the nurse immediately after the dressing is performed. The duration of elevation of the limb is of two days, equal to the inflammatory reaction after surgery. Pain Killers According to the type of surgery, pain will last from several hours to several days after cessation of the

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anesthesia. The surgeon should accurately determine the degree of pain of his surgery to adapt the postoperative analgesia. Some procedures are less painful than others. For example, phenolization, tangential excision, ligation of the pedicle of a myxoid pseudocyst, and amazingly removal of a subungual exostosis are very comfortable. Lateral longitudinal biopsy, nail avulsion, excision of the whole nail unit, and small flaps on the bed are more painful. The most painful is the rotation of the whole nail unit for nail malalignment. In a series of 62 patients that underwent nail surgery (42 minor and 20 major procedures) 19% of patients experienced “no pain” in the first two weeks after surgery. During the first three days after surgery 29% had “mild pain,” 35% “moderate pain,” and 16% “very bad pain” (17). First postoperative pain management starts with adequate anesthesia (see chap. 4). Long-lasting anesthetics (up to 8 hours) are a must for painful surgery. In most instances, paracetamol 500 mg every four hours on the first day then 3/d on the second day will suffice. Patients may be instructed to add anti-inflammatory agents such as ibuprofen, naproxen, or meloxicam if needed. Although there is a caution against nonsteroidal anti-inflammatory drugs in nail surgery in a U.S. guideline (18), we have found them useful, as other authors (17), with no effect on postoperative bleeding. Most patients usually need analgesia for the first day and drop the treatment afterward. For moderate pain, combination of paracetamol and codeine works nicely. If severe pain is expected, like in realignment, mild opioid-type narcotic analgesics (dextropropoxyphene, tramadol, naloxone associated with tilidine) should be prescribed and precise doses and side effects explained. All drugs indicated on our postoperative flyer are over the counter drugs and dosing is clearly indicated. In case of an anxious patient with low pain tolerance, we always add a prescription of a stronger analgesic to reassure the patient. In almost every case, the patient will not have to use it. DRESSING REMOVAL AND REPLACEMENT Patients fear pain from sticky dressings that are abruptly pulled out. This is why the dressing should be adapted to nail surgery (see pp. 18–19). In most instances, it will not stick to the wound even if there is almost always some bleeding into the dressing.

21

Figure 6 Painful superficial erosion of the dorsal aspect of the great toe from friction of a dry stiff dressing left in place too long. This bothered the patient much more than the phenolization of the lateral horns of the matrix!

The dressing is removed on the second day postsurgery. Sometimes early removal is necessary after 24 hours if bleeding is severe, because the impregnated gauze of the bulky dressing dries, becomes stiff, and may cause unpleasant or painful compression. If left in place too long, such dry and hard dressings may induce superficial erosion on the skin of the proximal and/or lateral nail folds (19) (Fig. 6). In case of adherence, never try to pull but soak the dressing in lukewarm water until it detaches spontaneously. Further care will depend on the type of surgery. Usually, the dressing is left in place for the first two days and then renewed by the surgeon. If the wound is clean and has no more bleeding (i.e., surgery with stitches), the bandage is left in place for another approximately five to seven days before changing it again. A large plaster, half split in four on its length, will cover easily a great toe or a finger (Fig. 7A–E). After phenolization or secondary intention healing, on the contrary, due to exudation, the dressing should be renewed once or twice per day until complete healing that may take up to several weeks. Greasy antiseptic ointment should be applied for the first two weeks to avoid the wound to dry. Then, application of povidone iodine solution twice a day until healing is complete. The wound should be covered by a plaster at all times. POSTOPERATIVE LONG-TERM PARESTHESIA Occurrence of dysesthesia after nail surgery is a phenomenon well known by experienced nail surgeons. However, no quantification of its frequency,

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22

Figure 7

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(A–E) The plaster is half split in four in its length, wrapped around the toe, and each part is folded one after the other.

its location, duration, and impact on daily was ever done. Recently, it has been shown that a sensory disturbance was observed in about half of the patients (47%) without any relationship to the extent of the surgery undertaken. The most reported sensations were numbness or loss of sensation (16%) and tingling (8%). When mapping the locations

of altered sensation (Fig. 8), the digit tip was the most commonly affected (34%) with the proximal nail fold (28%) and margin beneath the free edge of the nail (24%). Complete or partial resolution was noted in 35% of cases after 6 to 12 months but 11% had still no improvement. There is no clear explanation for this phenomenon up to now (17).

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23

8.

9.

10.

11.

Figure 8 Scheme illustrating site and frequency of paresthesia after nail surgery. Source: Adapted from Ref. 17.

12.

13.

REFERENCES 1. Otley CC. Perioperative evaluation and management in dermatologic surgery. J Am Acad Dermatol 2006; 54:119–127. 2. Richert B, Baghaie M. Medical imaging and MRI in nail disorders: report of 119 cases and review of the literature. Dermatol Therapy 2002; 15:159–164. 3. Abimelec P., Dumontier C.. Basic and Advanced Nail Surgery. In: Scher RK, Daniel CR, eds. Nails: Diagnosis, Therapy, Surgery. 3rd ed. Philadephia: Elsevier Saunders, 2005:265–289. 4. Richert B. Basic nail surgery. Dermatol Clin 2006; 24:313–322. 5. Wright TI, Baddour LM, Berbari EF. Antibiotic prophylaxis in dermatologic surgery: advisory statement 2008. J Am Acad Dermatol 2008; 59:464–473. 6. Jellinek NJ. Nail surgery: practical tips and treatment options. Dermatol Ther 2007; 20:68–74. 7. Zook EG. Preoperative and postoperative management. In: Krull EA, Zook EG, Baran R, et al., eds.

14.

15.

16. 17.

18.

19.

Nail Surgery: A Text and Atlas. Philadelphia: Lippincott Williams & Wilkins, 2001:29–35. Alam M, Goldberg LH. Serious adverse vascular events associated with perioperative interruption of antiplatelet and anticoagulant therapy. Dermatol Surg 2002; 28:992–998. Alcalay J, Alkalay R. Controversies in perioperative management of blood thinners in dermatologic surgery: continue or discontinue? Dermatol Surg 2004; 30:1091–1094. Kovich O, Otley CC. Thrombotic complications related to discontinuation of warfarin and aspirin therapy perioperatively for cutaneous operation. J Am Acad Dermatol 2003; 48:233–237. Klebish DJ, Zurakowski D, Wilson MG, et al. Preoperative skin preparation of the foot and ankle: bristles and alcohol are better. J Bone Joint Surg 2005; 87: 986–992. Bibbo C, Patel DV, Gehrmann RM, et al. Chlorhexidine provides superior skin decontamination in foot and ankle surgery. Clin Orthop Relat Res 2005; 438:204–208. Ng AB, Adeyemo FO, Samarji R. Preoperative footbaths reduce bacterial colonization of the foot. Foot Ankle Int 2009; 30:860–864. Tanner J, Khan D, Walsh S, et al. Brushes and picks used on nails during the surgical scrub to reduce bacteria: a randomized trial. J Hosp Infect 2009; 71: 234–238. Becerro de Bengoa Vallejo R, Losa Iglesias ME, Alou Cervera L, et al. Preoperative skin and nail preparation of the foot: comparison of the efficacy of 4 different methods in reducing bacterial load. J Am Acad Dermatol 2009; 61:986–992. Available at: www.dressing.org. Walsh ML, Shipley DV, de Berker DAR. Survey of patient’s experiences after nail surgery. Clin Exp Dermatol 2009; 34:e154–e156. Drake LA, Dinehart SM, Farmer ER, et al. Guidelines of care for nail disorders. J Am Acad Dermatol 1996; 34:529–533. Richert B, Dahdah M. Complications in Nail Surgery. In: Nouri K, ed. Complications in Dermatologic Surgery. Philadelphia: Mosby Elsevier, 2008:137–158.

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4

Anesthesia of the nail apparatus Bertrand Richert

For most people, nail surgery is an emotional experience. As the visit to the dentist, patients are more often more apprehensive about the needle stick than the actual procedure. The preoperative consultation should assess all aspects of the procedure, and the patient should be fully reassured. Premedication may be useful in anxious patients (see p. 16). INTRODUCTION l A good knowledge of the techniques of anesthesia of the nail apparatus is mandatory to have surgery at that site comfortable, both for the patient and surgeon. l A good knowledge of the nerve anatomy of the digits is mandatory (see chap. 1). Paired palmar and plantar nerves lie at the sides of the flexor tendon sheath and proper digital arteries. These digital nerves divide into three main branches just distal to the distal interphalangeal joint. One branch goes to the nail bed, one to the tip of the digit and the other onto the pulp (Fig. 1) (1). l Always check for a history of allergy to lidocaine or bupivacaine or parabens (contained in both as preservative). l Local anesthetics may be contraindicated in patients with cardiac disease such as heart block (2). ANESTHETIC PRODUCTS a. Plain lidocaine 1% or 2% is the reference local anesthetic. Plain 2% should be preferred as it seems slightly more efficient (3). b. Lidocaine with epinephrine is safe for digital anesthesia, but there remains a very deeply ingrained resistance to its use for digital anesthesia. It is widely thought that this will lead to irreversible digital artery vasospasm (4). Multiple studies involving thousands of patients support the premise that the use of lidocaine with epinephrine is safe in the digits. All cases of digital gangrene after anesthetic block occurred more than 50 years ago when epinephrine was manually added by the surgeon or the nurse to cocaine or procaine that were responsible for

c.

d.

digital infarction. There have been no case reports of digital gangrene using commercial lidocaine with epinephrine since its introduction in 1948 (5). A recent study used duplex scanner and Doppler probe to measure actual changes of digital artery flow consecutive to digital block with 2% lidocaine with epinephrine: a dramatic decrease of 50% of the arterial flow was noted after five minutes but returned to normal by 60 minutes (6). As the temporary vasoconstrictor effect is reversible, the threat of complication from vasoconstrictor-induced ischemia is theoretical (7). The use of lidocaine with epinephrine has clear advantages such as quicker onset, fewer reinforcement doses, less need for special maneuvers to stop bleeding, and longer total time of postoperative analgesia (8). However, most surgical nail procedures require a completely bloodless field that is only achieved when using a tourniquet. Therefore, lidocaine with epinephrine is of little interest for performing nail surgery (9). Bupivacaine 0.5% has a duration of action of eight hours (10). Injecting 0.5 to 1 mL of bupivacaine immediately postoperatively, as a lateral wing block, will ensure a very comfortable postoperative pain relief for the patient. It also acts as a “volumetric” tourniquet: the load of liquid injected on the lateral aspect of the finger/toe compresses the digital proper arteries, thus stopping postoperative bleeding. Ropivacaine has the same quick onset as lidocaine, provides better postoperative pain relief (up to 9 hours) (11,12) and is less cardiotoxic than bupivacaine (13). Pain at infiltration depends on concentration: pain occurs over 5 mg/mL. Mean time to regain full sensation is over 7 hours for 2 mg/mL. Ropivacaine appears to produce vasoconstriction at low dosages (14). For all these reasons, we use ropivacaine 2 mg/ mL in routine with very confortable anesthesia and postoperative for our nail surgery patients. We restrict the use of this anesthetic for patients without any history of vasospastic disease, diabetes mellitus, Raynaud’s disease, heavy tobacco use, etc.

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25

twofold: thinness of the needle decreases pain from puncture and limits the anesthetic flow thus performing a very slowly progressive swelling of the soft tissues. It is common for the physician to spend more time administering the anesthetic than performing the surgical procedure. PROCEDURES l It is best to have patients in a reclining position during the administration of anesthesia in the event a vasovagal episode occurs. l It is judicious to inform the patient when the needle stick is about to occur to avoid a dangerous reflex jerk (15).

Figure 1 Scheme illustrating the distribution of the branches of the digital nerves at the tip of the digit.

MATERIAL l As all types of anesthesia at the nail apparatus are high resistance injections (weak dilatation of tissues), it is mandatory to use Luer Lock syringes or dental syringes (Fig. 2) on which needles are tightly secured (screw-on system) avoiding their detachment under high pressure. l The use of very thin needles (30 G for fingers, 27 G for toes, 30 G for children in all instances) is

Figure 2 Dental syringe and Luer lock. Note that the needles are very thin and screwed on the syringe allowing thus injection under high pressure.

Proximal Digital Block (Formerly Called Ring Block) l The term “ring block” should be abandoned as it suggests injection of anesthetic all around the base of the finger. This historical technique induces constriction of the blood flow through a tourniquet of fluid at the proximal phalanx. It should not be performed anymore. The proximal digital block is the updated and adequate procedure of this old type of anesthesia. l With the patient’s hand pronated the needle punctures the skin in the midline of the lateral aspect of the proximal phalanx, with an angle of 458 from the proximal bony phalanx, 1 cm distal to the interdigital web. The needle is advanced until it touches bone, where 1.5 to 2 mL of anesthetic is deposited to numb the digital nerve (Fig. 3). l The procedure is then repeated on the opposite side of the digit to complete the block.

Figure 3

Proximal block.

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26 l

l

NAIL SURGERY

A complete block is usually achieved in 10 to 15 minutes, sometimes more. The use of a needleless injection system (J-Tip device) for digital ring block has been proposed for “needle phobic” and young patients. This is nothing different than a disposable DermoJet. The liquid is delivered in an aerosol form subcutaneously to a depth of 5 to 8 mm, fanning out on maximum penetration to a width of 8 to 10 mm. This technique is not reliable since it requires in all patients an additional anesthetic administration of 3 mL to achieve adequate anesthesia of the tip of the toe (16).

Distal Digital Block (Wing Block) l This is the most useful in routine nail surgery as it acts immediately. l The injection site is at a point about 1 cm proximal and lateral to the junction of the proximal nail fold and the lateral nail fold. l By directing the needle at a 458 angle directed distal down to the bone, slow injection of about 0.5 mL of anesthetic will distend and blanch both folds and anesthetize the three branches of the dorsal nerve (Fig. 4A). The infusion and bleaching of the lateral nail fold resembles a wing as it progresses distally (17). l Blanching of the lateral part of the lunula is often noted. l Resistance to injection suggests that the needletip has penetrated some fibrous tissue such as ligament or the periosteum. Careful withdrawal of the needle will result in a free flow. l Because of some minor anatomic variation, it may be necessary to complete the procedure by an injection into the lateral nail fold up to the hyponychium to ensure complete anesthesia of the tip of the digit: the needle may be bent at 1208 and reinserted at the previously anesthetized site and pushed distally to the distal extremity of the lateral nail fold (Fig. 4B). 0.5 mL of anesthetic is deposited into the lateral nail fold in a retrograde motion (9). This will provide anesthesia of half of the nail apparatus. For complete anesthesia, the procedure should be repeated on the opposite side and the proximal nail fold should be infiltrated on its whole width. l The procedure requires about 1.5 mL/side. l When finished the entire digital tip appears swollen and white, creating a bloodless field for surgery (Fig. 5). l The volume load often acts as a “volumetric” tourniquet, creating a bloodless field rending

Figure 4 (A) Distal digital block, first step. (B) Distal digital block, lateral distal complement.

Figure 5 Blanching of the whole nail apparatus after completing a bilateral distal digital block.

l

some surgical procedures possible without the use of a real “mechanical” tourniquet. If more advanced surgery is planned (i.e., flaps), anesthesia of the ventral root is necessary: the

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needle is inserted at the initial puncture site and pushed downward skimming the lateral aspect of the phalanx, and 0.5 mL are injected into the pulp to anesthetize the ventral nerve roots. Matricial Block l This technique allows an immediate anesthesia of the proximal nail fold, the matricial area, and the proximal half of the nail bed. It is identical as intramatricial injection of steroids. l The needle punctures the skin in the midline of the proximal nail fold, about 5 to 7 mm proximal to the cuticle, bevel upward, at 608 from the surface of the proximal nail fold. l The needle is pushed forward until it touches the bone, then slightly withdrawn (1 mm backward). The anesthetic is very slowly injected, with progressive blanching of the lunula and the proximal nail bed (Fig. 6). l If reflection of the proximal nail fold is expected, infiltration of the junction of the lateral nail foldproximal nail fold is mandatory. Transthecal Digital Block l This technique involves a single palmar percutaneous injection of lidocaine into the space of the flexor tendon sheath, resulting in centrifugal anesthetic diffusion and complete anesthesia of the digital nerves of the finger (18). l This is the favorite block of the authors for intralesional injection of steroids at the nail apparatus and operations on nails of the index, middle, and ring fingers. l The mechanism of action of this procedure was revealed by study on cadavers: the injected

Figure 6

Matricial block.

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solution escapes from the flexor tendon sheath around the vincular vessels at the base and head of the proximal phalanx, flows smoothly through the perivascular loose areolar tissue, and then spreads alongside the digital nerve and vessels and their palmar and dorsal branches. After injection very little fluid remains inside the sheath (19). The procedure requires a small volume of plain lidocaine, has a rapid onset of anesthesia (3–4 minutes), and has a little risk of direct mechanical trauma to the neurovascular bundles because the needle is not placed in the vicinity of vascular and neural structures. This technique is only indicated for anesthesia of the index, middle, and ring fingers. Because of anatomic variations, it is not reliable at the first and fifth digits and toes. 3 mL of 2% plain lidocaine in a Luer Lock syringe with 27 G are used. With the hand supinated to expose its palmar aspect, the needle is inserted at the palmar digital crease, sharply through both flexor tendon and tendon sheath, straight to the bone, perpendicular to the volar skin. The needle is then withdrawn slowly away from the bone while gentle pressure is applied on the plunger of the syringe. While the needle tip lumen is against the bone or within the substance of the tendon, there is almost complete resistance to anesthetic flow. Immediately as the needle tip lumen clears the tendon on slow pullback of the needle, the anesthetic solution flows easily at low pressure into the tendon sheath. While injecting, pressure should be applied proximally to the site of puncture to promote the distal flow of the anesthetic (Fig. 7) (20).

Figure 7

Transthecal block.

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Immediately after infusion, the patient should keep his limb hanging downward to help diffusion of the anesthetic distally. Full block is obtained in about five minutes, and partial digit amputations have been performed without patient discomfort (19). A study comparing single injection transthecal block and traditional digital block for anesthesia of the finger has shown that these techniques are clinically equal in terms of time to anesthesia and visual-analog pain score (21).

Hyponychial Block l This block is painful and is not recommended. However, this technique should be known as a way to inject steroids intralesionally in the nail bed, after transthecal block for example. l A 30 G needle punctures the hyponychium, about 1 mm under the nail plate in the midline. The needle is pushed under the plate within the nail bed laterally to avoid hitting the distal phalangeal ungual process. l Fanning motions allow deposition of fluid wherever needed. l In some instances, because of a prominent ungual process, a more lateral approach is needed (3). KEY POINTS l Always take your time for performing anesthesia. Inject slowly. Talk to the patient (inducing the so-called talkesthesia). l Learn the time of action from your anesthetic and type of block. l Be patient when performing a proximal digital block or a transthecal block. Let your patient rest in a room and see another patient in the meantime. l Check the efficacy of your anesthesia before embarking on surgery. Do probing with some sharp instrument on both anesthetized and nonanesthetized areas: complete numbness of the anesthetized area will fully reassure the patient. EVOLUTION l Knowing the accurate length of your anesthesia according to the technique and anesthetic used, inform your patient about the appearance of postoperative pain and how to deal with it (see p. 19–21). l Plain 1% or 2% lidocaine will last for up to two hours.

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When bupivacaine is added either with the lidocaine or as a postoperative wing block, expect a numbness of about eight hours. Ropivacaine 2 mg/mL will act up to eight hours. Transthecal block with plain lidocaine will last up to six hours. The length of action of other blocks will depend on the anesthetic used.

TIPS Reducing Pain from the Needle Prick l Use very thin needles (30 G for fingers, 27 G for toes, 30 G for children at all sites). l The use of EMLA cream under occlusive, at least one hour prior to the local anesthesia, will alleviate the pain caused by needle insertion (22) but not the one from the swelling and deposition of the local anesthetic (23). l Ice packs, topical cryogen spray, cold air, etc. may reduce the discomfort from the pick (17). l Pressure and vibration at the expected site of injection for several minutes (around 5 minutes), may minimize the concurrent pain from the needle prick (24). This is particularly helpful in children and needle phobic patients. We routinely use a vibrating frog for children (Fig. 8), primarily dedicated for neck massage. Reducing Pain from Infusion of the Anesthetic l Inject extremely slowly, thus performing a very slowly progressive swelling of the soft tissues: the subungual space is limited and nonexpendable. l Lidocaine is acid. Its alkalinization (1 volume of bicarbonate for 9 volume of lidocaine) reduces pain during infusion (25). Addition of too much

Figure 8

Vibrating frog.

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sodium bicarbonate will result in a milky solution secondary to flocculation. This may impair the flow through the needle that may even become obstructed. Keeping the anesthetic out of the fridge or at body temperature in a water bath will render the infusion less painful.

COMPLICATIONS AND MANAGEMENT From the Anesthetic l It is not recommended to use epinephrine or ropivacaine in patients with vasospastic, thrombotic, or extreme medical conditions. l Prolonged ischemia may be reversed with nitroglycerin ointment or phentolamine injection (26). l Adding to much bicarbonate to buffer the lidocaine has been associated with necrosis (27). From the Technique l Proximal digital block: Complications are rare, but the major drawback is the potential hazard of injury to the digital neurovascular bundles, including direct trauma and spasm (28). Ignorance of the delay between anesthesia and surgery often leads to infusion of a large volume of anesthetic from repeated injections. This load of liquid may impair the lymphatic and venous blood flow and induce a painful edema at the operation site. l Distal digital block: Complications are exceptional. Local necrosis may be encountered in exceptional instances, mostly on one lateral nail fold (Fig. 9). This may result from a local vasospasm in patients with impaired blood supply of the limb, diabetes, or under blood thinners. As this condition is very painful, except in case of severe polyneuropathy, prescribe potent painkillers and check the wound at regular intervals. To avoid discomfort from retraction of the crust, keep the area humid with greasy antiseptic occlusive dressings. The necrosis will be eliminated in four to six weeks and will leave no scar. l Transthecal block: No complications have been reported from transthecal injections in the literature up to now (20). The theoretical risk of this technique is a possible flexor tendon sheath infection (strict asepsis is mandatory), tendon rupture or late occurrence of trigger finger. Pain at the site of injection 24 hours after injection may be observed in 50% of patients. It usually resolves in one day.

Figure 9 (A) Necrosis of the lateral wall in a diabetic patient four days after surgery. This was not even that painful because of the polyneuropathy. (B) Healing at four weeks. (C) Hemorrhage three days postoperatively in a patient taking warfarin.

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REFERENCES 1. Morgan AM, Baran R, Haneke E. Anatomy of the nail unit in relation to the distal digit. In: Krull EA, Zook EG, Baran R, et al., eds. Nail Surgery: A Text and Atlas. Philadelphia: Lippincott Williams & Williams, 2001: 1–28. 2. Zook EG, Baran R, Haneke E, et al. Nail surgery and traumatic abnormalities. In: Baran R, Dawber RPR, de Berker DAR, et al., eds. Nail Diseases and Their Management. Oxford: Blackwell Scientific Publications, 2001:425–514. 3. Abimelec P. Tips and tricks in nail surgery. Semin Cutan Med Surg 2009; 28:55–60. 4. Sylaidis P, Logan A. Digital blocks with adrenaline. An old dogma refuted. J Hand Surg Br 1998; 23:17–19. 5. Thomson CJ, Lalonde DH, Denkler KA, et al. A critical look at the evidence for and against epinephrine use in the finger. Plast Reconstr Surg 2007; 119:260–266. 6. Sylaidis P, Logan A. Epinephrine in digital blocks: revisited. Ann Plast Surg 1999; 43:572. 7. Whilelmi BJ, Blackwell SJ, Miller JH, et al. Do not use epinephrine in digital blocks: myth or thruth? Plast Reconstr Surg 2001; 107:393–397. 8. Andrades PR, Olguin FA, Calderon W. Digital blocks with or without epinephrine. Plast Reconstr Surg 2003; 111:1769–1770. 9. Richert B. Anesthesia of the nail apparatus: techniques and tips. Dermatol Online 2005; 11(1). 10. Reichl M, Quinton D. Comparison of 1% lignocaine with 0.5% bupivacaine in digital ring blocks. J Hand Surg Br 1987; 12:375–376. 11. Peng PW, Coleman MM, McCartney CJ, et al. Comparison of anesthetic effect between 0.375% ropivacaine versus 0.5% lidocaine in forearm intravenous regional anaesthesia. Reg Anesth Pain Med 2002; 27:595–599. 12. Moffit DL, de Berker DAR, Kennedy CTK, et al. Assessment of ropivacaine as a local anaesthetic for skin infiltration in skin surgery. Dermatol Surg 2001; 27:437–440. 13. Fayman M, Beeton A, Potgieter E, et al. Comparative analysis of bupivacaine and ropivacaine for infiltration analgesia for bilateral breast surgery. Aesthetic Plast Surg 2003; 27:100–103. 14. Gherardini G, Samuelson U, Jernbeck J, et al. Comparison of vascular effect of ropivacaine and lidocaine on

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20. 21.

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isolated rings of human arteries. Acta Anaesthesiol Scand 1995; 39:765–768. Salashe S. Surgery. In: Scher RK, Daniel CD, eds. Nails: Therapy, Diagnosis and Surgery. Philadelphia: Saunders, 1990:258–280. Dialynas M, Hollingsworth S, Cooper D, et al. Use of a needleless injection system for digital ring block anesthesia. J Am Podiatr Med Assoc 2003; 93:23–26. Jellinek NJ. Nail surgery: practical tips and treatment options. Dermatol Ther 2007; 20:68–74. Chiu DT. Transthecal digital block: flexor tendon sheath used for anesthetic infusion. J Hand Surg Am 1990; 15A:471–473. Whetzel TP, Mabourakh S, Barkhordar R. Modified transthecal digital block. J Hand Surg Am 1997; 22A:361–363. Torok PJ, Flinn SD, Shin AY. Transthecal digital block at the proximal phalanx. J Hand Surg Br 2001; 26:69–71. Hill RG, Patterson JW, Parker JC, et al. Comparison of transthecal digital block and traditional block for anesthesia of the finger. Ann Emerg Med 1995; 25:604–607. Browne J, Fung M, Donnely M, et al. The use of EMLA reduces the pain associated with digital ring block for ingrowing toenail correction. Eur J Anaesthesiol 2000; 17:182–184. Serour F, Ben-Yehuda Y, Boaz M. EMLA cream prior to digital nerve block for ingrown toenail surgery does not reduce pain at injection of anesthetic solution. Acta Anaesthesiol Scand 2002; 46:203–206. Smith KC, Comite SL, Balasubramanian S, et al. Vibration anesthesia: a non-invasive method of reducing discomfort prior to dermatologic procedures. Dermatol Online J 2004; 10(2):1. Cornelius P, Kendall J, Meek S, et al. Alkalinisation of lignocaine to reduce the pain of digital nerve blockade. J Accid Emerg Med 1996; 13:339–340. Aycock BG, Hawtof DB, Moody SB. Treatment of peripheral ischemia secondary to lidocaine containing epinephrine. Ann Plast Surg 1989; 23:27–30. Fays-Michel S, Vieu C, Tre´chot P, et al. Cutaneous necrosis following ambulatory phlebectomy: the role of sodium bicarbonate used in local anesthesia. Ann Dermatol Venereol 2007; 134:76–77. Flarity-Reed K. Methods of digital block. J Emerg Nurs 2002; 28:351–354.

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Surgery of the nail plate Bertrand Richert

The nail plate, commonly called “the nail,” is a platelike keratinous structure, which is exclusively formed by the matrix. It has several functions: it exerts a counterpressure against the upward force of the pulp—thus allowing a fine prehension—and protects the distal phalanx. The nail constitutes a very useful tool, but also is an awesome weapon. It is a very passive structure as its alterations may come from any surrounding structure (matrix, bed, proximal nail fold, etc.) or from any exogenous cause (infection, color, trauma, etc.). NAIL PLATE BIOPSY Indications l Confirm or exclude a fungal origin of a nail dystrophy. l Distinguish melanin pigmentation from hemosiderin. l Differential diagnosis of onychomycosis and ungual psoriasis often possible. Anesthesia l Not necessary except for proximal subungual onychomycosis. Reassure the patient as in some instances the procedure may be uncomfortable. l For proximal subungual onychomycosis, best choice is matricial block but bilateral distal digital block is another good option. Tools l Dual action nail nippers l Curette l 4 mm punch l Scalpel with No. 15 blade Surgical Procedure Technique: easy As for the exploration of a black/brown pigmentation of the nail, a simple nail clipping of the pigmented plate at the free edge is sufficient. In fungal infection, the procedure will depend on the type of onychomycosis (1). Distal lateral subungual onychomycosis (DLSO): First, remove the nail plate using the nail nippers. Then curette the subungual debris, especially in the

most proximal part (where viable hyphae are located) for mycological culture. For histopathology of the nail, try to cut the nail together with as much of the subungual hyperkeratosis as possible. Indicate that you want the confirmation of a fungal infection, which requires a periodic acid-Schiff stain. Superficial white onychomycosis (SWO): Remove the leukonychia by scratching the surface of the nail plate using the curette, or carve a thin slice of nail from its surface. Proximal subungual white onychomycosis (PSWO): After local block, the whitish proximal part of the nail plate is sampled using a 4-mm punch. Another option is to cut successive thin slices of infected nail plate using a scalpel. Total dystrophic onychomycosis (TDO): Removal of as much of material (nail plate) as possible using dual action nail nippers and curette. Complications and Management The only risk may be encountered when punching the proximal nail plate in PSWO. The risk of injuring the underlying matrix is quite limited. If it anyway occurs, the postoperative surgical dystrophy is barely visible as the nail plate biopsy is performed in the area of the lunula (distal matrix producing the undersurface of the nail plate, see chap. 10). NAIL PLATE AVULSION Removing a whole nail plate is not a benign procedure as thought by many physicians. This procedure will never cure a nail by itself, except in retronychia (2), if not associated with some systemic treatment (i.e., onychomycosis) or added surgical procedure (i.e., removal of a tumor). Moreover, total nail plate avulsion may be associated with some postoperative morbidity (see pp. 32–34). For this reason, whenever possible, partial plate avulsion or total nail avulsion with plate replacement is preferable to total plate avulsion. Tailoring nail plate avulsion for each patient’s clinical presentation is a must. It requires forethought and understanding of nail anatomy, histology, and potential disease processes and neoplasms of the nail unit. The choice should take into account the facility of a successful surgery while minimizing artifacts, complexity, anatomic trauma, and postoperative morbidity (3).

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TOTAL NAIL AVULSION: DISTAL APPROACH Indications l Exposure and surgical removal of onychomatricoma (see “Onychomatricoma,” pp. 118–120). l Removal of a dermatophytoma in a TDO. Anesthesia l

Distal digital block.

Tools l Nail avulsion tray. l Hemostatic solution (aluminium chloride 35%).

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Key Point l Freeing the corners of the plate from the lateral horns of the matrix. Postoperative Care Postoperative pain: little l

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Surgical Procedure Technique: easy l

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The proximal nail fold (PNF) is freed on its whole width from its attachments from the underlying nail plate, with back-and-forth motions of the elevator. Orient the instrument to adapt its curve to that of the nail plate (Fig. 1A). The elevator is then placed under the free edge and gently pushed proximally under the plate, toward its base, to detach it from the underlying bed (Fig. 1B). The instrument is used with a firm pushing motion while maintaining the dorsal pressure vector toward the overlying ventral plate. The most adherent connection between the nail plate and the bed exists distally at the onychodermal band, just proximal to the hyponychium. Once this attachment loosens, less pressure is required to advance the instrument (3). The sensation of release or “give” means that the instrument has reached the matrix area to which the nail plate is loosely attached. Repeat the procedure on the whole width of the nail bed using only back-and-forth motions (Fig. 1C). Pay attention to carefully detach the lateral horns of the nail plate, by pushing the elevator laterally (Fig. 1D), as the nail plate adheres firmly to them. Slide a jaw of a sturdy hemostat under the lateral border of the nail plate and grasp it along its entire length (Fig. 1E). An upward rotating motion avulses the nail plate from one side to the other (Fig. 1F). If the nail resists to removal, never force! This means failure to free the corners of the plate from the lateral horns of the matrix. Reinsert the elevator beneath the nail plate to focus the effort on freeing these areas by pushing the elevator to the outside. Avulsion is then easy.

Compression for 10 to 20 seconds, with cottontipped applicators dipped into hemostatic solution, suffices to stop any bleeding.

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Cover the nail bed with a large amount of antiseptic ointment and a tulle gras. Apply several layers of gauze, both for protection and absorption of serum and blood. Perform a bulky dressing with elastic gauze bands, securing the dressing either to the wrist or to the ankle.

Complications and Management l Loss of counterpressure induced by the disappearance of the nail plate allows dorsal dislocation of the distal pulp and promotes distal embedding with a subsequent hyperkeratotic reaction (impacted nail) (Fig. 2). If the patient is asymptomatic or complains of minor discomfort, conservative treatment is indicated: reducing the hyperkeratosis in front of the distal nail by using 50% urea occlusive dressing at night and debridement of the hyperkeratosis with a blade. Massaging back in a distal-plantar direction is recommended. Consistent taping is a very valuable alternative. If there is severe pain, then surgery is mandatory to free the distal edge of the plate (4) (see “Distal Embedding,” pp. 97–100). As prevention of such a complication, an acrylic nail may be affixed to the new growing nail (5) when it has reached one-third of its length. However, the upward force exerted by the pulp during gait often detaches the artificial nail (4). l In the setting of matrix surgery, scarring from the PNF may be responsible for pterygium. For this reason, when removing an onychomatricoma, as the nail plate cannot be replaced, it might be advisable to push some tulle gras under the PNF and to secure it with some stitches to the lateral nail folds for two weeks to avoid any potential adherence between the naked operated matrix and the ventral part of the PNF (Fig. 3). Using a nail substitute made from a 10 or 20 mL syringe is a valuable alternative (6). l Forcing an elevator may injure the hyponychium and/or destroy the distal nail bed.

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Figure 1 (A) The proximal nail fold is detached from the plate by repeated back and forth motions of the elevator. (B) The elevator is inserted under the free edge of the plate and pushed proximally until it gives way. (C) The procedure is repeated along the whole width of the plate. (D) Carefully detach the lateral horns of the plate. (E) A jaw of a sturdy hemostat is inserted under the plate and grasp it. (F) An upward rotation motion avulses the plate.

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determine the cleavage plane between the nail plate and the nail bed. Anesthesia l Distal digital block. Tools l Nail avulsion tray. l Hemostatic solution (aluminium chloride 35%). Surgical Procedure Technique: intermediate to difficult Figure 2 Distal embedding following nail avulsion for retronychia.

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Figure 3 A tulle gras is slid under the proximal nail fold and secured with two stitches.

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Never perform lateral movements with the elevator as this may injure permanently the fragile longitudinal ridges of the nail plate with subsequent permanent onycholysis. For the same reasons, never detach the nail plate using repeated openings and closures of scissors.

TOTAL NAIL AVULSION: PROXIMAL APPROACH Indications l This approach is recommended when the distal hyperkeratosis is severe (thick dermatophytoma, pachyonychia) or when the nail plate firmly adheres to its bed (i.e., retronychia, some dermatophytoma), rendering it difficult to

The PNF is detached on its whole width, using anteroposterior movements of the elevator (Fig. 4A). The elevator then reflects the PNF and is delicately inserted under the base of the nail plate where adherence to the matrix is weak. This might be difficult (Fig. 4B). The procedure is repeated along the whole width of the plate. The avulsion progresses distally following the natural cleavage plane (Fig. 4C). The procedure is repeated on the entire width of the nail bed. The nail plate is elevated (Fig. 4D) or grasped with a sturdy hemostat, and its last distal subungual attachments are freed with scissors. Compression for 10 to 20 seconds, with cottontipped applicators dipped into hemostatic solution suffices to stop any bleeding (Fig. 4E).

Key Point l Inserting the elevator under the nail plate and finding a cleavage plane. Postoperative Care Pain: little l Cover the nail bed with a large amount of antiseptic ointment and a tulle gras. l Apply several layers of gauze, both for protection and absorption of serum and blood. l Perform a bulky dressing with elastic gauze bands, securing the dressing either to the wrist or to the ankle. Complications and Management l Loss of counterpressure induced by the disappearance of the nail plate allows dorsal expansion of the distal pulp and promotes distal

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Figure 4 (A) The elevator detaches the proximal nail fold from the plate. (B) The elevator reflects the proximal nail fold and is pushed distally. (C) The avulsion progresses distally, either with the elevator or with the help of a hemostat. (D) Late phase of avulsion. Sometimes, section of the last subungual attachments with scissors is needed. (E) Hemostasis with cotton-tipped applicators dipped into hemostatic solution.

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embedding with a subsequent hyperkeratotic reaction (impacted nail) (Fig. 2). If the patient is asymptomatic or complains of minor discomfort, conservative treatment is indicated: reducing the hyperkeratosis in front of the distal nail using 50% urea occlusive dressing at night and debridement of the hyperkeratosis with a blade. Massaging back in a distal-plantar direction is recommended. If there is severe pain, then surgery is mandatory to free the distal edge of the plate (4) (see “Distal Embedding,” pp. 97–100). Forcing the elevator in an inappropriate plane may injure the matrix or destroy the distal nail bed with subsequent nail dystrophy or onycholysis.

TOTAL NAIL AVULSION WITH PLATE REPLACEMENT During avulsion, some nail bed or matrix keratinocytes remain attached to the ventral aspect of the avulsed nail. This is clearly seen on histologic slides. It is thought that replacing the avulsed plate with this material acts as a split-thickness graft on the bed, thus enhancing healing (7). After surgery of the exposed structures, the plate is laid back on its bed and secured to the lateral nail folds. This procedure, for some unknown reasons, offers a less painful postop to the patient.

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When the elevator gives way, this means that it has reached the matrix area to which the nail plate is loosely attached (9). This anterior-posterior movement is repeated several times from one side of the nail plate to the other. Then caution must be taken to detach the lateral horns of the plate by pushing firmly the elevator in the posterolateral angles. The plate is grasped with a hemostat and lifted upward like a trap door or the hood of a car (Fig. 5A). However, it might be difficult to reach the most proximal part of the bed and the distal matrix with the instruments. To gain a bit more of exposure and ease in the manipulation of the instruments, two oblique incisions in the

Trap Door Avulsion Indications l Visualization of the hyponychium, nail bed, and distal matrix (Fig. 5A) (8). l Useful procedure for removal of longitudinal erythronychia, onychopapilloma, or tumors of the bed. Tools l Nail avulsion tray l Basic nail surgery tray Surgical Procedure Technique: easy l

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The avulsion starts by undermining the free edge of the nail plate with the elevator and applying firm pressure dorsally to the ventral nail plate to avoid trauma to the hyponychium. The instrument is pushed proximally while maintaining the dorsal pressure upward. The most adherent connection between the plate and its bed is located distally then loosens in the middle part of the bed (3).

Figure 5 (A) Trap door avulsion exposing the whole nail bed. Note the exostosis lifting up the bed. (B) After removal of the exostosis, the nail is put back in place and secured to the distal wall. Two holes performed with a 3-mm punch will allow drainage of any potential hematoma.

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proximal nailfold will release lateral restraint on the reflected plate (3). After exploration, biopsy, or removal of a tumor, the nail is put back in place and sutured to the lateral nail folds or the distal wall (Fig. 5B). Simple stitches are effective and enough. More complicated securing of the plate to the lateral folds (10) is possible but is not more effective.

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Surgical Procedure Technique: easy l

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Key Point l Freeing the lateral horns of the plate. Postoperative Care l Bulky greasy antiseptic dressing. Evolution l The stitches should be removed after three weeks. l The nail may remain on site or will be shed after several weeks or even months. The patient should be instructed to keep the plate short and secured with adhesive tape as long as possible.

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The nail plate is detached from its bed by distal to proximal movements of the elevator as performed for the distal approach of total nail avulsion (see above) according to the area to be exposed. Then, a jaw of a straight hemostat is slid under the detached lateral aspect of the plate. The whole length of the plate is clamped and rolled away from the lateral sulcus, somewhat like opening a can of sardines (3) (Fig. 6A). The nail can be curled as much or little as needed to achieve adequate exposure of the underlying tissues. If the cul-de-sac needs to be exposed, the procedure starts with one or two lateral incisions at the corner of the lateral and PNF. After lateral curling of the plate, the PNF is lifted dorsally with fine

Complications and Management l If the nail is shed, the patient should be instructed to keep the nail, to put it back in place, and secure it with adhesive tape for as long as possible to prevent distal embedding. The tape should be changed at regular intervals and the undersurface of the plate gently brushed with some antiseptic soap. l Distal embedding remains exceptional with this procedure as the avulsed nail will continue to exert a counterpressure force on the distal pulp for some weeks. Curled Nail Avulsion Indications l This procedure offers complete exposure of the whole length of the nail bed and hyponychium, on a partial or whole width, with great ease for handling instruments. l When associated with reflection of the PNF, the whole nail apparatus including the most proximal structures are visible and easily reachable. Tools l Nail avulsion tray l Basic nail surgery tray l Fine-skin hooks

Figure 6 (A) Curled nail avulsion exposing the whole nail bed with its Bowen’s disease. (B) After Mohs’ surgery, the plate is laid back and secured to the lateral and distal wall.

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skin hooks, allowing then complete exposure of the cul-de-sac containing the proximal matrix. Key Point l To roll easily the plate laterally, the lateral horn of the plate has to be freed completely. l Grasp the whole length of the plate in the hemostat, otherwise the plate may be torn in its thinnest proximal part. l After biopsy or removal of what was the reason for avulsion, the nail plate is put back in place. If the PNF was not reclined, the most proximal part of the plate is slid under the PNF using the elevator. The plate is secured to the lateral nail fold and to the distal wall. This last stitch will push the plate backward, keeping the plate in the cul-de-sac (Fig. 6B). If the PNF was reflected, the lateral incisions are closed with one simple stitch. l When replacing the plate it might be helpful to trim the free lateral edge of the nail by approximately 1 mm to minimize lateral embedding with postoperative edema (3). Postoperative Care l Greasy antiseptic bulky dressing. Evolution l The stitches should be removed after three weeks. l The nail may remain on site or will be shed after several weeks. The patient should be instructed to keep the plate short and secured with adhesive tape as long as possible. Complications and Management l If the nail is shed, the patient should be instructed to keep the nail, to put it back in place, and secure it with adhesive tape for as long as possible to prevent distal embedding. The tape should be changed at regular intervals and the undersurface of the plate gently brushed with some antiseptic soap. l Distal embedding remains exceptional with this procedure as the avulsed nail will continue to exert a counter pressure force on the distal pulp for some weeks. PARTIAL NAIL AVULSION The considerable advantage of partial surgical nail avulsion is that a large portion of the normal plate will remain in place, exerting a pressure on the underlying tissues, reducing the risk of distal embedding (8). Onycholytic distal portions of the nail plate may be removed without anesthesia in most instances when using an adequate nail nipper not forcing on the lateral adherent edges.

Indications l Partial avulsion is required in the treatment of some types of onychomycosis (longitudinal streaks, lateral disease, onycholysis, dermatophytoma, onychomycosis caused by molds). l Partial avulsion is part of many surgical procedures such as partial matricectomies (see “Removal of a Spicule,” pp. 110–112), treatment of acute paronychia (see “Acute Paronychia,” pp. 42–43), or removal of longitudinal melanonychia (see “Excision of Longitudinal Melanonychia,” pp. 124–131). Anesthesia l Distal digital block. l Proximal block or transthecal block for acute paronychia. Tools l Nail avulsion tray Surgical Procedure Technique: easy, except for partial proximal avulsion, difficult l

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It is performed in the same manner as the distal approach of total nail avulsion, but restricted to a portion of the nail plate. The portion of nail plate to be avulsed is freed from its bed attachment by inserting the elevator under the plate (Fig. 7A). The latter is sectioned to the desired size with fine scissors (11) or fine nail clippers to avoid inducing any lateral onycholysis (Fig. 7B). Bleeding is stopped with hemostatic solution. Various shapes of partial avulsion are possible.

Evolution l The avulsed portion of nail will regrow normally with the nail’s growth. l In the setting of nail matrix surgery, the nail may not regrow with a full normal aspect according to the type of matrix surgery performed. Complications and Management l If the avulsion involves the whole width of the plate, distal embedding may occur in some instances. l Proximal partial avulsion without matrix surgery (i.e., in acute paronychia) will be followed by a fully normal regrowth of the nail without any risk of distal impaction as the distal nail will remain in place and will continue to grow out progressively.

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Proximal partial avulsion with matrix surgery may be followed with a regrowth of a modified nail (thinner nail, split nail, loss of luster, dystrophic nail) according to the type of surgery performed on the matrix. Lateral nail avulsion associated with destruction of the corresponding matrix area will not show any trouble during regrowth unless incomplete removal of the matrix. Lateral nail avulsion without destruction of the matrix (i.e., lateral onychomycosis) may be associated with a lateral ingrowing toenail as the corner from the new healthy nail grows out. In all these potential secondary ingrowing nails, treatment is conservative: taping and acrylic nails are excellent indications (5).

PARTIAL NAIL AVULSION WITH PLATE REPLACEMENT In the majority of cases, partial nail avulsion is not associated with plate replacement as the avulsed nail is kept for mycologic investigations (dermatophytoma) or the partial avulsion is therapeutic (see “Acute Paronychia,” pp. 42–43) or corresponding matrix and bed are chemically or physically destroyed (ingrowing toenail) or the partial avulsion is too small to be put back in place. There is however a very important case where the plate has to be put back in place: the partial proximal nail plate avulsion for exploration and treatment of longitudinal melanonychia (see “Excision of Longitudinal Melanonychia, pp. 124–131) Partial Proximal Nail Avulsion with Plate Replacement Indication l Exposure of the whole cul-de-sac and matrix. l Removal of the origin of a longitudinal melanonychia. Anesthesia l Matricial block Tools l Nail avulsion tray l Basic nail surgery tray Figure 7 (A) The elevator detaches the part of nail plate to be removed. (B) The detached portion of nail plate is clipped away. (C) Hemostasis.

Surgical Procedure Technique: difficult l

Two lateral incisions at the corner of the proximal and lateral nail folds allow reflection of the dorsal nail fold.

