HAND SURGERY

Nail Fusion Plasty Nail Cosmetic Results and Assessment Criteria of Nail Reconstruction An-Yuan Wang, MD, Wei-Yang Gao, MD, Li-Min Wu, MD, Zhi-Jie Li, MD, Xing-Long Chen, MD, and Xiao-Yang Li, MD Purpose: This study aimed to develop a scoring system for evaluating the nail appearance after nail fusion plasty of the duplicated thumb, and to investigate the operation indication of the combination procedure and its effect on the postoperative nail appearance. Methods: The nail fusion plasty technique was carried out in 20 patients with congenital thumb duplication. The patients were followed up to observe the appearance of nail, and the results were assessed by our nail appearance evaluation criteria. Results: Twenty patients were followed up for 18 to 92 months (48 months on average). According to our criteria, we achieved excellent results in 12 cases, good in 6 cases, fair in 1 case, and poor in 1 case. Conclusions: The combination procedure is recommended when the size of the thumb is less than 80% of the size of the normal side or the width of the nail is less than 80% of that of the normal side. Satisfactory results can be obtained by careful operation. The newly devised scoring system assesses the nail appearance in a very comprehensive manner. Key Words: assessment criteria, nail fusion plasty, duplicated thumb, nail reconstruction (Ann Plast Surg 2015;75: 290Y294)

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humb duplication is one of the most common congenital malformations of the hand.1 The ideal reconstruction of thumb duplication aims to produce a thumb that has full motion, normal growth, normal width and length, stable interphalangeal and metacarpophalangeal joints, minimal scarring, and minimal nail deformity.2 The Bilhaut-Cloquet procedure, which was first described by Bilhaut,3 is recommended for thumbs of equal size and shape. Some surgeons do not prefer to use the Bilhaut-Cloquet procedure or any other combination procedures because of the high incidence of nail deformity. However, there are no objective criteria to evaluate the nail appearance; thus, it is difficult to compare the results of different procedures. The purpose of this study was to evaluate the nail appearance after the nail fusion plasty according to the assessment criteria we developed and to investigate the indications for the combination procedure.

PATIENTS AND METHODS Twenty cases (between 2005 and 2012) of duplicated thumb were included in this study. The mean postoperative follow-up was

48 months (range, 18Y92 months). The average age of the patients at the time of the initial surgery was 20 months (range, 7Y120 months). According to the Wassel classification, 1 case was Wassel type I, 6 cases were Wassel type II, 4 cases were Wassel type III, and 9 cases were Wassel type IV. All cases had a nail width less than 80% of that of the nonaffected side. All cases underwent combination procedures such as the classic or modified Bilhaut-Cloquet procedure or other thumb fusion procedures according to the Wassel type.3Y5 We developed the following nail fusion plasty technique: (1) measure the width of the nail on the contralateral thumb as the basis for reconstruction; (2) remove the nail plate and design the incision at the top of the nail cross section (Fig. 1A); (3) seek a point where the longitudinal length of the lunula is equal in both segments of the duplicated thumb, and the total width of the lunula of both segments is also equal to that of the contralateral side; (4) strip the nail bed wide (Fig. 1B); thus, we have a good view of operation and we can make the surface of combined bone more round; (5) attaching 2 distal phalangeal bones after oblique osteotomy (Fig. 1C) in a transverse plane creates a semicircular nail bed (Fig. 1D); the transverse Kirschner wire or needle can be used for fixing bones, and the plaster immobilization was used for 3 weeks; (6) suture the nail bed: the first stitch should be performed at approximately the distal edge of the lunula, the second stitch should be performed at the base of the nail matrix, the third stitch should be performed at the distal edge of the nail (Fig. 1E), and finally suture the rest of the nail bed; (7) manage the nail fold: lay the eponychium on the digit, resect the excess eponychium, and suture; and (8) place one of the removed nails over the nail bed to facilitate nail-bed remodeling (Fig. 2). At the recent visit in 2013, we evaluated postoperative nail shape and size using a scoring system that we devised to enable us to assign points for the shape and size of the reconstructed nail, using the points presented in Table 1. A score of 10 to 12 indicates an excellent outcome, a score of 7 to 9 indicates a good outcome, a score of 4 to 6 indicates a fair outcome, and a score of 0 to 3 indicates a poor outcome. The study was approved by the institutional review board and Independent Ethics Committee of our hospital, and all patients gave written informed consent for the surgical procedures. The written consents were given to the parents of the children participants, for their information to be stored in the hospital database and used for research.

