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This model allows the resident to practice each step of the nail avulsion, including sterilization, anesthesia, tourniquet placement, partial and total nail avulsion, and chemical or surgical matricectomy. Nail fold and bed skin are simulated by the rubber fingertip, which also serves to cover and protect the plastic hand model. Proximal nail fold reflection can be performed to expose the matrix. Nail structures and nail unit pathology can be illustrated using nail polish. Nail polish “cuticles” are a good reminder that these need to be released from the nail plate in live situations, as the plastic nail tip cannot be released until the nail polish is pushed off with a nail elevator. Afterward, the plastic nails and rubber fingertips can be reapplied to the model for further practice and training if they have not been altered as part of the procedure. The base hand model remains intact, so even if new “nails” and “fingers” are necessary, they are available for low cost at most

pharmacies, supermarkets, and office supply stores. At the residency program, residents report more comfort with nail procedures after physically going through nail procedure steps on this model. The model serves as an intermediary between “see one” and “do one.”

Reference 1. Sarker SK, Patel B. Simulation, and surgical training. Int J Clin Pract 2007;61:2120–5.

David Allen Pate, MD Ikue Shimizu, MD Department of Dermatology Texas Tech University Health Sciences Center Lubbock, Texas The authors have indicated no significant interest with commercial supporters.

Nailing It: Promoting Nail Procedural Training in Residency and Beyond The authors commend Pate and Shimizu1 on their novel and creative replica of the nail unit to improve familiarity and comfort with nail procedures in residency. Although training in procedural dermatology has expanded over the past several years, exposure to nail surgery is often limited in residency. In a survey of third-year dermatology residents, 58% had performed 10 or fewer nail procedures and 25% had observational experience alone. One third of graduating residents reported that they did not feel competent in nail surgery.2 Nail surgery training in residency and fellowship is critical, and predictive of future surgical practice. Mohs surgeons, who had performed 10 nail surgeries or more in training, currently perform twice as many nail procedures as their counterparts. In addition, those Mohs surgeons with more experience in fellowship were more likely to perform tangential/shave biopsies of the nail matrix and bed.3 Dermatologists are uniquely trained to identify suspicious cutaneous lesions and expedite diagnoses through a thoughtful approach about who/when/how/ where to biopsy. Nail biopsies are of particular

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importance as clinical signs of nail disease may be subtle.4,5 Diagnosis is often delayed. Nail melanoma continues to be diagnosed with 77% presenting at American Joint Committee on Cancer stage II or greater.6 Five-year survival rates for invasive disease range from 40% to 59%.7 Lack of clinical awareness and challenges in performing satisfactory biopsy have both been cited as reasons for the delay in diagnosis.6 Overall accuracy of dermatologists in the clinical diagnosis of nail matrix melanoma in situ ranges from 46% to 55%.8 Biopsy remains the gold standard.9 To improve these dismal statistics, we in medicine must accomplish the following: (1) educate our patients about high risk nail lesions, (2) include a detailed nail examination in our patient encounters, and (3) perform diagnostic biopsies earlier in the disease course. Indeed, with such emphasis, the authors have witnessed a marked trend toward diagnosing and treating nail melanoma in situ versus deeply invasive tumors. Longitudinal melanonychia, the most common presentation of nail melanoma, may also result from

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© 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