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Proximal avulsion starts on one lateral side of the nail plate, approximately 5 mm ahead of the distal lunula. A jaw of a nail splitter is inserted in the lateral sulcus under the lateral side of the plate. The plate is cut horizontally from one side to the other. A jaw of a straight hemostat is slid under the lateral proximal portion of the nail plate and clamped. The plate is lifted laterally, exposing the distal matrix and the most proximal part of the bed. Avulsion is easy as the plate is very loosely attached to the matrix. Reflection of the PNF with fine-skin hooks allows visualization of the whole matrix and cul-de-sac (Fig. 8A).

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After surgery on the matrix, the plate is laid back in place and secured to the lateral nail fold (Fig. 8B).

Key Point l Sliding the jaw of the nail splitter or nipper under the lateral side of the nail plate. Evolution l Amazingly, replacing the plate renders the postoperative very comfortable for the patient. l Stitches are removed after three weeks. The patient should be instructed to keep the plate in place using adhesive tape as long as possible. l The avulsed nail is usually shed in several weeks or even months. l The proximal part of the nail continues to grow out normally and has to be trimmed regularly. Complications and Management l This type of partial avulsion is not associated with distal embedding as the distal part of the plate remains in place and grows out normally. l To minimize potential lateral embedding it might be indicated to trim the free lateral edge of the plate by approximately 1 mm (3). Partial Longitudinal Nail Plate Avulsion with Plate Replacement Indication l Exposure of longitudinal strip of nail bed and distal matrix for removal of a longitudinal tumor Anesthesia l Matricial block Tools l Nail avulsion tray l Basic nail surgery tray Surgical Procedure Technique: easy l

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Figure 8 (A) Proximal nail plate avulsion exposing the whole matrix area. (B) After removal of the pigmented lesion, the plate is put back in place and secured to the lateral folds.

The elevator is inserted under the distal edge of the nail plate and pushed proximally to detach its subungual attachments. The procedure is repeated as many times as necessary to detach the adequate portion of plate. The detached strip of plate is clipped longitudinally with straight nail nippers without entering under the PNF, leaving thus the most proximal part of the nail plate as a whole.

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Complications and Management l This type of partial avulsion is not associated with distal embedding as the rest of the plate will act for counterpressure.

REFERENCES

Figure 9 Partial longitudinal nail plate avulsion for removal of an onychopapilloma. The detached strip of nail will be put back in place and secured with adhesive tape. l

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Using a small hemostat, the plate is lifted up to expose the corresponding bed and distal matrix. After biopsy of removal of what pushed to avulsion, the strip of nail is laid back in place and secured either with one stitch into the lateral nail fold or with adhesive strips.

Key Point l Avoiding clipping the nail to its most proximal part, which would render the replacement impossible. l Working in between narrow edges (Fig. 9) is sometimes difficult, especially when suturing. Evolution l The strip of nail will detach several days or weeks after removal of the suture. Try to keep it on site as long as possible with circular adhesive tape. At that time, the underlying wound will be healed.

1. Baran R, Hay R, Haneke E, et al. L’examen mycologique et histopathologique. In: Baran R, Hay R, Haneke E, et al., eds. Onychomycosis. 2nd ed. London: Informa, 2006:53–74. 2. de Berker DA, Richert B, Duhard E, et al. Retronychia: proximal ingrowing of the nail plate. J Am Acad Dermatol 2008; 58:978–983. 3. Collins SC, Cordova K, Jellinek NJ. Alternatives to complete nail plate avulsion. Dermatol Surg 2008; 59:619–626. 4. Richert B, Dahdah M. Complications in nail surgery. In: Noury K, ed. Complications in Dermatologic Surgery. Philadelphia: Mosby Elsevier, 2008:137–158. 5. Arai H, Arai T, Nakajima H, et al. Formable acrylic treatment for ingrowing toenail with gutter splint and sculptured nail. Int J Dermatol 2004; 43:759–765. 6. Koenen W, Haneke E, Schmieder A, et al. Nail substitute with a syringe splint. J German Soc Dermatol 2010; 8:63–64. 7. Haneke E, Baran R. Longitudinal melanonychia. Dermatol Surg 2001; 27:580–584. 8. de Berker DAR. Trap door nail avulsion to minimise trauma in nail surgery when accessing the nail bed and matrix. Br J Dermatol 2006; 155(suppl1):100. 9. Richert B. Basic nail surgery. Dermatol Clin 2006; 24:313–322. 10. Bristol SG, Verchere CG. The transverse figure-of-eight suture for securing the nail. J Hand Surg Am 2007; 32A:124–125. 11. Abimelec P, Dumontier C. Basic and advanced nail surgery. In: Scher RK, Daniel CR 3rd, eds. Nails: Diagnosis, Therapy, Surgery. 3rd ed. Philadelphia: Elsevier Saunders, 2005:265–289.

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Surgery of the proximal nail fold Eckart Haneke, Bertrand Richert, and Nilton Di Chiacchio

The proximal nail fold (PNF) covers and protects most of the matrix and the newly formed nail plate. The pocket formed by the PNF is called the proximal nail groove. Its most proximal part is named the culde-sac. The most distal part of the PNF forms an acute angle, giving rise to the cuticle, adhering to the plate, and sealing the proximal groove. Disruption of this seal is responsible for inflammatory and infectious disease of the PNF. ACUTE PARONYCHIA Introduction l The term acute paronychia refers to an acute and abrupt inflammation of the proximal nail fold (PNF). It is a real nail emergency. In almost all instances it results from a minor trauma to the PNF enabling bacterial inoculation (1), evolving rapidly toward pus collection. As there is currently no evidence that oral antibiotics are any better or worse than drainage (2) the following attitude may be suggested. If empiric medical treatment (antistaphylococcal antibiotics) fails after 48 hours in adults or 24 hours in children it is highly recommended to perform a surgical cure of the condition both for therapeutic (alleviation of pain and permanent dystrophy) and diagnostic purposes (sampling and culture of pus). This is especially mandatory in children where the matrix is very fragile. l Differential diagnosis includes herpes simplex where pus collection is observed later but instead coalescent clusters of small vesicules, which are clear in the beginning. Herpetic whitlow is less rare than often estimated, as many cases are misdiagnosed as a paronychial felon and treated with systemic antibiotics and healing occurs from spontaneous healing. A diagnostic clue for a digital herpes simplex is disproportionate pain and early lymphangitis.

recommended for obvious reasons: (i) the prick of the needle will cause an unbearable pain in the inflamed area, (ii) the infection may be propagated, and (iii) the anesthetic will not diffuse properly in the tissue because of the edema and will not be effective because of the more acid pH of the inflamed tissue. Therefore, it is advisable to perform either a proximal digital block or a transthecal block. Tools l Nail avulsion tray. l Swab for bacterial culture. Surgical Procedure Technique: easy l

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Anesthesia l For bulla repens, or runaround, no anesthesia is necessary. l Because of the infectious process within the paronychium, a distal wing block is not

In case of a bulla repens (runaround), the epidermis is cut away with curved pointed scissors and the wound generously rinsed with an antiseptic solution. Never perform any incision on the PNF as this may injure the underlying matrix. Best treatment is achieved with avulsion of the proximal third of the nail plate, as it will allow drainage of pus, and then irrigation of the whole cul-de-sac and its lateral corners (Fig. 1A,B). The elevator is inserted under the PNF, which usually releases the pus from the cul-de-sac that is collected for culture. Proximal avulsion starts on one lateral side of the nail plate, approximately at the level of the distal lunula. As this part of the nail is loosely attached to the matrix (and even sometimes less from the dissection by the pus) the nail plate may be split transversally by inserting a jaw of a nail splitter under the lateral side of the plate. This procedure will limit the risk of injuring the matrix already weakened by the infection. Irrigation of the exposed cavity with antiseptic solution completes the procedure.

Key Point l Sliding the jaw of the nail splitter under the lateral side of the nail plate

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Figure 1 (A) Acute paronychia. The collection of pus is visible throughout the proximal nail fold. (B) Avulsion of the proximal third of the plate allows immediate drainage of the pus.

Postoperative Care Postoperative pain: very little l

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Antiseptic ointment (i.e., fusidic acid, mupirocin, etc.) is applied to fill the cavity and covered with a nonadherent dressing (tulle gras, Teflon-coated gauze, etc.) and several layers of gauze. The limb should be elevated for 48 hours. At time of the removal of the dressing, the antibiogram is available and the antibiotic therapy is adapted. Local treatment (antiseptics) should be performed for about one week.

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allergens, and primary irritants that maintain the inflammatory process. Before embarking on surgery, other causes [i.e., psoriasis, lichen planus, leukemia, hanseniasis (leprosy), retinoids] should be ruled out (3). Chronic paronychia defines a long-standing inflammation of the paronychium, especially the PNF, resulting in a swollen cushion around the base of the nail with subsequent disappearance of the cuticle and progressive separation of the PNF’s undersurface from the nail (Fig. 2).

Evolution l The distal nail will remain attached to the nail bed and will continue its linear growth until complete distal elimination. The new nail follows about 1 cm behind. Complications and Management l None unless late treatment that may be responsible for permanent nail scarring. CHRONIC PARONYCHIA Introduction l Chronic paronychia is an inflammatory disorder that involves one or more of the three nail folds and that lasts for more than six weeks. It affects more commonly women (3). l Its etiology is multifactorial. The role of Candida albicans has been questioned in recent years. Recurrent trauma from manicure, frequent contact with water, and exposure to chemical agents lead to the separation of the cuticle from the nail plate opening the cul-de-sac to microorganisms,

Figure 2 Chronic paronychia. Note the swelling of the proximal nail fold and the loss of the cuticle.

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Figure 3 Chronic paronychia. Note that there is, added to the swelling of the proximal nail fold and the loss of the cuticle, nail plate alteration and chromonychia.

Figure 4 Drawing showing the incision lines for removal of the proximal nail fold (whatever the technique) in chronic paronychia.

The nail plate often shows short transverse lines along a brownish longitudinal streak (Fig. 3). Intermittent (sub)acute episodes with painful pus collection are frequent (4). Treatment of early chronic paronychia should be conservative: avoidance of predisposing factors and use of potent topical steroids or even intralesional steroids (5). For recalcitrant or advanced stages, surgical treatment is indicated and consists in en bloc excision of the thickened PNF (5,6).

matrix underlying the very thin nail plate resting at the most proximal part of the cul-de-sac. The PNF is excised in a crescent-shaped fullthickness skin; 5 mm in its maximum width, extending from one lateral nail fold to the other. The incision should also take away the five most proximal millimeters of the lateral nail folds (Fig. 4). The excision may be performed with the blade perpendicular or oblique to the surface of the PNF. When the blade is perpendicular to the surface of the PNF, the blade runs from one lateral nail fold to the other (Fig. 5), removing the whole thickness of the PNF (Fig. 6). As the scalpel progresses, the elevator should be moved accordingly avoiding that the tip of the blade injures the underlying matrix. The oblique technique should be favored as it avoids removing too much of the ventral aspect of the PNF that is responsible for the normal shine of the nail plate (5–7). The incision line is the same as previously described (Fig. 7) but only the roof of the PNF is removed and the floor remains on site (Fig. 8). As the risk of injuring the matrix is very unlikely, protection of the undersurface of the PNF during the oblique resection is not mandatory.

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Anesthesia l Proximal or distal wing block l Transthecal block is another option Tools l Nail elevator l Blade No. 15 or 15C (better) l Curette 2 mm l Tourniquet Surgical Procedure Technique: intermediate l l

A tourniquet is placed. An elevator is inserted under the PNF to detach the PNF from the nail plate and to protect the

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Figure 5

Perpendicular excision of the proximal nail fold.

Figure 6 removed.

Figure 7

Oblique excision of the proximal nail fold.

Figure 8 After oblique excision, the floor of the proximal nail remains on site.

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Using a small curette (2 mm) or a gauze to gently clean the undersurface of the PNF may complete the procedure. The tourniquet is removed.

Key Point l The oblique incision should always be preferred. l Removing the most proximal 5 mm of the lateral nail folds. l Protecting the matrix through all the procedure.

The whole thickness of the proximal nail fold is

Postoperative Care Postoperative pain: very little l

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Antiseptic ointment is applied to the surgical wound and covered with nonadherent gauze and a bulky dressing. Paracetamol and elevation of the limb for one day. The dressing is removed after one day, the wound is washed with water and antiseptic soap twice a day and covered with a greasy ointment.

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Evolution l Healing is fast: epithelialization occurs within 10 days and the cuticle regrows and attaches to the nail plate in less than two months. l The nail plate alteration is replaced by a normal nail plate with the nail growth. l The PNF is usually slightly retracted giving rise to a longer nail (more lunula is visible).

Complications and Management l Complications are uncommon. l Nail dystrophy may appear if the nail matrix is injured.

NAIL SURGERY

CRESCENT EXCISION Introduction l Diagnosis of alterations of the free margin of the PNF, particularly for the histopathological diagnosis of collagen vascular diseases (8,9). l Treatment/reduction of a fibrotic, swollen PNF (chronic paronychia). l Very distally located myxoid pseudocyst (10–12) (Fig. 9A). Anesthesia l Proximal digital block, transthecal anesthesia, or bilateral distal digital block. l If the PNF is not too inflammatory or painful, a matricial block is a good option.

Figure 9 (A) Very distal myxoid pseudocyst. (B) Matricial block. Drawing of the incision. (C) Crescentic excision removing the myxoid pseudocyst. (D) Side view showing the oblique incision.

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Tools l Scalpel with No. 15 blade l Adson toothed forceps l Optional: hemostyptic agent or electro-/radiofrequency cautery Surgical Procedure Technique: easy l

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The incision runs from one lateral nail fold to the other, reaching its maximum width (maximum 5 mm) in the midline of the PNF. The incision should include the five most proximal millimeters of the lateral nail folds (Fig. 9B). The scalpel blade is held obliquely and a narrow piece of the free margin of the PNF is excised down to the underlying nail plate without cutting it (Fig. 9C). For myxoid pseudocysts, the excision should remove the lesion as a whole. No suture is necessary, and hemostasis commonly neither.

Key Point l Keeping the blade oblique during the whole incision (Fig. 9D). l Removing the most proximal part of the lateral nail folds. Postoperative Care Pain: very little l

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An antibiotic ointment, or tulle gras, is applied with a bulky dressing for 24 hours. The ointment usually avoids sticking of the dressing to the wound. This may then be replaced by a small band-aid with a bit of ointment. If the dressing is heavily blood-stained the dressing is gently dissolved with lukewarm soakings. Healing by secondary intention is fast and occurs in about one week.

Evolution l This procedure will give rise to a longer nail with more lunula visible (Fig 10A,B). Complications and Management l Biopsy of the PNF has virtually no complications. It should not be performed in acute infections.

Figure 10 (A) Distal myxoid pseudocyst. (B) Three months postoperatively. Note that the nail looks longer.

EPONYCHIAL FLAP Introduction l The so-called eponychial flap is indeed a hinged flap of the PNF where the most distal part of the PNF is folded backward to make the nail appear longer. l It is indicated to restore the length of a “short nail” after partial amputation of the distal phalanx (zone two of the finger pulp) or other events that had caused a shortening of the distal phalangeal bone and nail bed (Fig. 11A). Anesthesia l Proximal finger block, transthecal anesthesia, or bilateral wing block.

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Figure 11 Repair of a short nail with the so-called eponychial flap: (A) Schematic illustration of a short nail due to partial amputation of the distal phalanx. (B) A superficial rectangle of skin is excised and the lateral incision is marked. (C) The skin defect is sutured exposing more of the nail and thus making it appear longer. (D) Short nail due to partial amputation. The distal margin of the excision is sutured to its proximal end, thus pulling the free margin of the proximal nail fold back. The cuticle is temporarily moved dorsally and proximally. (E) Short nail after partial amputation. (F) Short nail after partial amputation: retraction of the proximal nail fold. This modification makes the nail look shorter longer by moving the entire proximal nail fold backward (proximally), while leaving the cuticle in its correct position. The skin fold overlying the distal interphalangeal joint disappears by itself within a few weeks. Source: Parts D, E, and F from Ref. 6.

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Tools l Nail avulsion tray l Basic nail surgery tray l 6-0 or 5-0 monofil suture Surgical Procedure Technique: difficult l

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A skin rectangle, which is as wide as the remaining nail and maximally 4 mm long, is marked on the PNF about 5 to 6 mm from the cuticle. This rectangle is de-epithelialized using a scalpel without injuring the cutaneous vascular network (Fig. 11B). The distal part of the dorsal aspect of the PNF is gently dissected from its ventral part using fine blunt-tipped scissors, thereby paying attention not to damage the superficial hypodermal vascular network. The PNF is separated from the underlying nail plate with an elevator. The PNF is incised on both sides, in the most distal portion as a full-thickness incision and in the proximal half distal of the rectangle only through the dermis, and the dissected distal dorsal PNF portion is pulled backward skin hooks (Fig. 11C) and sutured with 5-0 stitches to the proximal margin of the rectangle previously excised to shorten the PNF and give the illusion of a longer nail (Fig. 11D) (13–16). Lengthening of the nail is about one half of the length of the excised skin rectangle. Nail avulsion is not necessary. A variation of the technique (17) is to make two incisions in continuation of the lateral nail folds down to the nail, then through the skin just above the joint capsule about double the length of the depth of the nail pocket reaching into the distal third of the middle phalanx.

After separating the PNF from the underlying nail plate with an elevator, this flap is then undermined fine blunt scissor from the blind end of the nail pocket to the middle phalanx. Care has to be taken not to injure the nail matrix and the extensor tendon insertion. The flap is then plicated to expose more of the nail bed and sutured on both sides as shown in Figure 11F. The resulting skin fold gradually disappears by itself within two weeks (18). Key Point l Careful de-epithelialization of the excised skin rectangle.

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Gently pulling back the mobilized distal part of the PNF In case of using alternative 2, damage to the matrix, joint, and extensor tendon has to be avoided.

Postoperative Care Pain: moderate l

An antibiotic ointment, or tulle gras, is applied with a bulky dressing for 24 hours. The ointment usually avoids sticking of the dressing to the wound. This may then be replaced by a small band-aid with a bit of ointment. If the dressing is heavily blood-stained the dressing is gently dissolved with a lukewarm soaking.

Evolution l Healing takes about three to four weeks and finally gives the illusion of a longer nail.

Complications and Management l The PNF must not be traumatized and be fully vital. The cutaneous vascular network must not be injured to prevent necrosis of the flap and damage to the nail matrix. l To prevent posttraumatic and postoperative infection, perioperative antibiotic prophylaxis may be needed in risk patients.

ACQUIRED FIBROKERATOMA Introduction l Acquired fibrokeratomas (FK) are benign skincolored asymptomatic nodules with a hyperkeratotic tip that occur mostly in the periungual area. Trauma is thought to be a causative factor. Most FKs originate from the most proximal part of the ventral aspect of the PNF; their pressure on the underlying thin nail plate and matrix is responsible for a longitudinal groove running on the whole length of the plate. Another common location is the lateral groove (see “Fibrokeratoma,” pp. 91–92). Rarely, they may arise either from the matrix (see “Intraungual Fibrokeratoma,” p. 120) or from the nail bed (see “Fibroma/Fibrokeratoma,” pp. 66–69). l The multiple lesions associated with tuberous sclerosis are called Koenen tumors. They involve more commonly the toenails and their number

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increases with age. No histological difference has been found between isolated FKs and Koenen tumors (19).

Evolution l The longitudinal gutter will grow out distally and is replaced with a normal smooth nail. l Incomplete resection leads to recurrence.

Anesthesia l Distal digital block Tools l Basic surgery tray l Nail avulsion tray l Nonabsorbable sutures 5/0 Surgical Procedure Technique: intermediate l

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If the lesion is small and laterally located (Fig. 12A), an incision at 458, at the junction of the PNF and the lateral nail fold allows to recline the PNF and to expose the tumor (Fig. 12B). If the lesion is larger or medially located, the whole PNF has to be reclined with two lateral incisions (Fig. 13A,B). The PNF is freed from the underlying nail plate using an elevator. Be sure that the lateral incisions are long enough to visualize properly the most proximal part of the ventral aspect of the PNF. The ventral part of the FK resting in the longitudinal groove is either detached delicately from the nail plate using the elevator or, better, dissected from the plate with fine pointed scissors (Graddle are best) proximally toward its base where it is sectioned at the level of the periosteum (Fig. 12C,D). The PNF is then laid back and secured with 5/0 stitches (Fig. 12E).

Key Point l Visualize the base of the FK.

Postoperative Care Pain: very little l l l

Greasy nonadherent dressing. As pain is minimal, only paracetamol if needed. After two days, antiseptics soakings and topical antiseptics twice per day for one week until removal of the stitches.

Complications and Management l It is impossible to damage the matrix even though the nail plate is still in place and acts as a protection during dissection. l However, some reports mention slight longitudinal striations and loss of luster (20).

TUMOR OF THE PNF Introduction l Almost all tissue of the distal phalanx may give rise to a tumor: tumors of the PNF may be benign or malignant and be epithelial, fibrocystic, vascular, neurogenic, synovial, melanocytic, lymphomatous, or metastatic in origin. The most common tumorlike lesions are viral warts. Myxoid pseudocysts come second. l The indication for surgery of a PNF tumor depends on the nature (dignity, prognosis, potential to damage the underlying nail, etc.) of the lesion and its size.

Anesthesia l Proximal digital block, transthecal anesthesia, or bilateral wing block. l In most instances, a matricial block will suffice.

Tools l Basic nail surgery tray l 6-0 or 5-0 monofil, absorbable, or nonabsorbable suture

Surgical Procedure Technique: intermediate The technique of the surgical procedure depends on: l l l

Tumor location within the PNF Size of the tumor Nature of the tumor

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Figure 12 (A) Lateral fibrokeratoma on a thumb. Note the groove in which it rests. (B) Incision at 458 at the function PNF and lateral nail fold. (C) Dissection of the ventral aspect of the fibrokeratoma to its base where it is severed. (D) After removal. (E) One stitch closes the incision.

Tumor of the free margin of the PNF in central location: l The nail fold and nail plate are gently separated from each other with the nail elevator. l The latter is then left under the PNF to protect the soft nail plate and matrix and a wedge-shaped excision is carried out with

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the base of the wedge representing the free margin of the PNF and the tip pointing toward the distal interphalangeal joint (21). When the defect is not too wide, two relaxing incisions are carried out at both sides of the PNF in prolongation of the margin of the lateral nail

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Figure 13 (A) Small fibrokeratoma on the midline necessitating full reclining of the PNF with two lateral incisions. (B) One large fibrokeratoma resting on the whole width of the plate, necessitating two lateral incisions for complete exposure.

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folds thus forming two narrow flaps. They are moved toward each other and sutured in the center (Fig. 14A). The two secondary defects are each about one half of the original defect wide and are left for second intention healing, which is usually complete within 10 to 15 days. When the defect from tumor excision is too wide to allow narrow flaps to survive, two small rotation flaps are designed. A curved incision is made from the junction of the lateral with the PNF in the direction to the lateral aspect of the distal interphalangeal joint. Where the flap is lateral to the nail pocket, a horizontal incision is made to allow the flap to be dissected from the lateral aspect of the PNF. Both flaps are rotated toward each other and sutured in the center

Figure 14 Resection of tumors located on the PNF: (A) Lesions in central position: (left) small lesion, before and after repair; (right) larger lesion, before and after repair. (B) Lesion in lateral position requiring a relaxing incision to either close or reduce the size of the secondary defect. (C) Defect repair after removal of a large lesion from the PNF.

(Fig. 14A). The size of the resulting two crescentic secondary defects may be reduced with one or two sutures or just left for healing by secondary intention. Tumor on one side of the PNF: l The lesion may be excised as a wedge in an analogous manner with one incision on the other side of the PNF (Fig. 15A–C). Again, depending on the width of the defect the flap may be

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Figure 16 (A) Excision of a myxoid pseudocyst in a wedge. (B) Closure with a lateral bridge flap.

formed as a simple narrow transposition or a wider rotation flap. When there is still skin lacking, a relaxing incision on the lateral aspect of the distal phalanx and formation of a bridge flap may help to close the defect primarily (Fig. 14B, Fig 16A,B). This may slightly deform the convexity of the PNF’s free margin, which may later be corrected with a modified crescentic excision.

Figure 15 (A) Pigmented lesion on the lateral side of the PNF. (B) Excision in a wedge. (C) Closure with a lateral flap. Note that the stitches are not too tight.

Larger tumors not affecting the free margin of the PNF: l Those may be excised and the defect closed with a full-thickness skin graft. This can be comfortably taken from the inner aspect of the forearm or upper arm for fingers or the inner aspect of the thigh for toes (Fig. 14C).

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Key Point l Do not pull too tight the sutures of the secondary defects, just reapproximate. The residual defects will heal with secondary intention in a few days. Postoperative Care Pain: moderate l

An antibiotic ointment, or tulle gras, is applied with a bulky dressing for 24 to 48 hours. The ointment usually avoids sticking of the dressing to the wound. This may then be left for another week with a bit of ointment. If the dressing is heavily blood-stained the dressing is gently dissolved with a lukewarm soaking.

Evolution l Healing is fast in a few days. l Patient may feel uncomfortable (tight sensation) for the first week. Complications and Management l As for any flap, the risk is necrosis. This event is extremely rare at that site as the PNF is largely irrigated by two rich vascular arcades (see chap. 1). However, smoking is a risk for all acral flaps. REFERENCES 1. Rigopoulos D, Larios G, Gregoriou S, et al. Acute and chronic paronychia. Am Fam Physician 2008; 77: 339–346. 2. Shaw J, Body R. Incision and drainage preferable to oral antibiotics in acute paronychial infection? Emerg Med J 2005; 22:813–814. 3. Daniel CR. Simple chronic paronychia. In: Scher RK, Daniel CR 3rd. Nails: Diagnosis, Therapy, Surgery. 3rd ed., Philadelphia: Elsevier Saunders, 2005:99–103. 4. Tosti A, Piraccini BM, Ghetti E, et al. Topical steroids versus systemic antifungals in the treatment of chronic paronychia: an open randomized double-blind dummy study. J Am Acad Dermatol 2002; 47:73–76. 5. Baran R, Bureau H. Surgical treatment of recalcitrant chronic paronychia of fingers. J Dermatol Surg Oncol 1981; 7:106–107.

6. Grover C, Bansal S, Nanda S, et al. En bloc excision of proximal nail fold for treatment of chronic paronychia. Dermatol Surg 2006; 32:393–399. 7. Zook EG, Baran R, Haneke E, et al. Nail surgery and traumatic abnormalities. In: Baran R, Dawber RPR, de Berker DAR, et al., eds. Diseases of the Nails and their Managements. 3rd ed., Oxford: Blackwell Science, 2001:505–506. 8. Baran R, Sayag J. Nail biopsy—why, when, where, how? J Dermatol Surg Oncol 1976; 2:322–324. 9. Schnitzler R, Baran R, Civatte J, et al. Biopsy of the proximal nail fold in collagen diseases. J Dermatol Surg Oncol 1976; 2:313–315. 10. Baran R, Bureau H. Surgical management of some conditions in and around the nail. J Dermatol Surg Oncol 1976; 2:308–312. 11. Haneke E, Baran R, Bureau H. Surgery of the nail region. Z Hautkr 1977; 15:1107–1116. 12. Haneke E, Baran R. Nail surgery. Dermatol Clin 1992; 10:327–333. 13. Bakhach J. Le lambeau d’e´ponychium [Eponychial flap]. Ann Chir Plast Esthe´t 1998; 43:259–263. 14. Adani R, Marcoccio I, Tarallo L. Nail lengthening and fingertip amputations. Plast Reconstr Surg 2003; 112:1287–1294. 15. Bakhach J, Demiri E, Guimberteau JC. Use of the eponychial flap to restore the length of a short nail: a review of 30 cases. Plast Reconstr Surg 2005; 116: 478–483. 16. Adani R, Leo G, Tarallo L. Nail salvage using the eponychial flap. Tech Hand Up Extrem Surg 2006; 10:255–258. 17. Biraima AM, Ka¨ch KP, Calcagni M. Reconstruction of distal finger amputations using palmar fingerflaps and the dorsal eponychial flap. Handchir Mikrochir Plast Chir 2008; 40:128–132. 18. Niddam J, Londer J, Gay A, et al. Inte´reˆt du lambeau d’e´ponychium dans les amputations en zone 2 de pulpe chez l’enfant: a` propos de 23 cas. Chir Main 2008; 27:83–86. 19. Zeller J, Friedmann D, Clerici T, et al. The significance of a single periungual fibroma: report of seven cases. Arch Dermatol 1995; 131:1464–1466. 20. Saito S, Ishikawa K. Acquired periungual fibrokeratoma with accessory germinal matrix. J Hand Surg Br 2002; 27(6):549–555. 21. Haneke E. Cirugı´a dermatolo´gica de la regio´n ungueal. Monogr Dermatol 1991; 4:408–423.

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Surgery of the nail bed Bertrand Richert, Eckart Haneke, and Nilton Di Chiacchio

The nail bed represents more than the two-third of the whole length of the nail apparatus. It is reachable only after nail avulsion unless some process may be responsible for its disappearance. As it regenerates very easily and because nail dystrophies are very unlikely, the nail surgeon should not be afraid of working on it.

NAIL BED BIOPSY Introduction l Indications for nail bed biopsies are the diseases of the bed presenting as an onycholysis, a subungual hyperkeratosis or a tumor of the nail bed (1). l As the epithelium of the nail bed is tightly adherent to the ventral aspect of the plate, it may be damaged by nail avulsion and/or its upper part will remain attached to the plate after avulsion. In inflammatory diseases (i.e., psoriasis and lichen planus), nail plate and bed epithelium should undergo histopathologic examination; therefore avulsion should be avoided (2,3). l Nail plate avulsion (total or partial) is indicated in cases where histologic examination of the epithelium is not important (mostly tumors) (2,3). l Larger nail bed defects may result in permanent onycholysis. It has been advocated that the width of the defect should not exceed 4 mm (4).

Anesthesia l Proximal or distal digital block Tools l Tourniquet l Blade No. 11, 15, 15C l Biopsy punch 3, 4, and 6 mm l Nail elevator l Sharp fine-tipped curved scissor (Graddle or LaGrange) l Absorbable suture 4-0 or 5-0 l Sterile absorbable gelatin sponge (Gelfoam1)

Surgical Procedure Technique: easy, except for the double-punch technique, intermediate — With nail plate avulsion  A tourniquet is placed.  The nail plate is avulsed (see “Nail Plate Avulsion,” pp. 31–41). Total nail avulsion is only required if necessary for exposure or surgical exploration. Partial nail plate avulsion is more elegant, less invasive, and enough to allow adequate sampling for histological diagnosis (5).  After avulsion, punch biopsy of the bed (Figs. 1–3) is as simple as at any other site: the punch is pushed, perpendicular to the surface of the bed, in a rotating motion until hitting the bone. Sharp pointed tipped scissors (Graddle and LaGrange) are gently inserted at the level of the periosteum to release the specimen (5). Forceps should never be used as the fragile specimen may be crushed between the jaws (6). The specimen, once snipped, should only be harvested with a gauze or with the scissors tips. Bleeding is minimal and may be stopped with hemostatic solution. If not, a piece of Gelfoam may be pushed into the defect.  A more elegant way of punching the bed is the double-punch technique (7) (Figs. 4–6). A 6-mm punch is made through the plate only. The disk of keratin is removed with the tip of a No. 11 blade or an injection needle the tip of which had been bent at 908 before, and a smaller punch of 3 mm is performed on the nail bed down to the underlying bone. The enlarged hole in the plate overcomes the difficulty to harvest the biopsy material from a narrow window in the nail plate. Harvesting the specimen with sharp pointed curved tipped scissors from the bone is much facilitated. The keratin disk may be replaced and secured with adhesive strips and will act as a dressing. If the plate is needed for histology, the hole is filled with Gelfoam.

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Figure 1

Toenail before biopsy.

Figure 4 A 6-mm punch avulses a keratin disk.



Figure 2 After partial nail plate avulsion, a 3-mm punch is performed in the nail bed and harvested.

Figure 5 A 3-mm punch is pushed down to the bone and harvested with fine curved scissors.

If a larger specimen is required, then a longitudinal elliptical biopsy (Figs. 7–10) should be performed: the incision lines should be long and narrow and the specimen detached from the bone with sharp pointed scissors or with a blade (Beaver blades are particularly adequate). The ellipse can be as narrow as 2 mm as it will be cut longitudinally and extra width will not add to the suitability of the specimen, but make wound closure more difficult. Again, the specimen should never be handled with forceps at any time. As the bed has no laxity at all, it is mandatory to undermine the edges of the ellipse: the blade, resting flat on the bone, is gently slid laterally under the edges of the wound on at least 5 mm. This usually allows primary closure of the defect with 4-0 or 5-0 absorb-

Figure 3 Gelfoam placed in the defect allows perfect hemostasis.

Figure 6 place.

The keratin disk is put back in

able sutures. Do not pull on the lateral edges either with the forceps or the stitches, as it may tear off the bed. Reapproximation is enough, and the small remaining defect will close by secondary intention. —Without nail plate avulsion  A tourniquet is placed.  The specimen of nail bed should be harvested through the nail plate and that may be more difficult. To facilitate the cutting through the nail, the digit may be soaked in warm water for 10 minutes to soften the plate. Another option is to thin the nail by electric grinding (6). A 4-mm punch is pushed through the plate down to the bone. When withdrawing the punch, most of the time the disk of keratin will remain stuck in the metallic cylinder of the

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Figure 7

Toenail before biopsy.

Figure 9 An elliptic excision is carried out in the longitudinal axis of the bed.

punch. Harvesting of the specimen is difficult and should be very delicate using very fine sharp pointed and curved scissors or, again, a 27G needle with its tip bent 908; this also allows the nail plate disc to be gotten out. Never use any forceps. Extirpation of the specimen should be done with the scissors tips. Never use forceps. Gelfoam is pushed into the hole. This type of biopsy is not recommended by the

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Figure 8

Partial avulsion of the plate.

Figure 10

The defect is closed with absorbable suture.

authors, unless it involves the free edge of the plate (Figs. 11–13). Key Point l The choice of biopsy technique (with or without avulsion) will depend on the suspected diagnosis. l If the bed epithelium is important for histopathologic examination, the nail plate should be kept along with the bed specimen.

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Figure 11 Distal hyperkeratosis of the nail bed.

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Figure 12 A 3.5 mm punch is pushed perpendicular to the plate down to the bone.

Specimens with nail plate attached are very difficult to harvest, therefore thinning the plate is of great help. They are also very difficult to handle in the histopathology lab. As a help for an easy reapproximation of an elliptical biopsy of the bed, lateral undermining of the edges should be generous.

Figure 13 Harvesting the specimen is very easy as the scissors may be slid under the specimen from the hyponychium.

the nail bed after Mohs surgery may regenerate totally by secondary intention (1) (Figs. 14 and 15). One should then feel very comfortable with nail bed biopsies.

Postoperative Care Postoperative pain: very little for punch biopsy, little for elliptical biopsy l l l

Greasy nonadherent dressing. Weak pain killers are enough. Removal of the dressing at 24 hours, soakings in antiseptics twice daily for one week. Light dry dressing. Figure 14 Defect after four sessions of Mohs surgery for Bowen’s disease of the nail bed.

Evolution l Healing is fast without scarring or dystrophy.

Complications and Management l Bleeding is the most common complication. Compression, elevation of the limb and Gelfoam are of great help. l If a total avulsion was performed for surgical exploration purposes, it should be put back in place as it will act as a physiological dressing. l It is said that defects larger that 4 mm on the bed will lead to permanent onycholysis. Nevertheless, it is amazing to note that very large defect of

Figure 15

Results after secondary intention healing.

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TUMORS OF THE NAIL BED LONGITUDINAL ERYTHRONYCHIA Introduction l Longitudinal erythronychia (LE) defines a longitudinal red streak, usually from 2 to 3 mm wide, running from the distal matrix up to the point of separation of the nail plate and nail bed. It may be associated with some splinter hemorrhages. At the distal edge, focal onycholysis, nail splitting, and subungual hyperkeratosis may be observed (8) (Fig. 16). l Multiple LE can represent multifocal inflammatory diseases such as lichen planus or dyskeratosis follicularis of Darier White (8) when associated with longitudinal leuconychia. l It is recommended to remove surgically the isolated LE as histopathologic examination may reveal an inflammatory disease such as lichen planus (9), a benign tumor such as warty dyskeratoma (10), hyperplastic glomus structures (8), acantholytic dyskeratotic acanthoma (11), onychopapilloma with (12) or without multinucleated cells (13), but also a malignant tumor such as Bowen’s disease (13,14) or basal cell carcinoma (15). l The term onychopapilloma is a useful descriptive term but may not represent comparable histology in all instances and should be discarded (15).

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Surgical Procedure Technique: intermediate l

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To expose the lesion on its whole length two options are possible: partial longitudinal avulsion with plate replacement or total distal avulsion with plate replacement (lateral curled nail avulsion is best, trap door avulsion is an alternative). Partial longitudinal avulsion will allow excising the lesion on its whole length but it has to be wide enough to allow suturing between the lateral edges of the attached nail plate (Fig. 17). If the lesion is large and the defect suspected to be wide, then complete distal nail avulsion is recommended (Fig. 18A, B). Incise the nail bed around the lesion in a longitudinal ellipse, with no safety margins. The most proximal part of the ellipse should include the distal matrix (Fig. 18C). Carefully dissect the specimen from the bone with sharp and fine pointed scissors (i.e., Graddle), starting from the hyponychium and progressing proximally (Fig. 18D). An alternative is to push a Beaver blade No. 64 just above the periosteum in a distal to proximal motion to

Anesthesia l Distal digital block, unilateral or bilateral according to the location of the lesion. Another option is a transthecal block. Tools l Nail avulsion tray l Basic nail surgery tray

Figure 16

Clinical aspect of onychopapilloma.

Figure 17 Partial longitudinal avulsion, longitudinal excision of the onychopapilloma, primary closure, and plate replacement.

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Figure 18 (A) Large distal onycholysis with suspicion of a large potential defect. (B) Lateral curled nail avulsion exposing the tumor. (C) Elliptic longitudinal incision around the tumor including the most distal part of the matrix. (D) The defect after removal of the tumor is wider than 5 mm and needs closure by flaps. (E) Undermining the sides of the wound. (F) Relaxing incision on one side of the wound freeing a first flap. (G) Relaxing incision on the other side freeing the second flap. (H) Reapproximation of the two flaps with 5-0 absorbable sutures. (I) The plate is put back in place and secured to the lateral nail fold.

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Figure 18

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(Continued )

detach the specimen. This procedure is less traumatic than dissection with scissors. If the defect is less than 4 mm wide, secondary intention healing is an option, but there is a slight risk of onycholysis. Therefore, it is better to try to close the defect: always undermine each side of the wound using the scalpel blade, firmly pressed onto the bone (Fig. 18E) and reapproximate roughly the margins with absorbable sutures. Start suturing the proximal bed first to avoid pulling excessively on the matrix (Fig. 19A). Then suture the hyponychium and complete with the middle part of the bed. Reapproximation is perfect in the most distal and proximal portion with a very light gap in its middle part (Fig. 19B). If the defect is larger than 4 mm, then the defect should be closed by two lateral flaps: perform two longitudinal incisions parallel to the defect

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about 4 to 5 mm lateral to each margin or along the lateral sulci. Free these two flaps by undermining (slide the scalpel blade under the bed and perform gentle back-and-forth motions until complete freeing) (Fig. 18F, G). Reapproximate the defect with 5-0 or 6-0 absorbable sutures. Do not pull too much on the suture to avoid tearing the bed (Fig. 18H). Flip back the plate and secure it to the lateral folds and distal wall (Fig. 18I).

Key Point l Suturing between the lateral edges of the plate still attached to its bed is difficult (Fig. 17). l Undermining the bed widely to ensure sliding of the flaps (Fig. 18E). l Suturing the bed before the matrix. l A parallel pulley suture helps greatly and takes tension from the single stitch sutures.

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Figure 19 (A) Suturing the proximal nail bed first avoids pulling excessively on the matrix. (B) Reapproximation is perfect in the most proximal and distal bed. Discrete gapping in its middle portion.

Postoperative Care Postoperative pain: light to moderate l l

Greasy antiseptic slightly compressive dressing Elevation of the limb for two days

Evolution l Remove the stitches securing the plate to the folds after three weeks. l Ask the patient to secure the plate with adhesive tape and to keep it in place as long as possible. l When the nail is shed, complete healing of the bed has already occurred and a new nail has grown to about one-third of its length. l The scar in the bed may appear as a longitudinal leuconychia or erythronychia. l Even very large defects may heal very nicely with this technique (Fig. 20A–D). Complications and Management l Secondary healing may result in some onycholysis if the defect was over 4 mm. l A thinner nail may be observed from the partial resection of the distal matrix. Easy breakage may occur at this point. l A split results either from poor matrix suturing or from removal of the proximal matrix. PYOGENIC GRANULOMA Introduction l Pyogenic granulomas are eruptive angiomas most commonly developing after a minor trauma. When appearing in the nail bed, the trauma had to have pierced the nail plate, or may result from excessive rubbing of the shoe against the nail (16).

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Pyogenic granulomas are usually small, peasized tumors that are rapidly eroded and tend to bleed easily. Whether the erosive and bleeding lesions observed during/after treatment with retinoids, reverse transcriptase inhibitors, epidermal growth factor receptor inhibitors, docetaxel, mitoxantrone, and other drugs are true pyogenic granulomas as indicated in the literature or granuloma-like lesions more resembling granulation tissue remains to be clarified (17–19). Coccal nail fold angiomatosis is pyogenic granuloma like but has some discriminatory factors (20).

Anesthesia l Either proximal finger block, transthecal anesthesia, or bilateral wing block. Tools l Nail avulsion tray l Basic nail surgery tray l Curette l Optional: hemostyptic agent or electro-/radiofrequency cautery Surgical Procedure Technique: easy There are several possibilities to remove a nail bed pyogenic granuloma (21–23). l

When the lesion is subungual and presents with onycholysis from the oozing (Fig. 21A), avulsion

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Figure 20 (A) Very large onychopapilloma. (B) Very large defect on the bed after removal of the lesion. (C) Closure by two lateral flaps. (D) Outcome six months postoperatively. Note the absence of onycholysis and a residual light erythronychia from the scar in the bed.

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(either partial or lateral avulsion with replacement) will permit complete visualization of the lesion (Fig. 21B). The pyogenic granuloma may be cut horizontally at its base (Fig. 21C), or curetted and then gently cauterized using electrocautery or radiofrequency. When bleeding is mild and not pulsating a cotton-tipped applicator dipped into a hemostyptic solution such as 30% aluminum chloride or 20% to 40% ferric chloride is pressed on the small wound for a few minutes. The tumor may be cut off tangentially using an electric loop. When the pyogenic granuloma is bigger and located in the distal nail bed the plate overlying the lesion is generously cut away and the tumor

either removed tangentially as described above or excised and the defect sutured primarily. Alternative Treatments l Cryotherapy may also be used (24). l Carbon dioxide laser may be used to vaporize a pyogenic granuloma, whereas selective vessel damage and occlusion is thought to be the mechanism of action of a dye laser (25). l Recently, a subungual lesion was treated with sodium tetradecyl sulfate sclerotherapy (26). Key Point l Amelanotic melanoma is the most important differential diagnosis of pyogenic granuloma.

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Figure 21 (A) Proximal onycholysis and oozing. The dark discoloration results from application of silver nitrate. (B) Lateral nail plate avulsion exposes the tumor. (C) After shaving of the tumor at its base and application of hemostatic solution.

Therefore, destructive therapies are not recommended as they do not allow histological examination of the specimen. Postoperative Care Pain: very little l

An antibiotic ointment, or tulle gras, is applied with a bulky dressing for 24 hours. The ointment usually avoids sticking of the dressing to the wound. This may then be replaced by a small band aid with a bit of ointment. If the dressing is heavily blood-stained the dressing is gently dissolved with a lukewarm soaking.

Evolution l Healing is fast. A crust will appear and fall off in about two weeks. l If the nail plate was avulsed, the new nail will regrow without any dystrophy. Complications and Management l Simple horizontal excision, curettage, and cryotherapy are virtually free from complications except for possible recurrence. l Electrocautery may damage the surrounding nail bed tissue and matrix and has therefore to avoid too much heat generation. Excessive vaporization has to be avoided when using a CO2 laser. These may result in permanent onycholysis. l Infection may follow surgery with sutures.

KERATOACANTHOMA Introduction l Subungual keratoacanthoma (SUKA) should now be considered as a borderline tumor as some American pathologists name it “squamous cell carcinoma keratoacanthoma type” or even “keratocarcinoma.” l SUKA has a predilection for the three first fingers, especially the thumb (27). l Typically, KA is painful and arises very quickly (within weeks). l Clinical features associate onycholysis and keratotic-crusted nodule of the distal nail bed (27) (Fig. 22A). Location within the proximal nail fold is unusual and results in a painful paronychia with creamy discharge (28). l X-ray examination reveals a cup-shaped erosion of the underlying bone without accompanying sclerosis or periosteal reaction. The lytic defect is the result of pressure erosion rather than tumor invasion (29). l Multiple subungual KA-like lesions may arise as a late manifestation of incontinentia pigmenti. l Spontaneous involution as on the skin is exceptional. Anesthesia l Distal digital block. Tools l Basic nail surgery tray l Curette

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Figure 22 (A) Very painful distal onycholysis with extrusion of a chalky material. (B) Partial avulsion exposing the tumor. (C) En bloc excision of the tumor. (D) Reapproximation of the edges of the wound.

Surgical Procedure Technique: intermediate l

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the cavity may reapproximate the borders. Healing occurs then by secondary intention. Best treatment is Mohs’ surgery when available. The lesion is excised “en bloc” sticking as close as possible to the bone (Fig. 22C). The specimen is orientated and fixed. New sessions are performed, if necessary, until the margins are cleared of tumor.

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Two stitches will grossly reapproximate the margins of the defect and healing will occur partly by secondary intention (Fig. 22D). In both treatments, trap door and curled lateral nail avulsion are better options as putting back the plate on the bed and securing it to the lateral folds will act as a physiological dressing and will enhance healing. For multiple lesions as observed in incontinentia pigmenti, etretinate 1 mg/kg/day is an alternative.