RESULTS Received January 25, 2014, and accepted for publication, after revision, March 6, 2014. From the Department of Hand and Plastic Surgery, Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China. Conflicts of interest and sources of funding: none declared. Reprints: Wei-Yang Gao, MD, Department of Hand and Plastic Surgery, Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325027, China. E-mail: [email protected]. Copyright * 2014 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/15/7503-0290 DOI: 10.1097/SAP.0000000000000212

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The average nail size was 84% as wide and 103% as long in comparison to the other side. Fourteen patients had a nail width more than 85% of the other side, whereas 6 patients had a nail width more than 70% of the other side. Eleven patients had different levels of nail deformity; the most common deformity was a longitudinal ridge (10 patients). Two patients only had a longitudinal ridge, and 3 patients had a longitudinal ridge with malposition of the lunula, 4 patients had a longitudinal ridge with malposition of the nail fold, and 1 patient had a longitudinal ridge with dehiscence of nail. According to our criteria, we achieved excellent cosmetic results in 12 patients, Annals of Plastic Surgery

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FIGURE 1. Surgical techniques. A, Design the incision at the top of the nail cross section. B, Strip the nail bed wider. C, An oblique osteotomy in a transverse plane is performed for 2 distal phalangeal bones. D, Attaching 2 distal phalangeal bones creates a semicircular nail bed. E, The first stitch should be performed at the distal edge of the lunula, the second stitch should be performed at the base of the nail matrix, and the third stitch should be performed at the distal edge of the nail.

FIGURE 2. A, Preoperative condition. B, Preoperative x-ray. C and D, Dorsal skin marked in the center of the area to be excised. EYG, The nail appearance and the function of the thumb 9 months after surgery. * 2014 Wolters Kluwer Health, Inc. All rights reserved.

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TABLE 1. Scoring System for Postoperative Nail Evaluation Score Criterion The ratio (x) of the width of the operative side to the normal side The surface roughness of the nail: ridge or gap Malposition of the lunula Malposition of the nail fold Appearance of the nail: dehiscence of nail or growth failure Satisfaction of patients’ parents

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1

0

x Q 85% None* Smooth§ Normal# None Satisfactory

70% G x G 85% Slight† Slight malposition|| Slight malposition** Either Adequate

x e 70% Obvious‡ Obvious malposition¶ Obvious malposition†† Both Unsatisfactory

Total assessments: excellent, score of 10Y12; good, score of 7Y9; fair, score of 4Y6; poor, score of 0Y3. *No ridge or gap can be seen from above and front. †The ridge or gap cannot be seen from above, but can be seen from front. ‡The ridge or gap can be seen both from above and front. §Natural-looking appearance of lunula. ||A so-called seagull deformity of lunula. ¶An obviously uncontinuous or malposition. #Natural-looking appearance of nail fold (both the symmetry of the lateral nail fold and the smooth of the proximal nail fold). **Either the symmetry of the lateral nail fold or the smooth of the proximal nail fold. ††None of the symmetry of the lateral nail fold and the smooth of the proximal nail fold.

good in 6 patients, fair in 1 patient, and poor in 1 patient (Figs. 3Y6); overall, 90% of the patients had excellent or good cosmetic results.

DISCUSSION It is widely recognized that the combination procedure can yield a normal-sized thumb by combining 2 hypoplastic thumbs of equal size. However, the potential risks of postoperative nail deformity make some surgeons avoid nail reconstruction, especially when the width of the nail is more than 70% of that on the normal side.2 In addition, there is no uniform standard for the aesthetic evaluation of nail deformity; thus, it is difficult to compare the results of different procedures. Therefore, it is necessary to develop an evaluation system. In our study, we evaluated the results of the reconstructed nail by using the scoring system described in Table 1. This scoring system allows the nail appearance results from different techniques to be comprehensively compared. Maillet et al6 have reported that the Bilhaut-Cloquet procedure often gives a larger thumb with a nail fissure, but the thumb has a good cosmetic appearance. Ozalp et al7 found that a nail deformity was present in all cases treated by the Bilhaut-Cloquet technique. In our study, the rate of nail deformity was 55% (11/20). The 2 patients with a longitudinal ridge deformity and the 3 patients with a ridge deformity and malposition of lunula, as well as their families, were satisfied with the results of the procedure. However, the 4 patients who had a nail width less than 80% of that of the normal side were unsatisfied with the results of the procedure. Furthermore, some

