Nail Surgery ECKART ROBERT
HANEKE, MD BARAN, MD
Anesthesia
Operations on Paronychial Tissue
Regional anesthesia such as a digital ring block or a metacarpal block just proximal to the interdigital web or at the wrist level is adequate, but general anesthesia may be needed for very young children.‘J A distal wing block was proposed by Salasche and Peters.3 The injection is started about 3 mm proximal from the junction of the proximal and lateral nail folds and is continued distally and volarly to anesthetize the lateral digital nerve. The needle is then pushed across the proximal nail fold to the other side to block the transverse nerve and finally the other lateral nail fold is anesthetized. The pressure from the local anesthetic considerably reduces bleeding; however, this technique may be quite painful and, therefore, the addition of bicarbonate as a buffering agent has been proposed. Steroids and marcaine given at the completion of nail operation may avoid delayed pain,3 but they must not be used in case of infection. Preoperative and postoperative antibiotic prophylaxis is recommended only for type III, IV, and V injuries and for other nail operations if there may be contamination with organic material.* A 0.5-in. Penrose drain, a pneumatic drain, or a rubber glove finger rolled back to the web may be used as a tourniquet. Loupe magnification is highly recommended.4 A variety of surgical operations either not or only recently described in the dermatologic literature or less known are briefly reported here.
Proximal
From the Department of Dermatology, Ferdinand-Sauerbruch-Klinikum Elberjeld, Wuppertal, Germany, and the Dermatology Division, Cenfre Hospitalier, Cannes, France. Address correspondence to Eckhart Haneke, MD, Heinrich Heine University, Ferdinand Sauerbruch Clinic, Arrenberger Strasse 20,560O WuppertalElberfeld, Germany.
0
1992
by Elsevier
Science Publishing
Co., Inc.
l
0738-081x/92/$5.00
Nail Fold
It has been stated that asymmetric tissue loss of the proximal nail fold will almost always result in a distorted proximal nail fold5 and this is evidenced by the unsightly scarring often seen after injury to the proximal nail fold. Tumors of the proximal nail fold affecting its distal margin and reaching to the distal dorsal crease of the distal interphalangeal joint can be removed by a wedge-shaped excision as shown in Fig 1: The proximal nail fold is freed from the underlying nail plate and the tumor is excised with the narrow tip of the wedge directed proximally. Two lateral incisions of the proximal nail fold on either side will allow closure without tension. The narrow secondary defects will heal by granulation within 3 to 4 weeks and will be virtually invisible. There will be no change in the size and shape of the proximal nail fold after this technique.4,6 Chronic paronychia with thickening and induration of the proximal nail fold, leading to loss of the cuticle and to nonadherence of the eponychium to the nail plate (thus allowing moisture direct access and inviting the entrapment of foreign material under the proximal nail fold), as well as tumors in the most distal part of the proximal nail fold, may be treated by removal of nearly the entire proximal nail fold. A crescent of tissue is removed by starting the incision at the junction of the lateral and proximal nail fold and carrying it to the other side. The most proximal point of the incision line is roughly in the middle between the distal lunula border and the distal crease of the distal interphalangeal joint.5 About 75% of the entire proximal nail fold can be removed, but care must be taken not to injure the cul-de-sac and the most proximal portion of the proximal nail fold as this area is mainly responsible for the nail plate’s sheen. One can insert an elevator under the proximal nail fold when cutting the proximal nail fold
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resulted in an entirely normal-looking distal phalanx with normal proximal and lateral nail folds.12
a
b
i’1r ‘\ 7
Figure 2. Removal of tumors from the margin of the proximal nail fold. a. Tumor and incision lines are marked. b. Defect is sutured, leaving two narrow seconda y defects which rapidly heal by seconda y intention.
and move it with the tip of the scalpel blade so that the matrix and the more proximal extensor tendon insertion cannot inadvertently be injured.’ Beveling the scalpel creates a gently sloped wound which heals more rapidly than the conventional vertical-edged one. The proximal nail fold will be restored by secondary healing within 6 to 8 weeks.5 Acute paronychia in the more proximal part of the proximal nail fold not responding to antibiotic therapy within 48 hours requires removal of the base of the nail plate.’ No drain is required. Systemic antibiotic treatment according to the sensitivity of the cultured bacteria is necessary. “Eponychial marsupialization” has also been recommended for chronic recalcitrant paronychia. Here, a symmetric crescent of tissue is removed, leaving the proximal nail fold its vascular supply and avoiding injury to the dorsal aspect of the cul-de-sac. With daily changes of the dressing and warm soaks using diluted hydrogen peroxide the wound will be reepithelialized within a week.’ Loss of the proximal nail fold with scarring of the dorsal aspect of the digit’s distal portion and nail dystrophy is due mostly to burns and to avulsions caused by rapidly rotating belts and sanders. Scarring is usually too serious as to allow rotation of flaps* to form a functionally and esthetically acceptable proximal nail fold.9 Improvement of rotation flaps was described by lining the undersurface with split-thickness nail bed grafts.‘O A free composite graft from the rim of the ear helix was the dorsal aspect of the used by Rose. l1 Alternatively, proximal nail fold of the great toe or second toe may be used.9 Bowen’s disease may involve the major portion of the distal phalanx’ dorsal aspect. Its complete removal including the lateral nail folds and full-thickness skin graft
Lateral Nail Fold If a diagnostic longitudinal nail biopsy is necessary it should be performed as a lateral instead of median nail biopsy if possible. This results in only a slight narrowing of the nail, which will be virtually invisible after a relatively short time. It is unnecessary to excise the lateral nail fold.13 As described originally14 the proximal nail fold is sutured first; however, instead of simply suturing the lateral nail fold to the nail bed, which makes the lateral nail fold virtually disappear, backstitches are used to reconstruct the lateral nail fold.15*i6 The needle is inserted at the lateral aspect of the terminal phalax and is run through the nail bed and nail plate and again back through the lateral nail fold. On knotting of the thread, the lateral nail fold is slightly elevated and fully restored (Fig 2). The same technique can be used for the correction of racquet nail deformity. Two lateral longitudinal excisions are made, and lateral nail folds, which may be characteristically lacking in the racquet finger, are created by using the backstitches as shown in Fig 2.16
Nail Bed and Matrix Nail bed and matrix injuries should be repaired as meticulously as possible using fine surgical instruments and a head magnifier loupe or an operation microscope. It is essential to know the exact mechanism of the trauma as there are characteristic consequences of crushing the finger in a door, blowing the fingertip with a hammer, or applying force with a sharp object over a smaller area of the nail.‘,” A (xero)radiograph should always be taken to rule out or confirm a fracture. Type I injuries comprise small subungual hematomas (500/) o an d re q uire nail removal and suture of the ruptured nail bed and/or matrix using 6-O or 7-O absorbable material. Care must be taken to coapt any tissure fragments properly and to preserve blood circulation to small flaps. Any laceration of the proximal nail fold has to be sutured in two layers. When a tuft fracture is diagnosed (type III injury) the distal fragment must be stabilized and the nail bed and matrix must be repaired. If the nail plate cannot be used as a splint, consultation with a hand surgeon should be sought. In type IV injury, the matrix and/or nail bed fragmentation must be meticulously repaired. Type V injury is characterized by avulsion of the
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b
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C
Figure 2. Reconstruction of the lateral nail fold for the correction of racquet thumbnail. a. Incisions are marked. b. Two lateral longitudinal nail biopsies are performed and sutured as shown. c. At the end of the operation, the nail is narrowed and lateral nail folds are created.