Key Point l Excision “en bloc” being as close as possible to the bone. l Margins free of residual tumor Postoperative Care Pain: very little, as removing the tumor alleviates the pain from compression l

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Figure 23 Fibrokeratoma of the proximal part of the nail bed revealed by partial avulsion.

on the bed responsible for an onycholysis and associated with oozing (2) (Fig. 23) or an elongated flesh-colored lesion with a distal hyperkeratosis emerging under the free edge and causing a rim in the nail (32) (Fig. 24A).

Bulky antiseptic greasy dressing with elevation of the limb for 48 hours. Soakings twice daily in antiseptic solution until removal of the stitches securing the plate after three weeks.

Evolution l Pain will be alleviated by the surgery. l X rays may show some partial reconstitution of the bony defect (30) or even complete reossification (31). l Long-term follow-up is mandatory as recurrence may be observed as late as 22 months (28). Complications and Management l As surgery involves the bony phalanx, it might be recommended to prescribe prophylactic antibiotics (i.e., azithromycine, amoxycillin + clavulanic acid) starting the day prior to surgery. l Recurrences should undergo new sessions of Mohs surgery. Amputation is not an adequate treatment unless dealing with a very aggressive tumor. FIBROMA/FIBROKERATOMA Introduction l Fibrokeratomas are quite unusual on the nail bed. l When they develop in this location they present in two ways: (1) a pinkish dome-shaped tumor

Anesthesia l Distal digital block. Tools l Nail avulsion tray l Basic nail surgery tray Surgical Procedure Technique: easy to intermediate l

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A partial nail avulsion (lateral curled nail avulsion is best, trap door avulsion is an alternative) will expose the whole lesion and its vicinity (Fig. 24B). If the lesion is pedunculated, it is easily elevated from the bed and severed at its base and the nail laid back in place (Fig. 25A–D). If the lesion has a large base adhering to the bed, it has to be removed as a whole. Incise the nail bed around the lesion in a longitudinal ellipse, with no safety margins. Avoid notching the distal matrix (Fig. 24C). Carefully dissect the specimen from the bone with sharp and fine pointed scissors (i.e., Graddle), starting from the hyponychium and progressing proximally. An alternative is to push

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Figure 24 (A) Fibrokeratoma emerging from under the free margin of the plate. (B) Trap door avulsion exposing the whole tumor. (C) En bloc longitudinal excision of the tumor. (D) Closure of the defect with two lateral flaps. (E) Plate replacement.

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Figure 25 (A) Fibrokeratoma emerging under the distal margin of the plate. (B) Lateral curled avulsion exposes the tumor. (C) The lesion is pedunculated and emerges from the very proximal nail bed. (D) The tumor is severed at its very base. (E) Plate replacement.

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a Beaver blade No. 64 just above the periosteum in a distal to proximal motion to detach the specimen. This procedure is less traumatic than dissection with scissors. If the defect is less than 4 mm wide, secondary intention healing is an option. However, it is better to try to close the defect and reapproximate roughly the margins with absorbable sutures. If the defect is larger than 4 mm, then the defect should be closed by two lateral flaps: perform two longitudinal incisions parallel to the defect about 4 to 5 mm lateral to each margin. Free these two flaps by undermining (slide your scalpel blade under the bed and perform gentle back and forth motions until complete freeing). Reapproximate the defect with 5-0 or 6-0 absorbable sutures. Do not pull too much on the suture to avoid tearing the fragile bed (Fig. 24D). Flip back the plate and secure it to the lateral folds and/or distal wall (Fig. 24E). For multiple lesions as observed in tuberous sclerosis, shaving the tumors are their base is enough, as new lesion will develop and removal of all lesions en bloc would sacrifice too much bed.

Key Point l Section of the lesion at its very base to avoid recurrence. l Reapproximating the edges of the bed without pulling on the sutures to avoid tearing it off. l Careful freeing of the two lateral bridge flaps, with keeping the blade pressed flat onto the bone.

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Complications and Management l Bleeding and hematoma may be encountered in patients under blood thinners. Replacing the plate, securing it firmly to the lateral folds and the bulky dressing mostly suffice to limit the bleeding and absorb it. l If the defect is over 5 mm and not sutured, permanent onycholysis is very likely. SUPERFICIAL ACRAL FIBROMYXOMA Introduction l Superficial fibromyxoma is a distinct clinicopathologic entity described by Fetsch in 2001 (33). l Peak incidence is in middle-aged adults, but may occur at any age. There is a male predilection. l It usually develops on the finger and toes but more than of half of the cases involve the nail bed (34,35). l The lesion presents as a slowly growing, painless solitary nodule. It may reach considerable growth (Fig. 26A). Erosion of the bone from compression may be observed in some cases. Anesthesia l Distal digital block Tools l Basic surgery tray Surgical Procedure Technique: easy l

Postoperative Care Pain: from little to moderate according to the surgery l l

Greasy bulky dressing Elevation of the limb for 48 hours

Evolution l Remove the stitches securing the plate after three weeks and ask the patient to place a circular dressing slightly compressive for several weeks. l The nail will be shed very probably after four to six weeks. l At that time, healing of the bed will be complete and the new nail will cover about one-fourth of the bed.

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The lesion is very well circumscribed but not encapsulated. This renders the excision very easy. As the lesion is usually of great size, it is almost impossible to spare the bed as it has been completely destroyed by the tumor. Therefore, an enucleation is the best procedure, dissecting the tumor from the more distal part with sharp pointed scissors. It is quite easy to find a cleavage plane (Fig. 26B). Dissection is performed until complete removal of the tumor. Healing occurs with secondary intention healing as the defect most of the time sacrifices a very large part of the bed and leaves a deep defect.

Key point: l Finding the cleavage plane and stay there during all procedure. Injection of some local anesthetic

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Figure 26 (A) Huge rounded tumor evolving for more than 10 years on this nurse great toenail. (B) Dissection is easy as there is a cleavage plan. (C) One-year follow-up. There is a flat dystrophic nail with prominent ridging.

or physiological saline helps to find the cleavage plane (“hydrodissection”). l

Postoperative Care Pain: very little l l

When the defect is very large, it may be useful to fill it with Gelfoam and cover it with a large amount of antiseptic ointment.

Evolution l The nail bed may regenerate quite well but not completely. This will leave a flat dystrophic nail (Fig. 26C).

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Complications and Management l No complication should occur as long as the postoperative care is properly done. l If the defect is very large on a great toe; prophylactic antibiotics may be prescribed. l

GLOMUS TUMOR Introduction l Glomus tumor is a benign tumor affecting mostly the fingernails, but few cases involve the toes (36). l It is a “women’s disease” as up to 90% of cases are reported in women around the forties (37). l Clinically, it appears as a purple blue tender lesion under the nail plate (Fig. 27A). l Paroxysmal pain is the leading symptom. It may be minimal or severe, radiating in the arm, exacerbated with the slightest touch. Cold

sensitivity is very suggestive as it is 100% sensitive, specific, and accurate (38). Pain stops when a blood pressure cuff placed at the basis of the digit is inflated to 300 mmHg (Hildreth’s test). Pinpoint testing (Love’s test) is 100% sensitive and 78% specific: it will induce acute pain when pressing exactly at the site of the tumor. For these reasons, some teams consider that clinical exploration is typical enough to confirm the diagnosis and exact localization (39). However, medical imaging may help:  X ray will show an osteolysis in about 50% of cases (37).  Ultrasound will detect glomus tumors bigger than 3 mm (40). Recently, high variable frequency ultrasound was shown to be able to detect glomus tumors under 1 mm (41).  MRI is very specific when using adapted coils, but should be reserved for recurrences or atypical cases (42). Treatment is surgical. Recurrence may occur when excision is incomplete or there were multiple primary glomus tumors (43).

Anesthesia l Distal digital block Tools l Basic nail surgery tray l Nail avulsion tray l Absorbable suture 5-0 or 6-0

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Figure 27 (A) Glomus tumor of the nail bed presenting as a purple red patch on the nail bed. (B) Partial lateral avulsion exposes the tumor. (C) After longitudinal incision, dissection of the lesion with fine scissors. (D) Lesion extirpated. (E) After suturing of the nail bed. (F) Plate replacement. Note the tattooing of the plate according to the Love’s test (most painful point) before surgery. This is very helpful as the blue hue of the lesion disappears with bleaching from the anesthesia.

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Surgical Procedure Technique: intermediate l l

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As this surgery is very delicate, the field should be bloodless, and a tourniquet should be placed. Before anesthesia, it is mandatory to mark the plate with a surgical marker at the location of the tumor because bleaching from anesthesia and the tourniquet plus exsanguination will render location impossible (Fig. 27F). To perform a mark on the PNF and on both sides on the LNF with the tumor in the cross line is an alternative. A partial distal avulsion is performed (trap door or curled nail avulsion) in order to expose the nail bed tumor (Fig. 27B). The nail bed is sectioned longitudinally over the tumor according to its diameter. The tumor is very meticulously dissected from the surrounding tissues with blunt curved scissors (Fig. 27C) and enucleated (Fig. 27D). Holding the lesion with a forceps should be avoided at all time. The incision is closed with an absorbable suture (6-0) or not if the defect is very small. The nail plate is laid back in place and secured to the lateral and distal nail fold (Fig. 27F).

Key Point l Tattoo the nail plate after location of the tumor and before anesthesia. l Enucleate the complete tumor. Incomplete resection will end up in recurrence. Postoperative Care Pain: very little as the procedure will alleviate the pain from the tumor l

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Greasy nonadherent bulky dressing for two days. Stitches are removed after two weeks and circular tapes are recommended.

Evolution l Pain is immediately alleviated with the excision of the tumor. The Love test is negative at the removal of the dressing. Complications and Management l Recurrence may occur in case of incomplete resection. In these instances, MRI is very useful

and specific to locate the remnants of the tumor and will guide the surgical resection (42). One of the authors (BR) has observed a reflex sympathetic dystrophy (44) after removal of a glomus tumor in the bed.

BOWEN’S DISEASE—EPIDERMOID CARCINOMA—SQUAMOUS CELL CARCINOMA Introduction l Bowen’s disease is not as uncommon at the nail apparatus as might be thought from the limited number of cases published (45). l It is a distinctive type of “in situ” squamous cell carcinoma. As it may be difficult to distinguish invasive from in situ carcinoma, the term epidermoid carcinoma has been proposed (45). It is a low-grade carcinoma that is not as aggressive as on other body areas (45). l It develops either in the nail bed or in the nail folds. It affects mostly the three first finger of the left hand of middle age males. l Predisposing factors include HPV infection, pesticides, exposure to arsenic, radiodermatitis, and dyskeratosis congenita. l Clinical presentation is very variable according to the location of the disease. The most typical feature is a long standing hyperkeratotic lesion resembling a viral wart (46) (Fig. 28A). Associated longitudinal erythronychia is a clue for Bowen’s disease (47) (Fig. 28B). In some instances, the lesion may present with misleading features such as fibrokeratoma-like (48,49) (Fig. 28C), pseudo-onychomatricoma (50) (Fig. 28D), or longitudinal melanonychia (13) (Fig. 28E). Onycholysis with oozing is another characteristic presentation (51) (Fig. 28F). l Polydactylous involvement is rare but possible (52,53). l Preoperative evaluation should include hand radiographs before embarking for surgery. In case of bone involvement, amputation is mandatory (54). l Highest cure rate (over 95%) is achieved with Mohs’ surgery allowing adequate excision with maximal tissue-sparing excision maximizing hand and digit function (55,56). Anesthesia l Distal digital block Tools l Basic nail surgery tray l Skin hooks

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Figure 28 (A) Bowen’s disease, verruca-like. (B) Bowen’s disease presenting as longitudinal melanonychia. (C) Bowen’s disease, fibrokeratoma-like. Source: Coll J.Andre´, Brussels, Belgium. (D) Bowen’s disease, onychomatricoma-like. (E) Bowen’s disease presenting as a longitudinal erythronychia. (F) Bowen’s disease presenting with onycholysis and oozing.

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Surgical Procedure l When the lesion is limited, excisional surgery may be used for removal of the tumor (51). Closure is performed only when margins are clear, after complete histological examination. For this reason, the so-called “slow Mohs” is very adequate: the excision specimen is sent, fully orientated, to the pathologist and the defect kept under greasy antiseptic dressings, renewed every day, until pathological report. If needed, additional resection is done. l According to the size of the defect after histological examination of the margins, closure may be obtained by secondary intention healing (see “Closure with Secondary Intention Healing,” pp. 139–140) or bridge flap (see “Bowen’s Disease,” pp. 92–95). l Of course, if histological examination reveals incomplete excision, additional surgery is needed. Complete removal of the nail apparatus is common as the tumor may have occult extensions. Closure is obtained by grafting (see “Closure with a Graft,” pp. 140–143), reverse dermal flap (see “Closure by Reversed Dermal Flap,” pp. 142–144), or cross-finger flap (see “Cross-finger Flap,” pp. 144–147).

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Anesthesia l In some instances, anesthesia is useless as clipping of the onycholytic area (Fig. 29B) exposes the lesion that is gently removed with a curette (Fig. 29C). l If the corn is not easily removable, meaning it is deeply set in the bed, then a distal digital block is indicated for surgical removal. Tools l Nail nippers l Curette l Basic nail surgery tray Surgical Procedure Technique: easy l

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Key Point l Clear margin. l No bone involvement. l In case of diffuse involvement, choose for removal of the whole nail unit. l If bone involved, amputation is mandatory.

HELOMA—ONYCHOCLAVUS Introduction l Improper footwear (extremity of the shoebox not deep enough) and/or hallux erectus will result in friction against the upper part of the shoe responsible for a subungual hyperkeratotic reaction (57) called onychoclavus or heloma. l This subungual corn, affecting mainly the great toenail, is located at the distal part of the nail bed. It may be very painful and interfere with walking. l Its clinical feature is very discrete, except for the subjective symptoms: a pinkish or sometimes black patch is seen through the plate on which pressure causes considerable pain. It is accompanied by a more or less severe distal onycholysis (Fig. 29A).

Partial avulsion of the onycholic area reveals the lesion. This avulsion should be wide enough to ensure suturing without being bothered with the lateral edge of the nail. An elliptic incision is performed, down to the bone, and the lesion dissected from the periosteum with fine pointed scissors or a Beaver blade. According to the size of the defect, suturing may be performed or not. For hemostatic reasons, we prefer to place one or two stitches to reapproximate the borders of the defect. These may be absorbable or nonabsorbable sutures.

Key Point l Removal of the lesion down to the bone Postoperative care Pain: nil after curetting; moderate to severe after surgical removal l

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Evolution l The pain is immediately alleviated by decompression from the distal avulsion l The main point is that the patient has to be oriented to a podiatrist to correct the hallux erectus (Fig. 29D) and to teach the patient how to choose proper footwear. As this step is withdrawn by mostly all patients and doctors,

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Figure 29 (A) Painful heloma at the middle and distal part (the thickest part of the great toenail) associated with a slight onycholysis. (B) Clipping of the onycholysis exposes the lesion. (C) Here, a curettage of the lesion allowed its full removal. (D) Note the erectus and the location of the heloma. Podiatric correction is a must otherwise the lesion will recur.

recurrence is the rule after several months or years. Complications and Management l As this is very light surgery, no complication should occur unless some bleeding in patients under blood thinners. PACHYONYCHIA CONGENITA Introduction l Pachyonychia congenita (PC) is a hereditary disease. PC type I is due to a mutation in the keratin genes 6a and 16, PC type II in the keratin genes 6b and 17 (58). l PC mostly develops in early childhood (Fig. 30A, B) although very early cases and late onset are possible. l The main PC types show a slightly different expression of the mutated keratins: the keratins 6a and 16 are constitutively expressed in suprabasal cells of the ventral surface of the proximal nail fold, in the nail bed, and digital pulp, but not in the matrix whereas 6b/17 are expressed

Figure 30 (A, B) Pachyonychia congenital of the toenails and fingernails in an infant.

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throughout the nail bed and matrix epithelium starting in the basal layer (59,60). This may explain differences in the results of surgical treatments. l

Anesthesia l Either proximal finger block, transthecal anesthesia or bilateral wing block. Tools l Nail avulsion tray l Basic nail surgery tray. Surgical Procedure l There is no comparative study on the surgery of PC nail changes. Virtually all reports are anecdotic and based on single or few-case observations. l Cosman et al.’s patient was successfully treated with nail bed ablation (keratin 6a/16 possible mutation) (61). l Thomsen et al.’s patient responded well to matrix ablation (perhaps he had a KRT 6b/17 mutation) (62). l Electrofulguration, deep curettage, excision, and full-thickness skin grafting were used to ablate the matrix or nail bed. Digital amputation (sic!) was also reported (63). l Alternative treatment consisted in: high concentration urea paste (40%) or salicylic acid ointment (20%) used to soften the extremely thick and hard subungual material (64,65). Systemic treatment with vitamins A and E was also reported as being successful (66). Rapamycin (sirolimus) and short interfering RNA are new experimental approaches; however, the clinical trials had to be interrupted because of adverse effects (67,68). Key Point l This is a genetic disease and up to now only destruction of the responsible nail structure will lead to a long-term result. Postoperative Care The type of dressing depends on surgery. l

An antibiotic ointment, or tulle gras, is applied with a bulky dressing for 24 to 48 hours in case of cold steel surgery. The ointment usually avoids sticking of the dressing to the wound (69–72). This is then replaced by a dry sterile

bandage with a bit of ointment. If the dressing is heavily blood-stained, the dressing is gently soaked in lukewarm water. When electrosurgery was used to ablate the nail bed or matrix, sterile ointment dressings are usually sufficient.

Evolution As mentioned in the preceding text, the different PC types are genetic diseases. As long as the nail structure carrying the mutated genes are still present the same clinical expression will develop again. Complications and Management l The frequency of potential complications depends on the type of surgery. Electrosurgery wounds may heal slowly and be painful as the heat generated from the device may damage the underlying periosteum. Partial necrosis of fullthickness skin grafts may occur. l When matrix destruction is not complete spicules may develop. EXTENSION OF THE NAIL BED FOR LARGE DEFECTS Introduction l Elongation of the nail bed is necessary when the nail has been cut too short for a long period of time, when the nail was partially lost due to a mycosis or another nail disease, when the nail bed was injured by a trauma or a burn, which may lead to longitudinal shrinking of the nail bed, often complicated by the development of a distal nail wall (Fig. 31A). l A too short nail bed may also be seen when the distal phalangeal bone is resorbed, such as in acral scleroderma, although bone shortening is not always associated with shortening of the nail bed but may lead to a hook nail instead. l A functioning matrix appears to be the prerequisite of nail bed regeneration. l Lateral extension of the nail bed in its transverse direction is necessary when the nail is too wide in relation to too narrow a bed; again this is frequently seen after long-term loss of the nail and particularly in pincer nails. In both conditions, it is mainly the distal portion of the nail bed that is too narrow. Anesthesia l Either proximal digital block, transthecal anesthesia, or bilateral wing block.

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Figure 31 (A) Schematic illustration of nail bed elongation. Before surgery, illustration of a short nail bed that lead to a short nail plate (B) Schematic illustration of nail bed elongation. A strip of the skin just in front of the short nail (red) is excised. With the growth of the nail plate, nail bed epithelium will be formed during the time of secondary intention healing. Abbreviations: C, cuticle; DP, distal phalanx; E, eponychium; ET, extensor tendon; FT, flexor tendon; HO, hyponychium; M, matrix; NB, nail bed; NP, nail plate; O, distal dorsal traction osteophyte.

Tools l Nail avulsion tray l Basic nail surgery tray Surgical Procedure Technique: intermediate to difficult l

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pulp skin. The nail bed is dissected from the underlying bone, by sliding the scalpel blade under the bed and performing gentle back and forth motions until complete freeing (using a Beaver blade No. 64 helps greatly) whereby care has to be taken not to pierce the soft tissue of the nail bed. When it is freed from the bone till the adjacent lateral aspect of the distal phalanx, both sides are pulled outward and fixed with reverse tie-over sutures. This may result in a fusiform defect of the nail bed when there was not a surplus of tissue (see “Pincer Nail,” pp. 157–163). This may require a nail bed graft as both secondintention healing and a split-thickness skin graft

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will lead to an area of onycholysis. However, according to Ogo’s experience, a full-thickness skin graft allows a normal nail to regrow. When the distal phalangeal bone is preserved, nail bed elongation may be successful. Ogo recommended to remove the scar and cover the defect with a full-thickness skin graft allowing about 90% of the nail to regrow in the presence of an intact phalanx bone and about 70% in guillotine type amputations (69). Another approach is to cut out a crescentic strip of the scar with a maximum length of 5 mm from its proximal border. The defect is left for secondintention healing (70,71) (Fig. 31B). If there is still a distal nail bed scar this can be removed after about three months. A third such excision is possible.

As it is known that the connective tissue of the matrix and nail bed have very important morphogenetic properties, it may be wise not to excise down to the bone when the scar does not involve the full thickness of the nail bed. To cover the defect with a nail bed graft taken from the same digit, an adjacent digit or another donor site such as the big toe may be an alternative to second intention healing.

Key Point l The gain of nail bed length is relatively modest. l The results are not always predictable. l To find the correct plane of scar or hyponychium excision may be difficult. Postoperative Care Postoperative pain: moderate to severe l

l

An antibiotic ointment, or tulle gras, is applied with a bulky dressing for 24 to 48 hours in case of cold steel surgery. The ointment usually avoids sticking of the dressing to the wound. This is then replaced by a dry sterile bandage with a bit of ointment. If the dressing is heavily blood-stained, the dressing is gently soaked in lukewarm water. Splinting may be necessary for nail bed elongation.

patient with postoperative massage and taping are crucial. Complications and Management The frequency of potential complications depends on the type of surgery. It has recently been shown that the toenail bed is very difficult to clean from potentially pathogenic bacteria (see “Disinfection of the Surgical Field,” p. 18). Enterobacteria are of particular concern. Postoperative infection is possible and may be prevented with perioperative antibiotic treatment. SECONDARY INTENTION HEALING FOR LARGE DEFECTS Introduction l Secondary intention healing is indicated when there is an extensive tissue loss and when the edges of the wound cannot be reapproximated by direct suture (2). l It is indicated mostly after removal of extensive benign or malignant tumors of the nail bed and especially in subungual exostosis when the bed has been so much l Extended by the lifting effect of the tumor that it cannot be spared. l Healing by second intention is a frequently chosen option at the nail bed that often allows an excellent functional and cosmetic result (2,72). Anesthesia l Proximal or distal ring block

Tools l Antibiotic ointment (bacitracin, fusidic acid, mupirocin, etc.) l Sterile absorbable gelatin sponge (Gelfoam) l Mesh gauze l Elastic bands l Adhesive strips

Surgical Procedure Technique: difficult l

Evolution Nail bed elongation is not a routinely done procedure. As the elongation is modest compliance of the

After removal of the tumor, the wound is left open and covered with greasy antiseptic ointment and a bulky dressing until histopathologic report. If it takes several days, the dressing

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Figure 32 (A) Subungual exostosis. (B) Complete removal of the tumor induces a large defect that cannot be closed by primary intention. Secondary intention is the treatment option. (C) Four months later, healing is complete with only a slight distal and lateral onycholysis.

l

l

l

should be replaced twice per day after soaking in an antiseptic bath (i.e., povidone iodine soap). To prevent bleeding and hematoma formation, the defect may be filled with sterile absorbable gelatin sponge (Gelfoam). If the nail plate is not necessary for histological examination, it should be kept and put back in place and secured with appropriate stitches or circular adhesive strips. A custom-made nail bed splint from a 10-mL syringe is an alternative (73). This will also prevent irregular and excessive granulation. Several layers of mesh gauze are placed over the digit and secured with an elastic bandage.

Key Points l The replacement of the nail plate will act as a physiological dressing and promote quicker healing. l Adhesive strips or stitches should maintain a medium compression to keep the nail plate on the wound and avoid bleeding.

Postoperative Care Postoperative pain: minimal. l

l

Postoperative pain is minimal with this procedure as there is no pulling effect on tissues from stitches. The dressing is removed after 48 hours but the adhesive strip left in place. Antiseptic soakings

l

l

are done twice per day. Every 10 days, adhesive strips are replaced by new ones until complete healing. Wound care should be done properly twice daily. If the patient is unable to ensure his wound care alone, adequate nurse home care should be prescribed. If the piece of nail plate is loss, large amounts of antiseptic ointments will suffice to ensure a good granulation. Excessive fibrin should be curetted. To prevent its formation, cleaning the wound under the shower stream is a excellent procedure.

Evolution l Healing is longer (4–8 weeks according to the size of the defect) than primary intention healing. l Complete regrowth of the nail occurs without any dystrophy. In rare instances, a small area of onycholysis is noted, especially if the tumor was located in the most distal and lateral part of the bed (Fig. 32A–C).

Complications and Management l Infection after surgery of nail bed is a serious complication. In patients with poor personal care and diabetics, prophylactic antibiotics may be a good option. l Healing may be slower in heavy smokers and patients with vascular impairment of the limbs.

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NAIL BED GRAFTING Introduction l Nail bed injuries are common (74). Nail deformities are frequently seen after nail bed avulsions. l The nail bed is a unique structure attaching the nail plate very firmly to the underlying bone of the terminal phalanx. Its epithelium produces a tiny amount of keratin that is clearly different from the nail plate and is probably necessary that the nail plate can move over the nail plate without loosing its firm attachment. l Loss of the nail bed due to trauma (Fig. 33A), burn, chemical cautery, or scarring results in onycholysis as a scar cannot form nail bed epithelium again. l If sufficient undamaged nail bed is available, the recommended graft site is at the same digit. An injured adjacent finger is another option. A toenail is the third option (75).

Anesthesia l Either proximal digital block, transthecal anesthesia, or bilateral wing block.

l

l

l

l

The avulsed nail plate on the donor toe or finger is laid back and secured to the lateral nail folds with stitches. The thin nail graft is transferred to the recipient area (Fig. 33G) and fixed with either 7-0 resorbable sutures (Fig. 33H) or fibrin glue; as the nail bed grafts have no directional orientation labeling of their longitudinal axis is necessary (76,77). Since the graft is very thin there will be no donor defect. The graft should be covered with a normal nail (Fig. 33I), which may be taken from the donor digit. Nail bed flaps may be used to close narrow nail bed defects (see “Extension of the Nail Bed,” pp. 76–78).

Key Points l A free nail bed graft must be taken with care, not be thicker than half a millimeter. l Although nail bed growth is said not to be directional, it is wise to respect the longitudinal direction of the rete ridges of the nail bed. Postoperative Care Pain: moderate to painful

Tools l Nail avulsion tray l Basic surgery tray l Optional: coated blades, Beaver blades.

Surgical Procedure Technique: intermediate to difficult l

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l

l

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The nail plate is avulsed to expose the area to be grafted (Fig. 33B). The scar area is excised, shaved, or curetted (Fig. 33C). A pattern is made outlining the size of the nail bed defect to be repaired (Fig. 33D). Sterile paper or cardboard from instrument packings is very useful. On the donor finger or toe, the nail plate is cautiously avulsed and the pattern applied onto the bed (Fig. 33E). The graft is then taken about 1 to 2 mm larger than the defect. The scalpel is held horizontally with light pressure of the blade’s side on the bed. It is then moved with back-and-forth movements to cut a thin slice of about 0.25 to maximally 0.5 mm thickness (Fig. 33F).

l

An antibiotic ointment, or tulle gras, is applied with a bulky dressing for 24 to 48 hours. The ointment usually avoids sticking of the dressing to the wound. This is then replaced by a dry sterile bandage with a bit of ointment. If the dressing is heavily blood-stained, it is gently soaked in lukewarm water and the blood cleaned with 3% hydrogen peroxide solution.

Evolution l In a large study, 90% of the patients treated with nail bed grafts grew a normal nail again (77). Other authors state similarly good results (78–81).

Complications and Management l Failure of the graft to take and infections are the most likely complications. l Infection is a serious complication. In patients with poor personal care and diabetics prophylactic antibiotics may be a good option. l Grafting in heavy smokers and patients with vascular impairment of the limbs is not recommended.

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Figure 33 (A) Permanent distal onycholysis from a crush trauma. (B) Lateral nail avulsion exposes the fibrous scar on the bed. (C) The scar is partially shaved away. (D) A piece a sterile paper is pattern to the size of the defect to cover. (E) After nail plate avulsion of the donor toenail, the pattern is applied on the bed and a superficial incision all around it delineates the donor site. (F) The graft is harvested with a Beaver blade No. 64 pushed with back and forth movements. It should remain very thin. (G) The graft is transferred onto the recipient site. (H) The graft is secured with 7-0 absorbable sutures. (I) The plate is put back in place and firmly pressed onto the bed and the graft with stitches.

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Figure 33

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(Continued )

REFERENCES

1. Richert B. Basic nail surgery. Dermatol Clin 2006; 24(3): 313–322. 2. Krull E.A. Biopsy techniques. In: Krull EA, Zook EG, Baran R, et al., eds. Nail Surgery. A Text and Atlas. Philadelphia: Lippincott Williams & Wilkins, 2001; 54–81. 3. Rich P. Nail biopsy: indications and methods. Dermatol Surg 2001; 27:229–234. 4. Grover C, Nanda S, Reddy BS, et al. Nail biopsy: assessment of indications and outcome. Dermatol Surg 2005; 31:190–194. 5. Jellinek NJ. Nail surgery: practical tips and treatment options. Dermatol Ther 2007;20:68–74. 6. Zook EG, Baran R, Haneke E, et al. Nail surgery and traumatic abnormalities. In: Baran R, Dawber RPR, de Berker DAR, et al., eds. Diseases of the Nails and Their Management. 3rd ed. London: Blackwell Science, 2001:425–514.

7. Siegle RJ, Swanson NA. Nail surgery: a review. J Dermatol Surg Oncol 1982; 8:659–666. 8. de Berker DAR, Perrin C, Baran R. Localized longitudinal erythronychia. Arch Dermatol 2004; 140:1253–1257. 9. Richert B, Iorizzo M, Tosti A, et al. Nail lichen planus associated with onychopapilloma. Br J Dermatol 2007; 156:1071–1072. 10. Baran R, Perrin C. Focal subungual warty dyskeratoma. Dermatology 1997; 195:278–280. 11. Sass U, Kolivras A, Richert B, et al. Acantholytic tumor of the nail: acantholytic dyskeratotic acanthoma. J Cutan Pathol 2009; 36:1308–1311. 12. Baran R, Perrin C. Localized multinucleate distal subungual keratosis. Br J Dermatol 1995; 133:77–82. 13. Baran R, Perrin C. Longitudinal erythronychia with distal subungual keratosis: onychopapilloma of the nail bed and Bowen’s disease. Br J Dermatol 2000; 143:132–135.

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14. Cogrel O, Beylot-Barry M, Doutre MS. Subungual squamous cell carcinoma revealed by longitudinal erythronychia. Ann Dermatol Venereol 2008; 135:883–885. 15. Gee BC, Millard PR, Dawber RPR. Onychopapilloma is not a distinct clinicopathological entity. Br J Dermatol 2002; 146:156–157. 16. Richert B. Frictional pyogenic granuloma of the nail bed. Dermatology 2001; 202:80–81. 17. High WA. Geftinib: a cause of pyogenic granulomalike lesions of the nail. Arch Dermatol 2006; 142:939. 18. Devillers C, Vanhooteghem O, Henrijean A, et al. Subungual pyogenic granuloma secondary to docetaxel therapy. Clin Exp Dermatol 2009; 34:251–252. 19. Freiman A, Bouganim N, O’Brien EA. Case reports: mitozantrone-induced onycholysis associated with subungual abscesses, paronychia, and pyogenic granuloma. J Drugs Dermatol 2005; 4:490–492. 20. Davies MG. Coccal nail fold angiomatosis. Br J Dermatol 1995; 132:162–163. 21. Baran R, Bureau H. Surgical management of some conditions in and around the nail. J Dermatol Surg Oncol 1976; 2:308–312. 22. Haneke E, Baran R, Bureau H. Surgery of the nail region. Z Hautkr 1977; 15:1107–1116. 23. Haneke E, Baran R. Nail surgery. Dermatol Clin 1992; 10:327–333. 24. Ghodsi SZ, Raziei M, Taheri A, et al. Comparison cryotherapy and curettage for the treatment of pyogenic granuloma: a randomized trial. Br J Dermatol 2006; 154:671–675. 25. Tscharner GG, Hunziker T. Dye laser treatment of periungual pyogenic granuloma. J Dtsch Dermatol Ges 2006; 4:141–142. 26. Moon SE. Subungual pyogenic granuloma treated by sodium tetradecyl sulfate sclerotherapy. Dermatol Surg 2008; 34:846–847. 27. Baran R, Goettmann S. Distal digital keratoacanthoma: a report of 12 cases. Br J Dermatol 1998; 139:512–515. 28. Lovett JA, Haines TA, Bentz ML. Subungual keratoacanthoma masquerading a chronic paronychia. Plast Surg 1995; 38:84–87. 29. Levy DW, Bonakdarpour A, Putong PB, et al. Subungual keratoacanthoma. Skeletal Radiol 1985; 13: 287–290. 30. Pellegrini VD, Tomkins A. Management of subungual keratoacanthoma. J Hand Surg 1986; 11:718–724. 31. Sinha A, Marsh R, Langtry J. Spontaneous regression of subungual keratoacanthoma with reossification of underlying distal lytic phalanx. Clin Exp Dermatol 2005; 30:20–22. 32. Takino C, Mitoh Y. A case of acquired ungual fibroma located beneath the nail. Jap J Clin Dermatol 1983; 37:57–62. 33. Fetsch JF, Laskin WB, Miettinen M. Superficial acral fibromyxoma: a clinicopathologic and immunohistochemical analysis of 37 cases of a distinctive soft tissue tumor with a predilection for the fingers and the toes. Human Pathol 2001; 32:704–714.

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34. Andre´ J, Theunis A, Richert B, et al. Superficial fibromyxoma: clinical and pathological features. Am J Dermatopathol 2006; 26:472–474. 35. Al-Daraji WI, Miettinen M. Superficial acral fibromyxoma: a clinicopathological analysis of 32 tumours including 4 in the heel. J Cutan Pathol 2008; 35:1020–1026. 36. Sapuan J, Paul A, Abdullah S. Glomus tumour in the second toe. Foot Ankle Surg 2008; 47:483–486. 37. Van Geertruden J, Lorea P, Goldschmidt D, et al. Glomus tumours of the hand. J Hand Surg 1996; 21B(2):257–260. 38. Bhaskaranand K, Navadgi BC. Glomus tumour of the hand. J Hand Surg 2002; 27B:229–231. 39. Cigna E, Carlesimo B, Bistoni G, et al. The value of clinical diagnosis of glomus tumors. Acta Chir Plast 2008; 50:55–58. 40. Marchadier A, Cohen M, Legre R. Subungual glomus tumors of the fingers: ultrasound diagnosis. Chir Main 2006; 25:16–21. 41. Wortsman X, Jemec G. Role of high variable frequency ultrasound in the preoperative diagnosis of glomus tumors: a pilot study. Am J Clin Dermatol 2009; 10: 23–27. 42. Drape´ J-L, Idy-Peretti S, Goettmann S, et al. Subungual glomus tumors: Evaluation with MR imaging. Radiology 1995; 195:507–515. 43. McDermott EM, Weiss AP. Glomus tumors. J Hand Surg 2006; 31A:1397–1400. 44. Roca B, Climent A, Costa N. Reflex sympathetic dystrophy after nail surgery. Ann Med Intern 2000; 17:506. 45. Mikhail GR. Subungual epidermoid carcinoma. J Am Acad Dermatol 1984; 11:291–298. 46. Tosti A, Richert B, Pazzaglia M. Tumors of the nail apparatus. In: Scher RK, Daniel CR, eds. Nails: Diagnosis, Therapy, Surgery. 3rd ed. Philadelphia: Elsevier Saunders, 2005:195–204. 47. Baran R, Eichmann A. Longitudinal melanonychia associated with Bowen’s disease. Dermatology 1993; 186:159–160. 48. Haneke E. Epidermoid carcinoma (Bowen’s disease) of the nail simulating acquired ungual fibrokeratoma. Skin Cancer 1991; 6:217–221. 49. Baran R, Perrin C. Pseudo-fibrokeratoma of the nail apparatus with melanocytic pigmentation: a clue for diagnosing Bowen’s disease. Acta Derm Venereol 1994; 74:449–450. 50. Baran R, Perrin Ch. Bowen’s disease simulating an onychomatricoma. J Am Acad Dermatol 2002; 47:947–949. 51. Baran R, Richert B. Common nail tumors. Dermatol Clin 2006; 24:297–311. 52. Goodman G, Mason G, O’Brien T. Polydactylous Bowen’s disease of the nail bed. Australas J Dermatol 1995; 36:164–165. 53. Koch A, Schonlebe J, Haroske G, et al. Polydactylous Bowen’s disease. J Eur Acad Dermatol Venereol 2003; 17:213–215. 54. Peterson SR, Layton EG, Joseph AK. Squamous cell carcinoma of the nail apparatus with evidence of bone

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involvement: a multidisciplinary approach to resection and reconstruction. Dermatol Surg 2004; 30:218–221. Zaiac M, Weiss E. Mohs micrographic surgery of the nail unit and squamous cell carcinoma. Dermatol Surg 2001; 27:246–251. de Berker DAR, Dahl MG, Malcolm AJ, et al. Micrograhic surgery for squamous cell carcinoma. Br J Plast Surg 1996; 49:414–419. Richert B. Adornment of the foot; the fashion shoe and its repercussion on the nail apparatus. J Appl Cosmetol 2000; 18:15–21. Smith FJD, Liao H, Cassidy AJ, et al. The genetic basis of pachyonychia congenita. J Invest Dermatol 2005; 10:21–30. De Berker DA, Wojnarowska F, Sviland L, et al. Keratin expression in the normal nail unit: markers of regional differentiation. Br J Dermatol 2000; 142:89–96. McGowan KM, Coulombe PA. Keratin 17 expression in the hard epithelial context of the nair and nail, and its relevance for the pachyonychia congenita phenotype. J Invest Dermatol 2000; 114:1101–1107. Cosman B, Symonds FC Jr., Crikelair GF. Plastic surgery in pachyonychia congenita and other dyskeratoses. Case report and review of the literature. Plast Reconstr Surg 1964; 33:226–236. Thomsen RJ, Zuehlke RL, Beckman BI. Pachyonychia congenita: surgical management of the nail changes. J Dermatol Surg Oncol 1982; 8:24–28. Wright C. The developmental nature of pachyonychia congenita: a twenty year study of a case. Int Rec Med Gen Pract Clin 1956; 169:368–370. Milstone LM, Fleckman P, Leachman SA, et al. Treatment of pachyonychia congenita. J Invest Dermatol Symp Proc 2005; 10:18–20. El-Darouti MA, Marzouk SA, Nabil N, et al. Pachyonychia congenita: treatment of the thickened nails and palmoplantar circumscribed callosities with urea 40% paste. J Eur Acad Dermatol Venereol 2006; 20: 615–617. Mahajan BB, Pall A, Garg G, et al. Pachyonychia congenita-like nail changes treated successfully with a combination of vitamins A and E: a case report. Ind J Dermatol Venereol Leprol 2003; 69:338–339.

67. Hickerson RP, Leake D, Pho LNB, et al. Rapamycin selectively inhibits expression of an inducible keratin (K6a) in human keratinocytes and improves symptoms in pachyonychia congenita patients. J Dermatol Sci 2009; 56:82–88. 68. Leachman SA, Hickerson RP, Hull PR, et al. Therapeutic siRNAs for dominant genetic skin disorders including pachyonychia congenita. J Dermatol Sci 2008; 51:151–157. 69. O’Donovan DA, Mehdi SY, Eadie PA. The role of Mepitel silicone net dressings in the management of fingertip injuries in children. J Hand Surg Br 1999; 24:727–730. 70. Quell M, Neubauer T, Wagner M. Treatment of fingertip defect injuries with a semi occlusive dressing. Handchir Mikrochir Plast Chir 1998; 30:24–29. 71. Richert B, Dahdah M. Complications in nail surgery. In: Noury K, ed. Complications in Dermatologic Surgery. Philadelphia: Mosby Elsevier, 2008:137–158. 72. de Berker DAR, Baran R. Acquired malalignment: a complication of lateral longitudinal biopsy. Act Dermatol Venereol 1998; 78:468–470. 73. Ogo K. Does the nail bed really regenerate? Plast Reconstr Surg 1987; 80:445–447. 74. Schwarz M, Lemperle G, Hasse F. Rekonstruktion des Nagelbettes durch Serienexzision. Akt Chir 1992; 27: 252. 75. Lemperle G, Schwarz M, Lemperle SM. Nail regeneration by elongation of the partially destroyed nail bed. Plast Reconstr Surg 2003; 111:167–172. 76. Knox KR, Datiashvili RO, Granick MS. Surgical wound bed preparation of chronic and acute wounds. Clin Plast Surg 2007; 34:633–641. 77. Koenen W, Haneke E, Schmieder A, et al. Nail substitute with a syringe splint. J German Soc Dermatol 2010; 8:63–64. 78. Shepard GH. Treatment of nail bed avulsions with split thickness nail bed grafts. J Hand Surg 1983; 8:45–54. 79. Shepard GH. Management of acute nail bed avulsions. Hand Clin 1990; 6:39–56; discussion 57–58. 80. Shepard GH. Nail grafts for reconstruction. Hand Clin 1990; 6:79–102; discussion 103. 81. Shepard GH. Perionychial grafts in trauma and reconstruction. Hand Clin 2002; 18:595–614.

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8

Surgery of the lateral nail folds Bertrand Richert

The lateral nail folds are rolls that ensheath the nail plate on the lateral sides. They merge proximally with the proximal folds and distally with the hyponychium. They are often very pronounced in the lesser toes and sometimes the big toes promoting ingrowing nails. The lateral grooves are flat indentations framing the lateral nail margins and providing an abutment for the nail, for which they have a specialized connective tissue arrangement. HYPERTROPHIC LIP Introduction l Hypertrophic lateral nail fold results from longstanding ingrowing nail (Fig. 1A). l The nail looks normal. The soft tissues of the lateral fold may cover a part of the plate. Very often this condition is precipitated by pressure from the adjacent toenail. Surgery should not be recommended if the condition is asymptomatic. l In children, hypertrophic lips may be observed on the great toenails and may induce severe inflammation. Treatment should be conservative (corticoids under occlusion and taping) and surgery is contra indicated as the condition most always disappears spontaneously with time (1). l Four operative procedures are available: chemical cauterization of the lateral horn of the matrix, removal en bloc, fusiform excision of excess tissue from the lateral aspect of the distal phalanx, and transposition flap of nail wall. Anesthesia l Hemi distal digital block Tools l Basic nail surgery tray l Cotton-tipped applicators l Phenol 88% for lateral matrix phenolization l Scalpel blade No. 11 Surgical Procedure Technique: easy for chemical cauterization and resection en block intermediate for Dubois’ procedure and transposition flap — With Chemical Cauterization Chemical cauterization of the lateral horn of the matrix is an easy technique (see “Partial

Matricectomy,” pp. 103–110). The strip of plate to be avulsed corresponds to the lateral part of plate covered by the hypertrophic lip. After avulsion the exposed part of the matrix is chemically cauterized. — With Resection en Bloc Resection en bloc of the hypertrophic portion of the lateral nail fold with secondary intention healing is an option but is time consuming (daily dressings, up to to three weeks for healing) and uncomfortable for the patient (rubbing and pressure from the dressing against the adjacent toe) and may be associated with complete recurrence. — With Fusiform Excision In the fusiform excision of excess tissue (2), an elliptical wedge of soft tissue is excised within the distal lateral wall, down to the bone (Fig. 1B). Start with an ellipse of about 5 mm in its maximum width. Then, using strong toothed Adson forceps, pull down the upper part of the lateral fold and check if the amount of removed flesh is enough to free the lateral part of the nail. If not, remove an extra strip of skin from the lower part of the incision, maximum 2 mm at a time. When removal is adapted, suture the defect with nonabsorbable 3/0 or 4/0 suture. This pulls the lateral fold down away from the lateral edge of the plate (Fig. 1C). — With Transposition Flap of Tweedie and Ranger For the transposition flap of Tweedie and Ranger (3), the pointed extremity of a scalpel blade No. 11 is inserted vertically in the proximal part of the lateral nail sulcus to have it reappear about 1 cm below on the lateral aspect of the toe, transfixing the lateral nail fold (Fig. 1D). The blade is then pushed straight distally to free a flap. The flap is transposed inferiorly and its upper side sutured in place with 4/0 absorbable sutures (Fig. 1E). In some instances, it may be necessary to excise a Burrow triangle at the proximal part of the inferior aspect of the flap. The excess of tissue at the inferior part of the flap is cut away. Suturing the lower part of the flap ends surgery (Fig. 1F). Key Point l Evaluating the amount of flesh to be excised in the fusiform excision technique. Remove excess

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Figure 1 (A) Hypertrophic lip. (B) Removal of a crescent of excess flesh on the lateral side (hemi Dubois). (C) Suturing immediately lowers the lateral fold. (D) Schematic drawing of the Tweedie and Ranger flap: a No. 11 blade transfixes the lateral nail fold. (E) The flap is transposed inferiorly and sutured. (F) Postoperative aspect.

l

tissue sparingly at each time until the correct amount is removed. Having a large enough pedicle (1 cm at least) for the transposition flap.

Postoperative Care Pain: severe except for chemical cautery, little l

Greasy antiseptic dressings until complete healing.

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Both fusiform excision and flap transposition procedures are painful. Ensure proper analgesia with potent pain killers. Remove stitches after 10 to 15 days according to evolution.

Evolution l Healing is quick in about 8 to 10 days. l Pain may result from pressure on the wound from adjacent toe. Wearing large sandals is best!

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Complications and Management l In fusiform excision, removal of too much tissue or overtightened sutures will result in necrosis. l If the base of the transposition flap is not wide enough, there is a risk of necrosis. This may also occur in heavy smokers and patients with vascular impairment. If this happens, let it heal by secondary intention. Beware of too tight shoes as pressure may impair vascularization of the flap. l Recurrence may be observed with resection en bloc and in patients where adapted podiatric cares (abolition of overlapping toes with silicone prosthesis, proper footwear, etc.) are not performed.