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benign melanocytic hyperplasia, hemorrhage, infection, or other nonmelanocytic conditions. Further complicating the matter, rates of melanosis approach 35% in nail melanoma.6 Amelanotic melanoma of the nail may even mimic lichen planus or onychomycosis.5,10 Dermoscopy can be helpful, but dermoscopic patterns have not been validated by evidence-based studies.11 As with pigmented lesions on the skin, when in doubt, excisional biopsy (in the authors’ opinion, best performed through a tangential [shave] matrix removal), is ideal to avoid sampling error.12 Poor or improper technique, or biopsy deferral based on being uncomfortable with the procedure, may result in a missed or delayed diagnosis of melanoma, respectively. This extends to squamoproliferative lesions of the nails as well. Among nail squamous cell carcinomas, the most common malignant tumor of the nail unit, there is an average delay of 6 months in patients seeking evaluation. Even among dermatologists, several lesions are misdiagnosed as warts initially.13 In addition to allowing for early diagnosis of nail disorders, both malignant and nonmalignant, familiarity with nail procedures allows the practitioner to address structural and mechanical nail issues. Paronychia, onychogryphosis, ingrown and pincer nails, fibrokeratomas, glomus tumors, and myxoid cysts are just a few of the relatively common nail disorders seen in practice. An understanding of these conditions and their management approach must be incorporated into dermatologic training. Dermatologists contribute regularly to the nail literature, including more recently, updates on matricectomy techniques,14–16 and the management of digital myxoid cysts.17,18 Whereas other specialists may routinely use conscious sedation or general anesthesia for nail procedures, most dermatologists perform nail surgery with local anesthesia—this is a great service to their patients with other comorbidities, and a source of system-wide practice efficiency. Abbade and colleagues19 recently described the use of a banana as an inexpensive approach to simulating digital block anesthesia, tourniquet use, nail plate avulsion, and classic matricectomy. This model or the one described by Pate and Shimizu could also be used to simulate intralesional steroid

injections of the nail—a straightforward treatment for several inflammatory nail disorders, and yet a technique not routinely used by dermatologists in practice. Nail procedural training in residency may be limited because of few nail cases, referral to dermatologic surgeons or other specialties (i.e., podiatry, orthopedics, hand surgery), and/or limited resources for cadavers or surgical models in residency. Pate and Shimizu provide a potential solution for increasing nail procedural volume in residency training. It will be interesting to track their trainees to see if practice with the reusable model correlates with a greater sense of competency at the end of training and a higher number of nail cases in practice. Nevertheless, it is an important step toward addressing this gap in their training programs and reinforcing the role of dermatologists in diagnosing and treating nail disease. References 1. Pate D, Shimizu I. Not just nail polish: inexpensive reusable model for practicing nail procedures. Dermatol Surg 2015;41:423–4. 2. Lee EH, Nehal KS, Dusza SW, Hale EK, et al. Procedural dermatology training during dermatology residency: a survey of third-year dermatology residents. J Am Acad Dermatol 2011;64:475–83. 3. Findley A, Lee K, Jellinek NJ. Nail surgery among Mohs surgeons: prevalence, safety, and practice patterns. Dermatol Surg 2014;40:691–5. 4. de Berker DA, Dahl MG, Conaish JS, Lawrence CM. Nail surgery: an assessment of indications and outcome. Acta Derm Venereol 1996;76:484–7. 5. Andre J, Moulonguet I, Goettman-Bonvallot S. In situ amelanotic melanoma of the nail unit mimicking lichen planus: report of 3 cases. Arch Dermatol 2010;146:418–21. 6. Tan KB, Moncrieff M, Thompson JF, McCarthy SW, et al. Subungual Melanoma: a study of 124 cases highlighting features of early lesions, potential pitfalls in diagnosis, and guidelines for histologic reporting. Am J Surg Pathol 2007;31:1902–12. 7. Cohen T, Busam KJ, Patel A, Brady MS. Subungual melanoma: management considerations. Am J Surg 2008;195:244–8. 8. Di Chiacchio N, Hirata SH, Enokihara MY, Michalany NS, et al. Dermatologists’ accuracy in early diagnosis of melanoma of the nail matrix. Arch Dermatol 2010;146:382–7. 9. Jellinek NJ. Dermoscopy between the lines. Arch Dermatol 2010;146: 431–3. 10. Elloumi-Jellouli A, Triki S, Driss M, Derbel F, et al. A misdiagnosed nail bed melanoma. Derm Online J 2010;16:13. 11. Tosti A, Piraccini BM, de Farias DC. Dealing with melanonychia. Semin Cutan Med Surg 2009;28:49–54. 12. Jellinek NJ. Nail matrix biopsy of longitudinal melanonychia: diagnostic algorithm including the matrix shave biopsy. J Am Acad Dermatol 2007;56:803–10.