nail bed or matrix. The amputated epithelium is replaced by a split-thickness nail bed or full-thickness matrix graft harvested adjacent to the injury or from a toe, respectively. If the amputated nail bed can be recovered, it is replaced.* Partial avulsion of the germinal matrix as a distally based flap requires suturing it to its origin by a series of half-buried horizontal mattress sutures through the proximal nail fold. Is Whenever possible the original nail plate should be kept, cleaned, and put back as the optimal physiologic dressing. A suture through the tip of the fingerlg or a tie-over suture through the lateral nail folds*O will hold the nail in place. If the nail is no longer available a silicone sheet nail substitute will be used. To hold it in place, it is sutured with a horizontal mattress suture through the proximal nail fold, through the silicone, and back through the proximal nail fold. It is removed after 2 to 3 weeks.19 Posttraumatic onycholysis is a frequent sequela of nail bed scarring. Distal onycholysis may cause problems because of its unsightly appearance and because dirt becomes trapped beneath the nail and causes infection; proximal nonadherence makes the nail unstable and it may tear loose when caught in clothing. The scarred epithelium has to be replaced by normal nail bed.9 Splitthickness nail bed grafts may be taken from the injured digit or the great toe. By use of a microscope or strong head loupe a thin graft is taken with a 15~ scalpel. The graft should be so thin as to be transparent, allowing continuous observation of the cutting blade. This superficial wound will be reepithelialized with normal nail bed epithelium. Contracture of the graft is minimal as the nail bed dermis contains virtually no elastic fibers; however, the graft should be 1 to 2 mm larger. Although the dermal
ridges of the nail bed are unique in their regular parallel longitudinal arrangement, the graft need not be longitudinally oriented on the recipient site. A normal nail also grows when the graft is placed perpendicular to the longitudinal axis; however, full-thickness nail bed grafts and flaps must be oriented according to their longitudinal axis. The graft is sutured using 7-O chromic and the nail plate is thoroughly cleaned and replaced as a stent.‘O Linear ridging with distal nail plate splitting is often due to either a traumatic alteration or a bone spur, and preoperative xeroradiographs and computerized tomography scans, if appropriate, have to be taken. When a bone protrusion is identified under the nail bed, it must be removed. After cautious nail avulsion a linear incision over the bony prominence is made and the underlying bone is smoothed by clipping it with a double-action bone rongeur or nail clipper or filing with a fraise. The incision is closed with 7-O chromic sutures.18 If there is no bone alteration the abnormal thickened nail bed is excised and the defect closed with a split-thickness nail bed graft taken from the vicinity. As the original nail cannot be used as a physiologic dressing and splint because of its ridge, the nail bed is then covered with a segment of the great toenail and mesh gauze.9 Not infrequently a filamentous subungual tumor is the cause of linear ridging and distal nail split. This particular tumor is a variant of fibrokeratoma in a subungual location and its keratotic tip is pulled with the growing nail until it becomes visible at the hyponychium. All attempts to remove the lesion by following the longitudinal whitish to yellowish to reddish stripe to its origin and punching it have been unsuccessful (Haneke, unpublished). We therefore remove a nail plate portion about 10 mm wide to amply expose the lesion, which enables us to trace the
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subungual filamentous tumor and to excise it. The resulting defect is usually superficial and only 1 to 2 mm wide and does not require a free graft. The split nail is usually due to a longitudinal scar in the germinal matrix and nail bed. This may be the consequence of a trauma, and then it is often associated with a step formation between the two sides of the matrix and nail bed or with a median longitudinal nail biopsy.21 The traditional approach to split nail repair is the resection of the scar, lateral mobilization of matrix and nail bed from the paronychium, and coaption of the wound marginsz2 The results are generally not satisfying. Seckelz3 recommended insertion of a self-advancing silicone sheet between the nail plate and nail bed after split repair. The poor results of these techniques are attributed to the tension required for closure of matrix and nail bed.9 Tension can be reduced when the matrix and nail bed are sutured independently from the nail plate: After meticulous coaption of the former, the nail plate from which about 1 mm more has been removed on both sides is approximated using 3-O or 4-O monofil threads; however, this type of nail suture may sometimes provoke a step formation.4 The best results are apparently achieved using splitthickness grafts of the nail bed for nail bed defects and full-thickness matrix grafts from another finger or toe for matrix defects.9 The resection of tumors in the nail matrix may cause defects that are too large for primary closure after mobilization. A U-shaped nail flap was described to close defects situated in the central two thirds of the nail. Schemberg and Amielz4 proposed removal of an entire block of proximal nail fold, matrix, nail bed, and hyponychium down to the bone. The narrow part of the nail organ remaining was completely undermined and an incision was carried from the hyponychial end of the excision along the hyponychium into the lateral nail groove to the very tip of the lateral matrix horn to form the U-shaped nail flap. Mobilization under the proximal end of the matrix may be delicate as the matrix is firmly attached to the bone, the epithelium reaches very close to the bone, and the extensor tendon must not be injured. Using 6-O absorbable material the flap is sutured from the proximal matrix to the nail bed, the proximal nail fold is sutured separately for its ventral and dorsal surfaces, and 5-O or 4-O sutures are used for the hyponychium. We have used a modification taking into account that the proximal nail fold is not usually affected by matrix tumors and that the distal tip of the flap may be at risk for circulatory problems. 4~25Two incisions are made at the lateral sides of the proximal nail fold to reflect it and expose the matrix for exact evaluation of the matrix lesion. The lesion is removed either with the nail plate or
after its removal. A block of matrix and nail bed is resected and a parallel incision is made on the lateral aspect of the terminal phalanx. The nail bed and matrix are released from the bone and undermining is continued to the lateral incision, creating a bipedicled flap of matrix, nail bed, and lateral nail fold. The primary defect is sutured, starting with the matrix and continuing to the nail bed and hyponychium. The proximal nail fold is sutured last, and depending on whether or not there is a surplus of tissue, the lateral incisions may be extended to small wedge-shaped excisions. The secondary defect is allowed to granulate in. Wound healing is completed within 2 to 3 weeks and the scar from the secondary defect soon becomes virtually invisible. This technique avoids scarring in the hyponychial groove and there is no risk of necrosis of the flap’s distal tip. Similarly, a parallel incision may be performed in the lateral nail groove to create a small bipedicled matrixnail bed flap when there is too much tension at closure of a split nail defect. Extensive malignant tumors of the nail organ may require the extirpation of the entire nail organ. We have already described the use of reverse dermal grafts, 26 full-thickness grafts,27 and distant bridge flaps,27 to cover the resultant defect; however, all these techniques have some disadvantages. We have therefore used cross-finger and cross-toe flaps, respectively, to cover the dorsal half of the entire terminal phalanx after melanoma surgery. As soon as the size of the future defect is known a template is made for the designed flap. Usually it is wise to cut the flap and partially undermine it to train its blood supply for about 1 week. Only after this training should the flap be raised and transferred to the neighboring finger or toe. It is sutured with 6-O absorbable material and the defect is closed with a full-thickness skin graft. The dressing after operation has to immobilize both fingers but must not impair blood circulation. We have found that changing the dressing after 24 hours in a tepid warm bath with povidone -iodine and cleansing with 3% hydrogen peroxide is advisable, as it is usually heavily blood-stained. The new dressing can then be left for 3 to 5 days. The pedicle of the cross-finger flap may be cut after about 3 weeks. The functional and cosmetic results are excellent.