INGROWING NAIL WITH HYPERTROPHIC LATERAL WALLS Introduction l Chronic ingrown nail will induce, with time, hypertrophy of the lateral and distal nail fold, the nail appearing then very narrow. l Some authors claimed that “the term ingrowing toenail is infortunate in that is incriminates the nail as the causative factor” and theorized that weight bearing caused the tissue to bulge over the sides of the nail (4). l Narrowing the nail plate in these instances will not solve the problem and will end in a very narrow nail on a bulky extremity. Here, the surgical procedure should be directed toward the excess of soft tissues that covers the plate (the term onychocryptosis is here very adequate). l Several techniques are available: the Vandenbos’ procedure (4,5), the Noe¨l’s procedure (6), the Super U (7), and the Howard-Dubois’

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procedure (also described in chap. 9 for distal embedding) (8). Anesthesia l Proximal or distal digital block Tools l Tourniquet is mandatory. l Basic surgery tray. Surgical Procedure Technique: easy — Vandenbos’ Procedure (Fig. 2A–C). l The first incision runs proximally for 1 cm through the proximal nail fold, about 5 mm medially from the junction of the proximal and lateral nail folds. A second incision is carried from the proximal end of the previous one and extended laterally to reach the lower third of the lateral aspect of the toe until the distal wall where it curves up to reach the free edge exactly facing the first incision on the proximal nail fold. l All soft tissues contained between the two incisions are very generously removed with the blade down to the bone, leaving a soft tissue defect of about 1.5 by 3 cm. A portion of the lateral aspect of the distal phalanx bone is exposed. l At any time of the procedure, neither the plate nor the bed or the matrix are touched. l Light cauterization is performed along the soft tissue exposed by the resection. l Healing is obtained by secondary intention.

Figure 2 (A) Preoperative aspect. The lateral nail folds cover the nail plate. (B) Very large debulking of the hypertrophic tissues. (C) One-year follow up. Source: Courtesy of H. Chapeskie, Canada.

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Incisions are deep enough, down to the lower third of the toe, to remove a large volume of soft tissues, with preservation of some skin of the lateral aspect of the nail to ensure direct closure. At any time of the procedure, neither the plate nor the bed or the matrix are touched. The defect is closed with simple interrupted 4/0 sutures.

Figure 2 (D) Preoperative aspect. Note the small appearing nail. (E) Very large debulking of the hypertrophic tissue. (F) Oneyear follow up. Source: Courtesy of I. Peres Rosa, Brazil.

—Super U (Fig. 2D–F). l This technique developed by the Brazilian dermatologist Peres Rosa is very similar to the one of Vandenbos. It removes all the excess tissue very generously in a U-shaped manner. l The only differences are that the most proximal part of the incision does not include the proximal nail fold and that hemostasis is obtained with either separate stitches or a running lock suture. l Improvement is dramatic. —Noe¨l’s procedure (Fig. 2G–I). l The first incision runs from the middle of the distal wall through the lateral nail groove up to one centimeter into the proximal nail fold. The second incision starts from the end of the previous one and extend laterally to remove a wedge-shaped ellipse of soft tissues.

Figure 2 (G) Preoperative aspect. Note the incision lines. (H) Large debulking of the hypertrophic tissue without removing the skin. (I) Immediate postoperative aspect.

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—Howard-Dubois’ procedure (Fig. 2J–M). l A fish-mouth incision is carried out parallel to the distal groove around the tip of the toe, about 5 mm below the level of the distal and lateral grooves reaching 5 mm into the lateral aspects of the distal phalanx. The incision runs from the medial to the lateral aspect of the distal interphalangeal joint. l A second incision is then made to yield a wedge of 5 mm at its greatest width in the middle of the distal wall. l One extremity of the crescent is held with a sturdy Adson forceps and pulled strongly to help dissect the area to be removed at bone contact with sharp pointed scissors. l Check that enough tissue has been removed by pulling on the two edges of the wound with fine hooks. If not, re-excise a new strip of 3 mm maximum from the lower edge of the wound. Check again and repeat the procedure until accurate removal of tissue. l Do not hesitate to remove enough fat and fibrous tissue. l Suturing the defect immediately frees the distal edge of the nail. Sutures may be simple stitches or a running lock suture for hemo-

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static purposes. They should reapproximate the defect and not pull too much on the distal wall to avoid wound margin necrosis. This technique is adequate for moderate hypertrophic walls.

Key Point l In all these procedures, which are variants of each other, it is important to remove enough soft tissues to avoid recurrences. Postoperative Care Pain: minimal to intermediate for secondary intention healing techniques, severe for Howard-Dubois’ and Noe¨ l’s techniques l

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Very greasy nonadherent dressing. Use Tulle Gras and Teflon-coated gauze (Telfa1, Melolin1). Very bulky dressing as the wound may bleed. The dressing should be replaced after 24 hours, not later, as bleeding may render the dressing hard and uncomfortable. Antiseptic soaks twice per day, until complete healing. The limb should be elevated for 48 hours.

Figure 2 (J) Hypertrophic walls moderate form. Preoperative aspect. (K) Removal of a large strip of skin and fat from one side to the other of the distal interphalangeal joint. (L) Suturing the defect frees the lateral edges of the nail. (M) The left toenail was operated six weeks ago. Note the scar running around the nail. Compare with the opposite toenail.

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Evolution l Overall cosmetic results for all procedures are excellent. l In the Vandenbos’ and the Super U procedures, healing by secondary intention may take up to 10 weeks. l In Howard-Dubois’ and Noe¨ l’s procedures, healing is quicker as it is first intention healing.

Complications and Management l No complication has been reported yet for the Vandenbos’ and Noe¨l’s procedures. l Necrosis is a possible complication for HowardDubois’s technique in case of overtightened sutures. HORN OF THE LATERAL SULCUS Introduction l This condition is mostly observed on the lateral aspect of the fifth toe and in rare instances on the fourth and affects almost exclusively women. l The condition develops from the lateral rotation of the fifth toe because of spread foot development and precipitated by footwear (pointed shoes). The toe is orientated such that the patient ambulates

on the lateral aspect of the nail plate. Friction against the shoe box results in hyperkeratotic reactions (9): it is usually benign and presents as onychophosis (hyperkeratosis of the lateral nail folds), but in some instances a real horn may develop. The latter is very thick (Fig. 3A) and goes deep down to the bone inducing excruciating pain on pressure. Anesthesia l Hemi distal digital block Tools l Basic nail surgery tray Surgical Procedure Technique: intermediate l

The lesion is removed in an ellipse oriented longitudinally and deep to the bone. There is no reason to curve the proximal part of the incision, as there is no removal of the matrix horn here. One horizontal mattress suture, starting from the lateral nail fold toward the plate will usually suffice on the fifth toenail (Fig. 3B).

Figure 3 (A) Painful thick horn of the lateral sulcus of the fifth toe. (B) The lesion is excised in a straight incision and the lateral edges reapproximated with one horizontal mattress stitch. (C) Very thick horn of the distal aspect of the lateral nail fold. (D) Closure of the defect with a wide relaxing incision.

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As the skin of the lateral aspect of the toe is thick it is almost always impossible to close the defect, even with large undermining. To help the closure, a relaxing incision made 1 cm laterally may suffice to help closing small defects (Fig. 3C, D). This relaxing incision will usually run over the pulp of the fifth toe. If the relaxing incision is not sufficient, a translation bridge flap is freed by inserting fine pointed scissors in the excisional defect, which are pushed down and laterally to emerge within the relaxing incision. Repeated openings and closures of the scissors will free the flap. The flap is grasped with fine Adson forceps or better skin hooks to check its mobility and its ability to be lifted up to the lateral aspect of the nail. If not, the flap has to be extended either proximally of distally. Using nonabsorbable 3/0 suture, the flap is affixed to the lateral edge of the plate with one horizontal mattress suture, starting from the flap toward the plate. One such stitch will usually suffice on the fifth toenail. For hemostatic purposes, one simple stitch may be added at each extremities of the incision. The lower defect is not sutured and will heal by secondary intention (10,11).

Key Point l Freeing the flap from the underlying tissues. As the surgery is performed on a thick skin with few fat padding, mobility is quite limited.

Postoperative Care Pain: severe l

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Bleeding is the rule! After removal of the tourniquet, inject some extra anesthetic (ropivacaine or buvipacaine) as a distal digital block to press onto the digital arteries. Apply a large amount of greasy antiseptic ointment and Tulle Gras on the wound and pad with several layers of gauze. Apply firmly, but not too tight, an elastic band around the whole foot and secure to the ankle. Keep the patient with the limb elevated for about half an hour before returning home. This surgery is painful. Prescribe potent pain killers for two days. Remove the stitches within two to three weeks according to healing.

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Evolution l Healing is quite fast and the defect will close in about three weeks. l It has been shown that semiocclusive dressings may enhance healing (10). Silicone dressings (Mepitel1) are very effective (11). l No infection is observed with the secondary intention healing if proper care is performed (12). l Some patients may complain about pain in the secondary intention healing area than elsewhere. This may be due to the wound retraction observed in such healing. l After recovery, proper footwear is a must and podiatric examination to correct any imbalance with insole is especially useful. Otherwise, recurrence is the rule.

Complications and Management l Necrosis of the flap is exceptional. Beware of heavy smokers and patients with impaired vascular flow at the extremities. l No dystrophy or retraction is observed at this location as the defect remains of small size.

FIBROKERATOMA Introduction l At this location acquired periungual fibrokeratomas (FK) are identical to the digital acquired FK (13). They may present as flat to dome shaped, or tall and hyperkeratotic flesh-colored asymptomatic nodules with a hyperkeratotic tip (Fig. 4). Trauma is thought to be an causative factor.

Figure 4

Digital fibrokeratoma.

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Anesthesia l Hemi distal digital block

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Tools l Basic surgery tray l Nonabsorbable sutures 5/0

l

Surgical Procedure Technique: easy l

l

The tumor is excised, as in the skin elsewhere, in a longitudinally oriented ellipse, parallel to the lateral border of the plate. One or two stitches suffice to close the defect. l

Postoperative Care Pain: very little l l l

Greasy nonadherent dressing. Pain is minimal, paracetamol if needed. After two days, antiseptics soakings and topical antiseptics twice per day for one week until removal of the stitches.

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Evolution l Healing without scar

Complications and Management l None major

BOWEN’S DISEASE, EPIDERMOID CARCINOMA, AND SQUAMOUS CELL CARCINOMA Introduction l Bowen’s disease is not as uncommon at the nail apparatus as thought (14). l It is a distinctive type of “in situ” squamous cell carcinoma. As it may be difficult to distinguish invasive from in situ carcinoma, the term epidermoid carcinoma has been proposed (14). It is a low-grade carcinoma that is not as aggressive as on the other area of the body (14).

It develops either in the nail bed or the nail folds. It affects mostly the three first finger of the left hand of middle age males. Predisposing factors include HPV infection, pesticides, exposure to arsenic, radiodermatitis and dyskeratosis congenita. Clinical presentation is very variable according to the location of the disease. The most typical feature is a long-standing hyperkeratotic lesion resembling a viral wart (Fig. 5A) (15). Associated longitudinal melanonychia is a clue for Bowen’s disease (16). In some instances, the lesion may present with misleading features such as FK-like (17,18), pseudo-onychomatricoma (19) or longitudinal erythronychia (20). Onycholysis with oozing is another possible presentation (21). Polydactylous involvement is rare but possible (22,23). Preoperative evaluation should include hand radiographs before embarking for surgery. In case of bone involvement, amputation is mandatory (24). Highest cure rate (over 95%) is achieved with Mohs’ surgery allowing adequate excision with maximal tissue-sparing excision maximizing hand and digit function (25,26). When the lesion is limited, excisional surgery may be used for removal of the tumor (21). Closure may be obtained by secondary intention healing or bridge flap (see below). Of course, if histological examination reveals incomplete excision, additional surgery is needed (see “Removal of the Whole Nail Unit,” pp. 137–138). For this reason, the socalled “slow Mohs” is very adequate: the excision specimen is sent, fully orientated, to the pathologist and the defect kept under greasy antiseptic dressings, renewed every day, until pathological report. If needed, additional resection is done. Closure is performed only when margins are cleared (Fig. 5B).

Anesthesia l Distal digital block

Tools l Basic nail surgery tray l Skin hooks

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Surgical Procedure Technique: difficult l

l

The lesion should be first excised in an S-shaped way, with 3-mm safery margins, similar but larger, to the one performed for the lateral longitudinal biopsy (see “Lateral Longitudinal Biopsy,” pp. 133–135). The incision starts halfway between the cuticle and the distal interphalangeal joint and progresses distally through the proximal nail fold (where the

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nail is the softest), the nail plate and its bed to the hyponychium. It may be hard to cut through the plate: repeated up and down stabbing movements with the blade with distal progression (as cutting a tart) helps greatly. Proximally, the incision takes a laterally curved direction that extends about halfway on the lateral aspect of the finger, up to the distal interphalangeal crease. This allows complete removal of the lateral horn of the matrix and ensures a more anatomical closure at the junction of the proximal and lateral nail folds. A

Figure 5 (A) Bowen’s disease verruca like. Note the margins of excision. (B) After complete resection of the lesion and histologically clear margins. (C) Suture of the pulpar flap onto the lateral remaining nail. (D) Side view showing the large defect that allowed the transposition and that will heal by secondary intention. (E) Aspect at six months postoperatively. (F) Side view showing that healing by secondary intention did not leave any scar.

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l

the proximal nail fold and at the hyponychium, simple stitches are enough (Fig. 5C). This creates a secondary defect that is not sutured and that will heal by secondary intention (Fig. 5D).

Key Point l Carefully design the flap with its sigmoid shape. l Freeing the flap properly to ensure its maximal mobility.

Figure 6 Drawing of a sigmoid excision for removal of tumors on the lateral nail fold and bed.

Postoperative Care Pain: intermediate to severe l

l l

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second incision, starting from the distal extremity of the previous one, runs from the hyponychium to join the proximal end of the previous incision. It parallels the first one ensuring a sigmoid excision (Fig. 6). The specimen is fully oriented. The defect is filled with antiseptic ointment, covered with a bulky dressing and renewed everyday until pathological report. In case of incomplete excision, a new excision is performed according to the histopathological report. The wound is left open and covered as mentioned above. When histopathological results show free margins, the procedure is finished and closure may be performed. A new incision starts distally in the pulp and runs proximally following the lower margin of the defect, with a width of minimum 1 cm all along. Fine pointed scissors are inserted in the defect and pushed down and laterally to emerge within the new incision. Repeated openings and closures of the scissors will free the flap. The flap is grasped with fine Adson forceps or better skin hooks to check its mobility and its ability to be lifted up to the lateral aspect of the nail. If not, the flap has to be extended either proximally of distally. Using nonabsorbable 3/0 suture, the flap is affixed to the lateral edge of the plate with one horizontal mattress suture, starting from the flap toward the plate. The needle is inserted 5 mm under the margin of the flap and runs through the bed and its plate, then returns through the plate and its bed toward the flap leaving about 2 to 3 mm of suture resting on top of the plate. Such a stitch is very useful to recreate a lateral fold. On

l

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Bleeding is the rule! After removal of the tourniquet, inject some extra anesthetic (ropivacaine or buvipacaine) as a distal digital block to press onto the digital arteries. Apply a large amount of greasy antiseptic ointment and Tulle Gras on the wound and pad with several layers of gauze. Apply firmly, but not too tight, an elastic band around the whole foot and secure to the ankle. Keep the patient with the limb elevated for about half an hour before returning home. This surgery is painful. Prescribe potent pain killers for two days. Remove the stitches within two to three weeks according to healing.

Evolution l Healing is quite fast and the secondary defect will close in about three to five weeks (Fig. 5E, F). l Silicone dressings (Mepitel) may enhance healing (11) and may be used when the defect is filled with new tissue. l No infection is observed with the secondary intention healing if proper care is performed (12). Amazingly, the scar is barely visible afterward. l With this design, this lateral pulpar flap should ensure a nice junction between the proximal and lateral folds (Fig. 5E). Complications and Management l Bleeding is quite common. Apply a bulky dressing, keep the patient in the office for half an hour with the limb elevated. Renew the dressing the following day. Keeping the dressing for several days renders the gauze as hard as cardboard and may be responsible for painful superficial erosions (27).

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Necrosis is unlikely if the flap has less than 1 cm width and in patients with severe vascular impairment or heavy smokers. If the resection takes out more that a 3-mm strip of plate with corresponding matrix, a lateral deviation may occur with time, as it may for lateral longitudinal biopsy (28).

IMPLANTATION CYST Introduction l Epidermal inclusion cysts develop from the traumatic implantation of epidermal cells into the dermis or subcutaneous tissues. l They are an infrequent complication of nail surgery. Their postoperative incidence after surgical nail matricectomies (Emmert or Kocher type) has been evaluated at 5.5% (29). Recently they were reported as being the most common complication after full-thickness grafts following complete nail unit excision (30); however, this may point to a poor technique. They have been observed after unguodermal rotation flap for congenital malalignment of the great toenail (31). One of the authors (B. Richert) has only encountered them after partial ablation of the nail apparatus followed by closure by a flap. l When posttraumatic they may be even encountered in the bony phalanx itself (see “Inclusion Cyst,” p. 155). l Clinically they present as asymptomatic soft mass in the immediate vicinity of a scar, adherent to the skin and underlying tissues (Fig. 7A). They enlarge progressively over time. One of the authors (E. Haneke) has recently observed a rapidly growing cyst that, because of its sheer volume, caused the nail plate to disappear. Anesthesia l Hemi distal digital block

Figure 7 (A) Implantation cyst occurring after surgery of the lateral nail fold for chronic radiodermatitis six months priorly. Note the whitish nodule in the vicinity of the scar. (B) Extirpation of the implantation cyst. The defect will be left open for secondary intention healing to avoid any recurrence.

l

Tools l Basic surgery tray Surgical Procedure Technique: intermediate l

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A large incision, larger than the diameter of the cyst, runs longitudinally over the cyst, at least 3 to 5 mm out of the previous scar. Careful dissection is performed with fine blunt tipped scissors all around the porcelain white cyst until complete enucleation (Fig. 7B). Do not try to grasp the cyst with forceps, this may break

the fragile lining. If so, copiously drain the cavity with saline and curette the cavity to ensure that there is no remnant of lining. Closure of the cavity should be done as atraumatically as possible. In some cases, a compressive dressing is enough. If suture is mandatory, one horizontal mattress suture should be preferred for its eversion properties.

Key Point l Removal of the cyst in a whole without rupturing it. Postoperative Care Pain: moderate l l

Slight compressive dressing. Remove stitches after two weeks.

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Evolution l

Usually occurs without trouble

Complications and Management l Several recurrences in a row may be observed even with complete enucleation as one piece. This may be a sign of dislodgement of several epidermal pieces. REFERENCES 1. Piraccini BM, Parente GL, Varotti E, et al. Congenital hypertrophy of the lateral nail fold of the hallux: clinical features and follow up of seven cases. Pediatr Dermatol 2000; 17:348–351. 2. Baran R. L’ongle incarne´. Ann Dermatol Venereol 1987; 114:1597–1604. 3. Tweedie JH, Ranger I. A simple procedure with nail preservation for ingrowing toenails. Arch Emerg Med 1985; 2:149–154. 4. Vandenbos KQ, Bowers WF. Ingrown toenail: a result of weight bearing on soft tissue. US Armed Forces Med J 1959; 10:1168–1173. 5. Chapeskie H. Ingrown toenail or overgrown toe skin. Can Fam Phys 2008; 54:1561–1562. 6. Noe¨l B. Surgical treatment of ingrowing toenail without matricectomy. Dermatol Surg 2008; 34:79–83. 7. Rosa IP. Hipercurvatura transversa da lamina ungueal (pincer nail) e lamina ungueal que na˜ o cresce. Tratamento ciru´rgico: Remoc¸a˜o do “U” largo de pele, osteocorrec¸a˜o do leito e cicatrizac¸a˜o por segunda intenc¸a˜o (Tese). Sa˜o Paulo. Universidade Federal de Sa˜o Paulo. Escola Paulista de Medicina, 2005:156. 8. Gre´co J, Kiniffo HV, Chanterelle A, et al. Approach to the soft parts, the secret of the surgical cure of ingrown nails. Technical points. Ann Chir Plast 1973; 18:363–366. 9. Richert B. Adornment of the foot: the fashion shoe and its repercussion on the nail apparatus. J Appl Cosmetol 2000; 18:15–21. 10. Mennen U, Wiese A. Fingertips injuries: management with semi occlusive dressings. J Hand Surg Br 1993; 18:416–422. 11. O’Donovan DA, Mehdi SY, Eadie PA. The role of Mepitel silicone net dressings in the management of fingertip injuries in children. J Hand Surg Br 1999; 24:727–730. 12. Quell M, Neubauer T, Wagner M. Treatment of fingertip defect injuries with a semi occlusive dressing. Handchir Mikrochir Plast Chir 1998; 30:24–29. 13. Kint A, Baran R, de Keyser H. Acquired digital fibrokeratoma. J Am Acad Dermatol 1985; 12:816–821. 14. Mikhail GR. Subungual epidermoid carcinoma. J Am Acad Dermatol 1984; 11:291–298.

15. Tosti A, Richert B, Pazzaglia M. Tumors of the nail apparatus. In: Scher RK, Daniel CR, eds. Nails: Diagnosis, Therapy, Surgery. 3rd ed. Philadelphia: Elsevier Saunders, 2005:195–204. 16. Baran R, Eichmann A. Longitudinal melanonychia associated with Bowen’s disease. Dermatology 1993; 186:159–160. 17. Haneke E. Epidermoid carcinoma (Bowen’s disease) of the nail simulating acquired ungual fibrokeratoma. Skin Cancer 1991; 6:217–221. 18. Baran R, Perrin CH. Pseudo-fibrokeratoma of the nail apparatus with melanocytic pigmentation: a clue for diagnosing Bowen’s disease. Acta Derm Venereol 1994; 74:449–450. 19. Baran R, Perrin CH. Bowen’s disease simulating an onychomatricoma. J Am Acad Dermatol 2002; 47:947–949. 20. Baran R, Perrin CH. Longitudinal erythronychia with distal subungual keratosis: onychopapilloma of the nail bed and Bowen’s disease. Br J Dermatol 2000; 143:132–135. 21. Baran R, Richert B. Common nail tumors. Dermatol Clin 2006; 24:297–311. 22. Goodman G, Mason G, O’Brien T. Polydactylous Bowen’s disease of the nail bed. Australas J Dermatol 1995; 36:164–165. 23. Koch A, Schonlebe J, Haroske G, et al. Polydactylous Bowen’s disease. J Eur Acad Dermatol Venereol 2003; 17:213–215. 24. Peterson SR, Layton EG, Joseph AK. Squamous cell carcinoma of the nail apparatus with evidence of bone involvement: a multidisciplinary approach to resection and reconstruction. Dermatol Surg 2004; 30:218–221. 25. Zaiac M, Weiss E. Moh’s micrographic surgery of the nail unit and squamous cell carcinoma. Dermatol Surg 2001; 27:246–251. 26. de Berker DAR, Dahl MG, Malcolm AJ, et al. Micrograhic surgery for squamous cell carcinoma. Br J Plast Surg 1996; 49:414–419. 27. Richert B, Dahdah M. Complications in nail surgery. In: Noury K, ed. Complications in Dermatologic Surgery. Philadelphia: Mosby Elsevier, 2008:137–158. 28. de Berker DAR, Baran R. Acquired malalignment: a complication of lateral longitudinal biopsy. Act Dermatol 1998; 78:468–470. 29. Wadhams PS, McDonald JF, Jenkin WM. Epidermal inclusion cysts as a complication of nail surgery. J Am Pod Med Assoc 1990; 80:610–612. 30. Lazar A, Abimelec P, Dumontier C. Full-thickness skin graft for nail unit reconstruction. J Hand Surg Br 2005; 30:194–198. 31. Baran R, Bureau H. Two post-operatice epidermoid cysts following realignment of the hallux nail. Br J Dermatol 1988; 119:245–247.

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Surgery of the distal fold Bertrand Richert

The distal fold contains several major structures: the hyponychium, the distal groove, and the tip of the digit. The hyponychium is the physiologic separation of the plate from its strong adherence to the onychodermal band. The distal groove is a narrow rim of transitional skin as it lacks epidermal ridges. This area is linked to the periosteum of the ungual process by deep connective fibers. DISTAL EMBEDDING Introduction l Distal nail embedding occurs after nail avulsion or nail shedding or when the nail has been too short for too long a period. The nail offers vigorous resistance against the upward forces exerted during gait. Because of the loss of counterpressure from the absence of the nail, the plantar and distal portion of the pulp becomes dislocated dorsally when the foot rolls up and the body weight presses on the tip of the great toe during walking. This results in a bulky distal wall that interferes with the growth of the newly formed nail (1). The latter abuts distally on this thick distal wall and is unable to overcome it (Fig. 1A). It turns thick, opaque and yellow. l For these reasons, distal embedding in mostly observed on the great toenails although fingernails may also be affected. l With time, hyperkeratosis forms at the meeting point of the plate and distal wall thus aggravating the condition (Fig. 1B). l In long-standing distal nail walls, a traction osteophyte on the distal dorsal extremity of the distal phalanx is usually observed on X-rays requiring its removal. l Conservative treatments should be tried first in minor forms: massaging back in a distal-plantar direction, softening the plate with 40% urea paste, debriding the hyperkeratosis in association with taping (Fig. 1C) or applying acrylic nails to flatten the distal wall. l Surgery is indicated for painful embedding, impairing with shoe wearing and walking or cases not responding to conservative treatment. It consists in removing some soft tissue to reduce the thickness of the distal wall and to flatten it (2).

Figure 1 (A) Distal embedding showing how the nail abuts on the distal wall. (B) Distal embedding with hyperkeratosis. (C) Taping as a conservative treatment of distal embedding.

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Anesthesia l Distal digital block Tools l Tourniquet l Basic nail surgery tray l Nonabsorbable suture 3/0

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Surgical Procedure Technique: intermediate — Howard-Dubois’ Procedure (Fig. 2A–G) l As this is a bleeding procedure, placing a tourniquet is mandatory. l A fish-mouth incision is carried out parallel to the distal groove around the tip of the toe or the digit, about 5 mm below the level of the distal and lateral grooves reaching 5 mm into the lateral aspects of the distal phalanx. The incision starts and ends 5 mm proximal to the end of the lateral nail fold. l A second incision is then made to yield a wedge of 5 mm at its greatest width in the middle of the distal wall.

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One extremity of the crescent is held with a sturdy Adson forceps and pulled strongly to help dissect the area to be removed at bone contact with sharp pointed scissors. Check that enough tissue has been removed by pulling on the two edges of the wound with fine hooks. If not, re-excise a new strip of 3 mm maximum from the lower edge of the wound. Check again and repeat the procedure until accurate removal of tissue. When there is a ski jump–like dorsal extension of the distal end of the bone this has to be removed generously with a bone rongeur. Do not hesitate to remove enough fat. Suturing the defect immediately frees the distal edge of the nail (Fig. 3A–C). Sutures may be simple stitches or a running lock suture for hemostatic purposes. They should reapproximate the defect and not pull too much on the distal wall to avoid wound margin necrosis.

Figure 2 (A) Distal embedding on a finger (side view). (B) Distal embedding (upper view). (C) Distal embedding (front view). (D) After removal of excess tissue (side view). (E) Suturing pulls down the distal wall (upper view). (F) Suturing pulls down the distal wall (front view). (G) Suturing pulls down the distal wall (side view).

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Figure 3 (A) Distal embedding on a great toe (upper view). (B) Distal embedding on a great toe (side view). (C) Suturing pulls down the distal wall (upper view). (D) Suturing pulls down the distal wall (side view).

Key Point l The distance from the lateral and distal nail grooves to the first incision should never be less than 5 mm. l Remove excess tissue progressively, sparingly at each time, until the correct amount is removed. l Excess bone, if any, has to be removed. l Do not overtighten stitches.

Evolution l The new nail seems to grow faster and with normal thickness as it is freed. l Pain and discomfort may remain for several weeks. l Anesthesia and dysesthesia of the distal wall may persist for up to one year and result from section of numerous tiny nerves on the distal wall.

Postoperation Care Pain: severe

Complications and Management l Main complication is necrosis from overtightened sutures after excess removal of soft tissues (Fig. 4). l Poor removal will not be curative and results in recurrence.

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Very greasy nonadherent dressing. Use Tulle Gras and Teflon-coated gauze (Telfa1, Melolin1). Very bulky dressing as the wound may bleed. The dressing should be replaced after 24 hours, not later, as bleeding may render the dressing hard and uncomfortable. Antiseptic soaks twice per day with removal of any crust is highly recommended. The limb should be elevated for 48 hours. A first set of stitches is removed after 10 days. The remaining ones are removed one week later.

— Shaving Procedure (Fig. 5A, B) Technique: easy l

If the distal embedding is not too severe and there is no dorsal extension of the corona unguicularis, this technique might be a nice alternative.

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It is a quick and safe technique with very few side effects, also very comfortable for the patient. With a No. 15 blade held horizontally on the nail bed just in front of the nail at the level of the proximal end of the distal groove, the excessive distal tissue on which the nail abuts is tangentially excised from side to side. Compression with aluminum chloride solution suffices to ensure hemostasis.

Key point l Be generous in your excision and check that the distal edge of the nail is free. Postoperative care Pain: very little Figure 4

Partial necrosis from overtightened sutures.

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Pain is very limited as the pressure from the nail has been relieved. Healing takes place by secondary intention: greasy dressings with twice daily soakings until complete healing.

Evolution l The freed nail seems too grow faster as it has been freed. l Healing by secondary intention occurs in about three weeks. Complications and Management l Poor postoperation care may result in infection. l Poor excision will result in recurrence.

TUMORS OF THE DISTAL FOLD Introduction l The distal wall is covered by normal glabrous skin over a fatty cushioning protecting the distal tuft of the phalanx. It contains many nerve endings. Thus tumors of various origins may be observed on the distal wall, as it may be encountered elsewhere on the skin. This skin differs however by the fact that it is ridged skin without follicles and sebaceous glands. Figure 5 (A) Discrete, but painful distal embedding after avulsion for retronychia. (B) After tangential excision of the distal wall impairing with the nail’s growth. The distal edge of the nail is completely freed.

Anesthesia l Distal digital block or transthecal block

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Figure 6 (A) Pigmented lesion on the distal fold. (B) Punch excision of the lesion. (C) Suture with one stitch. This is usually more comfortable for the patient as healing occurs quicker and dressing are less demanding.

Figure 7 (A) Subcutaneous nodule in the distal wall. (B) Extirpation of the lesion (neurofibroma). (C) After suturing.

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Tools l Basic nail surgery tray l Punch biopsy Surgical Procedure l Surgery will depend on the size of the lesion. As for skin, several procedures are available: punch excision with (Fig. 6A–C) or without suture, excision with direct suturing (Fig. 7A–C), excision with relaxing incision (Fig. 8), and A-to-T flap (Fig. 9). Because of the mobility of the distal wall on the deep structures, secondary intention healing is not frequently indicated. Key Point l All incisions should be carried parallel to the distal edge of the nail when possible. l However, the distal wall heals amazingly well and even longitudinal incisions will result with virtually invisible scars afterward.

Figure 9

Scheme of a A-to-T flap for lesion of the distal fold.

Postoperative Care l Will depend on the surgery l Will heal like normal skin elsewhere Evolution l Like in the skin. l Inform the patients about long-term (up to one year) possible dysesthesia at that site. REFERENCES 1. Zook EG, Baran R, Haneke E, et al. Nail surgery and traumatic abnormalities. In: Baran R, Dawber R, Berker DAR, et al., eds. Diseases of the Nails and Their Managements. 3rd ed. Oxford: Blackwell Science, 2001:425–514. 2. Gre´co J, Kiniffo HV, Chanterelle A, et al. Approach to the soft parts, the secret of the surgical cure of ingrown nails. Technical points. Ann Chir Plast 1973; 18:363–366.

Figure 8 After removal of a large hyperkeratotic tumor at the distal and lateral junction of the plate, suturing is possible with a relaxing incision.

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Surgery of the matrix Nilton Di Chiacchio, Bertrand Richert, and Eckart Haneke

The nail matrix covers the bottom of the cul-de-sac and rises on the posterior quarter (or even less) of the ventral aspect of the proximal nail fold (PNF) (see chap. 1). The matrix rests on the base of the distal bony phalanx and forms a crescent with posteriorinferior concavity (Fig. 1A). One should bear in mind that on the great toes, both lateral ends of the crescent (also called the lateral horns of the matrix) expand much proximal on the lateral aspect of the phalanx than that of the fingers (Fig. 1B). This anatomical particularity explains why spicules are the most common complication of surgical treatment for ingrowing toenail and lateral longitudinal biopsies in unskilled hands. The lateral horns may reach to or even beyond the midline of the lateral aspect of the great toe. Two other important points should be kept in mind when performing nail matrix surgery. 1.

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The proximal portion of the matrix produces the upper third of the nail plate and its distal part the lower two thirds (Fig. 1C). This is why removing a part of the distal matrix (e.g., with a punch) will not lead to nail dystrophy: the defect will be covered by the upper part of the plate synthetized by the proximal matrix. The thickness of the nail plate is proportional to the length of the matrix.

PARTIAL MATRICECTOMY NARROWING THE MATRIX —With Surgery Introduction l The goal of this surgery is the excision of the lateral horn of the nail matrix. It is a therapeutical option for treating ingrowing toenails, but this should be reserved for skilled surgeons. l In cases of ingrown toenail associated with a hypertrophy of the lateral nail fold, wedge excision is indicated (Fig. 2); however, this must be done including the lateral matrix horn. l In cases of light stages of ingrown nail, only the lateral horn of the matrix should be removed and the lateral nail fold preserved.

Anesthesia l Proximal or distal digital block

Tools l Tourniquet l Basic nail surgery tray l Nonabsorbable suture 3/0 or 4/0

Surgical Procedure Technique: difficult Wedge excision l A tourniquet is placed. l As the nail plate is not to be examined histologically, it may be removed first, allowing an easier technique than in the lateral longitudinal biopsy. l A 2 to 3 mm wide lateral strip of nail plate is detached from its bed and from the PNF using an elevator. The strip is cut longitudinally with a nail clipper and removed. l An incision is carried out starting at the hyponychium with the blade sticking vertically to the lateral part of the clipped nail, and progresses proximally along the bed and through the PNF until it reaches a point halfway between the cuticle and distal interphalangeal crease. The incision then takes on a laterally curved direction. It is extended until the most lateral part of the nail plate is visualized (1). Contact with the bone is mandatory all time. l The second incision starts at the same point and extends laterally through the lateral fold, removing the excess tissue, parallels the first incision and curves laterally at the most proximal part to ensure section of the lateral horn of the matrix to meet the end point of the first incision. l The wedge of tissue is then removed distally to proximally, sticking to the bone, working with fine-tipped curved scissors “tips down” or with a No. 64 Beaver blade shaving the periosteum.

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Figure 2 Scheme illustrating the two surgical ways of narrowing the matrix: A, with preservation of the nail fold; B, wedge excision in case of hypertrophy of the lateral nail fold. l

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Figure 1 (A) Anatomical location of the matrix. (B) Anatomical location of the matrix on a great toe. Transverse and lateral views. (C) Production of plate by the matrix: the proximal matrix produces the upper part of the matrix, and the distal matrix the lower part. A punch biopsy in the middle part of the matrix induces a defect that will be included within the thickness of the nail plate.

PNF and hyponychium are closed with single stitches using 4/0 nonabsorbable sutures. A half-buried horizontal mattress suture from the lateral nail fold through the nail plate will recreate a lateral nail sulcus and fold. The tourniquet is released.

Preserving lateral nail fold l A tourniquet is placed. l Any granulation tissue is curetted first (Fig. 3A, B). l As the nail plate is not examined histologically, a 2 to 3 mm wide lateral strip of nail plate is detached from its bed and from the PNF using an elevator. The strip is cut away with a nail clipper. l An incision is carried out starting at the hyponychium with the blade sticking vertically to the lateral part of the clipped nail, and progresses proximally along the bed and through the PNF until it reaches a point halfway between the cuticle and distal interphalangeal crease. The incision then takes on a laterally curved direction, that extends up to half of the lateral aspect of the digit (Fig. 3B) (1). Contact with the bone is mandatory all time. l The PNF and the lateral nail fold are reflected back and laterally, respectively, to help visualizing the whole area. l This procedure allows the lateral horn of the matrix to be visualized. l Dissection of the strip of bed and matrix to be excised starts distally and medially to stick to the bone surface, defining the depth of the excision. l This dissection progresses proximally and laterally until the whole strip of nail bed and

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Figure 3 (A) Ingrown toenail with pyogenic granuloma. The black stain results from silver nitrate. (B) Note how the incision curves proximally to ensure removal of the whole lateral horn of the matrix. (C) Removal of bed and matrix in one piece. (D) Four months postoperatively.

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matrix horn have been removed. It is better to have it in one piece (Fig. 3C), as it allows an easier control of the area removed, but as no histological examination is needed, it may come in several parts. The cavity is inspected for white glistening fibers that may indicate matrix remnants. If so, they have to be removed with fine scissors. Only fibrofatty tissue should remain. The PNF and hyponychium are closed with single sutures using 4/0 or 5/0 nonabsorbable sutures. A half-buried horizontal mattress suture from the lateral nail fold through the nail plate will recreate a lateral nail sulcus and fold. The tourniquet is released.

Key Point l In the wedge resection procedure, partial nail avulsion first may help to perform a more comfortable medial incision through nail bed and nail matrix.

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Always check that there are no remnants of matrix left. If any structure looks suspicious, remove it with scissors.

Postoperative Care Pain: severe l

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Antiseptic ointment is applied into the surgical wound and covered with nonadherent gauze and a bulky dressing. Prescribe potent pain killers as those procedures are painful from the periosteum trauma. The dressing is removed after one day, the wound is washed with antiseptic soap twice a day, and covered with a greasy ointment. Sutures are removed after 10 to 14 days.

Evolution l Healing is fast. l The patient should be checked after two months to ensure that there is no recurrence (Fig. 3D).

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Complications and Management l Complications are very common with nonskilled surgeons. l Curettage of the matrix is not an effective option for removing the matrix. It leaves a myriad of tiny amounts of matrix cells that will form keratin later on. l They present as recurrence of the ingrowing toenail – as the nail matrix has not been removed completely – and small remnants of matrix tissue may be responsible for epidermal cyst, spicules or inclusion of nail (2). l Treatment of these complications is removal of the cyst (see “Implantation Cyst,” pp. 95–96), of the spicule (see “Removal of a Spicule,” pp. 110–112) or new surgery for treating the ingrowing toenail. —With Chemocautery Introduction l Some conditions of the nail unit can be treated by narrowing the nail matrix, such as plicated nail, pincer or tile nail, and mainly ingrowing nail. l Ingrowing nail is classified in three stages. Stage 1 is characterized by erythema, slight edema and pain on pressure. In stage 2, the symptoms increase with local infection and discharge. In stage 3, granulation tissue and lateral wall hypertrophy are added (Fig. 4A). l Chemical cautery with 88% phenol has been performed for more that half of a century (3) and is widely used (4,5). More recently, it has been shown that 10% sodium hydroxide solution may reach the same success rate (5). One team proposed 100% trichloracetic acid cautery (6). l Selective matrix chemocautery is considered the most effective technique for definitive treatment, in terms of morbidity and success rate. The latter is over 97% according to large studies (5,7,8). It is indicated in stages 2 and 3. Stage 1 may benefit from conservative treatments. l As chemical cautery induces demyelination of terminal nerve endings, there is minimal postoperative discomfort. Anesthesia l Proximal or distal digital block Tools l Tourniquet l Nail avulsion tray l Curette 3 mm

NAIL SURGERY l l

Cotton-tipped applicators Phenol 88%, sodium hydroxide 10% or trichloracetic acid 100%

Surgical Procedure Technique: very easy l

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A tourniquet is placed to ensure a completely bloodless field. If blood is present, the cauterant will turn into a brown jelly, meaning that it has coagulated the blood proteins instead of those of the matrix epithelium. When granulation tissue is present, it should be curetted for a better view of the nail plate avoiding an excessive nail plate removal (Fig. 4B). The procedure starts with a lateral (or bilateral if the condition affects both sides) avulsion of a strip of nail about 3 to 5 mm of lateral nail plate: it is detached from the nail bed, and the lateral and PNF using a nail elevator (Fig. 4C). Pay particular attention to fully free the proximal lateral horn from the plate. The nail plate is split using scissors or nail nippers up to it most proximal edge under the PNF (Fig. 4D). Grab the strip of plate with sturdy hemostat on its whole width. Avulse the nail in a sideways rotating motion (Fig. 4E). Any residual attachment may be cut with scissors. Remnants of granulation tissue on the bed and in the lateral sulcus are gently curetted away. The exposed nail bed and matrix are carefully dried with a gauze or a cotton swab pushed along the lateral sulcus and under the PNF. No blood should remain. Check that the nail overlying the matrix is fully removed because any remnant nail will protect the matrix from the chemical cauterant and prevent its destruction. A cotton swab is soaked with the phenol solution 88%, then cautiously padded on a gauze to have it just moistened and not dripping. If there is excess of liquid on the cotton-tipped applicator, it will spill onto the nail folds causing unnecessary burn. This is why the first description of the technique recommended protecting the surrounding skin with some greasy ointment. Any overflow should be mopped away immediately with a gauze. Other applicators may be used for applying the cauterant: orange sticks, urethral swabs or the elevator itself (9). Push the applicator into the lateral sulcus down under the proximal fold and rub it vigorously onto the matrix (Fig. 4F). Work it carefully in the

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Figure 4 (A) Ingrowing toenail with granulation tissue. (B) The granulation tissue is curetted. (C) A lateral strip of nail is detached from the proximal nail fold and from its subungual attachments. (D) The plate is split from the free edge up to its hilt. (E) The strip of nail is avulsed using a hemostat in a rotation motion. (F) Cauterization of the bed and matrix with a cotton swab.

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lateral and proximal pocket of the matrix (review the anatomy of the lateral horns of the matrix of the great toes in chap. 1). The time of application depends on the chemical cauterant used: two to three minutes for phenol (10), one minute for sodium hydroxide (5) and trichloracetic acid 100% (6). The applicator may be replaced once or twice during the procedure. There is no need to neutralize the cauterant as it will be inactivated immediately with the blood flow returning after release of the tourniquet.

Key Point l A tourniquet is mandatory as any blood will impair chemical cautery. This is the main cause of recurrence. l Be sure to remove the complete lateral nail strip, as leaving some remnant nail will protect the matrix from cautery. l Never curette the matrix has this may be responsible for periostitis postoperatively (11). l The applicator should be only moistened with cauterant and not dripping, thus avoiding unnecessary burn.

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Patients must be instructed that oozing is not an infection. Chemical cautery is possible in diabetic patients (12–14). Care should be taken about vascular impairment. There is no toxicity from phenol matrix ablation, and no cardiac monitoring is necessary as with phenol peel.

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Antiseptic ointment is applied into the surgical wound and covered with a nonadherent gauze and a bulky dressing. The limb should be kept elevated for one day. The dressing is removed after one day and the wound cleaned with 3% hydrogen peroxide. The lateral sulcus is filled with a thin layer of antiseptic ointment, lotion or antibiotic pellet and covered with a simple plaster. The patient is asked to soak his foot twice daily until oozing disappears.

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Evolution l Oozing appears on the third day and may continue to up to six weeks for phenol, two weeks for sodium hydroxide, and one week for trichloracetic acid. It can be reduced by applying ferric chloride 20% at the end of phenolization (15). l A slight edema in the proximal and the lateral nail folds may remain for one week from the irritation from the cautery (16). l Both preoperative and postoperative antibiotic treatment were not shown to be necessary (17,18). l The efficacy of the treatment will not be proven until a third of the nail has regrown. Complications and Management l Complications are uncommon. l Infection is the most common complication as drainage promotes bacterial contamination. It is mostly observed in patients with poor hygiene and lack of proper home care (14). l Intense inflammation at the junction of the lateral and PNF about six weeks after surgery and perfect healing suggests that the nail plate was not severed up to its hilt: the growing nail pushes the remnant of the former wider nail out, irritating the lateral pocket (Fig. 4G). It is cut out with nail nippers allowing complete cure. No new matrix cauterization is necessary. l When the avulsion induces an over detachment of the plate from the matrix, overzealous cautery with dripping applicators may result in a definitive nail dystrophy (Fig. 4G).

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—With Laser Introduction l The laser is a technical miracle that uses light of unique properties: laser light is monochromatic, monophasic and collimated. This means that this light is extremely powerful and can exert biophysical actions hitherto unknown. For matricectomies, whether partial or total, an ablative type laser is commonly used, that is, the carbon dioxide laser.

Anesthesia l A proximal digital block, transthecal anesthesia or distal wing block are adequate. Tools l For the procedure itself: CO2 laser, small gauze pads, pincette, or hemostat clamp l To remove the ingrown strip of nail: nail avulsion tray l Tourniquet l Optional: methylene blue

Surgical Procedure Technique: easy l

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Figure 4 (G) Lateral horn of the former nail plate resulting from incomplete section of the plate to its hilt. This spike was responsible for a subacute paronychia.

The lateral ingrown nail margin is removed as described earlier (see “Partial Nail Avulsion,” pp. 38–41) without damaging the PNF and a tourniquet is applied. The exposed lateral matrix horn is dried from any blood. The roof of the PNF is retracted with a hook or a thread (Fig. 5A) (19) allowing the lateral matrix horn to be vaporized with the CO2 laser (Fig. 5B). Usually, a continuous wave mode with about 4 W and a spot size of 1 mm is used; however, this may be varied according to personal experience and the machine used. Some authors prefer to open the PNF over the lateral matrix horn to see more clearly the extent of laser vaporization (20,21). Staining the lateral matrix horn with sterile methylene blue solution also aids in estimating the degree of matrix ablation (22). At the end of laser surgery, the wound is cleaned and antibiotic pellets may be inserted into the small wound cavity or an antibiotic ointment with tulle gras is applied, then a normal toe dressing.

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Figure 5 (A) A lateral incision allows exposure of the lateral horn of the matrix. Here the lateral strip of nail was removed with the laser beam in a cutting mode. Note the stitches reflecting the proximal nail fold. (B) After vaporization of the lateral horn of the matrix. Source: Courtesy of E. Duhard, France.