patients with longitudinal malposition were operated on in the early phase, which was closely related to a lack of clinical experience. We believe that malposition of the lunula and nail fold can be avoided through careful alignment. The consensus among medical professionals is that the Bilhaut-Cloquet procedure is an appropriate technique to treat thumb duplication if both thumbs are symmetric and hypoplastic. Lu et al8 have stated that for patients with asymmetric thumb duplication, the smaller thumb should be resected when the retained thumb is more than 75% of the size of the contralateral thumb, and the resection thumb should be made into a fillet f lap to augment the conserved thumb when the size of the retained thumb is more than 65% of the size of the contralateral thumb. Baek et al4 have recommended the modified Bilhaut-Cloquet procedure when the bifid thumbs are symmetric and their nail size is less than two thirds of the normal contralateral thumb, or smaller than that of the index finger in patients with bilateral involvement. According to our assessment criteria, 90% of the patients achieved excellent or good cosmetic results in our study. We believe that combination procedure may yield satisfactory results through careful operation. In consideration of the nail appearance after operation, we agree that combination procedure should be recommended when the size of the thumb is less than 80% of the size of the normal side or the width of the nail is less than 80% of that of the normal side. Reconstructing a thumb with 80% to 90% of the normal thumb size is quite a reasonable goal. A rating system reported by Tada et al9 is widely used in postoperative function assessment of thumb duplication. Because

FIGURE 3. A and B, Case 1: appearance 4 years after surgery. Nail score was 11. 292

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FIGURE 4. A and B, Case 2: appearance 6 years after surgery. Nail score was 9.

FIGURE 5. A and B, Case 3: appearance 4 years after surgery. Nail score was 6.

FIGURE 6. AYD, Case 4: appearance 7 years after surgery. Nail score was 3. The patient, whose nail appearance is poor, is satisfied with the function of the thumb. * 2014 Wolters Kluwer Health, Inc. All rights reserved.

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cosmetic results are very difficult to assess objectively, this rating system does not contain any cosmetic items. Horii et al10 modified this rating system by adding cosmetic items, but it was light on details. Nail appearance is the major part of the postoperative cosmetic assessment of thumb duplication. Iwasawa et al11 devised a scoring system that enabled us to assign points for the shape and size of the reconstructed nail, but it was sketchy. The scoring system we devised contains 6 parameters at 3 levels, which assesses the nail appearance much more comprehensively. However, this scoring system is not quantitative; thus, it needs to be validated and possibly improved. REFERENCES 1. Kelikian H, Doumanian A. Congenital anomalies of the hand. J Bone Joint Surg Am. 1957;39-A:1002Y1019. 2. Tonkin MA, Bulstrode NW. The Bilhaut-Cloquet procedure for Wassel types III, IV and VII thumb duplication. J Hand Surg Eur Vol. 2007;32:684Y693. 3. Bilhaut M. Guerison d’un pouce bifide par un nouveau procede operatioire. Congr Fr Chir. 1889;4:576Y580.

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4. Baek GH, Gong HS, Chung MS, et al. Modified Bilhaut-Cloquet procedure for Wassel type-II and III polydactyly of the thumb. J Bone Joint Surg Am. 2007;89:534Y541. 5. Cooney WP, Wolf J, Holtkamp K, et al. Congenital duplication of the thumb. Handchir Mikrochir Plast Chir. 2004;36:126Y136. 6. Maillet M, Fron D, Martinot-Duquennoy V, et al. Results after surgical treatment of thumb duplication: a retrospective review of 33 thumbs. J Child Orthop. 2007;1:135Y141. 7. Ozalp T, Coskunol E, Ozdemir O. [Thumb duplication: an analysis of 72 thumbs]. Acta Orthop Traumatol Turc. 2006;40:388Y391. 8. Lu LJ, Xuan ZP, Zhang XJ, et al. Clinical analysis of 391 cases of thumb duplication. Chin J Hand Surg. 2007;23:258Y260. 9. Tada K, Yonenobu K, Tsuyuguchi Y, et al. Duplication of the thumb. A retrospective review of two hundred and thirty-seven cases. J Bone Joint Surg Am. 1983;65:584Y598. 10. Horii E, Nakamura R, Sakuma M, et al. Duplicated thumb bifurcation at the metacarpophalangeal joint level: factors affecting surgical outcome. J Hand Surg Am. 1997;22:671Y679. 11. Iwasawa M, Noguchi M, Mishima Y, et al. Long-term results of nail fusion plasty of the duplicated thumb. J Plast Reconstr Aesthet Surg. 2008; 61:1085Y1089.

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Nail Fusion Plasty: Nail Cosmetic Results and Assessment Criteria of Nail Reconstruction.

This study aimed to develop a scoring system for evaluating the nail appearance after nail fusion plasty of the duplicated thumb, and to investigate t...
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