Nail Plate The major nail plate anomalies amenable to surgical treatment are congenital malalignment, mainly of the great toe nail, lateral deviation as a result of foot deformation and trauma, crooked nails, pincer nails, and hooked nails; however, the nail operation most frequently performed is nail avulsion which is usually done as a distal approach.
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Although described over 25 years ago by Cordero’s the proximal nail avulsion is hardly known. It is indicated for nail lesions requiring nail removal with the nail presenting hyponychial hypertrophy, massive firm distal subungual hyperkeratosis, or lack of a distal free edge. A Freer septum elevator is pushed under the cuticle and eponychium with its blunt tip pointing to the nail. It is carefully moved back and forth from the center to the sides until the nail is freed from the proximal nail fold. It is then cautiously flipped around the proximal edge of the nail plate into the cleavage plane between matrix and plate and moved from one side to the other. It is then pushed further distally until it appears under the nail’s free edge. This approach to nail avulsion is less traumatic for the nail bed as it conforms with its growth direction. On onychogryphotic nails, where it is often difficult to insert, without considerable force, an elevator under the distal edge of the plate can be removed very easily with Cordero’s technique.4,29 Partial nail avulsion is a very useful alternative if a considerable portion of the nail is still normal and does not need to be removed.30s31 Often only a third or half of a nail is affected by onychomycosis. If combined medical and surgical treatment appears advantageous it is wise not to avulse the entire nail plate, thus reducing the damage to the extent necessary. In case a longitudinal portion has to be removed, a septum elevator is inserted under the nail some millimeters proximal to the pathologic alteration and the nail is cut longitudinally and then transversally. Corresponding nail bed hyperkeratoses are carefully removed. Partial nail avulsion is also necessary for subungual infections not responding to antibiotic treatment within 24 to 48 hours. The nail plate that is loose over the felon is cut and the proximal third is pulled out from under the proximal nail fold. The cul-de-sac is rinsed and drained with nonadherent impregnated gauze. Crooked nails are usually due to a lateral deviation of the nail bed and matrix. The deviation characteristically increases distally, giving the nail plate a curved appearance. The entire nail organ has to be aligned and flaps or full-thickness skin grafts are necessary to fill in the secondary defect to avoid pulling the nail bed back into the former misdirection, which would inevitably happen with split-thickness skin grafts or healing by secondary intention.9*10 Congenital malalignment of the hallux nail is a fairly common disorder, but its importance is frequently underestimated. Parents are therefore often told to wait for self-healing or puberty. Although some cases may show spontaneous improvement, treatment has to be instituted when there is a worsening of the condition with thickening and/or dystrophy of the nail. Baran proposed com-
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plete realignment of the entire nail organ prior to irreversible damage to the entire nail apparatus.32 This may even happen before the age of 2 to 3 years. A crescent wedge excision is carried out all around the tip of the great toe nearly to the interphalangeal joint. The nail bed and matrix are dissected from the phalanx which usually is still more cartilaginous than bony and can be readily cut with the scalpel blade. The insertion of the extensor hallucis tendon must not be injured. The nail apparatus is swung to correct its longitudinal axis and sutured. It may be necessary to excise a Burow’s triangle to facilitate the nail rotation. Rarely, there is a medial deviation that is treated correspondingly. Another variant is a very short globoid terminal phalanx with an up-growing hallux nail. A crescent wedge-shaped excision will usually correct this deformity; however, xeroradiography of the hallux in infants with congenital malalignment of the great toenail almost never reveals that there is also a deviation of the long axis of the terminal phalanx from that of the proximal one, indicating a more serious defect. Transverse overcurvature of the nail is usually seen in the great toenail, but may also occur in other digits. Symmetric pincer nails are commonly hereditary whereas nonsymmetric ones may result from a variety of different dermatoses, foot deformation, and degenerative osteoarthritis of the distal interphalangeal joint. Although most cases are surprisingly harmless they may cause excruciating pain and require treatment. Different surgical and conservative approaches have been described but none of them pays attention to the underlying bone deformation: Even in the symmetric form found in young people, radiographs invariably show a wide base of the distal phalanx and osteophytes on both sides. They cause the curved nail to straighten proximally which increases its curvature distally. As the lateral osteophytes cannot easily be removed without risk of injuring the lateral ligaments of the distal interphalangeal joint the nail plate has to be permanently narrowed. This is done by a bilateral selective matrix horn resection. Then the distal two thirds of nail bed is incised longitudinally, carefully dissected from the bone, and spread out. Usually a traction osteophyte is palpable on the dorsal aspect of the tip of the phalanx and has to be removed. The lateral nail folds are pulled laterally by using reversed tie-over sutures which are removed after 14 to 18 days. The nail bed is closed using 6-O absorbable sutures.4*6,33
Melanonychia Longitudinalis Longitudinal brown to black stripes in the nail that are due to melanin deposition are called melanonychia longitudinalis (LM). LM is caused by the continuous overproduction of melanin in the matrix, which may result from a
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nidus of functionally active melanocytes, a lent&o, a melanocytic nevus, or a malignant melanoma. Because in fair-skinned people acquired LM tends to be malignant rather than benign, complete excision is advisable for both diagnostic and therapeutic reasons.34,35 Only the surgical aspects of LM are briefly outlined here. If LM is localized in the lateral third of the nail plate a lateral longitudinal biopsy is the best method. If the central portion of the nail is affected, clipped nail from the LM should be submitted for histopathology; Fontana’s argentaffin reaction permits precise localization of the melanin, which provides a clue as to where the melanocytic focus is situated in the matrix: The more superficial the pigment, the more proximal is its production. This is important because proximal matrix lesions usually cause disturbances in nail growth. This LM not wider than 3 mm may be treated by punching the origin. Transverse fusiform excision is indicated for lesions 3 to 6 mm wide that originate in the distal matrix, whereas a nail flap after Schernberg and Amiel is recommended for lesions of the proximal matrix. LM wider
than
6 mm is associated
with
a high
risk of
malignant melanoma. More or less complete excision of the entire pigmented area is necessary. Periungual spread of pigment is also thought to represent acral lentiginous
melanoma.