Key Point l For those having a laser it is easy to perform laser matrix vaporization. l Laser vaporization of the matrix is no more or less effective than chemical cautery or radiofrequency. l Laser treatment is a very quick procedure. Postoperative Care Pain: little l

It is advisable to elevate the foot for about 24 hours. When there is no oozing the dressing is changed after two days. Showering is allowed also after two days and each time before applying a new small dressing.

Evolution l The results are usually good, the relapse rate is comparable or slightly higher to that of chemical matricectomy (19–21). Complications and Management l Complications are rare, provided the laser ablation was radical enough but vaporization was not performed too deep (19–26).

In the beginning, the relapse rate for partial CO2 laser matrix ablation was 48% (26), however, this is now between 0% and 5% (22,25). The partisans of laser matricectomy state that the CO2 laser is more selective as it only destroys the treated area and no surrounding tissue as might be the case with chemical cautery using phenol or sodium hydroxide when it spills over.

—With Radiosurgery Introduction l Radiofrequency devices are principally like other electrosurgical machines; however, they operate at much higher frequencies, usually around 3.6 to 3.8 MHz. l The heat is generated in the tissue itself and, in marked contrast to electrocautery, the treatment electrode remains “cold” throughout the procedure. This makes radiofrequency more selective and reduces heat generation thus producing only a very narrow margin of thermal tissue destruction. This accelerates wound healing and improves scarring. l The insulated matricectomy electrode is flexible and coated for protection of the upper tissue while it destroys the underlying cell layer. This renders it possible to cauterize the lateral horn of the matrix without injuring the ventral aspect ot the proximal fold (27). l These properties make the radiofrequency machine virtually as versatile as the CO2 laser at a much lower cost. Anesthesia l Proximal digital block, transthecal anesthesia, or distal digital block is adequate. Tools l For the procedure itself: radiofrequency machine, small gauze pads, pincette, or hemostat clamp l Special insulated spade-like active electrode; alternatively, any other type of electrode with a blunt tip can be used l To remove the ingrown strip of nail: nail avulsion tray l Tourniquet Surgical Procedure Technique: easy l

The lateral ingrown nail margin is removed as described earlier (see “Partial Nail Avulsion,” pp. 38–41). The exposed lateral matrix horn is

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Results l The results are usually good, the relapse rate is thought to be comparable to that of chemical and laser matricectomy. However no large studies are available.

Figure 6

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The insulated electrode inserted in the lateral pocket.

dried from blood to allow the matrix horn to be visualized. The spade-like electrode is introduced into the cavity of the lateral matrix horn (Fig. 6) and the matrix is cauterized. The power setting depends on personal experience, the type of electrode and machine used. For the Ellmann Surgitron1, the “partially rectified” current is applied two times three seconds on a great toe (27). The PNF over the lateral matrix horn may be opened to see more clearly the lateral matrix horn and to facilitate access to it. Staining the lateral matrix horn with sterile methylene blue solution also aids in estimating the degree of matrix ablation (22,27). At the end of radiofrequency surgery, the wound is cleaned and an antibiotic tablet may be inserted into the small wound cavity or an antibiotic ointment with tulle gras is applied, then a normal toe dressing. Some authors like to instillate some steroids lotion into the cavity to limit the postoperative inflammatory reaction (27).

Key Point l Radiosurgery should not be performed in patients with cardiac pacemakers. l Radiofrequency is a simple, time-honored, and cheap method compared with laser surgery. Postoperative Care Pain: moderate l

It is advisable to elevate the foot for about 24 hours. When there is no oozing the dressing is changed after two days. Showering is allowed also after two days and each time before applying a new small dressing. If there is more oozing and crust formation it is wise to clean the wound daily with a hand shower.

Complications and Management l Complications are rare, provided the radiofrequency ablation was radical enough but cauterization was not performed too deep avoiding a painful postradiofrequency periostitis (28,29). l When an insulated electrode is used of which only the tip cauterizes, damage to adjacent structures can be avoided. REMOVAL OF A SPICULE Introduction l Nail spicules are a common complication of surgical narrowing of the matrix, especially after wedge excision (see above) (Fig. 7A) performed for ingrowing toenails or lateral longitudinal biopsy (Fig. 7B) (see “Ungueodermal Flap for Congenital Malalignment of the Great Toenail,” pp. 135–137). l They develop because surgical removal left some remmants of nail matrix in place, especially from the lateral horn of the matrix (30). This is why the authors emphasize the fact that the most proximal part of a surgical resection of the matrix horn should curve proximally and laterally to ensure the whole removal of the lateral matrix horn. Anesthesia l A distal digital block will suffice. Tools l Tourniquet l Elevator l Chemical cauterant Surgical Procedure Technique: moderate l

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The procedure should be done in a bloodless field not to interfere with the coagulation effect of the cauterant. The spicule is very gently detached from its lateral attachements using the elevator. The later is pushed along the spicule, sticking to it without forcing. The idea is to act a bit like when performing an electrocoagulation of a hair. The procedure is repeated on both sides (Fig. 7C).

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Figure 7 (A) Two lateral spicules resulting from improper Emmert technique: note that the incisions do not curve proximally, resulting in incomplete removal of the lateral horns of the matrix with subsequent spicules. (B) One lateral spicule. The incision curves proximally but too early. (C) The spicule is delicately detached from surrounding tissues with the elevator. (D) The spicule is never pulled with a forceps or a hemostat. (E) The spicule is enucleated. (F) The cavity is cauterized with a cotton-tipped applicator (G) or using the elevator itself.

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Never pull on the spicule with a forceps. The spicule shoud be enucleated using the elevator only (Fig. 7D, E). This means that all attachements have been released. The very bottom of the cavity is cauterized. Several option are available according to the size of the cavity: if cotton-tipped applicators (Fig. 7F) are too wide, then use the elevator (Fig. 7G) or a toothpick. Dip it into cauterant and some liquid will adhere to the device by capillarity. Guide the drop at its tip to fall into the cavity. Let it pause for one to three minutes, whatever the cauterant. Release the tourniquet.

Key Point l Never pull on the spicule, this will break it and cauterization will fail. l Enucleate the spicule. l Prefer insertion of liquid in the cavity as forcing a cotton-tipped applicator inside it. Postoperative Care Pain: nil l

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Place a tiny amount of antiseptic ointment on top of the cavity and a small dressing. Ask the patient to fill the cavity everyday with a drop of antiseptic solution. Healing is quick, very little oozing last about two weeks.

Complications and Management l Infection is an exceptional complication. It mostly occurs in patient with poor hygiene and proper home care. l Recurrence is possible.

SHORTENING THE MATRIX Introduction l Nail thickening of idiopathic or hereditary cause originating in the matrix is hard to treat. Recently, Baran (31) described a simple and easy procedure for this condition: as the thickness of the nail plate is proportional to the length of the matrix, shortening the matrix leads to a thinning of the nail. Anesthesia l Distal digital block

Tools l Nail avulsion tray l Basic nail surgery tray Surgical Procedure Technique: moderate l l

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A tourniquet is placed. A distal nail avulsion is performed as already described (see “Total Nail Avulsion: Distal Approach,” pp. 32–34). The distal third of the matrix will be removed. Two parallel transverse incisions are performed: the distal one follows the distal border of the matrix and the proximal one reshapes the normal distal contour of the lunula. The matrix tissue is removed from the periosteum with fine scissors. No suture is needed. Healing occurs by secondary intention. Gelfoam1 may be an option for hemostatic purposes.

Key Point l Reshaping the distal contour of the lunula l Removal of the whole thickeness of the matrix Postoperative Care Pain: moderate l

Greasy dressing until healing

Evolution l The new formed nail is much improved; its thickness has been reduced dramatically. Complications and Management l The same as any other secondary intention healing: infection if proper home care is not done carefully. l Overzealous removal of the matrix may result in a very thin and dystrophic nail. TOTAL MATRICECTOMY Introduction l Total matricectomy refers to the complete removal of nail matrix and will lead to permanent nail loss (29). l It is indicated in onychauxis and onychogryphosis, some congenital or acquired nail dystrophies and in the chronic painful nail from recalcitrant ingrown toenail (29). In severe pincer nail, total matricectomy is an option when removal of the

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lateral horns of the matrix will leave a very narrow, unsightly detached nail (Fig. 8A) (29). Two procedures are available: surgical excision and chemical cautery of the whole nail matrix (29). As surgical excision is a difficult procedure, even for skilled surgeons, and very often associated with spicules formation (2), chemical cautery should be preferred as long as no pathological examination is necessary (29).

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Anesthesia l Proximal or distal digital block Tools For Surgical Excision l Basic nail surgery tray l Skin hooks l Gelfoam For Chemical Matricectomy l Tourniquet l Nail avulsion tray l 88% phenol solution (or 10% sodium hydroxide) Surgical Procedure Surgical excision Technique: difficult l l

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A tourniquet is placed. Two lateral oblique incisions at 458 are performed on both sides to recline backward the PNF and the lateral nail fold outward. A distal nail plate avulsion is performed as described in “Total Nail Avulsion, Distal Approach,” pp. 32–34. Skin hooks are used to fully expose the cul-de-sac containing the matrix. The matrix space is stained with methylene blue solution and then padded dry. The stained matrix will remains visible all throughout the procedure, helping the surgeon to dissect the entire matrix from the underlying bone, including the lateral horns. To delineate the lateral horn of the matrix, Austin has developed a very helpful technique: a straight needle pushed along the floor of the lateral nail groove, after nail avulsion, will always end at the very end of the lateral nail pocket (Fig. 8E). The whole matrix is very carefully dissected from the underlying bone using fine curved pointed scissors or a coated blade No. 15C or even better a Beaver blade No. 64. The blade or jaws of scissors should always stick to the periosteum.

The procedure has to be supplemented by the excision of the undersurface of the PNF, which removes the eponychium and the most proximal part of the matrix and the corresponding portion of the lateral nail grooves (Fig. 8F). Tourniquet is removed. Hemostatis is obtained by ligation or gentle electrocoagulation. Another easy and comfortable option is to apply Gelfoam in the wound. For heavy bleeding inject an extra shot of long acting anesthetics as a distal digital block: this will press onto the digital arteries and stop the bleeding immediately.

Chemical cautery of whole nail matrix Technique: easy l The procedure is identical to the one described for partial chemical matricectomy for ingrowing toenail (see “Narrowing the Matrix with Chemocautery,” pp. 106–108) but involve the whole nail matrix. l Here, a total distal nail avulsion is performed (Fig. 8B) (see “Total Nail Avulsion, Distal Approach,” pp. 32–34). l A bloodless field should be achieved to avoid inactivation of the chemical cauterant. The bed and matrix are padded dry. l Several cotton soaked into 88% phenol solution are rubbed strongly for up to one to two minutes (Fig. 8C), with changing the swabs if needed. l As the bed is responsible for a small amount of keratin production, it is better to cauterize the nail bed too to avoid the arising of an unsightly and bothering horny nail bed. l Tourniquet is removed. Key Point l The nail matrix should be completely visualized when excisional surgery is chosen. Staining with methylene blue is a good help. Use the Austin’s needle technique to ensure removal of the lateral horns of the matrix. l Chemical cautery should be here generous and vigorous. The caution rules to avoid overcautery or spilling of the cauterant do not apply as in partial chemocautery for ingrowing toenails. Postoperative Care Pain: for excisional surgery, severe; for chemical cautery, nil to very little l

Antiseptic ointment is applied into the surgical wound and covered with nonadherent gauze and a bulky dressing.

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Figure 8 (A) Very severe and painful pincer nail. Cauterization of the two lateral horns of the matrix would have been an option but would have left a very narrow strip of nail. (B) After complete nail avulsion. (C) Immediately after cauterization of the bed and matrix. Note clearly visible longitudinal ridges of the bed. (D) Three weeks postoperatively. Very good granulation tissue. (E) A needle inserted along the lateral nail groove may serve as a guide to the lateral horn of the matrix (M). (F) Scheme of surgical matricectomy.

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The dressing is removed after one day, the wound is washed with water and antiseptic soap twice a day, and covered with a greasy ointment until complete healing.

Evolution Surgical excision l Healing is rapid but the average time out of work of two weeks constitutes the major drawback from the procedure. Chemical cautery l Oozing will occur for about four to six weeks for phenol a bit less with sodium hydroxide. Return to work is possible after two days. l The cosmetic aspect of the toe of digit is much improved (Fig. 8D) as well as the comfort from shoe wear. Complications and Management Surgical excision l Recurrence with painful oozing from remnants of matrix (especially from the lateral horn) (2). l Too deep and generous excision in the most proximal part of the matrix may damage the underlying extensor tendon. Chemical cautery l Complications are uncommon. l Recurrences are exceptional. They present as a spicule emerging from on lateral sulcus. They are not included and not responsible for implantation cysts. Most of the time, patients are so relieved from the procedure and not bothered by the spicule at all that they are not willing to remove it. If removal of the spicule is wished, proceed as for spicule removal (see “Removal of a Spicule,” pp. 110–112). MATRIX TRANSPLANTATION Introduction l The nail matrix is the sole structure to produce the nail plate. When it is destroyed, variable degrees of nail dystrophy will result. l The nail matrix is made up of the matrix epithelium and its connective tissue layer. The latter has a remarkable morphogenetic potential. When a superficial wound of the matrix is produced leaving a considerable portion of the matrix dermis intact normal matrix epithelium can be formed again and so also a normal nail. This has been seen in split matrix graft donor

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sites as well as after tangential nail matrix biopsy (see “Excision of Longitudinal Melanonychia, Tangential Excision,” pp. 129–131). Matrix transplantation is used to cover defects of the matrix that cannot be closed primarily or with matrix flaps, to repair a cicatricial pterygium and traumatic partial avulsion of the matrix. The aim of the procedure (Fig. 9) is to transfer a very superficial graft from the donor toe (usually a great toenail) patterned to the size of the cicatricial defect of the recipient finger. To allow best healing the graft should be covered by a normal nail plate. In most instances, the donor toenail is also transferred and patterned to the size of the recipient fingernail. The donor toe is covered with the avulsed recipient altered nail plate.

Anesthesia l Proximal digital block, transthecal anesthesia or distal digital block are adequate. When the donor nail is on another digit two anesthesias have to be performed. Tools l Tourniquet l Nail avulsion tray l Fine nail surgery tray with Teflon-coated scalpel blade No. 15, fine pincette, fine hooks (i.e., Gillies) l 6/0 or 7/0 absorbable stitches l Head magnifier lens Surgical Procedure Technique: difficult l

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Depending on the type of nail damage, the dystrophic plate is cautiously avulsed (Fig. 9B). The area of damaged matrix is outlined making a pattern, and very superficially excised. When the defect is small and laterally located a thin slice of tissue is taken from the adjacent matrix and transferred to the defect. Care has to be taken to orient the graft in the correct direction. The matrix slice is taken with the scalpel in a way a tangential excision is carried out. The tip of the scalpel should be visible through the matrix graft. This is achieved with a graft that is about 0.25 to 0.5 mm thick. The matrix graft is sutured in place with 7/0 or 6/0 absorbable suture material. As the matrix has a directional orientation, labeling of the

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Figure 9 Scheme of free matrix transplant. (A) Split nail dystrophy. (B) Avulsion of the dystrophic fingernail. (C) The donor toenail plate is carefully avulsed here with the proximal approach. (D) The donor matrix is incised according to the pattern of the defect to cover on the recipient matrix. (E) After tangential excision of the graft. (F) The graft is transferred to the recipient finger. (G) The graft is placed on the recipient area. (H) The graft is sutured with 6/0 or 7/0 absorbable sutures. (I) The donor great toenail is trimmed to the size of the recipient fingernail and secured to it. (J) The donor great toe receives the altered fingernail. (K) Aspect of the recipient fingernail after three months. (L) Aspect of the recipient fingernail after two years. (M) Aspect of the donor toenail after five months.

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graft’s longitudinal axis and placing it in the correction direction is essential. Whenever possible, the graft and its surrounding tissue should be covered with an intact nail plate. When the defect is larger or the same digit is not adequate as the donor, the hallux toe may be chosen. The nail is avulsed using the proximal approach (see “Total Nail Avulsion: Proximal Approach,” pp. 34–36) and kept moist (Fig. 9C). A matrix area according to the pattern drawn before is superficially incised (Fig. 9D) and a tangential excision of the split-thickness matrix

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is performed (Fig. 9E). The scalpel blade is put with its side on the adjacent matrix and slightly pressed against it. With sawing back and forth motions a thin slice of the size as defined by the previous superficial incision is cut and harvested. Again, orientation of the matrix is important. The graft is transferred to the recipient site (Fig. 9F, G) and sutured in place in its corect direction (Fig. 9H). Either the original nail is laid back and fixed or the toenail is trimmed to the size of the recipient fingernail and fixed to it (Fig. 9I). The donor site

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receives the altered fingernail (Fig. 9J). The nails remain stitched for about three weeks. Then a thin new nail will have formed over the matrix and the nail bed will exhibit some transitory keratosis. Key Point l The procedure must be carried out without traumatizing the graft. l The graft is taken in a so-called shaving technique, and it is carried to the recipient site on the scalpel blade, thus avoiding pinching it with a pincette. l As the growth of the matrix is directed the graft must be oriented in the correct direction. Postoperative Care Pain: moderate l

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A thick layer of an antibiotic ointment is applied on both the recipient as well as the donor digit and a padded dressing is applied. It is replaced after 24 to 48 hours as there will be some bleeding. Blood remnants are meticulously removed using 3% hydrogen peroxide solution. The new dressing can be smaller and with only a thin layer of ointment. It is advisable to elevate the hand for about 24 hours.

Evolution l According to the size and the complexity of the defect, a new nail will grow out from the recipient nail with much improved aspect (Fig. 9K, L). The donor great toenail will progressively show a normal regrowth (Fig. 9M). l The results of free matrix transplantation are variable (32,33) with many authors claiming that split-thickness matrix grafts do not take or not produce nail. It is known that the connective tissue of the nail matrix contains specialized mesenchymal cells called onychofibroblasts that are CD10 positive and possibly are critical for the morphogenetic properties of matrix dermis (34–37). When the layer of matrix connective tissue is too thin they may either disappear or not be strong enough to induce nail formation.

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TUMORS OF THE MATRIX ONYCHOMATRICOMA Introduction l Onychomatricoma is a fibroepithelial nail matrix tumor that has been described mainly in adults. It is much more common on the fingernails than on the toenails (42,43). Only one case has been reported in a child (44). Its true nature is still a matter of debate. l Clinically, it is characterized by a longitudinal xanthonychia with transverse and longitudinal overcurvature, and splinter hemorrhages (Fig. 10A) (42,43). l Sometimes, the free edge of the nail plate exhibits tiny holes within the thickened yellow nail. l Nail avulsion exposes a villous tumor of the matrix with filamentous digitations extending into multiple holes of the nail plate (42,43,45). l MR images are typical and useful when clinical features are not clear (45). Anesthesia l Proximal or distal digital block Tools l Nail avulsion tray l Basic nail surgery tray Surgical Procedure Technique: moderate l l

Complications and Management l Complications may be infection and graft necrosis. Smoking is strictly forbidden as it was shown

to be associated with a high percentage of graft necrosis (38). The take of split-thickness matrix grafts was deemed unpredictable (39), however, recent publications and own experience have shown much better results. Nail unit matrix transplantation is an alternative (40). Recently, it was shown that cooling after transplantation of composite nail grafts plus prostaglandin E1 infusion, 50 mg/day over three days, improved the survival of grafts and may also be an option to improve the outcome of free matrix grafts (41).

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Figure 10 (A) Clinical presentation of an onychomatricoma. (B) Proximal partial lateral avulsion and reflection of the proximal nail fold exposing the tumor. (C) After tangential excision of the tumor from the matrix. (D) Nail laid back in place and secured. (E) One year postoperatively.

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avulsion with plate replacement are convenient. Avulsion of the nail should be very delicate not to tear the digitations. The PNF is reclined and maintained backward with either sutures or skin hooks (Fig. 10B). The tumor is literally shaved from the matrix with a Teflon-coated blade (Fig. 10C). The PNF is replaced in its anatomical location and the two lateral incisions sutured (Fig. 10D). The tourniquet is released.

ventral part of the PNF and the matrix resulting in pterygium. After three weeks the Tulle gras may be removed and at that time the matrix will already have healed and synthetized some nail keratin. Postoperative Care Pain: very little l l

Key Point l The tumor should only be shaved. l As it is impossible to replace the plate (which is altered and should undergo histological examination) it might be wise to slide some tulle gras under the PNF and secure it with two stitches. This will avoid any adherence between the

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Greasy nonadherent dressing. Elevation of the limb for 48 hours. The dressing is removed after 24 hours. Twice daily antiseptic soakings are performed until completing healing. The stitches of the PNF are removed after seven days. Stitches securing the Tulle gras are removed after three weeks.

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Evolution l Healing is fast. l A new nail grows out with a normal aspect (Fig. 10E). Some very light dystrophy may be observed such as irregularity of the plate surface or discrete erythronychia at the location of the previous longitudinal xanthonychia. l Long-term follow-up of the technique in large series have yet to be published. Complications and Management l Nail plate dystrophy can be observed especially when the tumor is larger and deeper and cannot be completely removed without hurting the nail matrix. INTRAUNGUAL FIBROKERATOMA Introduction l Fibrokeratomas (FK) are relatively common benign nail tumors. They present as skin-colored asymptomatic nodules with a hyperkeratotic tip that occur mostly in the periungual area. Trauma is thought to be an initiating factor for their development. Most FKs originate from the most proximal part of the ventral aspect of the PNF; their pressure on the underlying thin nail plate and matrix is responsible for a longitudinal groove running along the whole length of the nail plate. Another common location is the lateral groove (see “Fibrokeratoma,” pp. 91–92). Rarely they may arise from the nail bed (see “Longitudinal Erythronychia,” pp. 59–62 and “Fibroma/Fibrokeratoma,” pp. 66–69) or the matrix. When originating from the matrix, the FK will grow in the nail plate and eventually emerge in the middle of the nail plate, giving rise to a distal longitudinal groove and a rim proximal of its emergence. These intraungual FK (Fig. 11), also called “dissecting ungual FK” may be distressing as they may cause nail splitting or trap dirt in the hole they produce in the nail (46). Histologically, intraungual FK are lined by matrix epithelium and covered all around with nail substance. Anesthesia l Distal digital block Tools l Nail avulsion tray l Basic nail surgery tray

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Surgical Procedure Technique: intermediate to difficult There are four possibilities to remove an intraungual FK: 1. When the lesion is large enough that a pointed scalpel blade can be introduced into the hole, the scalpel is taken around the lesion in the direction of the canal in the nail. It is then dissected from the periosteum, which may be a bit difficult when the hole is small. 2. When this is not possible, the nail is separated from proximal lateral, allowing to look under the nail plate and identify the origin of the lesion. An incision is made around the FK in an oblique proximal direction down to the bone, from which it is severed. Sutures are usually not necessary. 3. Starting from the emergence of the FK, the thin nail plate is dissected distally to proximally (Fig. 11A), exposing the tumor progressively to its base. Then the PNF is reflected to expose its most proximal attachement (Fig. 11B). The FK is severed at its base (Fig. 11C). The PNF is laid back in its original position and sutured (Fig. 11D). 4. If the FK is very laterally located and small, it may be removed as a whole as in a lateral longitudinal biopsy (see “Lateral Longitudinal Biopsy,” pp. 133–135). Key Point l Visualization of the base of the FK to allow section at its origin Postoperative Care Pain: moderate Greasy antiseptic dressings once to twice daily for one week, then antiseptic solution with adhesive plaster.

Evolution l The nail will regrow without any dystrophy.

Complications and Management l If resection was incomplete, recurrence may occur. This is quite frequent is this variety. l The new regrowing lateral strip of nail may get ingrown in some rare instances. Conservative treatment is a must (taping is best).

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Figure 11 Intraungual FK. (A) Dissection of the thin nail plate covering the intraungual FK distally to proximally. (B) The proximal nail fold is reflected to expose the most proximal part of the tumor. (C) The lesion is severed at its base. (D) Postoperatively. Abbreviation: FK, fibrokeratoma.

SUBMATRICIAL GLOMUS TUMOR Introduction l Glomus tumor is a benign tumor affecting mostly the fingernails, but few cases involve the toes (47). l Up to 90% of cases are reported in women around their forties (48). l At that location, it clinically appears as a purple blue tender macule in the lunula, or as a longitudinal erythronychia with distal notching. l Paroxysmal pain is the leading symptom. It may be minimal or severe, radiating into the arm, exacerbated with the slightest touch. Cold sensitivity is very suggestive as it is 100% sensitive, specific and accurate (49). l Pain stops when a blood pressure cuff placed at the base of the digit is inflated to 300 mmHg (Hildreth’s test). l Pinpoint testing (Love’s test) is 100% sensitive: it will induce acute pain when pressing exactly at the site of the tumor (the macule or the most proximal part of the longitudinal erythronychia).

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For this reason, some teams consider that clinical exploration is typical enough to confirm the diagnosis (50). However, medical imaging may help.  X ray shows a pressure osteolysis in about 50% of the cases.  Ultrasound is able to detect tumors bigger than 3 mm (51). Recently, high variable frequency ultrasound was shown to be able to detect glomus tumors under 1 mm (52).  MRI is very specific when using adapted coils, but is usually reserved for recurrences or atypical cases (53). Treatment is surgical. Recurrence may occur when the excision is incomplete (54). Pseudorecurrences occur when the tumor was multiple, which is commonly missed on clinical grounds.

Anesthesia l Proximal or distal ring block

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Tools l Tourniquet l Nail avulsion tray l Basic nail surgery tray with fine instruments l Gillies hooks l Absorbable suture 6/0 l Magnifying lens Surgical Procedure Technique: difficult l

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As this surgery is very delicate, the field should be bloodless, and a tourniquet should be placed. Before anesthesia, it is mandatory to tattoo the plate with a surgical marker at the location of the tumor because bleaching from anesthesia will render its location impossible (Fig. 12A, B). A proximal partial avulsion or a lateral curled avulsion is performed to expose the distal matricial area. When the tumor is very proximal and hidden by the PNF, it is mandatory to recline the dorsal fold with two lateral incisions at 458. If this procedure is performed after the nail plate avulsion, then an elevator should be slid under the proximal fold to avoid injuring the matrix with the blade. The tumor is visible through the thin overlying matrix (Fig. 12C). The nail matrix is incised transversally over the tumor. The tumor is very delicately dissected from the surrounding tissues using small repeated openings and closings of very fine Graddle scissors and enucleated (Fig. 12D, E). The matrix incision is closed with an absorbable suture (5/0 or better 6/0) (Fig. 12F). The nail plate is put back in place and secured to the lateral and distal nail fold (Fig. 12G).

Key Point l Tattoo the nail plate after location of the tumor before anesthesia. l Enucleate the complete tumor. Incomplete resection will end in recurrence. l Do not tear the matrix epithelium. Postoperative Care Pain: little, as the procedure will alleviate the pain from the tumor l l

Greasy nonadherent bulky dressing for two days. The limb should be elevated for two days.

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Stitches are removed after two weeks. Ask the patient to keep the nail in place as long as possible by securing it with adhesive tape.

Evolution l Pain is immediately alleviated with the excision of the tumor. The Love test is negative at the removal of the dressing. l Nail shedding may occur after several weeks. l Complete regrowth without any dystrophy will take about six months for a finger. Complications and Management l Recurrence may occur in case of incomplete resection. In these instances, MRI is very useful and specific to locate the remnants of the tumor and will guide the surgical resection (53). l One of the authors (Bertrand Richert) has observed a reflex sympathic dystrophy (55) after removal of a glomus tumor. SUBMATRICIAL MYXOID PSEUDOCYST Introduction l Subungual myxoid pseudocysts (SMP) may present in many different manners as a result of their specific relationship with the matrix and the local microvasculature. This will have an impact on the nail matrix function, the nail shape and the color of the area (56). l The findings of a red, or sometimes blue, lunula, altered curvature and variable nail destruction provide a good basis for the clinical diagnosis of a subungual myxoid pseudocyst (56). l Transillumination (diaphanoscopy) is usually positive. l If the nail is thinned from the elevation by the SMP, puncture through the nail plate allows drainage of some gelatinous material. l In cases where the diagnosis is not clear, MRI is a useful tool. l In a large series, it has been demonstrated than more that 80% of the SMP arose from the distal interphalangeal joint (56). Anesthesia l Distal digital block Tools l Basic nail surgery tray l Sterile methylene blue l 5/0 absorbable suture

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Figure 12 (A) The location of the glomus tumor is tattooed on the plate. (B) Bleaching after local anesthesia with a distal digital block. (C) Lateral nail avulsion and reclining of the proximal nail fold exposing the whole matrix area, with the tumor visible through the thin matrix. (D) Enucleation of the glomus tumor using fine pointed curved scissors. (E) Defect after enucleation. (F) Suture of the defect with 5/0 absorbable sutures. (G) Nail plate laid back in place and secured.

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nail pigmentations have their origin in the distal nail matrix, but they can also originate in the proximal nail matrix (58). Different causes such as hypermelanosis (melanocyte activation), lentigo, pigmented nevus and melanoma (melanocyte proliferation) may be at their origin (57–60). The goal in the management of melanonychia is early diagnosis of melanoma (57). Clinical examination, dermatoscopy of the nail plate and dermatoscopy of the nail matrix (9) may help to narrow the differential diagnosis of longitudinal melanonychia, but histological examination remains the gold standard (57,58,60). A longitudinal melanonychia should never be partially biopsied as this does not allow complete examination of the pigmented lesion. According to the size of the longitudinal melanonychia, several techniques are available to remove the pigmented origin in the matrix (58–60). —With Punch Excision Introduction l Punch excision is indicated when the pigmented band does not exceed 3 mm in width, measured with a dermatoscope (58,59). Figure 13 (A) Clinical presentation of a subungual myxoid pseudocyst. (B) Puncture confirms the diagnosis and is a treatment option if repeated and associated with compressive dressings.

Surgical Procedure l Best treatment is achieved by ligature of the origin of the SMP. It is fully described in the chapter devoted to surgery of the joint (see “Myxoid Cyst,” pp. 165–169). l If the patient refuses surgery, puncture and drainage of the cyst followed by compressive dressing is a good alternative (Fig. 13A, B). Recurrence is, however, possible but repeated puncture resulted in long-term clearance (56). Evolution l If the SMP is no more connected to the distal interphalangeal joint, it will flatten and dry off. This will result in fully normal regrowing nail.

Anesthesia l Matricial block if only partial proximal nail avulsion is planned. Proximal or distal digital block if total nail avulsion with removal is expected. Tools l Tourniquet l Nail avulsion tray l Skin hooks l 3-mm punch l Fine curved pointed scissors

Surgical Procedure Technique: intermediate l

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EXCISION OF LONGITUDINAL MELANONYCHIA Longitudinal melanonychia is a brown or black band of the nail plate caused by activation or proliferation of melanocytes of the nail matrix (57,58). Most of the

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As the surgical field should be bloodless to perfectly visualize the pigmented area, a tourniquet is applied. The PNF is gently detached from the nail plate with back and forth movement of the elevator. Two lateral incisions are made at 458 to recline the PNF. In some instances, it is necessary to extend the incision if the PNF cannot be reflected completely. Two skins hooks placed under the PNF allow complete exposure of the area. If the surgeon is

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Figure 14 (A) Three-millimeter punch through the thin proximal nail plate at the origin of the pigmented band. (B) Proximal partial avulsion exposes the whole nail matrix area. (C) Harvesting the specimen with fine pointed scissors. (D) The proximal nail fold is put pack in place and the lateral incisions are secured with adhesive strips.

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working alone, two stitches may pull and stabilize the PNF backward. This procedure exposes the most proximal nail plate overlying the matrix. The origin of the pigmented band is visualized. If the band is lightly pigmented, a 3-mm punch is pushed around its most proximal origin, through the very thin and soft proximal nail plate, down to the bone (Fig. 14A). Punching before avulsing is useful when dealing with very light bands: in some instances, the source of pigment is superficial and proximal avulsion detaches the superficial pigmented upper layers of the matrix epithelium, rendering the origin of the band hardly visible. If the band is heavily pigmented, there is no need to go through this phase. According to the surgeon’s choice, a lateral curled avulsion (see “Total Nail Avulsion with Plate Replacement: Curled Nail Avulsion,” pp. 37–38) or a partial proximal avulsion (see “Partial Proximal Nail Avulsion with Plate Replacement,” pp. 40–41), both with nail replacement, is performed (Fig. 14B). Avulsing the nail has two main issues: visual confirmation that the lesion has been fully removed (which is not the case when harvesting with the nail plate attached) and easy harvesting of the specimen (nothing is more difficult than trying to harvest a small cylinder of matrix through a 3 mm hard hole of keratin, this usually leads to crushing and tearing of the specimen). The whole pigmented nest should fit in the 3-mm punch. If the pigmentation is more elliptic, then proceed as described below (see “Excision of Longitudinal Melanonychia, Crescent Excision,”

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pp. 128–129). The punch is pushed though the nail matrix down to bone contact. Do not press too much on the bone, as this may be responsible for postoperative pain. Without using forceps, which tend to crush the matrix tissue, fine-tipped scissors, preferably curved, are inserted vertically around the specimen and delicately used to sever the specimen cylinder at the level of the periosteum. Once this is complete, the scissors tips can gently lift and remove the specimen without crushing it (Fig. 14C). Always examine the punch instrument as the keratin disk very often remains stuck in the metallic cylinder. Remove it using a strong needle or with an injection needle the tip of which has been bent about 908. The nail plate has to be examined histologically. Put it in the jar with the matrix specimen. Suture is not necessary. Some Gelfoam may be placed into the defect. The nail plate is laid back in place and sutured to the lateral nail fold. The PNF is released and returned to it anatomic location. The two lateral incisions may be sutured (this is interesting only for hemostatic purposes) or secured with adhesive strips (SteriStrips 1 ) (Fig. 14D). The tourniquet is released.

Key Point l Avulsion, whatever the type is mandatory. l Replacing the plate enhances healing without risk of pterygium.

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If dealing with a light band, punch before avulsing. Never grasp the specimen with forceps. When the origin of the band is fully visualized, the patient should be informed about the risk of nail plate dystrophy if the origin of the band is in the proximal nail matrix.

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Surgical Procedure Technique: difficult l

Postoperative Care Pain: little l

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A greasy bulky antiseptic dressing covers the digit. The limb should be kept elevated for two days. After 48 hours the dressing is removed. The digit is soaked in lukewarm water and blood crusts are removed with peroxide. Antiseptic solution is applied twice per day and covered with a simple plaster. Stitches of the PNF are removed after seven days.

Evolution l When the origin of longitudinal melanonychia is in the distal matrix, the new nail plate grows out without any nail plate dystrophy. Complications and Management Bleeding may induce a painful hematoma under the nail plate. Be sure to ensure some compression with the first dressing. l Improper technique and proximal origin of the band will result in nail scarring (split nail deformity, pterygium). —With Elliptical Excision Introduction l Elliptical excision is indicated when the origin of a longitudinal melanonychia on the matrix has a more oval than a round shape (Fig. 15A). Anesthesia l Matricial block if only partial proximal nail avulsion is planned. Proximal or distal digital block if total nail avulsion with removal is expected. Tools l Tourniquet l Nail avulsion tray l Skin hooks

Basic nail surgery tray with fine instruments Absorbable suture 5/0 or 6/0

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The first steps are identical to the ones described above for exposure of the nail matrix. An elliptical incision is carried around the pigmented lesion with minimal margins, but the entire lesion should be removed as a whole. The specimen is detached from the underlying periosteum using fine-tipped scissors. It should never be handled with forceps at any time. Use the curved tip of the scissors to harvest the specimen (Fig. 15B). Undermine generously (at least 5 mm) the borders of the incision with back and forth round movements of a No. 15 or 15C blade pushed under the edges. The Beaver blade No. 64 is another very helpful option as the Ucurved blade has a cutting edge on both it upper and lower side. Reapproximate the edges of the incision with 5/ 0 or 6/0 absorbable sutures. Do not pull on the stitches to avoid tearing the fragile matrix. Do not suture too close to the borders of the incision, start at least 3 mm laterally (Fig. 15C). Two to three stitches are usually enough. Replace the nail plate on top and secure it to the lateral nail fold. Release the PNF and suture the two lateral incisions (or secure with adhesive strips) (Fig. 15D).

Key Point l Never hold the specimen with forceps. l Undermining is mandatory to reapproximate the defect. l Do not pull on the fragile matrix. l A little defect remaining between the two edges of the incision is totally acceptable. Postoperative Care Pain: little l

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A greasy antiseptic dressing covers the digit. The limb should be kept elevated for two days. Cotton and gauze are placed under the micropore and a cotton bandage covers them. The dressing is removed after 48 hours. The digit is soaked in lukewarm water and blood crusts removed with peroxide. Antiseptic solution is

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Figure 15 (A) Partial proximal lateral avulsion exposing the matrix area with a longitudinal pigmentation. (B) Removal of the whole matrix pigmentation in an ellipse. (C) Suturing the defect with 5/0 absorbable sutures. (D) Immediately post operation. (E) Six months postoperatively.

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applied twice per day and covered with a simple plaster. Stitches of the PNF are removed after seven days.

Evolution l The new nail will grow out without any dystrophy as long as the most proximal part of the matrix has not been involved.

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A discrete longitudinal erythonychia may sometimes be visible as the only remaining trace of the excision (Fig. 15E).

Complications and Management l Improper technique and proximal origin of the band may result in nail scarring.

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—With Crescent Excision Introduction l Crescentic excision is indicated when the origin of a longitudinal melanonychia on the matrix is very wide and relatively short. Recently, it has been superseded by the technique of horizontal excision (“shave biopsy”) (see “Tangential Excision,” pp. 129–131). Anesthesia l Matricial block if only partial proximal nail avulsion is planned. Proximal or distal digital block if total nail avulsion with removal is expected.

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Tools l Tourniquet l Nail avulsion tray l Skin hooks l Basic nail surgery tray with fine instruments l Absorbable suture 5/0 or 6/0 Surgical Procedure (Fig. 16A–D) Technique: difficult l

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The first steps are identical to the ones described above for exposure of the nail matrix. A crescentic incision with its convex portion matching the contour of the lunula is performed, extending down to the level of the bone. The entire pigmented lesion should be removed as a whole. The specimen is very carefully detached from the periosteum. It should not be handled at any time with forceps; this will crush the fragile matrix epithelium. The curved tip of the scissors

Figure 16

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may be used to transfer the specimen to the formalin jar. The borders of the defect are generously undermined with back and forth round movements of a No. 15 or 15C blade pushed under the edges. The Beaver blade No. 64 is another very helpful option as the U-curved blade has a cutting edge on both it upper and lower side. Reapproximate gently the edges of the incision with 5/0 or 6/0 absorbable sutures. Do not pull on the stitches to avoid tearing the fragile matrix. Do not suture too close to the borders of the incision, start at least 3 mm ahead of the edge. Put a minimum of stitches. Replace the nail plate on top and secure it to the lateral nail fold. Release the PNF and suture the two lateral incisions (or secure with adhesive strips). Release the tourniquet.

Key Point l Never hold the specimen with forceps. l Undermining is mandatory to reapproximate the defect. l Do not pull on the fragile matrix. l A little defect remaining between the two edges of the incision is totally acceptable. Postoperative Care Pain: little l

A greasy antiseptic dressing covers the digit. The limb should be kept elevated for two days. Cotton and gauze are placed under the micropore and a cotton bandage covers them.

Scheme of crescent excision of a pigmented lesion on the matrix.

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After 48 hours the dressing is removed. The digit is soaked in lukewarm water and blood crusts removed with peroxide. Antiseptic solution is applied twice per day and covered with a simple plaster. Stitches of the PNF are removed after seven days.

Evolution l According of the size of the defect, a new nail will grow out with more or less dystrophy. As long as the most proximal part of the matrix has not been involved, the new nail will only be a bit thinner. Complications and Management l Improper technique and proximal origin of the band may result in nail scarring.

—With Tangential Excision Introduction l Most melanonychias are due to melanocyte activation in the matrix epithelium, a lentigo or a junctional nevus. Compound, dermal and blue nevi are rare. l Melanomas originating in the matrix start as in situ lesions. l Intraepithelial lesions can be adequately and completely removed with a tangential excision that contains a superficial dermal layer (57–59). l Thin defects of the matrix as those taken for free split matrix grafts heal without postoperative nail dystrophy (57–60). Anesthesia l Matricial block if only partial proximal nail avulsion is planned. Proximal or distal digital block if total nail avulsion with removal is expected.

Tools l Nail avulsion tray. l Basic nail surgery tray. l Microcoated surgical blades No. 15 (Personna Plus1) offer a superior cutting edge designed to glide smoothly with precision (9). These blades are extremely useful for tangential nail matrix (“shave”) biopsy.

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Surgical Procedure Technique: very difficult l

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The first steps are identical to the ones described above for exposure of the nail matrix. A shallow incision, through the matrix epithelium and the papillary dermis, with a 2-mm safety margin, is carried out around the lesion (Fig. 17A). The scalpel is then held horizontally and, with slight pressure of the side of the blade on the matrix, sawing motions are performed to tangentially remove the lesion. Use the full length of the curve of the No. 15 blade (Fig. 17B). The thickness of the surgical specimen is such that the scalpel blade is seen shining through it; this allows a specimen to be taken thick enough for complete removal of any in situ lesion thereby guaranteeing healing of the superficial wound without postbiopsy nail dystrophy (Fig. 17C). The tissue specimen is carried to a wet compress with the scalpel and put on it upside down. From here, it is taken with a piece of filter paper, which was lightly pressed on the cut undersurface of the specimen, into the jar with the fixative. A simple ball-pen drawing of the matrix or nail on the filter paper according to the lesion’s localization and orientation helps the histopathology lab to orient the specimen, which comes as a perfectly spread tissue slice, according to the needs of the clinician and/or surgeon. The nail plate is laid back and fixed either with a suture strip (SteriStrip) or a stitch of 5/0 polypropylene (9,57–61). The PNF is then laid back and also held with either suture strips or stitches (Fig. 17D). Depending on the localization of the melanonychia, the lateral PNF incisions can sometimes be omitted. This is particularly the case when the lesion is small and located in the very distal matrix (58).

Key Point l Be sure to remove the whole pigmented lesion. Using per operative dermoscopy with sterile gel may be of great help (62). l Remember that the blade should remain visible through the specimen during the whole procedure, ensuring a thickness of less than 1 mm (60). l The specimen is very thin, never handle it with forceps. l Place the specimen flat on filter paper and orientate the specimen properly for the pathologist (9,57–61,63–65).

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Figure 17 (A) Proximal lateral avulsion and reclining the proximal nail fold exposes the whole nail matrix area. (B) A superficial incision delineates the area containing the pigment to be removed. (C,D) The area is tangentially removed with a No. 15 coated blade. (E, F) Harvesting of the specimen without using any forceps. (G) The avulsed proximal part of the nail is laid back in place and secured to the lateral nail fold. (H) Before surgery. (I) Regrowth postoperatively at three months. The proximal part of the nail shows a complete normal nail.

Postoperative Care Pain: very little l

A bulky dressing with plenty of antibiotic ointment is applied for 24 to 48 hours. The first change of the dressing is usually made in a warm finger or foot bath. The next dressing is left for about one week. The stitches are removed after 10 to 14 days.

Evolution l Tangential excisions comprising virtually the entire matrix were seen to result in complete lesion removal and complete restoration of a new nail (Fig. 17E). Complications and Management l Complications appear to be very rare, except for a recurrence with a light brown streaky

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pigmentation probably due to too narrow horizontal safety margin. However, this is only important when there was any doubt as to the histopathological diagnosis. A postoperative nail dystrophy is seen when the biopsy is not carried out tangentially, but in a saucer-shaped or scoop-like manner or when the pigment is located very proximally. Healing is very rapid, which may be due to two main factors: first, the wound is very superficial, leaving almost the entire matrix connective tissue intact, which allows wound healing to take place very rapidly from the the wound margins under the morphogenetic influence of the matrical connective tissue; second, at least in part, the fact that there always remains one-third to one-half of the matrix epithelium attached to the nail plate that is laid back on the superficial wound at the end of the procedure, acting perhaps like an epithelial graft.

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11. Sugden P, Levy M, Rao GS. Onychocryptosis – phenol burn fiasco. Burns 2001; 27:289–292. 12. Giacalone VF. Phenol matricectomy in patients with diabetes J Foot Ankle Surg 1997; 36:264–267. 13. Felton PM, Weaver TD. Phenol and alcohol chemical matrixectomy in diabetic versus nondiabetic patients. J Am Podiatr Med Assoc 1999; 89:410–412. 14. Tatlican S, Eren C, Yamangokturk B, et al. Chemical matricectomy with 10% sodium hydroxide for the treatment of ingrown toenails in people with diabetes. Dermatol Surg 2010; 36(2):219–222; [Epub November 10, 2009]. 15. Aksakal AB, Atahan C, Oztas P, et al. Minimizing postoperative drainage with 20% ferric chloride after chemical matricectomy with phenol. Dermatol Surg 2001; 27:158–160. 16. Gilles GA, Dennis KJ, Harkless LB. Periostis associated with phenol matricectomies. J Am Podiatr Med Assoc 1986; 76:469–472. 17. Reyzelman AM, Trombello KA, Vayser DJ, et al. Are antibiotics necessary in the treatment of locally infected ingrown toenails? Arch Fam Med 2000; 9:930–932. 18. Dovison R, Keenan AM. Wound healing and infection in nail matrix phenolization wounds. Does topical medication make a difference? J Am Podiatr Med Assoc 2001; 91:230–233. 19. Leshin B, Whitaker DC. Carbon dioxide laser matricectomy. J Dematol Surg Oncol 1988; 14:608–611. 20. Serour F. Recurrent ingrown big toenails are efficiently treated by CO2 laser. Dermatol Surg 2002; 28:509–512. 21. Takahashi M, Narisawa Y. Radical surgery for ingrown nails by partial resection of the nail plate and matrix using a carbon dioxide laser. J Cutan Laser Ther 2000; 2:21–25. 22. Ozawa T, Nose K, Harada T, et al. Partial matricectomy with a CO2 laser for ingrown toenail after nail matrix staining. Dermatol Surg 2005; 31:302–305. 23. Apfelberg DB, Maser MR, Lash H, et al. Efficacy of the carbon dioxide laser in hand surgery. Ann Plast Surg 1984; 13:320–326. 24. Kaplan BR, D’Angelo AJ, Johnson CB. The carbon dioxide laser in podiatric medicine. Clin Podiatry 1985; 2:519–522. 25. Tada H, Hatoko M, Tanaka A, et al. Clinical comparison of the scanning CO2 laser and conventional surgery in the treatment of ingrown nail deformities. J Dermatol Treat 2004; 15:387–390. 26. Wright G. Laser matricectomy in the toes. Foot Ankle 1989; 9:246–247. 27. Hettinger DF, Valinsky MS, Nucci G, et al. Nail matricectomies using radio wave technique. J Am Podiatr Med Assoc 1991; 81:317–321. 28. Heidelbaugh JJ, Lee H. Management of the ingrown toenail. Am Fam Physician 2009; 79:303–309. 29. Baran R, Haneke E. Matricectomy and nail ablation. Hand Clin 2002; 18:693–696, viii; discussion 697. 30. Richert B, Dahdah M. Complications in nail surgery. In: Nouri K, ed. Complications in Dermatologic Surgery. Philadelphia: Mosby Elsevier, 2008:137–158.