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© 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

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13. Lecerf P, Richert B, Theunis A, Andre J. A retrospective study of squamous cell carcinoma of the nail unit diagnosed in a Belgian general hospital over a 15-year period. J Am Acad Dermatol 2013;69:253–61.

Nicole F. Vélez, MD Westmoreland Dermatology Associates Monroeville, Pennsylvania

14. Perez CI, Maul XA, Heusser M, Zavala A. Operative technique with rapid recovery for ingrown nails with granulation tissue formation in childhood. Dermatol Surg 2013;39:393–7. 15. Altinyazar HC, Demirel CB, Koca R, Hosnuter M. Digital block with and without epinephrine during chemical matricectomy with pheno. Dermatol Surg 2010;36:1568–71. 16. Bostanci S, Kocyigit P, Parlak N, Gugnor HK. Chemical matricectomy with sodium Hydroxide: long-term follow-up results. Dermatol Surg 2014;40:1221–4. 17. Park SE, Park EJ, Kim SS, Kim CW. Treatment of digital mucous cysts with intralesional sodium tetradecyl sulfate injection. Dermatol Surg 2014;40:1249–54. 18. Eke U, Ahmed I, Ilchyshyn A. Proximal nail fold flap dissection for digital myxoid cysts—a seven year experience. Dermatol Surg 2014;40: 206–8. 19. Abbade LP, Silva F, Guiotoku MM, Miot HA. Banana: a new simulation model to teach surgical techniques for treating ingrown toenails. Dermatol Surg 2013;39:1274–6.

Nathaniel J. Jellinek, MD Dermatology Professionals, Inc., East Greenwich Rhode Island Department of Dermatology The Warren Alpert Medical School of Brown University, Providence, Rhode Island Division of Dermatology University of Massachusetts Medical School Worcester, Massachusetts The authors have indicated no significant interest with commercial supporters.

A Comparison of Reticle Size to Determine Follicular Unit Density in Hair Restoration The overarching goal of hair transplantation surgeries in patients presenting with androgenic alopecia is to maximize coverage in the region(s) of hair loss by redistributing hair mass from the donor region without compromising coverage in that region. Consequently, the long-term outcome of the procedure is largely dependent on the hair loss pattern at presentation (i.e., the patient’s Norwood Classification)1 and the properties of the hair within the donor region. Although factors such as hair and skin color, hair curl, and the age at which hair loss began may be determined by routine visual assessment and review of patient history, the more significant predictive factors (i.e., hair diameter, follicular miniaturization, follicular unit [FU] density, and hair density)2 must be measured with specialized tools during physical examination. Unfortunately, standardized methods for determining these values are either nonexistent or too time- and labor-intensive to provide reliable data; therefore, the purpose of this work was to evaluate 3 reticle sizes (1.0, 0.5, and 0.1 cm2) for follicular density quantification to determine if the reduced area offers equivalent donor assessment to that of the 1.0 cm2 gold standard while improving reliability in complex donor regions.3

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Experiment Participants Follicular unit measurements were obtained from 40 randomly selected male patients between the ages 23 and 50 (average, 34 6 7) years across a range of ethnicities (67.5% white, 12.5% Asian/non-Indian, 10% Middle Eastern, 5% Hispanic, and 5% Asian/ Indian). Only scalps without previous surgical procedures were considered. All participants had given informed consent. Calculation of Follicular Unit Densities Photographs were taken at 3 magnification levels of the area 7.5 cm lateral to the central point of the donor region between the occipital protuberance and 3.0 cm above the auricle with the head in the transverse horizontal plane for all patients using a dermatoscope attached to a basic point-and-shoot camera. The boundary for the reticle size under investigation (1.0, 0.5, or 0.1 cm2) was demarcated with a black line, and FUs within that area were circled and numbered individually. Follicular units positioned directly on the black line or beyond were not considered. Individual

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© 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

Nailing it: promoting nail procedural training in residency and beyond.

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