Complications Nail operations, like any other surgical intervention, may be followed by complications. To prevent postoperative infections
perioperative
antibiotic
prophylaxis
is recom-
mended whenever an operation is done on a possibly contaminated nail. Recently, reflex sympathetic dystrophy was described after nail biopsy in a 44-year-old man suffering from adult-onset diabetes mellitus, coronary artery disease, and hypertension. This operation
was done under local anesthesia of the proximal and lateral nail folds. Histopathology revealed invasive onychomycosis.
He had severe
pain 2 days after operation,
bulla
formation around the nail, and stiffness of the finger. Five years later, he had sclerodactyly-like changes of his hand with osteoporosis. Considerable subjective improvement was obtained with prednison 10 mg daily.36 We observed a similar though not as extensive case after nail biopsy
under digital ring block (Haneke, unpublished). Epidermal inclusion cysts may develop after operation on the nail bed and matrix, especially after incomplete nail bed resection and correction of congenital malalignment of great toenails. The lateral matrix horn of the great toenail is frequently very far proximally and laterally volarly located. Remnants may therefore be left, giving rise
to cysts which may have either an epidermis-like an “onycholemmal” appearance.37,38
or even
References 1. Keyser JJ, Littler JW, Eaton RG. Surgical treatment
of infections and lesions. Hand Clin 1990;6:137-53. 2. Van Beek AL, Kassan MA, Adson MH, Dale V. Management of acute fingernail injuries. Hand Clin 1990;6:23-35. 3. Salasche SJ, Peters VJ. Tips on nail surgery. Cutis 1985;35:428-38. 4. Haneke E. Cirugia dermatol6gica de la regi6n ungueal. Monogr Dermatol 1991;4:408-23. 5. Baran R, Bureau H. Surgical treatment of recalcitrant chronic paronychias of the fingers. J Dermatol Surg Oncol 1981;7:106. 6. Haneke E, Baran R. Nails: Surgical aspects. In: Parish LC, Lask GP, editors. Aesthetic dermatology. New York: McGraw Hill, 1991:236-47. 7. Salasche SJ. Myxoid cysts of the proximal nail fold: A surgical approach. J Dermatol Surg Oncol 1984;10:35. 8. Barfod 85-7.
B. Reconstruction
of the nail fold. Hand
1972;4:
9. Zook EG, Russell RC. Reconstruction of a functional and esthetic nail. Hand Clin 1990;6:59-68. Hand Clin 10. Shepard GH. Nail grafts for reconstruction. 1990;6:79-102. 11. Rose E. Nailplasty utilizing a free composite graft from the helical rim of the ear. Plast Reconstr Surg 1980;66:23 -9. 12. Neukam D resection of nails for purposes of 13. Scher RK. Longitudinal biopsy and treatment. J Dermatol Surg Oncol 1980;6:805. Why, when, where, 14. Baran R, Bureau H. Nail biopsyhow? J Dermatol Surg Oncol 1976;2:322. 15. Haneke E. Reconstruction of the lateral nail fold after lateral longitudinal nail biopsy. In: Robins I’, editor. Surgical gems in dermatology. New York: Journal Publishing Group, 1988;91-3. einiger Nagelfehlbildungen. In: 16. Haneke E. Behandlung Wolff HH, Schmeller E, editors. Fortschritte der operativen Dermatologie: vol. 2. Fehlbildungen, NBvi, Melanome. Berlin/Heidelberg/New York: Springer, 1985; 71- 7. 17. Guy RJ. The etiologies and mechanisms of nail bed injuries. Hand Clin 1990;6:9 - 19. 18. Shepard GH. Management of acute nail bed avulsions. Hand Clin 1990;6:39-56. 19. Zook EC. Discussion of “Management of acute fingernail injuries.” Hand Clin 1990;6:37-8. 20. Recht P. Fingertip injuries and a plea for the nail. J Dermatol Surg 1976;2:327-8. 21. Zaias N. The longitudinal nail biopsy. J Invest Dermatol 1967;49:406.
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22. Johnson RK. Nailplasty. Plast Reconstr Surg 1971;47: 275-6. 23. Seckel BR. Self advancing silicone rubber splint for repair of split nail deformity. J Hand Surg 1986;11A:143-4. 24. Schemberg F, Amiel M. Lokale Verschiebelappen des Nagels. Handchiirgie 1987;19:259-62. 25. Haneke E. Modifications of Schemberg’s nail flap technique. Xth International Congress of Dermatologic Surgery, Brussels, Book of Abstracts, 1989:79. 26. Haneke E. Das umgedrehte Koriumtransplantat zur Defektdeckung im Schadelbereich. Z Hautkr 1981;56:84-7. 27. Haneke E, Binder D. Subunguales Melanon mit streifenfijrmiger Nagelpigmentierung. Hautarzt 1978;29: 389-91. 28. Corder0 FA. Ablation ungueal: So uso en la onicomicosis. Dermatol Int 1965;14:21. 29. Bureau H, Baran R, Haneke E. Nail surgery and traumatic abnormalities. In: Baran R, Dawber RPR, editors. Diseases of the nails and the management. Oxford: Blackwell, 1984:347-402. 30. Baran R, Hay RJ. Partial surgical avulsion of the nail in onychomycosis. Clin Exp Dermatol 1985;10:413-8.
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31. Baran R, Bureau H. Congenital malalignment of the big toenail as a cause of ingrowing toenail in infancy. Clin Exp Dermatol 1983;8:613-23. 32. Baran R. Partial nail avulsion. G Ital Chir Dermatol, in press. 33. Baran R, Haneke E. Surgery of the nail. In: Epstein E, Epstein E Jr, editors. Skin surgery. 6th ed. Philadelphia: Saunders, 1987:534-47. 34. Baran R, Haneke E. Diagnostik und Therapie der streifenformigen Nagelpigmentierung. Hautarzt 1984;35: 359-65. 35. Baran R, Kechijian P. Longitudinal melanonychia (melanonychia striata): Diagnosis and management. J Am Acad Dermatol 1989;21:1165-75. 36. Ingram GJ, Scher RK, Lally EV. Reflex sympathetic dystrophy following nail biopsy. J Am Acad Dermatol 1987;16:253-6. 37. Haneke E. Onycholemmal horn. Dermatologica 1983; 167:155-7. 38. Baran R, Bureau H. Two post-operative epidermoid cysts following realignment of the hallux nail. Br J Dermatol 1989;119:245-7.