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31. Baran R. An effective surgical treatment for thickening in Darier’s disease. J Eur Acad Dermatol Venereol 2005; 19:689–690. 32. Saito H, Suzuki Y, Fujino K, et al. Free nail bed graft for treatment of nail bed injuries of the hand. J Hand Surg Am 1983; 8:171–178. 33. Shepard GH. Perionychial grafts in trauma and reconstruction. Hand Clin 2002; 18:595–614. 34. Lee KJ, Kim WS, Lee JH, et al. CD10, a marker for specialized mesenchymal cells (onychofibroblasts) in the nail unit. J Dermatol Sci 2006; 42:65–67. 35. Lee DY, Lee KJ, Kim WS, et al. Presence of specialized mesenchymal cells (onychofibroblasts) in the nail unit: implications for ingrown nail surgery. J Eur Acad Dermatol Venereol 2007; 21:575–576. 36. Lee DY, Yang JM, Mun GH. Onychofibroblasts induce hard keratin in skin keratinocytes in vitro. Br J Dermatol 2009; 161:960–962. 37. Lee DY, Lee JH, Yang JM, et al. Versican is localized to nail mesenchyme containing onychofibroblasts. J Eur Acad Dermatol Venereol 2009; 23:1328–1329. 38. Foucher G, Norris RW. Distal and very distal digital replantations. Br J Plast Surg 1992; 45:199–203. 39. Pessa JE, Tsai TM, Li Y, et al. The repair of nail deformities with the nonvascularized nail bed graft: indications and results. J Hand Surg Am 1990; 15: 466–470. 40. Das SK. Nail unit matrix transplantation: a plastic surgeon’s approach. Dermatol Surg 2001; 27:242–245. 41. Sellah J, Andriamanday V, Rabaharisoa M, et al. Composite nail transfer by the traditional method. Chir Main 2000; 19:56–62. 42. Baran R, Kint A. Onychomatrixoma. Filamentous tufted tumour in the matrix of a funnel-shaped nail: a new entity. Br J Dermatol 1992; 126:510–515. 43. Perrin C, Goettmann S, Baran R. Onychomatricoma: clinical and histopathologic findings in 12 cases. J Am Acad Dermatol 1998; 39:560. 44. Piraccini BM, Antonucci A, Rech G, et al. Onychomatricoma: first description in a child. Pediatr Dermatol 2007; 24:46–48. 45. Khelifa E, Tschanz C, Masouye I, et al. A rare tumour of the nail apparatus: onychomatricoma. J Eur Acad Dermatol Venereol 2008; 22:1127–1128. 46. Haneke E. Intraoperative differential diagnosis of onychomatricoma, Koenen’s tumours and hyperplastic Bowen’s disease. J Eur Acad Dermatol Venereol 1998; 11:S119. 47. Sapuan J, Paul A, Abdullah S. Glomus tumour in the second toe: a clinical insight. J Foot Ankle Surg 2008; 47:483–486. 48. Van Geertruden J, Lorea P, Goldschmidt D, et al. Glomus tumours of the hand. J Hand Surg 1996; 21B(2):257–260.

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49. Bhaskaranand K, Naridji BC. Glomus tumour of the hand. J Hand Surg 2002; 27B:229–231. 50. Cigna E, Carlesimo B, Bistoni G, et al. The value of clinical diagnosis of glomus tumors. Acta Chir Plast 2008; 50:55–58. 51. Marchadier A, Cohen M, Legre R. Subungual glomus tumors of the fingers: ultrasound diagnosis. Chir Main 2006; 25:16–21. 52. Wortsman X, Jemec G. Role of high variable frequency unltrasound in the preoperative diagnosis of glomus tumors: a pilot study. Am J Clin Dermatol 2009; 10:23–27. 53. Drape´ J-L, Idy-Peretti S, Goettmann S, et al. Subungual glomus tumors: evaluation with MR imaging. Radiology 1995; 195:507–515. 54. McDermott EM, Weiss AP. Glomus tumours. J Hand Surg 2006; 31A:1397–1400. 55. Roca B, Climent A, Costa N. Reflex sympathetic dystrophy after nail surgery. Ann Med Intern 2000; 17:506. 56. de Berker DAR, Goettmann S, Baran R. Subungual myxoid cysts: clinical manifestations and response to therapy. J Am Acad Dermatol 2002; 46:394–398. 57. Haneke E. Operative therapie akraler und subungualer melanome. In: Rompel R, Petres J, eds. Operative und Onkologische Dermatologie. Fortschritte der Operativen und Onkologischen Dermatologie. Berlin: Springer, 1999:210–214. 58. Haneke E. Melanonychia longitudinalis und andere braune nagelpigmentierungen. In: Koller J, Hintner H, eds. Fortschritte der Operativen und Onkologischen Dermatologie. Berlin Wien: Blackwell Scientif Publications, 2000:19–26. 59. Haneke E, Baran R. Longitudinal melanonychia. Dermatol Surg 2001; 27:580–584. 60. Zook EG, Baran R, Haneke E, et al. Nail surgery and traumatic abnormalities. In: Baran R, Dawber RPR, de Berker DAR, et al., eds. Diseases of the Nails and Their Management. Oxford: Blackwell Science, 2001:425–514. 61. Abimelec P, Dumontier C. Basic and advanced nail surgery. In: Scher RK, Daniel CR, eds. Nails: Diagnosis, Therapy, Surgery. 3rd ed. Philadelphia: Elsevier Saunders, 2005:265–289. 62. Hirata SH, Yamada S, Almeida FA, et al. Dermoscopic examination of the nail bed and matrix. Int J Dermatol 2006; 45:28–30. 63. Braun RP, Baran R, La Gal FA, et al. Diagnosis and management of nail pigmentations. J Am Acad Dermatol 2007; 56:835–847. 64. Jellinek N. Nail matrix biopsy of longitudinal melanonychia: diagnostic algorithm including the shave matrix biopsy. J Am Acad Dermatol 2007; 56:803–810. 65. Richert B, Lateur N, Theunis A, et al. New tools in nail disorders. Semin Cutan Med Surg 2009; 28:44–48.

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Surgery of the whole nail unit Eckart Haneke, Bertrand Richert, and Nilton Di Chiacchio

Some surgical procedures involve the whole nail apparatus, either for biopsy purposes (removal of a thin strip containing all its structures) or detachment of the whole nail apparatus with subsequent rotation (realignment of a misdirected nail) or section and removal (malignant process). LATERAL LONGITUDINAL BIOPSY Introduction l Lateral longitudinal biopsy allows the study of all components of the nail unit including the matrix, the bed, the proximal nail fold and the hyponychium (Fig. 1). It is the most useful biopsy technique for the pathologist (1–4). It gives information over the entire period of the growth of the biopsied nail. l It is indicated:  in inflammatory disorders with alteration of the surface of the nail plate resulting from involvement of the proximal matrix,  in excision of tumors, located in the lateral third of the plate,  in excision of longitudinal melanonychia up to 4 mm wide affecting the lateral part of the plate, and  as an independent technique to narrow a nail, for example, in a racquet nail (see pp. 178–180).

Anesthesia l Proximal or distal digital block Tools l Tourniquet l Basic nail surgery tray l Blade No. 15C or No. 64 Beaver blades l Skin hooks (simple or double) l 4/0 or 3/0 nonabsorbable sutures Surgical Procedure Technique: difficult l l

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Scheme of lateral longitudinal biopsy.

A tourniquet is placed. The incision starts halfway between the cuticle and the distal interphalangeal crease and progresses distally through the proximal nail fold where the nail is the softest, and continues through the nail plate and its bed to the hyponychium. It may be hard to cut through the plate: repeated up and down movements with the blade with distal progression (as cutting a tart) helps greatly. Proximally, the incision takes a laterally curved direction that extends about halfway on the lateral aspect of the finger, up to the distal interphalangeal crease. This allows complete removal of the lateral horn of the matrix and ensures a more anatomical closure at the junction of the proximal and lateral nail folds. A second incision, starting from the distal extremity of the previous one, runs from the hyponychium into the lateral sulcus and joins the proximal end of the previous incision. It parallels the first one ensuring a sigmoid excision (Figs. 1 and 2A). The biopsy reaches a width of 2 to 3 mm at its widest point. For resection en bloc of a longitudinal melanonychia this width may be much larger but closure should be performed with a flap (see pp. 92–95). All incisions are carried down to bone contact. The specimen is then removed distally to proximally. Holding the specimen should be very cautious, using either a skin hook or delicate forceps (Fig. 2B). Another option is to grasp the free edge of the nail plate with a

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Figure 2 (A-E) (A) Incisions in a lateral longitudinal biopsy. Note how the most proximal part of the incisions curve to ensure removal of the lateral horn of the matrix. (B) Dissection of the specimen from the periosteum. (C) Removing the most proximal portion of the biopsy is the toughest part: be sure to remove the matrix by staying on the periosteum at all times. (D) Suture recreating a lateral nail fold. (E) Closer view.

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hemostat. This is especially useful at the great toenail, where the nail is thick. Using fine sharp curved scissors with “tips down” (5), the specimen is detached from the periosteum. At the proximal tip of the biopsy, great care must be taken, as the matrix should be part of the biopsy (Fig. 2C), and one should avoid coming up with scissors too soon and foreshortening the specimen (6). Another option, very smooth and easy, is to detach the whole specimen with a No. 64 Beaver blade pushed proximally and slide on the sides. The blade has to shave the specimen from the bone. The wound should be then reviewed to avoid leaving small remnants of matrix. Proximal nail fold and hyponychium are closed with single suture using nylon 4/0. A half-buried horizontal mattress suture with 3/ 0 nylon, starting in the lateral nail fold and through the nail plate is will recreate a lateral nail fold (Fig. 2D, E). The tourniquet is removed.

Key Point l Before surgery the digit should be soaked for about 10 minutes in antiseptic solution or even saline solution to soften the nail plate. Another option is to ask the patient to soften the nail by nightly application of a 30% to 40% urea paste the three to four nights prior to surgery. l The nail plate is a hard structure and it requires some force to cut through it. Be careful when reaching the hyponychium as the blade may come out abruptly from the plate. l Take extra care when removing the specimen in its most proximal part. Beginners most often come up too soon with the scissors leaving the matrix on site. l The lateral nail fold should not be included in this type of biopsy. It will be included for excision of a tumor (see pp. 91–92). l Be sure to have removed the whole lateral horn. l Suturing should not be too tight as the digit is prone to swelling and tight sutures produce pain and can result in local ischemia (6).

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Postoperative Care Postoperative Pain: moderate l l l l

Greasy nonadherent bulky dressing. Give potent pain killers. Ask to keep the limb elevated. Removal of the dressing at 48 hours, soakings in antiseptics twice daily for two weeks. Another option especially in patients frightened to do their wound care is to leave the new dressing in place for the next five to six days.

Evolution l Suture removal is performed at 14 days. l Healing is fast (Fig. 2F and 3A, B). l Long-term cosmetic outcome is great (Fig. 2G).

Figure 2 (F–G) (F) Aspect of the nail four weeks after a lateral longitudinal biopsy. (G) Long-term aspect. Seven years after a lateral longitudinal biopsy for lichen planus.

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Complications and Management l If the width of the biopsy or excision specimen is wider than 3 mm, lateral deviation toward the site of biopsy should be expected (7). l Postoperative cysts and spicules (8) are a common complication of such a biopsy. It may be avoided by careful examination of the most proximal aspect of the wound after removal of the specimen, checking that there is no remaining fragment of matrix. In case of doubt, the lateral matrix pocket should be debrided with fine forceps and scissors.

UNGUEODERMAL FLAP FOR CONGENITAL MALALIGNMENT OF THE GREAT TOENAIL Introduction l Congenital malignment of the big toenail (CMBT) is a relatively common condition (9–19). It may have a genetic background as it is seen both in homozygous twins as well as siblings (12–15). l The cause of CMBT is not correctly known. It was proposed that a hypertrophy of the dorsal expansion of the lateral ligament (20) exerts a pull on the lateral matrix horn of the hallux nail thus causing a malalignment of the matrix with consecutive oblique growth toward the lateral side of the foot (21–23). Elongation of the dorsolateral extension of the dorsal ligament has been recommended; however, its long-term effects were disappointing (23). There is more often than not also a deviation of the distal hallux phalanx in relation to the axis of the proximal phalanx and a widening of the base of the distal phalanx that is more pronounced medially pushing the medial matrix horn forward distally and thus the entire nail organ into an oblique position. This is later also seen in radiographs, which show a slightly oblique position of the epiphysis line. l Clinically, CMBT is characterized by a lateral deviation of the axis of the nail often aggravated by an additional lateral longitudinal curvature of the nail in itself, a marked degree of onycholysis usually allowing probing back to the matrix border, thickening of the nail with an oyster shell–like aspect, marked yellowish-greenish dirty discoloration (Fig. 3A), a sharp bend at its medial margin, and an overall triangular shape (Fig. 3B).

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Figure 3 (A–C) (A) Congenital malaligment of the great toenail. Note the oyster shell–like aspect and the greyish green color. (B) Congenital malaligment of the great toenail. Note the triangular shape and the bulky distal edge of the toe. (C) Congenital malalignment of the great toenail. Note the severe onycholysis and overcurvature indicating poor prognosis and the necessity of surgery. l

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The toe(s) is shorter and often bulbous. The hyponychium is retracted proximally and a distal nail wall has developed, which is, however, usually hidden under the nail. The medial aspect of the distal nail wall is more pronounced. In some cases, a spontaneous resolution is observed till the age of two (to five) years (12,13,17,18). This apparently depends on the degree of onycholysis: the more severe the onycholysis the less likely is spontaneous improvement. The best chances for a successful operation are when this is done before the age of two to five years; however, an absolute age cannot be given (23,24). When there is no tendency toward improvement until the age of two (13) surgery is recommended. In patients older than two to five years, the nail bed has often irreversibly shrunk and a distal nail wall formed. The rest of the nail field is epidermized obviating the potential to retransform into normal nail bed epithelium, which is unique in its property to firmly attach the nail (Fig. 3C). Without nail attachment, a normal nail cannot grow. Personal experience of one author (Eckart Haneke) suggests a positive effect on consistent massage of the nail bed with 20% azelaic acid cream (Skinoren1); however, no systematic trial has ever been performed with this drug. Untreated CMBT develops into onychogryphosis at older age.

Anesthesia l General anesthesia is preferred in little children. We combine this with a proximal digital block

with either ropivacaine 1% or bupivacaine 0.5%, which allows the general anesthesia to be very light and guarantees a pain-free period of 12 to 24 hours. Tools l Basic nail surgery tray l Bone rongeur or sturdy nail clipper Surgical Procedure Technique: very difficult l

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An incision is carried around the tip of the toe approximately 5 mm below the level of the nail bed. Another incision is performed at the toe tip such as to yield a crescentic wedge of soft tissue that is slightly wider on the anteromedial aspect (Fig. 3D). The nail organ is meticulously dissected from the phalanx, which at this age is not yet fully mature, while remaining directly on the bone. In most instances, the distal dorsal tuft of the distal phalanx is hypertrophic pointing upward (dorsally). It has then to be removed to give a straight surface of the distal phalanx. Care has to be taken not to perforate the nail bed while dissecting the nail bed and matrix from the underlying bone. The dissection has to be extended up to the joint without damaging the extensor tendon and the joint (Fig. 3E). The entire nail apparatus can be elevated as an unguodermal flap and rotated into the correct axis of the toe. Slight overcorrection is sometimes advisable. Whether or not Burow’s triangles are taken to facilitate rotation depends on the degree of malalignment. Avoiding removal of Burow’s

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Figure 3 (D–G) (D) U-shaped incision all around the toe tip. (E) After complete elevation of the whole nail apparatus. Note the shiny porcelain color of the terminal extensions of the extensor tendon. (F) After realignment and suture. Compare with Figure 3C. (G) This young lady had realignment of the right great toenail. The new nail is properly aligned, thin and nicely pinkish. Compare with the contralateral toenail not yet operated.

triangles may avoid to further damage the arterial blood supply. The unguodermal flap is then sutured in its correct position with 4/0 stitches (Fig. 3F). Key Point l Detaching the entire nail apparatus as a whole without perforating the bed of injuring the extensor tendon. l Ensure enough rotation of the flap, if necessary with Burrow triangles. Peri- and Postoperative Care Postoperative pain: very painful l

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The irregular nail plate as well as the onycholytic area of the nail harbor a tremendous amount of bacteria, of which staphylococci, enterococci and other gram-negative enterobacteria are the most important pathogens. Even with vigorous disinfection, the surgical field cannot be made sterile. We therefore give perioperative antibiotic prophylaxis: the anesthesiologist gives our little patients an intravenous injection of an antibiotic that covers these potential bacteria, for example, a second-generation cepholosporin (cefuroxim, cefotiam), before the surgery starts. It is advisable to elevate the foot for about 48 hours, which may be a real problem is some children. The dressing is changed the next day in a lukewarm foot bath with some povidone-iodine soap.

Evolution l The results of the unguodermal flap rotation are usually good in little children. The older the patient, however, the less likely is a good nail growth after surgery. However, a new smooth well aligned nail may grow out but that will remain short from the long-standing onycholysis with epithelialization of the bed (Fig. 3G). This is nevertheless much more comfortable for the patient during footwear. Acrylic nails may be stuck on it during summertime.

Complications and Management l Complications are partial flap necrosis, infection and insufficient recovery of the nail bed. l In young children, flap necrosis is exceptional. In older children and adolescents, tip necrosis may develop depending on the degree of tension necessary to rotate the unguodermal flap. l Infection may occur up to five days later and has to be vigorously treated with antibiotics according to bacterial sensitivity; until the results of an antibiogram are known a staphylococcus-fast antibiotic is recommended.

REMOVAL OF THE WHOLE NAIL UNIT Introduction l The nail apparatus is fully excised for two main reasons: malignant tumor and severe posttraumatic nail dystrophy.

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Amputation remains necessary in case of any suspicion of bone involvement for squamous cell carcinoma (25,26) and for invasive melanoma (27–29).

Anesthesia l This surgery is performed under local block, usually a proximal or distal digital block. Tools l Basic nail surgery tray Surgical Procedure Technique: intermediate l

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First, the incision lines are drawn on the tip of the digit according to the admitted safety margins: 6 mm minimum all around the nail apparatus (27). The incision starts at the tip of the finger or toe, 6 mm ahead of the hyponychium, and is prolonged on both sides, paralleling the lateral nail sulcus, 6 mm laterally, until the junction proximal-lateral nail fold. Here, it is mandatory to curve the incision line down and laterally to reach about the midline of the lateral aspect of the finger/toe, as the lateral horn of the matrix may extend that low, especially on the great toenail. This will avoid any spicule formation or recurrence of the tumor (Fig. 4A). The two lateral incision lines join with a transverse cut over the distal interphalangeal joint. The nail bed is dissected from the bony phalanx with sharp pointed scissors progressing proxi-

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mally. Using a Beaver blade No. 64 renders the task easier. Always stick to the bone, the periosteum should ideally be removed during the procedure. Elevation of the bed is difficult as the unit of the bed and plate are unbendable. Grasp the distal end of the nail apparatus with a sturdy haemostat and use it as a lever (Fig. 4B). When reaching the matrix area, be very delicate and be sure to detach the whole matrix from the bone, especially laterally. Again, this is much easier with the Beaver blade. When the whole matrix area is fully detached lifting of the whole nail apparatus becomes very easy. Progress proximally until reaching the most proximal incision over the distal interphalangeal joint. Take care of the extensor tendon that appears as a shiny whitish structure (Fig. 3E). Cut transversally the remaining attachments with scissors.

Key Point l Removing the whole matrix and avoiding to leave any remnant of it. l Care must be taken to prevent a distal extensor tendon injury. This event remains extremely rare as this structure is hard and easily recognizable. However in old patients this structure may be fragile and more easily torn up. Evolution l Closure of the defect may be done by secondary intention healing or skin grafting. l Usually, secondary intention healing is preferred on toes and grafting on fingers.

Figure 4 (A) Complete removal of the nail apparatus for extensive Bowen’s disease. Note how the most proximal part of the incision curves to remove the most lateral part of the matrix horns. (B) Elevation of the bed using a hemostat. (C) A running locked suture around the wound will dramatically decrease postoperative bleeding after removal of the tourniquet.

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CLOSURE WITH SECONDARY INTENTION HEALING Introduction l Secondary intention healing allows excellent functional results. It is a simple and cost-effective method for reconstruction (30): granulation tissue will develop and cover the defect. l Second intention healing has several advantages (31):  As safety margins are not known during surgery of the tumor, the wound can be left open until histological results are known (Mohs’ surgery). Then, if necessary, a new excision may be performed until margins are clear. Afterward, the surgical site may go on with the secondary intention healing or shift for grafting.  Surgical time is much shortened compared with closure with skin grafting.  No new wound is performed on the donor site. l Repair time is longer (up to eight weeks) than closure with grafts and instructions must be given to patients accordingly. Surgical Procedure l After complete removal of the nail unit, if secondary intention healing is planned, a running locked suture is performed all around the wound to avoid bleeding (Fig. 4C). Postoperative Care Pain: very little l If dealing with a high risk patient (diabetic, impaired limb vascularization) prophylatic antibiotics should be prescribed.

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The first dressing is left in place for 48 hours and then gently removed. If adherent, soak until complete detachment. Never pull. The wound is thereafter soaked twice daily in lukewarm water with antiseptic soap, tapped dry and covered with a large amount of greasy antibiotic ointment. A nonadherent dressing (Telfa1, Tulle Gras1, Mepitel1) is placed over it, covered with a layer of cotton gauze and secured with an elastic bandage. The wound must be kept very clean. Patients are orientated to wash the wound with saline solution twice a day and hydrogel is placed into the wound. The wound should never dry out. Absorbent silver coated dressing can also be used and changed weekly until complete healing. These dressings are more expensive, but some patients will appreciate them as they will not have to check and clean the wound. Moreover this type of dressing prevents infection.

Key Points l Following the patient at regular intervals to adapt the local treatment accordingly. l Remove fibrous tissue with a curette if needed. This is painless.

Evolution l If proper care is performed and the patient is in good general health, healing time will take from four to eight weeks (Figs. 5A–C, 6A–E, and 7A–D).

Figure 5 (A) Melanoma of the thumb. (B) Removal of the whole nail unit revealed an in situ melanoma. (C) Results at eight months postoperatively.

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Figure 6 (A) Melanoma of the great toenail. (B) Removal of the whole nail unit revealed an in situ melanoma. (C) Result at two months. (D) Result at three months. (E) Result at four months.

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In diabetics, smokers and other person at risk healing may take up to 12 weeks.

Complications and Management l Infection is unusual but remains a serious complication especially because of the naked bone at the very beginning. Therefore some practioners prefer to cover the first week with prophylactic antibiotics. l Overgranulation may occur in young adults. Stop the greasy ointments. Compressive dressings associated with drying lotion (i.e., povidoneiodine lotion) for several days usually suffice. If not, silver nitrate or a topical steroid will help.

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Retraction is a common phenomenon and may be responsible for traction scars that may be uncomfortable. Repeated massaging and silicone dressings help greatly.

CLOSURE WITH A GRAFT Introduction l Full-thickness skin grafting is an easy and safe procedure with low morbidity. It can withstand more mechanical stress than a split-thickness graft (32). l Selection of the donor site should take into account minimal functional impairment from the removal of tissue, maximal hiding of the scar as well as the proximity to the recipient site (33). It

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Figure 7 (A) Bowen’s disease of the nail bed and lateral nail fold. (B) As the first excision showed massive lateral involvement of the bed, it was decided to remove the whole nail apparatus of this old man’s fifth finger to limit surgical sessions from Mohs’ surgery. (C) After two weeks. (D) After seven weeks.

is obvious that the area should be as hairless as possible. For this reason, the most common selected site is the homolateral medial aspect of the arm. Other options are the groins, the gluteal folds and the lateral side of the trunk. Anesthesia l Distal digital block l Tumescent anesthesia with epinephrine for the donor site Tools l Basic surgery tray Surgical Procedure Technique: intermediate l

To have an idea of the area of skin to harvest, the width of the defect corresponds to the maximum

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width of the fusiform excision. Using a ruler is a must. Draw the fusiform excision on the donor site, oriented along the Langer lines. Tumescent anesthesia helps for a clean dermohypodermal dissection with few fat cells (33). The harvested graft is laid flat in a Petri dish with cold sterile saline. The defect is better closed with a running subcutaneous suture. The graft is placed directly on the bone and secured at four points (two lateral and proximal and two lateral and distal) with 5/0 absorbable or nonabsorbable sutures (Fig. 8A). The edges of the graft are sutured to the borders of the defect with 5/0 absorbable sutures (Fig. 8B). Only at the end, the graft is shaped and patterned to the size of the recipient size using fine Adson forceps and fine sharp iris scissors (Fig. 8C). This avoids to have too a narrow graft from a misevaluation of its size.

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Figure 8 (A–E) (A) The graft is laid on the defect. (B) The graft is sutured to the borders of the wound. (C) The graft is only patterned and shaped at the end of the procedure. (D) After eight days, the graft looks bluish and edematous. (E) One month postoperatively.

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Key Point l Shaping the graft to the exact size of the defect, keeping in mind that the graft retracted after harvesting and may spread a bit when pulled. So do not leave too much loose tissue, this may favor liquid collection under the graft. The latter should be a bit stretched over the bone. l Suturing the edges of the graft to the borders of the defect should be perform very carefully and tend to be a bit eversant

Postoperative Care Pain: nil at recipient site, moderate at donor site l

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The graft is covered with antiseptic ointment and nonadherent dressing such as petrolatum coated gauze (Tulle Gras, Bactigras 1 , Adaptic 1 , Jelonet 1 ) possibly added with antiseptics (Betadine Tulle1, Fucidin Tulle1). Several layers of gauze and an elastic bandage will complete the dressing. This dressing should be changed after 48 hours to remove the blood-stained gauze. The graft most commonly looks edematous and bluish and superficial blisters are often observed (32,34).

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This is normal and does not compromise future healing (Fig. 8C, D). The new dressing should be left then for a week. This is safer as it does not interfere with revascularization of the graft, which starts at day 3. It is mandatory to ask the patient to strictly keep the limb elevated to avoid congestion at the operating site.

Evolution l Functional results are very good as almost normal distal interphalangeal joint mobility and sensory discrimination are achieved (32–34). However, patients may experience some difficulty with precise handling (i.e., buttoning up) (35) that varies according to the operated finger. l Patients are mostly satisfied with the cosmetic appearance and full-thickness graft often go unnoticed by a noninformed audience and are often forgotten by the patients themselves (32,34,35).

Complications and Management l Graft take is achieved in almost all instances. In case of graft failure, healing will occur with secondary intention. l In a series of 13 cases, Lazar reported that the most common complication was implantation cyst (5/13) (33). l Dawn hairs may grow on the graft and may disturb some patients (Fig. 8E). Reassurance is the rule and no treatment is required. Laser hair removal after a year is an option.

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CLOSURE BY REVERSED DERMAL GRAFT Introduction l When neither a flap nor a full-thickness skin graft are feasible, the reversed dermal graft is a valuable option. l The reversed dermal graft is a very versatile graft. As it does not contain epidermis, but only dermis it is relatively cell poor and thus not demanding. However, it gives a layer of connective tissue comparable to normal nail bed and matrix thickness (36,37). It is mechanically strainable (38,39) and adapts also to oral and genital mucosa (40–42). l The critical point of a reversed dermal graft is that its superficial side with its enormous number of sectioned capillaries is laid upside down on the phalangeal bone. The preformed vessels are used in the process of graft take. This allows it to be used as a sandwich graft together with split skin (38). Anesthesia l A proximal digital block, transthecal anesthesia or distal wing block are adequate for the procedure. l Common infiltration anesthesia or tumescence anesthesia are used for the donor site. Tools l Basic nail surgery tray l Dermatome Surgical Procedure Technique: difficult l

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Figure 8

(F) Down hairs growing on the graft.

A pattern of the defect is made. An area overlapping the pattern for at least 1 cm is anesthetized in a region with a thick dermis; the anterior or anterolateral aspect of the thigh should be prefered. A very thin split-thickness graft is cut with the dermatome and folded back, but left in place like a flap. Then the exposed dermis is incised according to the pattern and raised in exactly the same manner like a full-thickness skin graft: It is dissected from the adipose tissue with blunt scissors. If there is some fat adhering to its undersurface this is meticulously removed. The thin flap of split-thickness skin at the donor site is laid back and stitched to close the donor defect. It may be perforated to allow drainage from the base of the wound.

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The graft is transferred to the defect and put on it upside down. It is then sutured with 5/0 stitches. It has been shown that a reversed dermal graft can be immediately overgrafted with split-thickness skin.

Key Point l The reversed dermal graft is rich in connective tissue, but cell poor—this makes it much less demanding than a full- or even split-thickness skin graft. l In contrast to skin grafts, it is put on the base of defect upside down so that the enormous number of fine capillaries present in the papillary dermis comes into contact with the wound base and will be reused for graft vascularization. l It is critical to never let the reversed dermal graft dry out. l The remnants of skin appendages either disappear completely as this is known for the hair follicles, or remain functionally silent as the sweat glands. l When fresh granulation tissue is seen on its surface re-epidermization by secondary intention occurs or a split-thickness skin graft may be used. Postoperative Care Pain: moderate l

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At the end of surgery, a dressing with plenty of vaseline-based antibiotic ointment is applied as drying out of the graft must be avoided. It is advisable to elevate the hand or foot for about 24 hours. The dressing is changed after about 24 hours. Antiobiotic ointment is reapplied and covered with a water-proof sheet like Opsite1 or Tegaderm1. This procedure is repeated after two or three days, then twice a week.

Results l The new surface of the graft, the former dermohypodermal border, develops small granulations in a period of 7 to 10 days. It may then be overgrafted with split-thickness skin or left for second intention epidermization. l The results of dermal grafts are functionally excellent. Complications and Management l Complications are very rare. The graft is poor in cells and when put upside down on the base of

the defect, the many sectioned capillary vessels are used to revascularize the graft.

CROSS-FINGER FLAP Introduction l When neither another flap nor a full-thickness graft are feasible the cross-finger flap is a valuable option. l The cross-finger flap is a more demanding, three-stage technique to repair a full-thickness defect of a digit, particularly the dorsal aspect of the tip of a finger. l The critical point of a cross-finger flap is training of the flap before raising it completely and transposing it to the defect. Another 18 to 20 days are allowed to heal for the flap before its pedicle is severed. l Usually the volar skin of the middle phalanx an adjacent finger is used (Fig. 9A) except for the thumb where the volar skin of the proximal phalanx of the index finger is used (Fig. 10A). l The thenar flap is another option for the index, middle and ring fingers. l Abdominal skin is also an alternative. Anesthesia l A metacarpal block anesthetizing the neighboring sides of adjacent fingers is useful; however, proximal digital block or transthecal anesthesia may also be used. Tools l Basic nail surgery tray l Tourniquet

Surgical Procedure Technique: difficult l

A U-shaped incision is made on the volar aspect of the middle phalanx for the four long fingers or on proximal phalanx of the index finger for the thumb. Its base is at the lateral aspect neighboring the defect. The transversely oriented flap is gently undermined from its tip to the base without completly severing all connective tissue connections. This reduces blood supply to about 10% of its original. The operation is then terminated with a light dressing, which is changed after 24 to 48 hours

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Figure 9 (A) Scheme of cross-finger flap for index finger. (B) Early invasive melanoma is seen After removal of the proximal half of the nail and reflexion of the proximal nail fold. (C) After training of the flap it is elevated and laid on the primary defect of the adjacent index finger. (D) The flap has grown to the wound base and is severed; sutures allow a good reconstruction of the fingertip and the donor site. (E) The cross-finger flap three years after surgery provides an excellent functional and acceptable cosmetic result.

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to remove blood-stained gauze compresses. The flap is allowed to recover for about 10 days. In the second stage (Figs. 9B–E and 10B–F), the defect is refreshened and cleaned. The flap from the adjacent finger is completely dissected allowing it to be transposed to the defect on the dorsal aspect of the distal phalanx of the neighboring finger. Because of their different length, the long fingers have to be bent to a certain degree, which also prevents, to a great

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degree, postoperative stiffness. The flap is sutured in place. The donor site is covered with a full-thickness skin graft taken from an area with thin skin, for instance the inner aspect of the forearm. Gentle cooling and infusion of 50 mg/day of prostaglandin E1 (or prostacyclin) for three days increase the survival chances of the flap. A dressing with Tulle Gras and an antibiotic ointment is made, which is changed after 48 hours. The flap is left pedicled for 2.5 to

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Figure 10 (A) Scheme of cross-finger flap for thumb. (B) An extensive in situ melanoma of the thumb is removed by an en bloc excision of the dorsal half of the distal phalanx. The figure schows the defect and the surgical specimen. (C) The flap from the volar aspect of the proximal phalanx of the neighboring index finger is laid on the defect of the thumb. (D) The cross-finger flap is sutured in place. (E) The pedicle of the flap is severed and sutured. (F) Excellent function and good cosmesis eight months after the third step of surgery.

3 weeks. During this period, the neighboring fingers are kept apart by gauze pads that should be regularly dried and disinfected to prevent the keratin from degrading and becoming smelly.

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When the flap has taken on a rosy color after approximately 18 to 20 days, its pedicle is severed and both the donor site and the recipient fingertip are modeled to give an optimal esthetic result (Figs. 9D and 10D).

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Key Point l Adequate training of the flap is of paramount importance as the transverse orientation of the flap makes it a random pattern flap. l It takes 10 to 12 days for the vascular supply of the flap to reorient its direction—this is the period that must be allowed for training of the flap. l When the flap is transferred to the defect it takes approximately three weeks until sufficient blood supply will come from the base of the wound, which finally permits the flap pedicle to be severed. Postoperative Care Pain: intermediate l

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It is advisable to elevate the hand or foot for about 24 hours. The dressings are changed as outlined above.

Evolution l The results of cross-finger flaps are functionally excellent and cosmetically pleasing (Figs. 9E and 10F). They provide a resistant dorsal fingertip, which resembles a finger nail when looked at from a distance. Complications and Management l Complications are varied and relate to the different stages of the surgery. l There are generally no problems after the first stage of cutting and gently undermining the flap. When the flap is transposed too early it may necrose. Improper wound care may risk infection. l Sufficient blood supply from the recipient wound bed has be insured before severing the flap pedicle otherwise tip necrosis may develop.

REFERENCES 1. Richert B. Basic nail surgery. Dermatol Clin 2006; 24:313–322. 2. Haneke E, Baran R. Nail surgery. Clin Dermatol 1992; 10:327–333. 3. Haneke E. Nail surgery. Eur J Dermatol 2000; 10:237–241. 4. Rich P. Nail biopsy: indications and methods. Dermatol Surg 2001; 27(3):229–234. 5. Jellinek N. Nail matrix biopsy of longitudinal melanonychia: diagnostic algorithm including the matrix shave biopsy. J Am Acad Dermatol 2007; 56:803–810.

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6. de Berker DAR. Lateral longitudinal nail biopsy. Australas J Dermatol 2001; 42:142–144. 7. de Berker DAR, Baran R. Acquired malalignment: a complication of lateral longitudinal biopsy. Acta Derm Venereol 1998; 78:468–470. 8. Richert B, Dahdah M. Complications in nail surgery. In: Noury K, ed. Complication in Dermatologic Surgery. Phildelphia: Mosby Elsevier, 2008:137–158. 9. Samman PD. Great toenail dystrophy. Clin Exp Dermatol 1978; 3:81–82. 10. Baran R, Bureau H, Sayag J. Congenital malalignment of the big toenail. Clin Exp Dermatol 1979; 4:359–360. 11. Baran R. Congenital malalignment of toe-nail. Arch Dermatol 1980; 116:1346. 12. Dawson TAJ. An inherited nail dystrophy principally affecting the great toenails. Clin Exp Dermatol 1979; 4:309–313. 13. Dawson TAJ. An inherited nail dystrophy principally affecting the great toenails; further observations. Clin Exp Dermatol 1982; 7:455–457. 14. Barth JH, Dawber RPR, Ashton RE, et al. Congenital malalignment of great toenails in two monzygotic twins. Arch Dermatol 1986; 122:379–380. 15. Harper KJ, Beer WE. Congenital malalignment of the great toenails – an inherited condition. Clin Exp Dermatol 1986; 11:514–515. 16. Baran R, Bureau H. Congenital malalignment of the big toe-nail as a cause of ingrowing toe-nail in infancy. Pathology and treatment (a study of thirty cases). Clin Exp Dermatol 1983; 8:619–623. 17. Handfield-Jones SE, Harman RRM. Spontaneous improvement of the congenital malalignment of the great toenails. Br J Dermatol 1988; 118:305–306. 18. Dawson TAJ. Great toenail dystrophy. Br J Dermatol 1989; 20:139. 19. Katz AM. Congenital ingrown toenails. J Am Acad Dermatol 1996; 34:519–520. 20. Gue´ro S, Guichard S, Fraitag SR. Ligamentary structure of the base of the nail. Surg Radiol Anat 1994; 16:47–52. 21. Baran R, Grognard C, Duhard E, et al. Congenital malalignment of the great toenail. An enigma resolved by a new surgical treatment. Ann Dermatol Ve´ne´re´ol 1998; 125(suppl 1):1S56. 22. Von Zons P, Mainusch O, Haneke E. Congenital malalignment of the big toenail. 8th Int Cong Pediat Dermatol, Paris. Ann Dermatol Ve´ne´re´ol 1998; 125 (suppl 1):S56. 23. Baran R, Haneke E. Etiology and treatment of nail malalignment. Dermatol Surg 1998; 24:719–721. 24. Haneke E. Nail surgery: indications and outcome. Exp Rev Dermatol 2006; 1:93–104. 25. Mikhail GR. Subungual epidermoid carcinoma. J Am Acad Dermatol 1984; 11:291–298. 26. Sau P, McMarlin SL, Sperling LC, et al. Bowen’s disease of the nail bed and periungual area. A clinicopathologic analysis of seven cases. Arch Dermatol 1994; 130:204–209. 27. Haneke E, Binder D. Subunguales Melanom mit streifiger Nagelpigmentierung. Hautarzt 1978; 29: 389–391.

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28. Brodland DG. The treatment of nail apparatus melanoma with Mohs micrographic surgery. Dermatol Surg 2001; 27:269–273. 29. Moehrle M, Metzger S, Schippert W, et al. Functional surgery in subungual melanoma. Dermatol Surg 2003; 29:366–374. 30. Knox KR, Datiashvili RO, Granick MS. Surgical wound bed preparation of chronic and acute wounds. Clin Plast Surg 2007; 34:633–641. 31. Martinelli PT, Cohen PR, Schulze KE, et al. Periungual basal cell carcinoma: case report and literature review. Dermatol Surg 2006; 32:320–323. 32. Haneke E. Operative therapie akraler und subungualer melanome. In: Rompel R, Petres J, eds. Operative und Onkologische Dermatologie. Fortschritte der Operativen und Onkologischen Dermatologie. Vol. 15. Berlin: Springer, 1999:210–214. 33. Lazar A, Abimelec P, Dumontier C. Full thickness skin graft for nail unit reconstruction. J Hand Surg 2005; 30B(2):194–198. 34. Duarte AF, Correia O, Barros AM, et al. Nail matrix melanoma in situ: conservative surgical management. Dermatology 2010; 220:173–175; DOI:10.1159/ 000266038.

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35. Abimelec P, Dumontier C. Basic and advanced nail surgery. In: Scher RK, Daniel CR III, eds. Nails: Diagnosis, Therapy, Surgery. 3rd ed. Philadelphia: Elsevier Saunders, 2005:265–289. 36. Haneke E. The reversed dermal flap for defects of skull skin. Z Hautkr 1981; 56:84–87. 37. Haneke E. Versatility of dermal grafts. J Me´d Esthe´t 1981; 8:122–123. 38. Fratila AA, Bertlich R. The reversed dermal graft: surgical procedure and clinical applications. Facial Plast Surg 1997; 13:93–99. 39. Querings K, Bachter D, Balda BR. Meshed reversed dermal graft in patients with surgical defects of sole and scalp: technique and long-term results. Dermatol Surg 2002; 28:122–126. 40. Ueda M, Kaneda T, Oka T, et al. Experimental study of dermal grafts for reconstruction of oral mucosa. J Oral Maxillofac Surg 1984; 42:213–223. 41. Metin M, Dolanmaz D, Alkan A. Evaluation of autogenous grafts used in vestibuloplasty. J Int Med Res 2003; 31:335–339. 42. Bruck HG, Gitsch E, Husslein H. Vaginoplasty in aplasia vaginae by a reversed dermal graft. Geburtshilfe Frauenheilkd 1971; 31:409–415.

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Surgery of the bony phalanx Eckart Haneke, Nilton Di Chiacchio, and Bertrand Richert

The surgery of distal phalanx bone tumors requires a thorough knowledge of nail anatomy and must be performed in an operating room that meets orthopedic surgery standards. Strict adherence to aseptic operative techniques is required. When the overlying epidermis is intact no perioperative antibiotic prophylaxis is necessary. However, when there is a break in the skin an intravenous injection of an antibiotic that covers staphylococci, for example, a second-generation cepholosporin (cefuroxim, cefotiam), is injected 20 to 60 minutes before the start of surgery. Another option is azithromycine, 500 mg/day for three days starting the day prior to the surgery. EXOSTOSIS AND OSTEOCHONDROMA Introduction l Subungueal exostosis is a benign osteocartilaginous tumor, which most commonly occurs on the distal phalanx of big toes of adolescents and young adults. It is always almost located in the dorsomedial aspect of the tip of the toe (1). l It is thought to be promoted by repetitive trauma (1). l There is still a debate about whether exostosis and osteochondroma are different diseases or two expressions of the same condition (2,3). l The lesion appears as a firm swelling below the nail, more commonly around the tip, lifting up the nail plate or inducing a reddish onycholysis. When emerging from the undersurface of the free edge of the nail or from a lateral sulcus, it may show with a porcelain white surface is covered fine telangectasias at early stage. Often a collarette delineates the tumor (Fig. 1A). With time, the proliferation is covered with thick hyperkeratosis (Fig. 1B) (1–5). l Pain is absent or moderate in many cases but may be the leading symptom in others (1). l X ray confirms the diagnosis (Fig. 1C) (1).

Anesthesia l Proximal or distal digital block

Figure 1 (A) Subungual exostosis of the great toe. Note the porcelain white color, the telangiectasia and the collarette. (B) Subungual exostosis of the great toe lifting up the nail plate. Note the hyperkeratosis. (C) X ray from case shown in (A) demonstrating the exostosis.

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Tools l Tourniquet l Basic nail surgery tray l Nail avulsion tray l Bone rongeur l Gelfoam1

Surgical Procedure Technique: intermediate to difficult l

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A tourniquet is mandatory as cutting of spongious bone will lead to bleeding. According to the size of the tumor and its location, a partial avulsion is made, with preservation of the plate to cover the operation site postoperatively. For this reason, trap door or lateral curled avulsion are best (Fig. 2A). It is mandatory to try to keep as much as possible of the nail bed that as been largely expanded by the proliferation of the tumor. A longitudinal incision is performed along the whole length of the tumor completed by an incision running

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transversally following the curve of the hyponychium (reverse T incision). Starting from this point, a very meticulous dissection of the thin and fragile nail bed is carried out with Graddle scissors, or best with a No. 64 Beaver blade (Fig. 2B, C) until the whole tumor is fully exposed (Fig. 2D). The cartilaginous cap of the tumor should preserved. During this procedure, the nail bed is often torn off. Using either dual sterile nail nippers or a bone rongeur, the bony proliferation is severed at its base (Fig. 2E, F). Curettage of the cortical bone is recommended to limit recurrences. If available, pellets of antibiotics are dropped in the defect. The two lateral flaps of nail bed are put back in place. Their edges need sometimes to be trimed as the nail bed is too large and long from the expansion by the tumor. Suturing should be very cautious using 5/0 or 6/0 absorbable sutures. If the nail bed has been torn away in several pieces, just try a rough reapproximation to cover the defect (Fig. 2G).

Figure 2 (A) Lateral curled avulsion exposing the tumor. (B) Careful dissection of the bed from the cartilaginous cap with a Beaver blade on one side. (C) and the other side. (D) Full exposure of the tumor after dissection. (E) Bone rongeur in position. (F) After removal of the tumor. Note the base of the exostosis where some spongious bone may be seen. (G) After reapproximation of the two lateral bed flaps. (H) Nail laid back in place and secured.

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Figure 2

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(Continued)

If a small area of bed is missing, it will heal by secondary intention. Another option to close the defect is freeing two lateral flaps as described at “Longitudinal Erythronychia,” pp. 59–62 (Fig. 3A–C). The nail plate is laid back in place and firmly secured to the lateral and distal folds (Fig. 2H). In some instances it might be difficult to replace the plate as it was distorted by the underlying tumor. A V-cut in the middle of the nail plate allows flattening it. It is secured by two stitches to the distal fold (Fig. 4). If dissection of the bed is impossible because it is has been largely deformed or destroyed by the tumor, “en bloc” resection of the tumor with a bone rongeur with secondary intention healing is a good option (Fig. 5A–E).

Key Points l Delicate dissection of the bed from the underlying tumor. l Be generous in the removal of the bony tumor to avoid recurrence.

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Delicate suturing of the nail bed to cover the defect. If the defect is quite large and covering it with nail bed incomplete, the cavity may be filled with Gelfoam.

Postoperative Care Pain: amazingly, very moderate l l

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Greasy nonadherent dressing. The dressing should be removed after 24 hours as postoperative bleeding is common. Antiseptics soakings are performed twice per day up to completing healing. Stitches are removed after two to three weeks.

Evolution l The nail will be shed within several weeks (soon after removal of the stitches). l The nail should be kept in place with adhesive tape as long as possible, first to act as a physiological dressing but also to prevent distal embedding.

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Figure 3 flaps.

(A) Trap door avulsion exposing the exostosis. (B) Defect after excision of the tumor. (C) Reapproximation with two lateral

Complications and Management l Recurrence may be observed and results from incomplete removal. New more generous surgery should be performed. l No treatment is recommended in case of a slight onycholysis.

Figure 4 A V notch in the middle of the distal nail plate allows to flatten the distorted nail. Compare with Figure 1A.

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After complete regrowth of the nail, no nail dystrophy is observed. Sometimes, a small area of onycholysis of 2 to 3 mm is noted, especially if the tumor was located in the most distal and lateral part of the bed (Fig. 5B).

CHONDROMA Introduction l Chondroma is the the most frequent bony tumor of the hand but remains very rare in the distal phalanx (4,6,7). It mostly affects young adults in the twenties. l A chondroma in the distal phalanx, particularly of the nail matrix and/or nail bed, causes progressive deformation of the distal digit. However deformation of the plate is exceptional. l In one third of the cases, the tumor is revealed by a bony fracture. l Distal digit deformation, with functional and esthetic embarrassment, prompt the patient to seek removal.

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Figure 5 (A) Subungual exostosis presenting with an onycholysis and a red patch. (B) After partial nail avulsion. (C) Bone rongeur removing the tumor. (D) Defect after its removal. (E) Long-term follow-up after healing with secondary intention. There is only a slight remaining distal and lateral onycholysis. Compare with the size of the defect.

Anesthesia l A transthecal or proximal finger block is the ideal anesthesia.

Postoperative Care Pain: moderate l

Tools l Tourniquet l Basic nail surgery tray Surgical Procedure Technique: difficult l

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When the chondroma is under the matrix and nail bed, a lateral approach is recommended. A fish mouth incision usually permits access to it. The nail plate is spared if possible. The bluish tumor can be easily dissected from the surrounding tissue and taken out. The skin is closed with two to three stitches.

Key Point l Finding the tumor might be difficult if small.

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A padded dressing is applied and the extremity elevated for a day. Stitches are removed after 8 to 10 days.

Evolution l Shelling out of the lesion usually results in excellent function and cosmesis. Complications and Management l As with any surgery, delayed healing and infection may occur. ENCHONDROMA Introduction l Enchondroma is a relatively common benign tumor of the bones. l In contrast to periosteal and soft tissue chondroma, enchondroma grows in the bone and may considerable weaken its structure.

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Maffucci’s syndrome is a combination of multiple enchondromas with multiple soft tissue hemangiomas. Malignant degeneration to chondrosarcomas, but also other malignancies, are frequent. Even though the growth rate of an enchondroma cannot be predicted it is wise to remove it before it attains a size that interferes with nail formation and may eventually cause a pathological fracture.

Anesthesia l A proximal digital block or a transthecal block is ideal anesthesia. Tools l Tourniquet l Nail avulsion tray l Basic nail surgery tray l Fine hooks l Bone curette l Bone rongeur l Raspatory Surgical Procedure Technique: difficult l

Figure 6 (A) Clinical presentation of an enchondroma: note the clubbing of the ring finger. (B) X rays from Figure 6A: note the translucent tumor. l

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Subungual localization is uncommon and usually leads to enlargement of the terminal phalanx often clinically visible as an isolated clubbed digit (Fig. 6A) (9,10). Nail dystrophy and ridging may also be observed. A pathological fracture is the first sign in every third patient. Nail pigmentation and chronic paronychia have also been observed (11–13). A radiograph shows an area of translucency in the bone with thinning of the corticalis that appears to be blown out, sometimes spotty calcifications (Fig. 6B) (14). Histopathology shows normal cartilage tissue. Transition to chondrosarcoma is possible (15,16) and differentiation of chondroma from lowgrade chondrosarcoma can be very difficult (8).

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When the enchondroma presents with a pathological fracture, surgery has to be postponed for one to two months. It would otherwise be extremely difficult to fix the very thin cortical bone (4). Whenever possible, a lateral incision is performed (17). The nail plate is spared as it acts like a splint. The Cleland’s ligament, extending from the sides of the phalanges to insert into the lateral skin of the phalanx (18,19) has to be divided (4). The thin lamella of cortical bone is easily cut with a scalpel and opened to allow access to the enchondroma. The soft blue-gray tumor can be removed with a curette. Bone grafts are usually not necessary for the distal phalanx (4), except for very large lesions (8).

Key Point l Careful dissection of Cleland’s ligament. l Care has to be taken not to penetrate the distal interphalangeal joint when curetting the lesion.

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Postoperative Care Pain: moderate l l

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A splinted dressing is applied the duration of which depends on the size of the defect and the stability of the bone left. The wound dressing is changed after one to two days.

Evolution l The results are usually very good both functionally as well as esthetically (4,8).

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Complications and Management l The thin bone lamellae may fracture rendering stabilization of the terminal phalanx very difficult. Penetration into the cavity of the distal interphalangeal joint is possible. l Infection has to be treated early and aggressively. INCLUSION CYST Introduction l Implantation cyst within the bone is unsual. Careful questioning may sometimes recall a history of trauma. They are more common on the digits than on the toes and especially involve the first three fingers (20,21). l Clinically, they may present as a swollen, painful extremity (Fig. 7A) and with time may give rise to clubbing, parrot-beak nails (14,20,22) or pincer nail (23). Painful pressure may be the only symptom (24). l X rays are always mandatory when facing such deformities. The bony phalanx may show a welllimited area of osteolysis (Fig. 7B). In some cases, the epidermal cyst may be invisible on X-ray examination (23). Anesthesia l Distal digital block Tools l Nail avulsion tray l Basic nail surgery tray l Curette Surgical Procedure Technique: intermediate l

After partial, trap door or lateral curled avulsion (Fig. 7C), the bed is incised longitudinally over

the cyst. The bed may be eroded by pressure from the cyst. Using the curette, the cavity is emptied carefully from all the keratin material (Fig. 7D). Copiously rinse the cavity using saline under pressure injected in the cavity with a syringe (Fig. 7E). If possible, reapproximate the borders of the bed with 5/0 absorbable suture (Fig. 7F). If the plate is replaced (trap door of lateral curled avulsion) perform one or two holes in the middle of the plate using a 3-mm punch to allow drainage. Replace the plate and secure it to the lateral borders and the distal wall to ensure enough pressure.

Key Point l Complete evacuation of the keratin material. Be generous in the curettage. Postoperative Care Pain: very little l

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Pain is immediately alleviated as the bone has been decompressed. Slightly compressive bulky dressing. Renew after 24 hours. Soakings in antiseptic solutions twice per day for two weeks. Remove the stitches after three weeks.

Evolution l The nail will be shed two to four weeks after removal of the stitches. Inform the patient to keep it in place as long as possible with adhesive tape. l The bone will not show reossification on longterm X rays (24). l The distorted nail plate may return to a normal shape (Fig. 7G) (23). Complications and Management l Incomplete removal may lead to recurrence. l As with any surgery, delayed healing and infection may occur. OSTEOID OSTEOMA Introduction l Osteoid osteoma is a rare, benign, usually painful osteoblastic tumor composed of osteoid and atypical bone (25,26).

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Figure 7 (A) Painful swollen finger in a gardener. (B) X rays showing the cavity within the distal phalanx. (C) Note the cyanotic bed after partial nail avulsion. (D) Curettage of the cavity brings back thick keratin. (E) After the cavity has been thoroughly rinsed out. (F) Reapproximation of the edges of the cavity with two large stitches. (G) Postoperatively at four months. A new normal nail is growing out.

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Localization of osteoid osteomas in the distal phalanx is rare. Toes are more often involved than fingers (27,28). About two thirds of the cases occur in male patients. Most patients are between 10 and 35 years of age although they may also be seen in younger individuals (29). Osteoid osteoma has a characteristic clinical symptomatology with nagging night pain often

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of pulsating character that is poorly localized and typically responds to acetylosalicylic acid and other nonsteroidal anti-inflammatory agents. Painless osteoid osteomas have also been described (30). When occurring in the distal phalanx, osteoid osteomas usually cause soft tissue enlargement or even hypertrophy of the entire distal phalanx, nail changes such as thickening or clubbing

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Tools l Nail avulsion tray l Basic nail surgery Surgical Procedure Technique: difficult l

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Figure 8 Osteoid osteoma. Note the enlargement of the distal phalanx compared with the contralateral digit. Source: Courtesy of R. Baran, Cannes, France.

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(Fig. 8) (31), pain upon probing, normal or slightly violaceous skin, sometimes increased sweating of the area. Osteoid osteoma may involute spontaneously (32); however, the duration of pain with impaired quality of life cannot be predicted and surgical excision has therefore deemed to be the treatment of choice. Radiological features are a circumsribed nidus of hyperdensity in X-ray pictures, which is also detected in CT scans. It may be located in the cancellous bone, the corticalis or subperiosteally. Magnetic resonance imaging shows a nidus with predominantly intermediate signal intensity on T1-weighted (T1W) sequences and with intermediate to high signal intensity on T2-weighted (T2W) sequences. High-grade bone marrow edema, limited to the affected bone and adjacent soft tissue edema can be identified in virtually all cases (29). Arteriography (33), thermography (34) and scintigraphy (35) reveal perilesional hypervascularization. The differential diagnosis has to rule out osteoma, osteoblastoma, and osteogenic sarcoma (36), but also painful inflammatory conditions like regional pain syndrome, osteitis terminalis, paronychia and ingrown nail. The pain that it usually accentuated at night, end phalanx and nail deformation with functional and esthetic embarrassment prompt the patient to seek treatment. When administration of nonsteroidal anti-inflammatory agents remains unsuccessful en bloc resection of the lesion is recommended.

Anesthesia l A proximal digital or transthecal block is the ideal anesthesia.

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Surgery starts with exposure of the lesion. A partial, trap door or lateral curled avulsion are indicated. In incision is made over the lesion, longitudinally on the nail bed, transversally on the nail matrix. The lesion is removed by an en bloc resection (37). This might be difficult as the cortical bone is very hard. Resection with radiofrequency is an alternative (38). The matrix and nail bed are closed with fine stitches and the plate laid back in place and secured to the lateral and distal nail folds.

Key Point l En bloc resection of the whole lesion Postoperative Care Pain: very little l Pain is immediately alleviated as the bone has been decompressed. l Slightly compressive bulky dressing. Renew after 24 hours. Soakings in antiseptic solutions twice per day for two weeks. l Remove the stitches after three weeks. Evolution l En bloc resection is considered the only curative treatment. Complications and Management l As with any surgery, delayed healing and infection may occur. l Recurrence may occur if the lesion has not been removed completely. However they are very rare (39). PINCER NAIL Introduction l Pincer nail is considered a type of transverse overcurvature of the nail (Fig. 9A) (40,41). The curvature increases from proximal to distal (Fig. 9B). It occurs much more frequently on toes than on fingers (40–42).

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Figure 9 (A) Pincer nail. (B) Avulsion of a pincer nail clearly demonstrating that the curvature of the nail increases from proximal to distal. (C) X rays of a pincer nail. Note the osteophytes at the base of the distal phalanx and the shape of the plate. (D) X rays of a pincer nail showing a traction osteophyte.

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Pincer nails may be hereditary or acquired, the latter due to different conditions, such as foot deformations, after trauma or operations, chronic dermatoses and degenerative osteoarthritis (40). In most cases, the base of distal phalanx enlarges thereby decreasing the curvature of the proximal nail plate and consequently increasing the curvature distally (40–42). X rays show an enlargement of the base of distal phalanx and the development of lateral osteophytes (Fig. 9C), which are often hook like and point distally. They are considerably more pronounced on the medial aspect thus pushing the nail laterally

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(40–42). As the nail bed is firmly attached to the bone, the progressive lifting of the plate pulls up the bed and the dorsal distal tuft may exhibit a traction osteophyte (Fig. 9D). Conservative treatments are indicated in light cases or for patients that cannot be operated. There are nonsurgical methods like nail braces, orthonyx, plastic bands, superelastic steel wires and nail ironing. As they do not attack the aetiopathogenesis, recurrences are inevitable and occur within a few weeks even after a month- or year-long treatment (43). Surgical treatment is very effective. It is particularly indicated in cases with tenderness, pain

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and interference with sports activities and wearing shoes (40,41). There are different methods according to the different degrees of severity.

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Anesthesia l Proximal or distal digital block Tools l Tourniquet l Nail avulsion tray l Basic nail surgery tray l Nail clipper, optional: bone rongeur l Cauterant (88% phenol, 10% sodium hydroxide)

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Surgical Procedure — Selective Matrix Horn Resection (Fig. 10 A-I) Technique: easy l

This method is based on the aetiopathogenesis (40) of pincer nails. Taking the outward pressure of the wide base of the terminal phalanx away from the matrix horns results in less uncurving of the proximal nail and thus less overcurving of the distal part of the nail plate. This alleviates pain immediatly postoperatively. For this purpose, chemical cautery of the lateral horns of the matrix is best (Fig. 10A–I). It is described at “Narrowing the Matrix with Chemocautery,” pp. 106–108.

— Matrix Horn Resection Plus Nail Bed Plasty (Fig. 11A) Technique: difficult l

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A tourniquet is placed and the two lateral matrix horns are removed by phenolization, using the same technique as described in chapter 10, p. 106 (Fig. 11B–E). The two distal thirds of the nail plate are then detached from the nail bed, cut transversally with a nail clipper and avulsed (Fig. 11F). A median longitudinal incision is carried out down to the bone in the pinched nail bed from the proximal margin of the remaining nail plate to the hyponychium. When the scalpel blade arrives at the distal dorsal traction osteophyte this is felt like a small bump. Another transverse incision in the skin of the tip of digit 0.5 cm beyond the hyponychium and perpendicular to the first one may be performed, like an inverse “T.” This allows better access to the underlying bone than just the longitudinal incision.

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The nail bed and distal skin are dissected from the bone, like two flaps freeing the deeply impressed lateral nail sulci and reflected laterally giving an excellent view of the terminal phalanx with its distal dorsal osteophyte (Fig. 11G). This is generously removed using a bone rongeur or a sturdy nail clipper to flatten the distal phalanx (Fig. 11H). The flaps of the nail bed are spread out using reversed tie-over sutures with 4/0 threads going from one lateral nail fold over the pulp to the other lateral nail fold and back again. These sutures are fixed at the volar aspect of the toe pulp. Thin rubber tubes may be inserted into the lateral nail sulci, over which these sutures are laid to avoid cutting of the threads through the paronychial tissue (Fig. 11I). When the nail folds are pulled outward a fusiform (in case of simple longitudinal incision) or a triangular (in case of the inverted T) defect appears, which is easily closed by an inward rotation of the inner margins of the nail bed flaps. The degree of rotation depends on the severity of nail bed pinching. When the hyperostosis is not too severe, a locked running suture may suffice to spread the bed. Another option is to enlarge the incisions of the T laterally and to remove a little crescent of soft tissue all around as a discrete Howard Dubois procedure (see chap. 9, pp. 98–100): when suturing the bed will be spread apart (Fig. 11J). The flaps are sutured to each other using 6/0 absorbable sutures. The tourniquet is removed. There are other surgical methods that are in fact variants of what is described above (44).

Key Point l Protecting the matrix through the entire procedure l Removing enough distal bone l Spreading the bed laterally Postoperative Care Pain: very little for selective matrix horns resection; severe with added nail bed plasty l

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Antiseptic ointment is applied on the surgical wound and covered with nonadherent gauze and a bulky dressing. The dressing is removed in an antiseptic bath, for instance with betadine solution, after two days, the wound is washed with water and antiseptic soap twice a day, and covered with a greasy ointment.

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Figure 10 (A) Pincer fingernail. (B) Section of two lateral strips of nail plate. (C) Avulsion of the two lateral strips of plate. (D) Chemical cauterization of the lateral horns of the matrix. (E) Six months post operation. (F) Same as (A) but front view. (G) Same as (B) but front view. (H) Same as (C) but front view. (I) Same as (E) but front view.

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Figure 11 (A) Scheme of the matrix horn resection plus nail bed plasty. (B) Pincer toenail upper view. (C) Pincer toenail front view. (D) Avulsion of two lateral strips of nail plate. (E) Chemical cauterization of the lateral horns of the matrix. (F) Avulsion of the two distal thirds of the plate. (G) Reversed T incision exposing the traction osteophyte. (H) After resection of the traction osteophyte. (I) Scheme of the reversed tie-over sutures with rubber tubes protecting the lateral sulcus from being torn of. (J) Immediately post operation with spreading of the bed with a locked running suture.

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Figure 11

(Continued)

Figure 12

(A) Pincer nail preop. (B) Same toenail five months after chemical cautery of the lateral horns.

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Figure 13 larger.

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(A) Severe pincer toenail preop. (B) Same toenail, six months post operation. Note how the new growing nail is flatter and

Figure 14 (A) Very painful pincer toenail even if overcurvature was moderate. X ray revealed a sharp traction osteophyte. (B) One year postoperatively. Note the enlargement and the flattening of the plate.

Evolution l Oozing will appears after three days and remains for one to two weeks, according to the cauterant used. l Healing is complete after four weeks whatever the technique. l The new nail plate grows flatter either with cauterization of the lateral horns of the matrix (Fig. 12A, B) or resection of the distal hyperostosis (Fig. 13 and 14).

Complications and Management l Complications are uncommon. l As with any surgery, delayed healing and infection may occur.

REFERENCES 1. Haneke E. Bone and cartilage tumors. In: Krull EA, Zook EG, Baran R, et al., eds. Nail Surgery. A Text and Atlas. 1st ed. Philadelphia: Lippincott Willians & Willians, 2001:287–291. 2. Lee SK, Jung MS, Lee YH, et al. Two distinctive subungual pathologies: subungual exostosis and subungual osteochondroma. Foot Ankle Int 2007; 28:595–601. 3. De Berker DA, Langtry J. Treatment of subungual exostoses by elective day case surgery. Br J Dermatol 1999; 140:915–918. 4. Dumontier CA, Abimelec P. Nail unit enchondromas and osteochondromas: a surgical approach. Dermatol Surg 2001; 27:274–279. 5. Suga H, Mukouda M. Subungual exostosis: a review of 16 cases focusing on postoperative deformity of the nail. Ann Plast Surg 2005; 55(3):272–275.

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6. Lichtenstein L, Goldman RL. Cartilage tumors in soft tissue, particularly in the hand and foot. Cancer 1964; 17:1203–1208. 7. Dumontier C, Abimelec P, Drape´ J-L. Soft tissue chondroma of the nail bed. J Hand Surg 1997; 22B:474–475. 8. Bauer HI, Kaatz M, Kluge HW, et al. Subunguales Chondrom, ein Fallbericht. Z Rheumatol 2002; 61: 58–61. 9. Jaffe HL. Juxtacortical chondroma. Bull Hosp J Dis 1956; 17:20–29. 10. Koff AB, Goldberg L, Ambergel D. Nail dystrophy in a 35-year-old man. Arch Dermatol 1996; 132:223. 11. Shelley WB, Ralston EL. Paronychia due to enchondroma. Arch Dermatol 1964; 90:412–413. 12. Pastinszky I, De´vai J. Paronychia et onychodystrophia enchondromatosa. Bo¨rgyo´gy Ve´ne´rol Szemle 1968; 44:176–178. 13. Wawrosch W, Rassner G. Monstro¨ses Enchondrom des Zeigefingerendgliedes mit Nageldeformierung. Hautarzt 1985; 36:168–169. 14. Schajowicz F, Aiello C, Slullitel I. Cystic and pseudocystic lesions of the terminal phalanx with special reference to epidermoid cysts. Clin Orthop Relat Res 1970; 68:64, 84–92. 15. Bellinghausen HW, Weeks PM, Young LV, et al. Chondrosarcoma of distal phalanx. Orthop Rev 1983; 12:97–100. 16. Nakajima H, Ushigome S, Fukuda J. Case report 482: chondrosarcoma (grade 1) arising from the right second toe in patient with multiple enchondromas. Skelet Radiol 1988; 17:289–292. 17. Clark RE, Madani S, Bettencourt MS. Nail surgery. Dermatol Clin 1998; 16:145–164. 18. Shrewbury MM, Johnson RK. The fascia of the distal phalanx. J Bone Joint Surg 1975; 57:784–788. 19. Gigis PI, Kuczynski K. The distal interphalangeal joints of human fingers. J Hand Surg 1982; 7:76–182. 20. Byers P, Mantle J, Salm R. Epidermal cysts of phalanges. J Bone Joint Surg 1966; 48B:577. 21. Fisher ER, Gruhn J, Skerrett P. Epidermal cyst in bone. Cancer 1958; 11:643. 22. Maccomb RK, Renner DW. Epidermoid (epithelial) cyst of the terminal phalanx of a finger: case report and review of the literature. Can Med Assoc J 1962; 87:770. 23. Baran R, Broutart JC. Epidermoid cyst of the thumb presenting a pincer nail. J Am Acad Dermatol 1988; 19:143–144. 24. Richert B, Azouaghe K, de la Brassinne M. Intraosseous implantation cyst. Abstract of the Fifth Congress of the European Academy of Dermatology, Lisbonne, 13/10/96. 25. Jaffe´ HL. Osteoid osteoma. A benign osteoblastic tumor composed of osteoid and atypical bone. Arch Surg 1935; 31:709–728.

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26. Rosborough D. Osteoid osteoma. Report of a lesion in the terminal phalanx of a finger. J Bone Joint Surg Br 1966; 48:485–487. 27. Aulicino PL, DuPuy TE, Moriatry RP. Osteoid osteoma of the terminal phalanx of finger. Orthop Rev 1981; 10:59–63. 28. Prietzel T, Hitzler P, Wojan M, et al. Painful enlargement of the 2nd toe due to an osteoid osteoma in the distal phalanx. Z Orthop Unfall 2009; 147:362–365. 29. Shukla S, Clarke AW, Saifuddin A. Imaging features of foot osteoid osteoma. Skeletal Radiol 2009; [Epub ahead of print]. 30. Wiss DA, Reid BS. Painless osteoid osteoma of the fingers—report of three cases. J Hand Surg Am 1983; 8:914–917. 31. Levy Y, Rosenheck S, Greiff M, et al. Osteoid osteoma of the distal phalanx of the thumb. Acta Orthop Scand 1979; 50:667–669. 32. Hedrich CM, Fiebig B, Sallmann S, et al. Osteoid osteomas of the fingers: an atypical localization? Two case reports and a review of the literature. Z Rheumatol 2008; 67:145–150. 33. Lindbom A, Lindvall N, Sodenberg G, et al. Angiography in osteoid osteoma. Acta Radiol Scand 1960; 54:327–333. 34. O’Hara JP, Tegmeyer C, Sweet DE, et al. Angiography in the diagnosis of osteoid osteroma of the hand. J Bone Joint Surg Am 1975; 57A:163–166. 35. Braun S, Chevro A, Tomeno B. Les oste´omes oste´oı¨des phalangiens. Me´d Hyg 1980; 38:1222–1229. 36. Shader AF, Schwartzenfeld SA. Osteoid osteoma: report of a case. J Foot Surg 1989; 28:438–441. 37. Mohr VD, Bauer T, Schmitt B. Osteoid osteoma at the end of the phalanx of the big toe. Dtsch Med Wochenschr 1990; 115:1470–1474. 38. Ramos L, Santos JA, Santos G, et al. Radiofrequency ablation in osteoid osteoma of the finger. J Hand Surg 2005; 30A:798–802. 39. Tsang DS, Wu DY. Osteoid osteoma of phalangeal bone. J Formos Med Assoc 2008; 107:582–586. 40. Haneke E. Etiopathoge´nie et traitement de l’hypercourbure transversale de l’ongle du gros orteil. J Med Esth Chir Dermatol 1992; 19:123–127. 41. Baran R, Haneke E, Richert B. Pincer nails: definition and surgical treatment. Dermatol Surg 2001; 27:261–266. 42. Haneke E. Pincer nails. In: Krull EA, Zook EG, Baran R, et al., eds. Nail Surgery. A Text and Atlas. 1st ed. Philadelphia: Lippincott Willians & Willians, 2001: 167–171. 43. Di Chiacchio N, Kadunc BV, Trindade de Almeida AR, et al. Treatment of transverse overcurvature of the nail with a plastic device: measurement of response. J Am Acad Dermatol 2006; 55:1081–1084. 44. Kosaka M, Kamiishi H. New strategy for the treatment and assessment of pincer nail. Plast Reconstr Surg 2003; 111:2014–2019.

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Surgery of the distal interphalangeal joint Bertrand Richert

The close neighboring of the distal interphalangeal joint with the most proximal part of the matrix is of major importance in surgical anatomy, especially when performing a complete resection of the nail apparatus for a malignant process with wide margins. In pathology, the complex formed by the distal interphalangeal joint and the matrix is considered nowadays as an enthesis, explaining the propagation of some inflammatory diseases (psoriasis) from the joint to the matrix. MYXOID CYST (GANGLION CYST) Introduction It is now quite well admitted that digital myxoid cysts (DMC) result from a joint fluid leaking (1) from a degenerative distal interphalangeal joint (DIJ) (2). MRI has shown that more than 80% of myxoid pseudocysts exhibit a communication between the cyst and the joint (Fig. 1) (3). On histology they do not show any lining, so the term cyst, although commonly accepted, is a misnomer and the term myxoid pseudocyst should be preferred (4). They present as a translucent nodule, typically arising on the dorsum of the digit, somewhere between the DIJ crease and the proximal nail fold (PNF) (Fig. 2). The most distal DMC may press on the underlying matrix and produce a longitudinal groove on the nail plate, the depth of which varies according to the pressure exerted by the volume of the lesion on the matrix (Figs. 3A, B and 7A). In all these locations, they may occasionally discharge some mucinous content with subsequent decompression of the nodule, which is later seen as an irregularity in the longitudinal depression of the nail. In some rare instances, a DMC develops under the matrix (see “Submatricial Myxoid Pseudocyst,” pp. 122–124). When the DMC is small and located very distally on the PNF it may be removed in the same manner as chronic paronychia (see “Crescent Excision,” pp. 46–47). A wide range of therapies have been proposed to remove DMCs: repeated puncture associated with compressive dressings, cryotherapy (5), injection of sclerosant (6), CO2 laser (7), infrared coagulation (8), but none has been able to reach the high rate of success (over 90%) achieved with surgery (1,4). Several techniques are available, all of them directed toward inducing some fibrosis around the joint to

stop leaking of the joint fluid. Hand surgeons usually remove the osteophytes and “clean” the joint capsule. This leads to very good results, but this aggressive surgery requires long-time immobilization of the DIJ and may result in restriction of joint mobility (up to 25%) and the post op is long and painful for the patients (9). Others propose flaps (10,11) or grafts (12) and it has been shown that skin removal is often not required (13). Methylene blue–guided surgery for ligature of the leak of joint fluid is a very elegant, quick and effective technique (4) as it provides very high success rate on the fingers (94%). On the toes, the technique reaches only 57% probably because in this location the presssure of fluid escaping from the joint is increased by the weight of the standing position (1). This procedure is also very comfortable for the patient. Anesthesia l Distal digital block, starting on the lateral sides of the DIJ, to ensure complete anesthesia of the joint. Transthecal anesthesia on the fingers and proximal digital block are other options. Tools l Tourniquet l Standard nail surgery tray l Sterile methylene blue solution l Insulin syringe, 30G needle l Absorbable suture 5/0 Surgical Procedure Technique: intermediate to difficult l

Insert the needle of an insulin syringe into the flexural crease of the DIJ, about 5 mm proximally to its midline, with the joint slightly flexed, needle pointed distally with an angle of 308 to 458 to the ventral aspect of the second phalanx (Fig. 4). Push the needle until it hits the bone. Withdraw the needle backward, very gently while pressing on the plunger. Resistance to injection means that the needle is within the periosteum; ease of the injection means that the needle is within the joint.

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Figure 1 joint.

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MRI showing connection between the cyst and the

Figure 2 Typical presentation of digital myxoid cyst between the proximal nail fold and the distal interphalangeal joint.

Figure 3 (A) DMC pressing on the underlying matrix. This DMC never varies in size, thus inducing a smooth and regular groove. (B) DMC that varies in size over time; the groove facing it is irregular. Abbreviation: DMC, digital myxoid cyst.

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Figure 4 Introduction of the needle into the ventral aspect of the digit to reach the capsule. Compare with Figure 9.

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Never inject more than 0.1 mL (10 units on the insulin syringe), or the whole operating field will turn blue. The average amount is usually around 0.05 mL (five insulin units). Remove the needle and exercise the joint several times to have the blue dye circulating. Observe closely the DMC as a pale bluish hue will appear confirming the communication (Fig. 5). Apply the tourniquet. Design a flap around the DMC: a good option, when feasible, is to use the dorsal creases as a horizontal incision posterior to the DMC, then a lateral incision running on the lateral aspect of the finger will free a large flap that allows visualization of the surroundings of the base of the pseudocyst (Figs. 6A and 7B). The leak may present in various sizes from a thin blue line to a large one.

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Figure 5 The cyst shows a pale hue, confirming connection between the joint and the cyst.

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Figure 6 (A) Elevation of a lateral flap showing a large pedicle. (B) Ligation of the pedicle.

Figure 7 (A) Irregular nail plate from a digital myxoid cyst pressing onto the matrix. (B) Elevation of a flap showing the pedicle. (C) Closure by simple nonabsorbable sutures. (D) Aspect of the plate after seven months. Compare with (A).

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Figure 8 (A) Complete reflection of dorsal aspect of the distal phalanx shows two large stalks: one is facing the lesion, and the other one is very laterally located. (B) Suturing the pedicles with 5/0 absorbable sutures. (C) Suturing completed. (D) Running suture with 4/0 nonabsorbable sutures.

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Tie off the connecting stalk with absorbable 5/0 suture (Fig. 6B). One stitch per blue line is usually enough. Placing to many stitches may induce some extra inflammatory reaction post operatively. Lay back the flap and suture it back in place. Nonabsorbable suture is classically used, but the absorbable suture previously used may fit nicely, they are more comfortable post operatively. Separate stitches (Fig. 7C) or a running suture are two possible options (Fig. 8D). In our series, we where wondering why some cysts turning blue after injection and in which the stalks were tied off recurred. When designing a flap that exposes the whole dorsal aspect of DIJ, we noted in some instances (about 10% of cases) that some communications between the cyst and the joint were very laterally located (Fig. 8A) and would not have been ligated (Fig. 8B, C) by a flap designed only around the cyst. Since we are using this procedure, we dramatically increased our success rate to almost 100%. It may be so that the large fibrosis induced around the by healing of this large flap plays a part in this success.

Figure 9 Injection within the capsule on section on cadaver. Source: Courtesy of D.A.R. de Berker, Bristol, U.K.

Key Point l Injection of methylene blue within the joint capsule and visualization of the leak after reflection of a dorsal flap. Check the sagittal view on a cadaver finger (Fig. 9). l Do not inject too much of methylene blue. l Do not place too many stitches around the pedicles.

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Dress the wound with antiseptic ointment, a tulle gras, and a bulky dressing. Ask the patient to elevate the limb for 48 hours: ask her/him to come with a large scarf that will be used as a sling. Skin sutures are removed after 10 to 15 days.

Evolution l Healing is very rapid. l Main trouble is rigidity that appears in a few days as the dressing maintains the finger straight. The dressing should be removed after two days, and a small dressing covering only the dorsal aspect of the distal phalanx should be placed. Physiotherapy should be taught to the patient: bending the distal phalanx while blocking the proximal interphalangeal joint with the opposite hand. Full mobility is recovered in less than three weeks. l Check the patient after three months. The nail should grow out without the longitudinal groove, thus proving the success of the procedure. After six months the nail shows no more surface alteration (Fig. 7D).

Complications and Management l They are very unusual. l As for subungual exostosis, this surgery must be performed in an operating room that meets orthopedic surgery standards. Strict adherence to aseptic operative techniques is required. l No prophylactic antibiotics are needed as long as there is no rupture of the capsule. l Irritation from the suture on the pedicle may occur in some instances, and present by a redness associated with a discrete swelling of the overlying skin (Fig. 10). Gentle massage for several weeks with some steroid cream enhances resolution. Healing occurs with complete resorption of the stitches that may take up to three months, according to the type of suture used. This mostly occurs when placing a large number of deep stitches. In two cases, there was perforation of the skin with extrusion of one extremity of a stitch. Cutting it very short allowed rapid complete healing in one, in the other a tiny retractile scar developed (Fig. 11).

Figure 10 Irritation of the dorsal aspect of the distal phalanx from overzealous suturing of the pedicles.

Figure 11 Retractile scar from a subcutaneous stitch. This was later excised and sutured, with very good outcome.

REFERENCES 1. de Berker D, Lawrence C. Ganglion of the distal interphalangeal joint (myxoid cyst): therapy by identification and repair of the leak of joint fluid. Arch Dermatol 2001; 137:607–610. 2. Lin YC, Wu YH, Scher RK. Nail changes and association of osteoarthritis in digital myxoid cyst. Dermatol Surg 2008; 34:364–369. 3. Drape´ JL, Idy Peretti I, Goettmann S, et al. MR imaging of digital myxoid cysts. Dermatol Surg 1996; 200: 531–536. 4. Haneke E. Operative Therapie der myxoiden Pseudozyste. In: Haneke E, ed. Gegenwa¨rtiger Stand der Operativen Dermatologie. Fortschritte der Operativen Dermatologie 4. Heidelberg: Springer, 1988:221–227.

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5. de Berker DA, Lawrence CM. Treatment of myxoid cysts. Dermatol Surg 2001; 27:296–299. 6. Audebert C. Treatment of myxoid cysts of fingers and toes by injection of sclerosants. Dermatol Clin 1989; 7: 179–182. 7. Hueter CJ, Whelland RG, Bailin PL, et al. Treatment of digital myxoid cysts with carbon dioxide laser vaporization. J Dermatol Surg Oncol 1987; 13:723–727. 8. Lonsdale-Eccles AA, Langtry JA. Treatment of digital myxoid cysts with infrared coagulation: a retrospective case series. Br J Dermatol 2005; 153:972–975. 9. Kasdan ML, Stallings SP, Leis VM, et al. Outcome of mucous cyst of the hand. J Hand Surg 1994; 19A: 504–507.

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10. Blanc S, Candelier G, Bonnan J, et al. Use of a bilobed flap for the treatment of mucous cyst. Chir Main 2004; 23:137–141. 11. Imran D, Koukkou C, Bainbridge C. The rhomboid flap: a simple technique to cover the skin defect prodiced by excision of a mucous cyst of a digit. J Bone Joint Surg 2003; 85B:860–862. 12. Jamnadas-Khoda B, Agarwal R, Harper R, et al. Use of Wolfe graft for the treatment of mucous cysts. J Hand Surg Eur Vol 2009; [Epub ahead of print]. 13. Lawrence C. Skin excision and osteophytes removal is not required in the surgical treatment of digital myxoid cysts. Arch Dermatol 2005; 141:1560–1564.

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14

Acute trauma of the nail unit Eckart Haneke and Bertrand Richert

Acute traumas to the nail apparatus are extremely common and represent a frequent cause of consultation at the emergency ward. Hand surgeons are not always available, and unfortunately it is common that the nail apparatus is poorly considered as long as the underlying bony structure is undamaged. This may result in severe nail dystrophies even without associated phalanx fracture. One should learn how to deal with them or should not hesitate to involve hand surgeons in the days shortly after the trauma.

SUBUNGUAL HEMATOMA Introduction l A subungual heamatoma is an accumulation of blood between two nonexpandable rigid structures (bone and plate) that may be responsible for throbbing pain. l Thumb and index are the most commonly involved digits (1). l A subungual hematoma resulting from an acute trauma is always remembered by the patient. Surgery, if indicated, should be performed as soon as possible (within 48 hours) to alleviate pain and to avoid any dystrophy secondary to a nail bed or matrix laceration. l A subungual hematoma resulting from repeated chronic microtrauma is painless and may raise several differential diagnoses. For this reason, nail clipping and Fontana-Masson staining are mandatory to rule out the presence of melanin (Fig. 1). However, subungual hematomas are never located in the free margin of the nail. If some pigmented material can be collected, for example, by scraping it out from under the nail, it should be dissolved in a drop of water and a Hemostix1 is dipped into it: blood is easily confirmed by this simple test. l Patients with a hematoma involving less than 25% of the surface of the nail usually do not require drainage as pain is limited and blood will be included in the nail keratin (Fig. 2) and eliminated with the nail growth even before reaching the free edge. l Patients with a hematoma over 25% of the surface of the nail should be drained to relieve pain and to avoid secondary infection (especially

Figure 1 (A) Complete black nail with nail fracture: hematoma. (B) Complete black nail with fracture: melanoma. Note the pigmentary periungual spreading on the tip of the toe.

Figure 2 Small proximal hematoma from a trauma four weeks before. The hematoma is being incorporated in the nail plate.

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fungal) or epithelialization of the bed responsible for permanent onycholysis (1). It has been proposed that a patient with a hematoma involving more than 50% of the nail surface should be surgically explored to rule out any occult laceration of the bed or matrix (2). This management is now considered as overzealous, as recent large studies have shown that drainage of the hematoma, regardless of its size and its association or not with underlying bone fracture, always cured patients without nail dystrophy (3) even in the fragile nail apparatus of children (4–6). Trephination was equal or superior to removal of the nail and formal nail bed repair with significant lower cost (4,6). No complication of drainage was reported in any of the series (3–6). In any heavy injury, X rays are essential to confirm or rule out a fracture (Fig. 3).

Anesthesia l For obvious reasons of comfort, especially after an acute trauma of the digit, it is suitable to work under a local proximal or a transthecal block. Tools l Paper clip or electrocautery l 3-mm punch Surgical Procedure Technique: easy l

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Perforation of the plate with a heated instrument (red hot paper clip or electrocautery) is easy to perform but the size of the hole is too small and will be obliterated by the blood clot impairing further drainage (Fig. 3A). The 3-mm punch should be favoured as the size of the hole is wide enough. The 3-mm punch is pushed through the nail plate in the middle of the bloody patch, always ahead of the lunula to avoid injuring the matrix (Fig. 4). If the procedure is performed within the 48 hours after the trauma, the blood is still liquid and will be evacuated very easily by gentle manual pressure.

Key Point l As the lunula is most of the time hidden by the hematoma, a 1-cm safety margin distal from the cuticle seems cautious enough for the thumbs. It may be shortened to 5 mm for other digits including the great toenails.

Figure 3 (A) Three small holes were performed with a hot paper clip to drain a subungual hematoma. The patient consulted because the nail was still painful on pressure. (B) X rays revealed a distal bony fracture.

Postoperative Care Pain: very little l

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The nail plate is then pressed onto the bed with compressive dressing such as adhesive bands or Steristips1 (avoiding to cover the hole in the plate) for at least two weeks to enhance adherence and avoid any recurrence. Pain killers are most of the time not necessary as pain is alleviated by drainage.

Evolution l The nail may in some instances readhere to its bed.

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Figure 4 (A) Painful hematoma on a great toenail. The nail was avulsed and cleaned with peroxide. No laceration was observed on the bed and matrix. (B) The plate was replaced, secured, and perforated.

Fungal contamination of an old hematoma is not rare (Fig. 5).

OTHER LACERATING AND CRUSH LESIONS OF THE NAIL APPARATUS Introduction l Nail traumas are divided (2,7–9) into: simple lacerations (36%), stellate lacerations (27%), severe crush injuries (22%) and avulsions (15%). l Fifty percent of the nail apparatus injuries are associated with a fracture of the terminal phalanx. When a subungual hematoma occupies more than 50% of the nail area it is most likely accompanied by a fracture of the bone. l Crushing the finger in a door is the most common cause of acute nail injury followed by smashing the fingertip between objects and injuries from saws and lawn mowers. l Children and young adults, particularly of male gender, are most commonly the victims of such injuries. The middle finger is most frequently involved followed by ring, index, little finger and thumb. l In any heavy injury, a radiograph is essential to confirm or rule out a fracture. l The history of an acute trauma, severe pain and the clinical finding of a large subungual hematoma suggest a nail bed and/or matrix trauma requiring surgical revision. Anesthesia l A proximal digital or a transthecal block is adequate when there is no injury to the proximal phalanx. Perioperative Antibiotic Prophylaxis l Whether or not perioperative prophylaxis should be given depends on the type and severity of the injury and whether there is contamination with soil and dirt. Tetanus prophylaxis should be considered.

Figure 5 l

Fungal contamination of an old hematoma.

Otherwise, it is shed within several weeks and a normal nail grows again.

Complications and Management l It has been clearly demonstrated that it is the absence of early drainage that is responsible for late onycholysis and nail dystrophy (7).

Tools l Tourniquet l Head magnifier lens l Basic nail surgery tray, with fine instruments l 6/0 or 7/0 absorbable sutures Surgical Procedure The hand is prepped surgically and a tourniquet applied. — Simple laceration l The nail is gently removed using a nail elevator from distal to proximal. The extremity of the

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elevator is directed toward the nail to avoid further injury to nail bed and matrix. The avulsed nail is cleaned from dirt and other extraneous material by scraping its undersurface and sides with a scalpel blade or a curette. Blood remnants are removed with wiping it with a gauze pad moistened in 3% hydrogen peroxide. It is then kept in povidone-iodine solution. The nail bed is meticulously repaired. Irregularities are only trimmed in case of major extent not to sacrifice too much of the unique matrix and nail bed tissue. If necessary, the wound edges are approximated with 7/0 chromic sutures or held in place with acrylic tissue glue (10). The nail plate is replaced if possible, otherwise a silicone sheet or a plastic nail (Fig. 6) or a custom-made nail substitute from the body of a 10- or 20-mL plastic syringe may be used (11,12). This nail substitute will not only protect the wound but also mold the irregularities as exactly together as possible. A hole is drilled into the nail or its substitute to allow drainage of any secretion from the wound in an area not directly over the laceration. The nail is held in place under the proximal nail fold with sutures through the hyponychium and nail. When the nail was torn out of the nail pocket, the matrix or parts of it may adhere to the nail plate.

Figure 6

Custom-made nail substitute.

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It is then gently separated from the nail and laid back into the proximal groove where it is secured with horizontal mattress sutures that run through the proximal nail fold on each side and in the middle. In addition, the matrix is sutured to coapt accurately its margins and to prevent step formation, which in turn would lead to a posttraumatic double nail (11). Any laceration involving the dorsal and the undersurface of the proximal nail fold has to be repaired with fine sutures of both the ventral floor and the roof. Suture knots should be buried to avoid irritation and inflammation of the matrix.

—Stellate Laceration l A more diffuse blow to the nail results in more fragmentation of the nail bed and matrix (7–9). Using a head magnifier lens, the nail plate is gently separated from matrix and nail bed tissue. Fragments are used as free grafts (2,7–9). Suturing or gluing (10) the fragments is necessary. The nail, if not too much damaged, is laid back, or a nail substitute is used (12,13). —Severe Crush Injury l These are usually beyond the scope of the dermatologic surgeon and taken care of in special trauma units. Again, all nail bed and matrix fragments are collected and returned as accurately as possible (2,7–9). A radiograph is essential to rule out a fracture, which has to be splinted: in case the fracture is stable the nail plate is returned and usually holds the bone fragments in good position. Unstable fractures and displaced fragments require fixation. In some instances, the nail surgeon may intervene to correct a late dystrophy (Fig. 7A–D). —Avulsion of the Matrix l Certain trauma mechanisms tear the nail out of the cul-de-sac with (parts of) the matrix remaining attached to it. If there is no more matrix fragmentation the nail is replaced into the nail pocket and secured with sutures that should optimally run through the uninvolved lateral and/or proximal nail folds. If suturing of the matrix is necessary it has to be separated from the nail beforehand. Loss of considerable parts of the matrix require repair with split matrix grafts from another digit (14,15) or from the adjacent nondamaged matrix (16), or a reversed dermal

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Figure 7 (A) Fifteen-year-old boy one year after severe crush injury of the distal phalanx of his left thumb. He had been treated in the emergency unit of a hand surgery department. (B) The nail is gently removed by the proximal approach, showing a very irregular undersurface and a deep impression in the matrix that was fixed to the bone. This was released, and a small dermal graft was inserted to fill the defect; the matrix epithelium was fixed over it. In addition, the entire proximal nail fold was rotated to the side of the defect between the proximal and lateral nail fold to reduce its size. The fibrokeratoma-like scar protrusion on the PNF was excised tangentially. (C) Three and a half months after surgery. (D) One year after surgery, the nail is straight, though there is still a split in the plate, which, however, does not embarrass the patient.

graft (17). Full-thickness matrix grafts though giving excellent results (18) leave a deformity of the donor digit. Postoperative Care l A padded dressing is applied and the extremity elevated. Depending on the nature of the injury it is replaced after three to seven days. l Pain medication is essential. l Clean wounds do not routinely require antibiotic treatment. Evolution l Provided the damage was not too severe and reapproximation of the nail matrix and bed fragments was meticulously performed a good result can be expected.

Complications and Management l There are a number of untoward results depending on the degree of nail damage and additional trauma such as bone fracture. l When the matrix could not be repaired sufficiently, a ridged nail or split nail may result. Larger scars obstructing the cul-de-sac will lead to a cicatricial pterygium. l Step formation in the matrix commonly results in a double nail. l Malalignment may be the result of a dislocation of the matrix or a lateral matrix defect (Fig. 8). l Dislocation of matrix fragments may cause nail spicules or a cyst. l Scarring of the nail bed usually results in onycholysis as does keratinization of the nail bed.

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Figure 8

Posttraumatic acquired malaligment.

Figure 9 Hook nail from distal bony amputation and shortening of the bed.

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In toenails a hypertrophic hyponychium or false distal nail wall will form when the nail is lacking or too short for too long a period. A hook nail results from a shortening of the bony phalanx (Fig. 9).