HANEKE, MD BARAN, MD
Anesthesia
Operations on Paronychial Tissue
Regional anesthesia such as a digital ring block or a metacarpal block just proximal to the interdigital web or at the wrist level is adequate, but general anesthesia may be needed for very young children.‘J A distal wing block was proposed by Salasche and Peters.3 The injection is started about 3 mm proximal from the junction of the proximal and lateral nail folds and is continued distally and volarly to anesthetize the lateral digital nerve. The needle is then pushed across the proximal nail fold to the other side to block the transverse nerve and finally the other lateral nail fold is anesthetized. The pressure from the local anesthetic considerably reduces bleeding; however, this technique may be quite painful and, therefore, the addition of bicarbonate as a buffering agent has been proposed. Steroids and marcaine given at the completion of nail operation may avoid delayed pain,3 but they must not be used in case of infection. Preoperative and postoperative antibiotic prophylaxis is recommended only for type III, IV, and V injuries and for other nail operations if there may be contamination with organic material.* A 0.5-in. Penrose drain, a pneumatic drain, or a rubber glove finger rolled back to the web may be used as a tourniquet. Loupe magnification is highly recommended.4 A variety of surgical operations either not or only recently described in the dermatologic literature or less known are briefly reported here.
Proximal
From the Department of Dermatology, Ferdinand-Sauerbruch-Klinikum Elberjeld, Wuppertal, Germany, and the Dermatology Division, Cenfre Hospitalier, Cannes, France. Address correspondence to Eckhart Haneke, MD, Heinrich Heine University, Ferdinand Sauerbruch Clinic, Arrenberger Strasse 20,560O WuppertalElberfeld, Germany.
0
1992
by Elsevier
Science Publishing
Co., Inc.
l
0738-081x/92/$5.00
Nail Fold
It has been stated that asymmetric tissue loss of the proximal nail fold will almost always result in a distorted proximal nail fold5 and this is evidenced by the unsightly scarring often seen after injury to the proximal nail fold. Tumors of the proximal nail fold affecting its distal margin and reaching to the distal dorsal crease of the distal interphalangeal joint can be removed by a wedge-shaped excision as shown in Fig 1: The proximal nail fold is freed from the underlying nail plate and the tumor is excised with the narrow tip of the wedge directed proximally. Two lateral incisions of the proximal nail fold on either side will allow closure without tension. The narrow secondary defects will heal by granulation within 3 to 4 weeks and will be virtually invisible. There will be no change in the size and shape of the proximal nail fold after this technique.4,6 Chronic paronychia with thickening and induration of the proximal nail fold, leading to loss of the cuticle and to nonadherence of the eponychium to the nail plate (thus allowing moisture direct access and inviting the entrapment of foreign material under the proximal nail fold), as well as tumors in the most distal part of the proximal nail fold, may be treated by removal of nearly the entire proximal nail fold. A crescent of tissue is removed by starting the incision at the junction of the lateral and proximal nail fold and carrying it to the other side. The most proximal point of the incision line is roughly in the middle between the distal lunula border and the distal crease of the distal interphalangeal joint.5 About 75% of the entire proximal nail fold can be removed, but care must be taken not to injure the cul-de-sac and the most proximal portion of the proximal nail fold as this area is mainly responsible for the nail plate’s sheen. One can insert an elevator under the proximal nail fold when cutting the proximal nail fold
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resulted in an entirely normal-looking distal phalanx with normal proximal and lateral nail folds.12
a
b
i’1r ‘\ 7
Figure 2. Removal of tumors from the margin of the proximal nail fold. a. Tumor and incision lines are marked. b. Defect is sutured, leaving two narrow seconda y defects which rapidly heal by seconda y intention.
and move it with the tip of the scalpel blade so that the matrix and the more proximal extensor tendon insertion cannot inadvertently be injured.’ Beveling the scalpel creates a gently sloped wound which heals more rapidly than the conventional vertical-edged one. The proximal nail fold will be restored by secondary healing within 6 to 8 weeks.5 Acute paronychia in the more proximal part of the proximal nail fold not responding to antibiotic therapy within 48 hours requires removal of the base of the nail plate.’ No drain is required. Systemic antibiotic treatment according to the sensitivity of the cultured bacteria is necessary. “Eponychial marsupialization” has also been recommended for chronic recalcitrant paronychia. Here, a symmetric crescent of tissue is removed, leaving the proximal nail fold its vascular supply and avoiding injury to the dorsal aspect of the cul-de-sac. With daily changes of the dressing and warm soaks using diluted hydrogen peroxide the wound will be reepithelialized within a week.’ Loss of the proximal nail fold with scarring of the dorsal aspect of the digit’s distal portion and nail dystrophy is due mostly to burns and to avulsions caused by rapidly rotating belts and sanders. Scarring is usually too serious as to allow rotation of flaps* to form a functionally and esthetically acceptable proximal nail fold.9 Improvement of rotation flaps was described by lining the undersurface with split-thickness nail bed grafts.‘O A free composite graft from the rim of the ear helix was the dorsal aspect of the used by Rose. l1 Alternatively, proximal nail fold of the great toe or second toe may be used.9 Bowen’s disease may involve the major portion of the distal phalanx’ dorsal aspect. Its complete removal including the lateral nail folds and full-thickness skin graft
Lateral Nail Fold If a diagnostic longitudinal nail biopsy is necessary it should be performed as a lateral instead of median nail biopsy if possible. This results in only a slight narrowing of the nail, which will be virtually invisible after a relatively short time. It is unnecessary to excise the lateral nail fold.13 As described originally14 the proximal nail fold is sutured first; however, instead of simply suturing the lateral nail fold to the nail bed, which makes the lateral nail fold virtually disappear, backstitches are used to reconstruct the lateral nail fold.15*i6 The needle is inserted at the lateral aspect of the terminal phalax and is run through the nail bed and nail plate and again back through the lateral nail fold. On knotting of the thread, the lateral nail fold is slightly elevated and fully restored (Fig 2). The same technique can be used for the correction of racquet nail deformity. Two lateral longitudinal excisions are made, and lateral nail folds, which may be characteristically lacking in the racquet finger, are created by using the backstitches as shown in Fig 2.16
Nail Bed and Matrix Nail bed and matrix injuries should be repaired as meticulously as possible using fine surgical instruments and a head magnifier loupe or an operation microscope. It is essential to know the exact mechanism of the trauma as there are characteristic consequences of crushing the finger in a door, blowing the fingertip with a hammer, or applying force with a sharp object over a smaller area of the nail.‘,” A (xero)radiograph should always be taken to rule out or confirm a fracture. Type I injuries comprise small subungual hematomas (500/) o an d re q uire nail removal and suture of the ruptured nail bed and/or matrix using 6-O or 7-O absorbable material. Care must be taken to coapt any tissure fragments properly and to preserve blood circulation to small flaps. Any laceration of the proximal nail fold has to be sutured in two layers. When a tuft fracture is diagnosed (type III injury) the distal fragment must be stabilized and the nail bed and matrix must be repaired. If the nail plate cannot be used as a splint, consultation with a hand surgeon should be sought. In type IV injury, the matrix and/or nail bed fragmentation must be meticulously repaired. Type V injury is characterized by avulsion of the
HANEKE
Clinics in Dermatology 1992;10:327-333
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b
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C
Figure 2. Reconstruction of the lateral nail fold for the correction of racquet thumbnail. a. Incisions are marked. b. Two lateral longitudinal nail biopsies are performed and sutured as shown. c. At the end of the operation, the nail is narrowed and lateral nail folds are created.