REFERENCES 1. Ranjan A. Subungual haematoma. J Indian Med Assoc 1979; 72:187–188.

2. Zook EG. Acute injury of the perionychium. In: Krull EA, Zook EG, Baran R, et al., eds. Nail Surgery: a Text and Atlas. Philadelphia: Lippincott Williams & Wilkins, 2001:91–109. 3. Seaberg DC, Angelos WJ, Paris PM. Treatment of subungual hematomas with nail trephination: a prospective study. Am J Emerg Med 1991; 9:209–210. 4. Roser SE, Gellman H. Comparison of nail bed repair versus nail trephination of subungual hematomas in children. J Hand Surg 1999; 24A:1166–1170. 5. Salazard B, Launay F, Desouches C, et al. Fingertips injuries in children: 81 cases with at least one year follow-up. Rev Chir Orthop Reparatrice Appar Mot 2004; 90:621–627. 6. Gellman H. Fingertip-nail bed injuries in children: current concepts and controversies in treatment. J Craniofac Surg 2009; 20(4):1033–1035. 7. Zook EG, Guy RJ, Russell RC. A study of nail bed injuries: causes, treatment and prognosis. J Hand Surg 1984; 9A:247–252. 8. Zook EG, Baran R, Haneke E, et al. Nail surgery and traumatic abnormalities. In: Baran R, Dawber RPR, de Berker DAR, et al., eds. Diseases of the Nails and Their Management. 3rd ed. Oxford: Blackwell Science, 2001:457–484. 9. Brown RE. Acute nail bed injuries. Hand Clin 2002; 18:561–575. 10. Hallock GG. Expanded applications for octyl-2cyanoacrylate as a tissue adhesive. Ann Plast Surg 2001; 46:185–189. 11. Haneke E, Klaucic A, Perusquı´a AM. Un˜a doble posttraumatica. Reporte du un caso. Med Cutan Iber Lat Am 2001; 29:106–108. 12. Purcell EM, Hussain M, McCann J. Fashionable splint for nail bed lacerations: the acrylic nail. Plast Reconstr Surg 2003; 112:337–338. 13. Koenen W, Haneke E, Schmieder A, et al. Nail substitute with a syringe splint. J Dtsch Ges Dermatol 2010; 8:63–64. 14. Swanker WA. Reconstructive surgery of the injured nail. Am J Surg 1947; 74:341–345. 15. Shepard GH. Nail grafts for reconstruction. Hand Clin 1990; 6:79–102. 16. Shepard GH. Treatment of nail bed avulsions with split thickness nail bed grafts. J Hand Surg 1983; 8:49–54. 17. Ashbell TS, Kleinert HE, Putcha SM, et al. The deformed fingernail, a frequent result of failure to repair nail bed injuries. J Trauma 1967; 7:177–190. 18. Saita H, Suzuki Y, Fujino K, et al. Free nail bed graft for treatment of nail bed injuries of the hand. J Hand Surg 1983; 8:171–178.

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15

Cosmetic nail surgery for congenital nail abnormalities Bertrand Richert

Nails play an important esthetic and functional role in our society. Nowadays, esthetic improvements become increasingly common. Some nail dystrophies may bother patients in daily life: denial of wearing sandals, hiding a finger by keeping their hands in pockets, clenching their fists in public, etc. Physicians should be aware that some congenital and acquired nail dystrophies might benefit from surgical cures allowing a nice cosmetic outcome when performed by skilled surgeons. Here will be reviewed some of the most common nail dystrophies that may be improved by surgery: malalignment of the big toenail, trapezoidal nails, racquet thumbs, vertical implantation and duplication of the nail on the fifth toe. For more complex dysplasias and malformations, involvement of hand surgeons is recommended.

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The condition is always symmetrical and affects both great toenails. Unlike racquet thumbs, no bony alteration is associated (1). This affection would only be a curiosity if the imbalance between the width of the nail plate and that of the nail bed would not promote distal lateral onychocryptosis in some patients (Fig. 2B), the distal borders of the nail plate pushing laterally on the nail folds. With time, this may promote the development of a hypertrophic lip.

MALALIGNMENT OF THE GREAT TOENAIL This congenital disease is discussed in “Ungueodermal Flap for Congenital Malalignment of the Great Toenail,“ pp. 135–137. This condition should be operated before the age of six to obtain the best cosmetic outcome. However, as there is no alternative treatment it may be indicated to try to improve the aspect of a severely distorted and thickened nail by surgically rotating the whole nail unit as described for children. This usually results in a correctly orientated nail, much thinner and shorter as the nail bed has been epithelialized in its distal part (Fig. 1A). In some instances, an almost normal nail may even grow out (Fig. 1B). A number of so-called onychogryphoses in nondebilitated persons are in fact due to an untreated congenital malalignment of the big toenail.

TRAPEZOIDAL NAILS Introduction l Trapezoidal nails are a congenital nail abnormality where the nail plate appears to widen distally as its proximal part remains hidden by the proximal portion of the lateral nail folds (Fig. 2A). The plate may look too wide for its bed, but in fact the PNF-LNF junction is too medial.

Figure 1 (A) Cosmetic outcome of reaxation of the great toenail in a young adult. Compare with the contralateral nail. The new nail is thinner and normally oriented and exhibits a nicer hue. In summertime, an acrylic nail may be stuck on it. (B) Almost complete recovery of a normal nail after surgery (compare with the contralateral nail). Note the scar from surgery (see arrow).

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The lateral fifth of the nail plate is detached from the nail bed and from the proximal nail fold using an elevator. The detached nail portion is split down under the proximal nail fold with thin nail nippers and then avulsed in a rotating motion with a hemostat. This procedure allows the lateral nail folds to flatten. They fill the space previously occupied by the avulsed nail strip. A cotton-tipped applicator or the elevator itself (if the lateral avulsion is narrow) dipped into the cauterant is pushed under the proximal nail fold and rubbed onto the exposed lateral horns of the matrix (1).

Key Point l This procedure has to be performed in a bloodless field (tourniquet) as blood neutralizes the phenol (2).

Figure 2 (A) Trapezoidal nail. The nail seems to wide distally. The lateral nail folds are pushed laterally. The contralateral nail benefited from bilateral chemical cautery eight weeks before. (B) Acute paronychia in a trapezoidal nail. l

The trapezoidal appearance of the nail may appear “too masculine” for some women seeking a cosmetic surgical improvement.

Anesthesia l Bilateral distal digital block Tools l Nail avulsion tray l 88% phenol, 10% sodium hydroxyde, or 100% trichloracetic acid l Cotton-tipped applicator Surgical Procedure Technique: easy l

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The goal of the treatment is the permanent narrowing of the nail plate either for achieving a cure of ingrowing toenail or for cosmetic reasons. Chemical cautery is the best choice (see “Narrowing the Matrix with Chemocautery,” pp. 106–108). This treatment is simple, time honored, cheap, and reproducible and produces a permanent cure with low recurrence rate.

Postoperative Care Pain: very little l

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Oozing from the chemical burn will last for about two to six weeks according to the type of cauterant. Soakings with antiseptic soaps twice per day, followed by application of antiseptic solution is mandatory during that time.

Evolution l Cosmetic results are dramatic (Fig. 3). Complications and Management l The same as for chemical cautery (see p. 108). RACQUET NAILS Introduction l This term refers to a hereditary malformation of the thumbs resulting in brachyonychia, the width of the nail plate and nail bed being greater than their length. Clinically, the thumb exhibits a gross, short and broad terminal phalanx that usually lacks the lateral nail fold (Fig. 4A). l Racquet thumbs are inherited as an autosomal dominant trait with variable penetrance and expression; females are three times more affected than men (3). l It affects symmetrically the thumbs. Some cases may be asymmetrical and involve only one thumb, rarely another finger or even a toe. Exceptionally, all fingernails are affected.

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Figure 3

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Trapezoidal nail (A) before and (B) after phenolization.

This deformity is caused by an early obliteration of the epiphyseal line of the thumbs, while the periosteal growth continues, leading to a wider and shorter bony phalanx covered with a nail plate of a similar shape (3). Narrowing the nail plate and recreating lateral nail folds may improve esthetic appearance.

Anesthesia l Bilateral distal digital block Tools l Standard nail surgery tray Surgical Procedure Technique: difficult l

Lateral longitudinal nail excisions in the shape of a so-called “lazy S” are performed on both sides of the thumbnail exactly as performed for the lateral longitudinal biopsy.

Figure 4 (A) Racquet thumb. (B) Narrowing the nail and the soft tissues in raquet nails. The longitudinal excision is a “lazy S” as described for lateral longitudinal biopsy.

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The lateral soft aspects of the distal phalanx are dissected from the bone almost down to the volar aspect. Back stitches (nonabsorbable 3/0 suture) are used to create lateral nail folds. The needle is run into the lateral aspect about 2 to 3 mm volar

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to the plane of the nail bed-bone interface, through the nail bed and plate, and back again through the lateral thumb skin, which, upon knotting, will be elevated, thus forming a lateral nail fold (Fig. 4B) (4,5). Nail groove epithelium develops by secondary intention. It might be interesting in some cases to try to give a longer shape to the plate by removing a crescent of the proximal nail fold as performed in chronic paronychia (see “Chronic Paronychia,” pp. 43–46).

Key Point l Removal of enough soft tissues to avoid the appearance of a narrow nail on a short broad extremity. l Back stitches are most important as to recreate the lateral nail folds. Postoperative Care Pain: severe l

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Injecting bupivacaine postoperatively as a distal wing block is two folds: (i) bleeding is severe after removal of the tourniquet; the volume of anesthetic will press onto the lateral digital arteries, thus reducing bleeding; (ii) this is a painful surgery from the large removal of tissue and traction from suture. Give strong painkillers (opioids are recommended) (see “Postoperative Pain Management, Pain Killers,” pp. 20–21). Bulky dressing is a must with renewal after 24 hours, not later.

Evolution l Healing is complete within three weeks. l Early mobilization is mandatory. Complications and Management l As for lateral longitudinal biopsy, incomplete removal of the lateral horn of the matrix will result in the growth of spicules. It starts with inflammation of the most proximal part of the lateral nail fold, with sometimes some purulent discharge. While the spicule has pierced the skin, inflammation lessens and healing occurs, leaving a horn popping out from the lateral sulcus or from the lateral aspect of the finger. VERTICAL IMPLANTATION OF THE FIFTH TOENAIL Introduction l In this rare disorder the aberrant implantation of the matrix of the fifth toenail is responsible for its vertical growth (Fig. 5A, B). l In addition to the esthetic inconvenience, it generates a real discomfort especially when pulling on stockings or socks, the nail being pushed backward. Ladies mostly complain of running their stockings. l Treatment is total nail ablation. Anesthesia l Bilateral distal digital block Tools l Basic nail surgery tray

Figure 5 (A) Vertical implantation of the fifth toenail. (B) Histological aspect. (C) Vertically implanted fifth toenail before surgery. (D) Cosmetic and functional outcome of a vertically implanted fifth toenail. Source: Part B: Collection of J. Andre´, Brussels, Belgium.

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COSMETIC NAIL SURGERY FOR CONGENITAL NAIL ABNORMALITIES

Figure 5

(Continued )

Surgical Procedure Technique: easy to intermediate l

l

l

l

181

The best cosmetic option is the definitive removal of the nail apparatus in one block in a transverse ellipse, down to the bone and half way down the lateral aspect of the toe to remove the lateral horns of the matrix, and suturing of the defect. In some instances, a relaxing incision at the tip of the toe is mandatory to free a flap from the hyponychium that is pulled dorsally to allow primary closure. This leaves a “naked” toe cosmetically very acceptable (Fig. 5C, D). If the patient is not willing to undergo such a surgery, chemical cautery of the whole nail matrix is the best alternative (1).

Key Point l Complete removal of the lateral horn of the matrix with a wide lateral excision, reaching the midline of the lateral aspect of the toe.

Postoperative Care Pain: intermediate l l

Greasy dressings Soakings and antiseptics until removal of the stitches

Evolution l Primary closure heals rapidly. l The defect left by the relaxing incision may take more time (up to three weeks depending on its size).

DUPLICATION OF THE FIFTH TOENAIL (DOUBLE LITTLE TOENAIL) Introduction l This condition is quite common and may probably be genetically determined (6). l Pain is promoted by the lateral rotation of the fifth toe in spread foot when the patients walk on the lateral aspect of the fifth toe (Fig. 6A).

Figure 6 (A) Scheme explaining the etiology of the duplication of the fifth toenail. (B) Clinical appearance of double little toe. (C) Preoperative aspect. (D) Immediate postoperative aspect.

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NAIL SURGERY

Figure 6 l

l

(Continued )

It presents as a horn filling the lateral sulcus (Fig. 6B, C). Patients search medical advice because the condition may be very painful. However, often it is just a chance observation.

Anesthesia l Distal digital block Tools l Basic surgery tray Surgical Procedure Technique: intermediate l

Excision in the shape of a so-called lazy S exactly as performed for lateral longitudinal biopsy (Fig. 6D)

Key Point l Complete removal of the lateral horn of the matrix, with a lateral excision reaching the midline of the lateral aspect of the toe Postoperative Care Pain: intermediate l l

Greasy dressing until healing. Unfortunately, pressure will occur on the wound from walking on it because of the forefoot alteration and may render the postoperation

quite uncomfortable. Try to perform this surgery in summertime when footwear is looser. Evolution l If the precipiting factors are not corrected, pain will recur. Podiatric support is a must with specific insoles. Orthopedic surgery is exceptionally indicated.

Complications and Management l Inflammatory reaction postoperatively is frequent from rubbing of the wound against the shoe. l Infection is possible. REFERENCES 1. Richert B, Choffray A, de la Brassinne M. Cosmetic surgery for congenital nail dystrophies. J Cosmet Dermatol 2008; 7:304–308. 2. Baran R, Haneke E. Matricectomy and nail ablation. Hand Clin 2002; 18:693–696. 3. Ronchese F. The racket thumbnails. Dermatologica 1973; 146:199–202. 4. Haneke E. Reconstruction of the lateral nail fold after lateral longitudinal nail biopsy. In: Robins P, ed. Surgical Gems in Dermatology. New York: Journal Publ Group, 1988:91–93. 5. Haneke E, Baran R. Nails: surgical aspects. In: Parish LC, Lash GP, eds. Aesthetic Dermatology. New York: Mc Graw Hill, 1991:236–247. 6. Haneke E. Therapie von Nagelfehlbildungen. In: Landthaler M, Hohenleutner U, eds. Fortschritte der Operativen Dermatologie. Vol. 12. Berlin, Wien: Blackwell Wiss-Verl, 1997:180–187.

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Index

Page numbers followed by f and t indicate figures and tables, respectively. Acquired fibrokeratoma anesthesia, 50 complications of, 50 evolution of, 50 key point, 50 management of, 50 overview, 49–50 postoperative care, 50 procedure for, 50 tools of, 50 Acute paronychia, 42–43, 43f anesthesia, 42 complications of, 43 differential diagnosis of, 42 evolution of, 43 key points, 42 management of, 43 overview, 42 postoperative care, 43 surgical procedure for, 42 tools for, 42 Analgesics in nail surgery, 21 Anesthesia Bowen’s disease lateral nail folds, 92 nail bed, 72 complications from anesthetic, 29 from technique, 29 management, 29 distal fold, tumors of, 102 distal nail embedding, 98 evolution of, 28 fibrokeratomas lateral nail folds, 92 nail bed, 66 for chondroma, 153 for closure by reversed dermal graft, 143 for cross-finger flap, 144 for duplication of fifth toenail, 182 for enchondroma, 154 for exostosis, 149 for graft, closure with, 141 for inclusion cyst, 155 for lacerating and crush lesions, 173

[Anesthesia] for lateral longitudinal biopsy, 133 for myxoid cysts, 165 for nail plate biopsy, 31 for nail removal, whole unit, 138 for osteochondroma, 149 for osteoid osteoma, 157 for partial nail plate avulsion, 38 longitudinal, 40 proximal, 39 for racquet nails, 179 for subungual hematoma, 172 for total nail plate avulsion distal approach, 32 proximal approach, 34 for trapezoidal nails, 178 for unguodermal flap for CMBT, 136 for vertical implantation of fifth toenail, 180 glomus tumor, 70 heloma, 74 horn of the lateral sulcus, 90 hypertrophic lateral walls, ingrowing nail with, 87 hypertrophic lip, 85 implantation cyst, 95 key points, 28 materials in, 25 nail bed biopsies, 55 elongation for larger defects, 76 grafting, 80 of nail apparatus, 24–29 pachyonychia congenita (PC), 76 procedures, 25–28 distal digital block/wing block, 26–27, 26f hyponychial block, 28 matricial block, 27, 27f proximal digital block, 25–26, 25f transthecal digital block, 27–28, 27f products, 24 pyogenic granulomas, 62 SUKA, 64 superficial fibromyxoma, 69 tips, 28–29 Antibiotics, prophylactic, 16–17 Avulsion of matrix, 174–175

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184

Avulsion, of nail plate, 31–41 partial, 38–41, 39f–41f total, 32–38, 33f–37f Beaver blade, 103 No. 64, 128 Beaver blade system, 14, 14f Biopsy, of nail plate, 31 anesthesia for, 31 complications, 31 indication for, 31 procedure for, 31 surgical tools for, 31 Blood thinners, discontinuation of, 18 Blood vessels, of nails, 3–4 Bone rongeur, 14 Bowen’s disease, lateral nail folds, 92–95, 93f, 94f anesthesia, 92 complications, 94–95 evolution, 94 key point, 94 management, 94–95 postoperative care, 94 surgical procedure, 93–94 surgical tools, 92 Bowen’s disease, nail bed, 72–74, 73f anesthesia, 73 key point, 74 surgical procedure, 74 surgical tools, 73 Bowen’s disease and curled nail avulsion, 37f Bupivacaine, 24 for racquet nails, 180 Candida albicans, 43 Cardiac disease local anesthesia and, 24 Chemocautery, 106–108, 107f, 108f anesthesia for, 106 complications of, 108 evolution of, 108 key point, 107 management of, 108 of whole nail matrix, 113 overview, 106 postoperative care, 107 procedure for, 106–107 tools of, 106 Chondroma, 152–153 anesthesia for, 153 complications of, 153 evolution, 153 key point of, 153 management of, 153 postoperative care, 153 surgical procedure for, 153 tools for, 153

INDEX

Chronic paronychia, 43–46, 43f, 44f anesthesia of, 44 complication of, 46 en bloc excision of, 44 evolution of, 46 key points of, 45 management of, 46 overview, 43–44 postoperative care, 45 surgical procedure for, 44–45, 45f tools of, 44 Cicatricial pterygium trauma and, 175 Cleaning, of surgical site, 17 Closure by reversed dermal graft, 143–144. See also Reversed dermal graft, closure by with graft, 140–143, 142f. See also Graft, closure with with secondary intention healing, 138f, 139–140, 139f–141f. See also Secondary intention healing, closure with CMBT. See Congenital malalignment of the big toenail (CMBT) Congenital abnormalities, cosmetic surgery for, 177–182, 177f–182f malalignment of great toenail, 177, 177f racquet nails, 178–180, 179f. See also Racquet nails trapezoidal nails, 177–178, 178f, 179f. See also Trapezoidal nails, cosmetic surgery for vertical implantation of fifth toenail, 180–181, 180f–181f. See also Toenail, fifth, vertical implantation of Congenital malalignment of the big toenail (CMBT) cause of, 135 characteristics of, 135, 136f unguodermal flap for, 135–137, 136f–137f anesthesia for, 136 complications, 137 evolution, 137, 137f key point of, 137 peri-operative care, 137 postoperative care, 137 procedure for, 136–137, 137f tools for, 136 Connective tissue matrix, with Vater-Pacini body, 9f subungual, neural structures in, 9f Cosmetic surgery for congenital abnormalities, 177–182, 177f–182f for vertical implantation of fifth toenail, 180–181, 180f–181f. See also Toenail, fifth, vertical implantation of malalignment of great toenail, 177, 177f racquet nails, 178–180, 179f. See also Racquet nails trapezoidal nails, 177–178, 178f, 179f. See also Trapezoidal nails, cosmetic surgery for Crescent excision, 46f, 128–129, 128f anesthesia, 46, 128 complication of, 47, 129 evolution of, 47, 129

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INDEX

[Crescent excision] key point, 47, 128 management of, 47, 129 overview, 46, 127 postoperative care, 47, 128–129 procedure for, 47, 128, 128f tools for, 47, 128 Cross-finger flap, 144–147, 145f–146f anesthesia for, 144 complications of, 147 evolution, 145f, 146f, 147 key point of, 147 postoperative care, 147 procedure for, 144–146, 145f–146f tools for, 144 Crush lesions, 173–176, 174f–176f anesthesia for, 173 complications of, 175–176, 176f evolution, 175 perioperative antibiotics for, 173 postoperative care, 175 procedure for, 173–175, 174f–175f severe injury, 174, 175f tools for, 173 Curled nail avulsion, 37–38 complications and management, 38 evolution, 38 indications for, 37 key points, 38 postoperative care, 38 procedure for, 37–38, 37f surgical tools for, 37 Cuticle, formation of, 7, 7f Cyst, nail trauma and, 175 Dental spatula elevator, 11, 12f Dental syringes, 25, 25f Digital myxoid cysts (DMC), 165–169 anesthesia for, 165 complications of, 169, 169f evolution, 167f, 169 key point of, 168, 168f management of, 169, 169f postoperative care, 169 surgical procedure, 165–168, 166f–168f tools for, 165 Discontinuation, of systemic treatments, 17–18 Disinfection, of surgical field, 18 Distal approach, for nail plate avulsion, 32–34 anesthesia for, 32 complications and management, 32, 34 indication for, 32 key point, 32 postoperative care, 32 procedure for, 32, 33f surgical tools for, 32 Distal digital block procedure, 26–27, 26f complications, 29, 29f

185

Distal embedding, 32, 34, 34f, 36 Distal fold distal embedding, 97–100 tumors of, 100–102 anesthesia, 102 evolution, 102 key point, 102 postoperative care, 102 surgical procedure, 101f, 102, 102f surgical tools, 102 Distal interphalangeal joint, surgery of, 165–169, 166f–169f Distal lateral subungual onychomycosis (DLSO), 31 Distal matrix. See Nail bed Distal nail embedding, 97–100 anesthesia, 98, 100 complications, 99, 100, 100f evolution, 99, 100 Howard-Dubois’ procedure, 98, 98f, 99f key point, 99, 100 management, 99, 100 postoperative care, 99, 100 shaving procedure, 99–100, 100f surgical tools, 98, 100 DLSO. See Distal lateral subungual onychomycosis (DLSO) DMC. See Digital myxoid cysts (DMC) Dorsal digital nerves, in distal phalanxes, 4, 4f Double little toenail, 181–182, 181f–182f Dressings, 18–19, 18f–19f absorbent, 19 nonadherent, 18–19, 19f removal, 21, 21f replacement, 21, 22f securing, 19, 19f Dual action nail nipper, 11, 12f Dura mater elevator, 11, 12f Dystrophy, nail subungual hematoma and, 173 Elevator, 11, 12f Elliptical excision, 126–127, 127f EMLA cream, 28 Enchondroma, 153–155, 154f anesthesia for, 154 complications of, 155 evolution, 155 key point of, 154 management of, 155 postoperative care, 155 surgical procedure, 154 tools for, 154 English nail splitter, 11, 12f Epinephrine, 24 Eponychial flap, 47–49, 48f anesthesia, 47 complications of, 49 evolution of, 49 key points of, 49 management of, 49 overview, 47

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186

[Eponychial flap] postoperative care, 49 procedure of, 49 tools of, 49 Exostosis, 149–152 anesthesia for, 149 complications of, 152 evolution, 151–152, 153f key points of, 151 management, 152 postoperative care, 151 surgical procedure, 150–151, 150f–153f tools for, 150 Extensor tendon, insertion, 1, 2f, 5, 6 Fibrokeratomas (FK), 49–50, 120 Fibrokeratomas (FK), lateral nail folds, 91–92, 91f anesthesia, 92 complications, 92 evolution, 92 postoperative care, 92 surgical procedure, 92 surgical tools, 92 Fibrokeratomas (FK), nail bed, 66–69, 66f anesthesia, 66 complications, 69 evolution, 69 key point, 69 management, 69 postoperative care, 69 surgical procedure, 66–69, 67f–68f surgical tools, 66 Fingernails shape and size of, 3, 3f FK. See Fibrokeratomas (FK) Flexor tendon, 2f, 4, 5, 5f Freer septum elevator, 11, 12f Fungal contamination subungual hematoma and, 173, 173f Ganglion cyst. See Digital myxoid cysts (DMC) Germinative matrix. See Nail matrix Gillies skin hooks, 14, 15f Glomus tumor, 70–72, 71f anesthesia, 70 complications, 72 evolution, 72 key point, 72 management, 72 postoperative care, 72 surgical procedure, 72 surgical tools, 70 Glove tourniquet, 11, 13f Graft, closure with, 140–143, 142f. See also Closure anesthesia for, 141 complications of, 142f, 143 evolution, 143 key point of, 142 management of, 142f, 143

INDEX

[Graft, closure with] postoperative care, 142–143, 142f surgical procedure for, 141–142, 142f tools for, 141 Hair, and nail, 6, 6f Hand, innervation, 4, 4f Healing by second intention, for larger defects, 78–79, 79f Heloma, 74–75, 75f anesthesia, 74 complications, 75 evolution, 74–75 key point, 74 management, 75 postoperative care, 74 surgical procedure, 74 surgical tools, 74 Hematoma, subungual, 171–173, 171f–172f, 173f. See also Subungual hematoma Hook nail trauma and, 176, 176f Horn of the lateral sulcus, 90–91, 90f anesthesia, 90 complications, 91 evolution, 91 key point, 91 management, 91 postoperative care, 91 surgical procedure, 90–91, 90f surgical tools, 90 Howard-Dubois’ procedure for distal nail embedding, 98–99, 98f, 99f for ingrowing nail with hypertrophic lateral walls, 89, 89f Hydroxyzine for nail procedures, 16 Hypertrophic hyponychium trauma and, 176 Hypertrophic lateral walls, ingrowing nail with, 87–90 anesthesia, 87 complications, 90 evolution, 90 Howard-Dubois’ procedure, 89, 89f key point, 89 Noe¨l’s procedure, 88, 88f postoperative care, 89 super U procedure, 88, 88f surgical tools, 87 Vandenbos’ procedure, 87, 87f Hypertrophic lip, 85–87 anesthesia, 85 complications, 87 evolution, 86 key point, 85, 86 management, 87 postoperative care, 86 surgical procedure, 85, 86f surgical tools, 85 Hyponychial block procedure, 28 Hyponychium, 2, 7, 9, 9f

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INDEX

Imaging, medical in preoperative assessment, 16 Implantation cyst, 95–96, 95f anesthesia, 95 complications, 96 evolution, 96 key point, 95 management, 96 postoperative care, 95 surgical procedure, 95 surgical tools, 95 Inclusion cyst, 155 anesthesia for, 155 complications of, 155 key point of, 155 management of, 155 postoperative care, 155, 156f surgical procedure for, 155, 156f tools for, 155 Ingrowing nail with hypertrophic lateral walls, 87–90 anesthesia, 87 complications, 90 evolution, 90 Howard-Dubois’ procedure, 89, 89f key point, 89 Noe¨l’s procedure, 88, 88f postoperative care, 89 super U procedure, 88, 88f surgical tools, 87 Vandenbos’ procedure, 87, 87f Intermediate matrix. See Nail matrix Interphalangeal joint, distal, 3, 5 Intraungual fibrokeratoma, 120 Irritation digital myxoid cysts and, 169, 169f Keratins, 9 Keratoacanthoma, 64–66, 65f. See also Subungual keratoacanthoma (SUKA) Koenen tumors, 49–50 Laceration, 173–176, 174f–176f anesthesia for, 173 complications of, 175–176, 176f evolution, 175 perioperative antibiotics for, 173 postoperative care, 175 procedure for, 173–175, 174f–175f simple, 173–174, 174f stellate, 174 tools for, 173 Laser anesthesia, 108 complications of, 109 evolution of, 109 key point of, 109 overview, 108 postoperative care, 109

187

[Laser] procedure for, 108–109, 109f tools for, 108 Lateral longitudinal biopsy, 133–135, 133f–135f, 136f anesthesia for, 133 complications of, 135 evolution, 135, 135f, 136f indications for, 133 key point of, 134 management of, 135 procedure for, 133–134, 133f–134f tools for, 133 Lateral nail folds (LNF), 2–3, 3f Lempert elevator, 11 Lesions, crush. See Crush lesions Lidocaine, 24 Limb elevation, after surgery, 20, 20f LNF. See Lateral nail folds (LNF) Locke elevator, 11 Longitudinal erythronychia (LE), 59–62, 59f–63f complications, 62 evolution, 62, 63f key point, 61, 59f, 60f management, 62 postoperative care, 62 surgical procedure, 59–61, 59f–62f surgical tools, 59 Longitudinal melanonychia, excision of with crescentic excision, 128–129 with elliptical excision, 126–127 with punch excision, 124–126 with tangential excision, 129–131 Longitudinal nail plate avulsion, partial, 40–41, 41f anesthesia for, 40 complications and management, 41 evolution, 41 indication for, 40 key point, 41, 41f procedure, 40–41 surgical tools for, 40 Luer Lock syringes, 25, 25f Lunula, 1, 2f Lymph vessels, of nails, 3–4, 4f Magnetic resonance imaging (MRI) in preoperative assessment, 16, 17f Magnification loupes, 14 Malalignment of great toenail, cosmetic surgery for, 177, 177f trauma and, 175, 176f Matricial block procedure, 27, 27f Matrix tumors of, 118–131 Matrix transplantation anesthesia for, 115 complications of, 118 evolution of, 118, 117f key points of, 118 overview, 115

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188

[Matrix transplantation] postoperative care, 118 procedure for, 115, 116f, 117–118, 117f tools of, 115 Matrix, narrowing the partial matricectomy with chemocautery anesthesia, 106 complications and management, 108 evolution, 108 postoperative care, 107 procedure, 106–107 tools, 106 with laser anesthesia, 108 complications, 109 evolution and management, 109 postoperative care, 109 procedure, 108 tools, 108 with radiosurgery anesthesia, 109 complications and management, 110 postoperative care, 110 surgical procedure, 109–110 tools, 109 with surgery anesthesia, 103 complications and management, 106 evolution, 105 postoperative care, 105 procedure, 103–105 tools, 103 Median nerve, in hand, 4, 4f Medical imaging, in preoperative assessment, 16 Meissner taste buds, 9 Melanocytes, in nail matrix, 1 Mepitel1 dressing, 19 Methylene blue–guided surgery, 165 Microcoated surgical blades No. 15, 129 Midazolam for nail procedures, 16 MRI. See Magnetic resonance imaging (MRI) Myxoid cysts. See Digital myxoid cysts (DMC) Myxoid pseudocysts, 46f, 47f, 50 Nail apparatus anatomy of, 1–10 advanced, 4–7, 5f–6f, 7f basic, 1–4, 2f–4f microscopic, 7–10, 7f, –10f anesthesia of, 24–29 dorsooblique view of, 2f ligamentary structure of, 5, 5f vascularization of, 3–4, 4f Nail avulsion, 118 Nail avulsion tray, 13, 14f Nail bed biopsies, 55–58, 56f–58f anesthesia, 55 complications, 58, 58f

INDEX

[Nail bed biopsies] indications, 55 key points, 57–58 management, 58, 58f postoperative care, 58 surgical procedure, 55–57 with nail plate avulsion, 55–56, 56f–57f without nail plate avulsion, 56–57, 58f surgical tools, 55 Nail bed elongation, for larger defects, 76–78, 77f anesthesia, 76 complications, 78 evolution, 78 key point, 78 management, 78 postoperative care, 78 surgical procedure, 77–78, 77f surgical tools, 77 Nail bed grafting, 78, 80, 81f–82f anesthesia, 80 complications, 80 evolution, 80 key point, 80 management, 80 postoperative care, 80 surgical procedure, 80, 81f–82f surgical tools, 80 Nail bed, anatomy of advanced, 6 basic, 1–2, 2f microscopic, 8–9, 8f, 9f Nail dystrophy, 36 Nail folds, proximal and lateral, 2–3, 3f, 7 Nail matrix chemical cautery of whole, 113–115, 114f Nail matrix, anatomy of advanced, 5–6, 5f, 6f and nail plate layers, 6, 6f basic, 1, 2f microscopic, 7f, 8, 6f Nail onycholysis, 36 Nail plate, 103 anatomy of advanced, 5, 6–7 basic, 3 microscopic, 9–10, 10f avulsion, 31–41 biopsy, 31 Nail removal, whole unit, 137–138, 137f, 138f anesthesia for, 138 evolution, 138 key point of, 138 surgical procedure for, 137f, 138, 138f tools for, 138 Nail spicules, 110 Nail surgery tray, 13–14, 14f Nail, hair and, 6, 6f Necrosis, distal digital block procedure and, 29, 29f

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INDEX

Nerves, of digits, 4, 4f branches of, 24, 25f Nippers, 11, 12f Noe¨l’s procedure, for ingrowing nail, 88, 88f Onychodermal band, 2, 3f Onychofibroblasts, 118 Onycholysis subungual hematoma and, 173 Onychomatricoma, 118–120, 119f Onychomycosis distal lateral subungual, 31 proximal subungual white, 31 superficial white, 31 total dystrophic, 31 Osteochondroma, 149–152 anesthesia for, 149 complications, 152 evolution, 151–152, 153f key points of, 151 management, 152 postoperative care, 151 surgical procedure, 150–151, 150f–153f tools for, 150 Osteoid osteoma, 155–157, 157f anesthesia, 157 complications of, 157 evolution, 157 key point of, 157 management of, 157 postoperative care, 157 surgical procedure, 157 tools for, 157 Pachyonychia congenita (PC), 9, 75–76, 75f anesthesia, 76 complications, 76 evolution, 76 key point, 76 management, 76 postoperative care, 76 surgical procedure, 76 surgical tools, 76 Pain chondroma and, 153 closure with graft and, 142 cross-finger flap and, 147 digital myxoid cysts and, 169 duplication of fifth toenail and, cosmetic surgery for, 182 enchondroma and, 155 exostosis and, 151 inclusion cyst and, 155 osteochondroma and, 151 osteoid osteoma and, 157 pincer nail and, 159 racquet nails and, cosmetic surgery for, 180 subungual heamatoma and, 172

189

[Pain] trapezoidal nails and, cosmetic surgery for, 178 vertical implantation of fifth toenail and, cosmetic surgery for, 181 Pain killers, 20–21 Pain management, postoperative, 19–21 Pain, reducing from infusion of anesthetic, 28–29 from needle prick, 28 Palmar digital nerves, in distal phalanxes, 4, 4f Paracetamol in nail surgery, 21 Paresthesia, postoperative, 21–22, 23f Partial nail avulsion, 38–41 anesthesia for, 38 complications and management, 38–39 evolution, 38 indications for, 38 procedure, 38, 39f surgical tools for, 38 with plate replacement, 39–41 longitudinal, 40–41 proximal, 39–40 Patient history of, 16 postoperative information to, 20t preoperative information to, 16, 17t Penrose drain, 11 Petrolatum-coated gauze, 18–19, 19f Phalanx bone, surgery of, 149–163 Phalanx(ges), distal, 1, 2f, 3 digital, innervation of, 4, 4f skeletal component of, 4–5, 5f Phenol, 108 Pincer nail, 157–163 complications of, 163 evolution of, 162f–163f, 163 key point of, 159 management of, 163 postoperative care, 159 PNF. See Proximal nail fold (PNF) Premedication, 16 Proximal approach for partial nail plate avulsion, 39–40 anesthesia for, 39 complications and management, 40 evolution, 40 indication for, 39 key point, 40 procedure, 39–40, 40f surgical tools for, 39 for total nail plate avulsion, 34–36 anesthesia for, 34 complications and management, 34, 36 indications for, 34 key point, 34 postoperative care, 34 procedure, 34, 35f surgical tools for, 34

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190

Proximal digital block procedure, 25–26, 25f complications, 29 Proximal nail fold (PNF), 42, 103, 165 acquired fibrokeratoma, 49–50 acute paronychia, 42–43 anatomy of advanced, 7 basic, 1, 2–3, 3f microscopic, 7, 7f chronic paronychia, 43–46, 43f, 44f crescent excision, 46–47 eponychial flap, 47–49, 48f tumor of anesthesia of, 50 complications of, 54 evolution of, 54 key points of, 54 management of, 54 overview, 50 postoperative care of, 54 surgical procedure of, 50–53 tools of, 50 Proximal nail groove, 2, 6 Proximal subungual white onychomycosis (PSWO), 31 PSWO. See Proximal subungual white onychomycosis (PSWO) Pterygium, 32 Pyogenic granulomas, 62–64, 64f alternative treatments, 63 anesthesia, 62 complications, 64 evolution, 64 key point, 63–64 management, 64 postoperative care, 64 surgical procedure, 62–63, 64f surgical tools, 62 Racquet nails, 178–180, 179f anesthesia for, 179 complications of, 180 evolution, 180 gender factors in, 178 key point of, 180 management of, 180 postoperative care, 180 surgical procedure for, 179–180, 179f tools for, 179 Radial nerve, in hand, 4, 4f Radiosurgery, 109–110 anesthesia, 109 complications of, 110 key point, 110 overview, 109 postoperative care, 110 procedure for, 109–110 tools of, 109

INDEX

Reversed dermal graft, closure by, 143–144. See also Closure anesthesia for, 143 complications of, 144 key point of, 144 postoperative care, 144 procedure for, 143–144 results of, 144 tools for, 143 Ropivacaine, 24 Scarring trauma and, 175 Secondary intention healing. See Healing by second intention Secondary intention healing, closure with, 138f, 139–140, 139f–141f. See also Closure advantages of, 139 complications of, 140 evolution, 139–140, 139f–141f key point of, 139 management of, 140 postoperative care, 139 surgical procedure, 138f, 139 Simple laceration, 173–174, 174f Skin hooks, 14 Sling, after surgery, 20, 20f Spencer suture-cutting scissors, 15, 15f Spicule, removal of anesthesia of, 110 complications and management of, 112 key points, 112 overview, 110 procedure for, 110–112, 111f tools of, 110 Spicules, nail trauma and, 175 Splinter hemorrhages development, mechanism, 1, 2f Split nail trauma and, 175 Stellate laceration, 174 Sterile matrix. See Nail bed Straight nail nippers, 11, 12f Submatricial glomus tumor, 121–122, 123f Submatricial myxoid pseudocyst, 122, 124, 124f Subungual hematoma, 171–172, 171f–172f, 173f anesthesia for, 172 complications of, 173, 173f evolution, 172 key point of, 172 management of, 173, 173f postoperative care, 172 surgical procedure for, 172, 172f, 173f tools for, 172 Subungual keratoacanthoma (SUKA), 64–66, 65f anesthesia, 64 complications, 66 evolution, 66 key point, 66 management, 66

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INDEX

[Subungual keratoacanthoma (SUKA)] postoperative care, 66 surgical procedure, 65–66, 65f surgical tools, 64 SUKA. See Subungual keratoacanthoma (SUKA) Super U procedure, for ingrowing nail, 88, 88f Superficial fibromyxoma, 69 anesthesia, 69 complications, 70 evolution, 70, 70f key point, 69–70 management, 70 postoperative care, 70 surgical procedure, 69, 70f surgical tools, 69f Superficial white onychomycosis (SWO), 31 Surgical blades, 14 Surgical site, preoperative cleaning of, 17 Surgical tools, 11–15 advanced, 14–15 basic, 11–14 Bowen’s disease lateral nail folds, 92 nail bed, 74 fibrokeratomas lateral nail folds, 92 nail bed, 66 for chondroma, 153 for duplication of fifth toenail, 182 for enchondroma, 154 for exostosis, 150 for inclusion cyst, 155 for lacerating and crush lesions, 173 for myxoid cysts, 165 for nail plate biopsy, 31 for osteochondroma, 150 for osteoid osteoma, 157 for partial nail plate avulsion, 38 longitudinal, 40 proximal, 39 for racquet nails, 179 for subungual hematoma, 172 for total nail plate avulsion curled nail avulsion, 37 distal approach, 32 proximal approach, 34 trap door avulsion, 36 for trapezoidal nails, 178 for vertical implantation of fifth toenail, 180 glomus tumor, 70 heloma, 74 horn of the lateral sulcus, 90 hypertrophic lip, 85 implantation cyst, 95 ingrowing nail with hypertrophic lateral walls, 87 longitudinal erythronychia (LE), 59 nail bed, 55, 59, 62, 64, 66, 69, 70, 72, 74, 76, 77, 78, 80 elongation for larger defects, 77 grafting, 80

191

[Surgical tools] pachyonychia congenita (PC), 76 pyogenic granulomas, 62 subungual keratoacanthoma (SUKA), 64 superficial fibromyxoma, 69 tumors of distal fold, 102 Suture strip, 129 SWO. See Superficial white onychomycosis (SWO) Systemic treatments discontinuation of, 17–18 Tangential excision, 129–131, 130f anesthesia, 129 complications of, 130–131 evolution of, 130, 130f key points of, 129 management of, 130–131 overview, 129 postoperative care, 130 procedure for, 129, 130f tools of, 129 TDO. See Total dystrophic onychomycosis (TDO) Toe shape and size of nails, 3, 3f phalanges, 5 Toenail, fifth duplication of, 181–182, 181f–182f anesthesia for, 182 complications of, 182 evolution, 182 key point of, 182 management of, 182 postoperative care, 182 surgical procedure for, 182, 182f tools for, 182 vertical implantation of, 180–181, 180f–181f anesthesia for, 180 evolution, 181 key point, 181 postoperative care, 181 surgical procedure for, 181, 181f tools for, 180 Toenail, great malalignment, cosmetic surgery for, 177, 177f Total dystrophic onychomycosis (TDO), 31 Total matricectomy, 112–115 anesthesia, 113 chemical cautery of whole nail matrix, 113, 114f complications of, 115 evolution of, 115, 114f key points of, 113 management of, 115 overview, 112 postoperative care, 113, 115 surgical excision for, 113, 114f tools for, 113

[gajendra][7x10 Tight][D:/informa_Publishing/Richert_2400061/z_production/z_3B2_3D_files/978-04154-7233-3_Index_O.3d] [12/11/010/15:20:34] [183–192]

192

Total nail avulsion distal approach, 32–34, 33f proximal approach, 34–36, 35f with plate replacement, 36–38 curled nail avulsion, 37–38 trap door avulsion, 36–37, 36f Tourniquet, 11, 13f, 106 Transthecal block procedure, 29 Transthecal digital block procedure, 27–28, 27f Trap door avulsion, 36–37, 36f complications and management, 37 evolution, 37 indications for, 36 key point, 37 postoperative care, 37 procedure, 36–37, 36f surgical tools for, 36 Trapezoidal nails, cosmetic surgery for, 177–178, 178f, 179f anesthesia for, 178 complications of, 178 evolution, 178, 179f key point of, 178 management of, 178 postoperative care, 178 surgical procedure for, 178 tools for, 178 Traumas, acute, 171–176, 171f–176f division of avulsion of matrix, 174–175 severe crush injury, 174, 175f simple laceration, 173–174, 174f stellate laceration, 174

INDEX

[Traumas, acute] lacerating and crush lesions, 173–176, 174f–176f. See also Crush lesions; Laceration subungual hematoma, 171–172, 171f–172f, 173f. See also Subungual hematoma Tumors of distal fold, 100–102 anesthesia, 102 complications, 102 evolution, 102 key point, 102 management, 102 postoperative care, 102 surgical procedure, 101f, 102, 102f surgical tools, 102 Ulnar nerve, in hand, 4, 4f Unguodermal flap, for CMBT, 135–137, 136f–137f Vater-Pacini bodies, 9, 9f Ventral nail, 8, 9f Vertical implantation of fifth toenail, 180–181, 180f–181f. See also Toenail, fifth, vertical implantation of Vibrating frog, 28, 28f Warfarin, 29f discontinuation, 18 Wedge excision, for matrix, 103–104 Wing block procedure, 26–27, 26f Work disruption, information on, 16 Zip-tie tourniquet, 11, 13f

Contents: Surgical anatomy of the nail apparatus * Instrumentation * General considerations * Anesthesia of the nail apparatus * Surgery of the nail plate * Surgery of the proximal nail fold * Surgery of the nail bed * Surgery of the lateral nail folds * Surgery of the distal fold * Surgery of the matrix * Surgery of the whole nail unit * Surgery of the bony phalanx * Surgery of the distal interphalangeal joint * Acute trauma of the nail unit * Cosmetic nail surgery for congenital nail abnormalities With over 500 color and black-and-white illustrations

Bertrand Richert, MD, PhD Clinical Professor, University of Liège and Consultant Dermatologist, Université Libre de Bruxelles, Belgium Second Vice President of the Council for Nail Disorders Former Secretary of the European Nail Society Author of L’ongle : de la clinique au traitement (2002; second edition, 2008), 50 cas de pathologie unguéale (2005), and a DVD on Basic Nail Surgery (2007)

Nilton Di Chiacchio, MD Head of Dermatology Clinic, Hospital do Servidor Público Municipal de São Paulo, Brazil Former Vice President of the Brazilian Society of Dermatologic Surgery His previous publications include Doenças das Unhas (2007)

Eckart Haneke, MD, PhD Department of Dermatology, University of Berne, Switzerland Dermatology Practice Dermaticum, Freiburg, Germany Centro de Dermatología Epidermis, Porto, Portugal and Department of Dermatology, Academic Hospital, University of Ghent, Belgium Former President, European Society for Dermatological Surgery Former President, International Society for Dermatologic Surgery Former President, European Society for Cosmetic and Aesthetic Dermatology His previous publications include Nail Surgery (2000), Diseases of the Nails and their Management (2001), Text Atlas of Nail Disorders (third edition, 2003), Onychomycosis (second edition, 2006), and The Nail in Differential Diagnosis (2007) Published in association with the Journal of Dermatological Treatment

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Richert • Di Chiacchio • Haneke

This text is a master-class for those wishing to perform nail surgery – a comprehensive practical guide to all types of nail surgery, including some cosmetic procedures, with clear descriptions of each stage involved and of any complications and how to deal with them.

Bertrand Richert Nilton DI Chiacchio Eckart Haneke