nail bed or matrix. The amputated epithelium is replaced by a split-thickness nail bed or full-thickness matrix graft harvested adjacent to the injury or from a toe, respectively. If the amputated nail bed can be recovered, it is replaced.* Partial avulsion of the germinal matrix as a distally based flap requires suturing it to its origin by a series of half-buried horizontal mattress sutures through the proximal nail fold. Is Whenever possible the original nail plate should be kept, cleaned, and put back as the optimal physiologic dressing. A suture through the tip of the fingerlg or a tie-over suture through the lateral nail folds*O will hold the nail in place. If the nail is no longer available a silicone sheet nail substitute will be used. To hold it in place, it is sutured with a horizontal mattress suture through the proximal nail fold, through the silicone, and back through the proximal nail fold. It is removed after 2 to 3 weeks.19 Posttraumatic onycholysis is a frequent sequela of nail bed scarring. Distal onycholysis may cause problems because of its unsightly appearance and because dirt becomes trapped beneath the nail and causes infection; proximal nonadherence makes the nail unstable and it may tear loose when caught in clothing. The scarred epithelium has to be replaced by normal nail bed.9 Splitthickness nail bed grafts may be taken from the injured digit or the great toe. By use of a microscope or strong head loupe a thin graft is taken with a 15~ scalpel. The graft should be so thin as to be transparent, allowing continuous observation of the cutting blade. This superficial wound will be reepithelialized with normal nail bed epithelium. Contracture of the graft is minimal as the nail bed dermis contains virtually no elastic fibers; however, the graft should be 1 to 2 mm larger. Although the dermal
ridges of the nail bed are unique in their regular parallel longitudinal arrangement, the graft need not be longitudinally oriented on the recipient site. A normal nail also grows when the graft is placed perpendicular to the longitudinal axis; however, full-thickness nail bed grafts and flaps must be oriented according to their longitudinal axis. The graft is sutured using 7-O chromic and the nail plate is thoroughly cleaned and replaced as a stent.‘O Linear ridging with distal nail plate splitting is often due to either a traumatic alteration or a bone spur, and preoperative xeroradiographs and computerized tomography scans, if appropriate, have to be taken. When a bone protrusion is identified under the nail bed, it must be removed. After cautious nail avulsion a linear incision over the bony prominence is made and the underlying bone is smoothed by clipping it with a double-action bone rongeur or nail clipper or filing with a fraise. The incision is closed with 7-O chromic sutures.18 If there is no bone alteration the abnormal thickened nail bed is excised and the defect closed with a split-thickness nail bed graft taken from the vicinity. As the original nail cannot be used as a physiologic dressing and splint because of its ridge, the nail bed is then covered with a segment of the great toenail and mesh gauze.9 Not infrequently a filamentous subungual tumor is the cause of linear ridging and distal nail split. This particular tumor is a variant of fibrokeratoma in a subungual location and its keratotic tip is pulled with the growing nail until it becomes visible at the hyponychium. All attempts to remove the lesion by following the longitudinal whitish to yellowish to reddish stripe to its origin and punching it have been unsuccessful (Haneke, unpublished). We therefore remove a nail plate portion about 10 mm wide to amply expose the lesion, which enables us to trace the
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subungual filamentous tumor and to excise it. The resulting defect is usually superficial and only 1 to 2 mm wide and does not require a free graft. The split nail is usually due to a longitudinal scar in the germinal matrix and nail bed. This may be the consequence of a trauma, and then it is often associated with a step formation between the two sides of the matrix and nail bed or with a median longitudinal nail biopsy.21 The traditional approach to split nail repair is the resection of the scar, lateral mobilization of matrix and nail bed from the paronychium, and coaption of the wound marginsz2 The results are generally not satisfying. Seckelz3 recommended insertion of a self-advancing silicone sheet between the nail plate and nail bed after split repair. The poor results of these techniques are attributed to the tension required for closure of matrix and nail bed.9 Tension can be reduced when the matrix and nail bed are sutured independently from the nail plate: After meticulous coaption of the former, the nail plate from which about 1 mm more has been removed on both sides is approximated using 3-O or 4-O monofil threads; however, this type of nail suture may sometimes provoke a step formation.4 The best results are apparently achieved using splitthickness grafts of the nail bed for nail bed defects and full-thickness matrix grafts from another finger or toe for matrix defects.9 The resection of tumors in the nail matrix may cause defects that are too large for primary closure after mobilization. A U-shaped nail flap was described to close defects situated in the central two thirds of the nail. Schemberg and Amielz4 proposed removal of an entire block of proximal nail fold, matrix, nail bed, and hyponychium down to the bone. The narrow part of the nail organ remaining was completely undermined and an incision was carried from the hyponychial end of the excision along the hyponychium into the lateral nail groove to the very tip of the lateral matrix horn to form the U-shaped nail flap. Mobilization under the proximal end of the matrix may be delicate as the matrix is firmly attached to the bone, the epithelium reaches very close to the bone, and the extensor tendon must not be injured. Using 6-O absorbable material the flap is sutured from the proximal matrix to the nail bed, the proximal nail fold is sutured separately for its ventral and dorsal surfaces, and 5-O or 4-O sutures are used for the hyponychium. We have used a modification taking into account that the proximal nail fold is not usually affected by matrix tumors and that the distal tip of the flap may be at risk for circulatory problems. 4~25Two incisions are made at the lateral sides of the proximal nail fold to reflect it and expose the matrix for exact evaluation of the matrix lesion. The lesion is removed either with the nail plate or
after its removal. A block of matrix and nail bed is resected and a parallel incision is made on the lateral aspect of the terminal phalanx. The nail bed and matrix are released from the bone and undermining is continued to the lateral incision, creating a bipedicled flap of matrix, nail bed, and lateral nail fold. The primary defect is sutured, starting with the matrix and continuing to the nail bed and hyponychium. The proximal nail fold is sutured last, and depending on whether or not there is a surplus of tissue, the lateral incisions may be extended to small wedge-shaped excisions. The secondary defect is allowed to granulate in. Wound healing is completed within 2 to 3 weeks and the scar from the secondary defect soon becomes virtually invisible. This technique avoids scarring in the hyponychial groove and there is no risk of necrosis of the flap’s distal tip. Similarly, a parallel incision may be performed in the lateral nail groove to create a small bipedicled matrixnail bed flap when there is too much tension at closure of a split nail defect. Extensive malignant tumors of the nail organ may require the extirpation of the entire nail organ. We have already described the use of reverse dermal grafts, 26 full-thickness grafts,27 and distant bridge flaps,27 to cover the resultant defect; however, all these techniques have some disadvantages. We have therefore used cross-finger and cross-toe flaps, respectively, to cover the dorsal half of the entire terminal phalanx after melanoma surgery. As soon as the size of the future defect is known a template is made for the designed flap. Usually it is wise to cut the flap and partially undermine it to train its blood supply for about 1 week. Only after this training should the flap be raised and transferred to the neighboring finger or toe. It is sutured with 6-O absorbable material and the defect is closed with a full-thickness skin graft. The dressing after operation has to immobilize both fingers but must not impair blood circulation. We have found that changing the dressing after 24 hours in a tepid warm bath with povidone -iodine and cleansing with 3% hydrogen peroxide is advisable, as it is usually heavily blood-stained. The new dressing can then be left for 3 to 5 days. The pedicle of the cross-finger flap may be cut after about 3 weeks. The functional and cosmetic results are excellent.
Nail Plate The major nail plate anomalies amenable to surgical treatment are congenital malalignment, mainly of the great toe nail, lateral deviation as a result of foot deformation and trauma, crooked nails, pincer nails, and hooked nails; however, the nail operation most frequently performed is nail avulsion which is usually done as a distal approach.
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Although described over 25 years ago by Cordero’s the proximal nail avulsion is hardly known. It is indicated for nail lesions requiring nail removal with the nail presenting hyponychial hypertrophy, massive firm distal subungual hyperkeratosis, or lack of a distal free edge. A Freer septum elevator is pushed under the cuticle and eponychium with its blunt tip pointing to the nail. It is carefully moved back and forth from the center to the sides until the nail is freed from the proximal nail fold. It is then cautiously flipped around the proximal edge of the nail plate into the cleavage plane between matrix and plate and moved from one side to the other. It is then pushed further distally until it appears under the nail’s free edge. This approach to nail avulsion is less traumatic for the nail bed as it conforms with its growth direction. On onychogryphotic nails, where it is often difficult to insert, without considerable force, an elevator under the distal edge of the plate can be removed very easily with Cordero’s technique.4,29 Partial nail avulsion is a very useful alternative if a considerable portion of the nail is still normal and does not need to be removed.30s31 Often only a third or half of a nail is affected by onychomycosis. If combined medical and surgical treatment appears advantageous it is wise not to avulse the entire nail plate, thus reducing the damage to the extent necessary. In case a longitudinal portion has to be removed, a septum elevator is inserted under the nail some millimeters proximal to the pathologic alteration and the nail is cut longitudinally and then transversally. Corresponding nail bed hyperkeratoses are carefully removed. Partial nail avulsion is also necessary for subungual infections not responding to antibiotic treatment within 24 to 48 hours. The nail plate that is loose over the felon is cut and the proximal third is pulled out from under the proximal nail fold. The cul-de-sac is rinsed and drained with nonadherent impregnated gauze. Crooked nails are usually due to a lateral deviation of the nail bed and matrix. The deviation characteristically increases distally, giving the nail plate a curved appearance. The entire nail organ has to be aligned and flaps or full-thickness skin grafts are necessary to fill in the secondary defect to avoid pulling the nail bed back into the former misdirection, which would inevitably happen with split-thickness skin grafts or healing by secondary intention.9*10 Congenital malalignment of the hallux nail is a fairly common disorder, but its importance is frequently underestimated. Parents are therefore often told to wait for self-healing or puberty. Although some cases may show spontaneous improvement, treatment has to be instituted when there is a worsening of the condition with thickening and/or dystrophy of the nail. Baran proposed com-
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plete realignment of the entire nail organ prior to irreversible damage to the entire nail apparatus.32 This may even happen before the age of 2 to 3 years. A crescent wedge excision is carried out all around the tip of the great toe nearly to the interphalangeal joint. The nail bed and matrix are dissected from the phalanx which usually is still more cartilaginous than bony and can be readily cut with the scalpel blade. The insertion of the extensor hallucis tendon must not be injured. The nail apparatus is swung to correct its longitudinal axis and sutured. It may be necessary to excise a Burow’s triangle to facilitate the nail rotation. Rarely, there is a medial deviation that is treated correspondingly. Another variant is a very short globoid terminal phalanx with an up-growing hallux nail. A crescent wedge-shaped excision will usually correct this deformity; however, xeroradiography of the hallux in infants with congenital malalignment of the great toenail almost never reveals that there is also a deviation of the long axis of the terminal phalanx from that of the proximal one, indicating a more serious defect. Transverse overcurvature of the nail is usually seen in the great toenail, but may also occur in other digits. Symmetric pincer nails are commonly hereditary whereas nonsymmetric ones may result from a variety of different dermatoses, foot deformation, and degenerative osteoarthritis of the distal interphalangeal joint. Although most cases are surprisingly harmless they may cause excruciating pain and require treatment. Different surgical and conservative approaches have been described but none of them pays attention to the underlying bone deformation: Even in the symmetric form found in young people, radiographs invariably show a wide base of the distal phalanx and osteophytes on both sides. They cause the curved nail to straighten proximally which increases its curvature distally. As the lateral osteophytes cannot easily be removed without risk of injuring the lateral ligaments of the distal interphalangeal joint the nail plate has to be permanently narrowed. This is done by a bilateral selective matrix horn resection. Then the distal two thirds of nail bed is incised longitudinally, carefully dissected from the bone, and spread out. Usually a traction osteophyte is palpable on the dorsal aspect of the tip of the phalanx and has to be removed. The lateral nail folds are pulled laterally by using reversed tie-over sutures which are removed after 14 to 18 days. The nail bed is closed using 6-O absorbable sutures.4*6,33
Melanonychia Longitudinalis Longitudinal brown to black stripes in the nail that are due to melanin deposition are called melanonychia longitudinalis (LM). LM is caused by the continuous overproduction of melanin in the matrix, which may result from a
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nidus of functionally active melanocytes, a lent&o, a melanocytic nevus, or a malignant melanoma. Because in fair-skinned people acquired LM tends to be malignant rather than benign, complete excision is advisable for both diagnostic and therapeutic reasons.34,35 Only the surgical aspects of LM are briefly outlined here. If LM is localized in the lateral third of the nail plate a lateral longitudinal biopsy is the best method. If the central portion of the nail is affected, clipped nail from the LM should be submitted for histopathology; Fontana’s argentaffin reaction permits precise localization of the melanin, which provides a clue as to where the melanocytic focus is situated in the matrix: The more superficial the pigment, the more proximal is its production. This is important because proximal matrix lesions usually cause disturbances in nail growth. This LM not wider than 3 mm may be treated by punching the origin. Transverse fusiform excision is indicated for lesions 3 to 6 mm wide that originate in the distal matrix, whereas a nail flap after Schernberg and Amiel is recommended for lesions of the proximal matrix. LM wider
than
6 mm is associated
with
a high
risk of
malignant melanoma. More or less complete excision of the entire pigmented area is necessary. Periungual spread of pigment is also thought to represent acral lentiginous
melanoma.
Complications Nail operations, like any other surgical intervention, may be followed by complications. To prevent postoperative infections
perioperative
antibiotic
prophylaxis
is recom-
mended whenever an operation is done on a possibly contaminated nail. Recently, reflex sympathetic dystrophy was described after nail biopsy in a 44-year-old man suffering from adult-onset diabetes mellitus, coronary artery disease, and hypertension. This operation
was done under local anesthesia of the proximal and lateral nail folds. Histopathology revealed invasive onychomycosis.
He had severe
pain 2 days after operation,
bulla
formation around the nail, and stiffness of the finger. Five years later, he had sclerodactyly-like changes of his hand with osteoporosis. Considerable subjective improvement was obtained with prednison 10 mg daily.36 We observed a similar though not as extensive case after nail biopsy
under digital ring block (Haneke, unpublished). Epidermal inclusion cysts may develop after operation on the nail bed and matrix, especially after incomplete nail bed resection and correction of congenital malalignment of great toenails. The lateral matrix horn of the great toenail is frequently very far proximally and laterally volarly located. Remnants may therefore be left, giving rise
to cysts which may have either an epidermis-like an “onycholemmal” appearance.37,38
or even
References 1. Keyser JJ, Littler JW, Eaton RG. Surgical treatment
of infections and lesions. Hand Clin 1990;6:137-53. 2. Van Beek AL, Kassan MA, Adson MH, Dale V. Management of acute fingernail injuries. Hand Clin 1990;6:23-35. 3. Salasche SJ, Peters VJ. Tips on nail surgery. Cutis 1985;35:428-38. 4. Haneke E. Cirugia dermatol6gica de la regi6n ungueal. Monogr Dermatol 1991;4:408-23. 5. Baran R, Bureau H. Surgical treatment of recalcitrant chronic paronychias of the fingers. J Dermatol Surg Oncol 1981;7:106. 6. Haneke E, Baran R. Nails: Surgical aspects. In: Parish LC, Lask GP, editors. Aesthetic dermatology. New York: McGraw Hill, 1991:236-47. 7. Salasche SJ. Myxoid cysts of the proximal nail fold: A surgical approach. J Dermatol Surg Oncol 1984;10:35. 8. Barfod 85-7.
B. Reconstruction
of the nail fold. Hand
1972;4:
9. Zook EG, Russell RC. Reconstruction of a functional and esthetic nail. Hand Clin 1990;6:59-68. Hand Clin 10. Shepard GH. Nail grafts for reconstruction. 1990;6:79-102. 11. Rose E. Nailplasty utilizing a free composite graft from the helical rim of the ear. Plast Reconstr Surg 1980;66:23 -9. 12. Neukam D resection of nails for purposes of 13. Scher RK. Longitudinal biopsy and treatment. J Dermatol Surg Oncol 1980;6:805. Why, when, where, 14. Baran R, Bureau H. Nail biopsyhow? J Dermatol Surg Oncol 1976;2:322. 15. Haneke E. Reconstruction of the lateral nail fold after lateral longitudinal nail biopsy. In: Robins I’, editor. Surgical gems in dermatology. New York: Journal Publishing Group, 1988;91-3. einiger Nagelfehlbildungen. In: 16. Haneke E. Behandlung Wolff HH, Schmeller E, editors. Fortschritte der operativen Dermatologie: vol. 2. Fehlbildungen, NBvi, Melanome. Berlin/Heidelberg/New York: Springer, 1985; 71- 7. 17. Guy RJ. The etiologies and mechanisms of nail bed injuries. Hand Clin 1990;6:9 - 19. 18. Shepard GH. Management of acute nail bed avulsions. Hand Clin 1990;6:39-56. 19. Zook EC. Discussion of “Management of acute fingernail injuries.” Hand Clin 1990;6:37-8. 20. Recht P. Fingertip injuries and a plea for the nail. J Dermatol Surg 1976;2:327-8. 21. Zaias N. The longitudinal nail biopsy. J Invest Dermatol 1967;49:406.
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22. Johnson RK. Nailplasty. Plast Reconstr Surg 1971;47: 275-6. 23. Seckel BR. Self advancing silicone rubber splint for repair of split nail deformity. J Hand Surg 1986;11A:143-4. 24. Schemberg F, Amiel M. Lokale Verschiebelappen des Nagels. Handchiirgie 1987;19:259-62. 25. Haneke E. Modifications of Schemberg’s nail flap technique. Xth International Congress of Dermatologic Surgery, Brussels, Book of Abstracts, 1989:79. 26. Haneke E. Das umgedrehte Koriumtransplantat zur Defektdeckung im Schadelbereich. Z Hautkr 1981;56:84-7. 27. Haneke E, Binder D. Subunguales Melanon mit streifenfijrmiger Nagelpigmentierung. Hautarzt 1978;29: 389-91. 28. Corder0 FA. Ablation ungueal: So uso en la onicomicosis. Dermatol Int 1965;14:21. 29. Bureau H, Baran R, Haneke E. Nail surgery and traumatic abnormalities. In: Baran R, Dawber RPR, editors. Diseases of the nails and the management. Oxford: Blackwell, 1984:347-402. 30. Baran R, Hay RJ. Partial surgical avulsion of the nail in onychomycosis. Clin Exp Dermatol 1985;10:413-8.
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31. Baran R, Bureau H. Congenital malalignment of the big toenail as a cause of ingrowing toenail in infancy. Clin Exp Dermatol 1983;8:613-23. 32. Baran R. Partial nail avulsion. G Ital Chir Dermatol, in press. 33. Baran R, Haneke E. Surgery of the nail. In: Epstein E, Epstein E Jr, editors. Skin surgery. 6th ed. Philadelphia: Saunders, 1987:534-47. 34. Baran R, Haneke E. Diagnostik und Therapie der streifenformigen Nagelpigmentierung. Hautarzt 1984;35: 359-65. 35. Baran R, Kechijian P. Longitudinal melanonychia (melanonychia striata): Diagnosis and management. J Am Acad Dermatol 1989;21:1165-75. 36. Ingram GJ, Scher RK, Lally EV. Reflex sympathetic dystrophy following nail biopsy. J Am Acad Dermatol 1987;16:253-6. 37. Haneke E. Onycholemmal horn. Dermatologica 1983; 167:155-7. 38. Baran R, Bureau H. Two post-operative epidermoid cysts following realignment of the hallux nail. Br J Dermatol 1989;119:245-7.
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