LETTERS AND COMMUNICATIONS
“Super U”—A Technique for the Treatment of Ingrown Nail
Ingrown toenail is a common problem that causes significant morbidity. There are many options to treat it, from simple conservative approaches to surgical procedures. Conservative treatments are indicated in mild cases.1 Concerning surgical procedures, 2 different approaches are well established: narrowing of the nail plate and debulking of soft tissues. The physician assistant must choose the best technique on a careful clinical examination of each individual patient.2 In cases of ingrown toenail with hypertrophy of lateral and distal folds, the authors have been using a “super U” technique described by Dr. Rosa in 1989.3 In this technique, 2 parallel incisions forming a “letter U” are performed encompassing the hypertrophic tissue that will be removed.
the lateral nail groove up to the distal fold, 2 or 3 mm distally from the hyponychium, turning to the other side and ending at the beginning of the contralateral nail groove. The hypertrophic tissue between the 2 inverted U incision lines is removed, including the fat tissue on the lateral folds but not on the distal fold (Figure 1). The fat tissue on the distal fold is kept in place to avoid postoperative pain because of the proximity of the distal phalanx to the skin when the healing is complete. Hemostasis is achieved with a running locked suture. Healing is by second intention. The wound is covered with a nonadherent dressing, cotton and gauze, to avoid bleeding. Antibiotics and painkillers are prescribed. The affected limb should be elevated for 2 days. After the removal of the dressing, antiseptic soaks should be used twice a day until the wound is completely healed. The healing time is about 30 to 40 days.
The procedure starts with a proximal block anesthesia with 2% plain lidocaine. Then, a bilateral straight incision, perpendicular to the proximal nail fold, is performed beginning at the cuticle line and ending at the external limit of the hypertrophic tissue. A second incision starts at this point, running perpendicular to the first one and parallel to the bilateral distal lateral fold, continuing straight forward to the distal fold, and then turning to the contralateral side, ending at the same initial point, but on the other nail fold, forming a large “U.”
Another technique suggesting the debulking of soft tissues was described by Vandenbos and Bowers.4 The differences are that, in the super U, the most proximal part of the incision does not include the proximal nail fold, the distal fold is also removed, and hemostasis is achieved with a running locked suture.
To form the second parallel U line, a third incision begins at the same place as the first one and runs through
The authors have also used this technique in cases of ingrown nail of other toes than the hallux. In such
Figure 1. (A) Severe ingrowing nail with hypertrophy of lateral and distal nail folds. (B) Draft of incisions. (C) Surgical wound after removal of lateral and distal nail fold. (D) Outcome after 8 months.
652
DERMATOLOGIC SURGERY
© 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
LETTERS AND COMMUNICATIONS
cases, the surgical matricectomy, narrowing the nail plate, results in an unaesthetic nail. In children, when conservative treatments fail, the authors have performed this technique for the same reason.
Ival Peres Rosa, PhD Department of Dermatology Federal University of Sao Paulo São Paulo, Brazil
The authors consider the super U technique as the best treatment option for severe ingrown nails, with hypertrophy of lateral and distal nail folds.
Nilton Di Chiacchio, PhD Nilton Gioia Di Chiacchio, MD Department of Dermatology Hospital do Servidor Público Municipal São Paulo, Brazil
References 1. Richert B. Surgical management of ingrown toenails—an update overdue. Dermatol Ther 2012;25:498–509. 2. Haneke E, Richert B, Di Chiacchio N. Surgery of the whole nail unit. In: Richert B, Di Chiacchio N, Haneke E, editors. Nail surgery. London: Informa Heathcare; 2010;133–48. 3. Rosa IP, Garcia MLP, Mosca FZ. Tratamento cirúrgico da hipercurvatura do leito ungueal [in Portuguese]. An Bras Dermatol 1989;64:115–7. 4. Vandenbos KQ, Bowers WF. Ingrown toenail: a result of weight bearing on soft tissue. US Armed Forces Med J 1959;10:1168–73.
Livia Caetano, MD Department of Dermatology Federal University of Sao Paulo São Paulo, Brazil The authors have indicated no significant interest with commercial supporters.
“Yin–Yang” Graft: A Simple Technique for Maximal Tissue Conservation and Minimal Donor Site Defects Full- and split-thickness skin grafts have been used to reconstruct postsurgical defects for many years. One of the concerns when considering a graft is the creation of a large donor site defect. It is ideal to minimize excess wasted tissue, such as large standing cone deformities, when closing the defect. Although other mathematical approaches for devising the size of skin grafts have been used, they often incorporate complicated calculations that cannot be easily performed at the patient’s bedside. This method suggests a simplified calculation that minimizes both the size of the donor defect and the amount of tissue discarded.
Methods Patients were evaluated and treated surgically using Mohs micrographic surgery. The surgical defects after obtaining clear margins ranged from 2.5 to 6.5 cm. The defects in each case were circular in shape (Figure 1A). After reviewing closure options, each
patient elected to proceed with a full-thickness skin graft. The diameter of each defect was then measured. To obtain the correct measurements for the graft, the authors divided each defect’s width in half and doubled its length. Donor sites were chosen based on tissue similarity and available reservoir. In these patients, skin was taken from either the adjacent clavicle or posterior upper arm. The donor site dimensions were then mapped out on the patient with a 45 line transecting the width of each graft specimen (Figure 1B). The donor areas were appropriately prepared for surgery, and a full-thickness excision was performed. Excess subcutaneous fat was then trimmed appropriately to encourage graft survival. The 2 pieces of the donor graft were placed in the defect site, with the pieces side by side in a “Yin–yang” pattern (Figure 1C). The grafts were sutured into place with 5-0 fast absorbing gut on both the periphery and the center. A 3% bismuth tribromophenate-USP petrolatum gauze bolster was sutured overlying each graft to reduce the risk of hematoma formation. The donor sites were closed
41:5:MAY 2015
653
© 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
“Super U”—A Technique for the Treatment of Ingrown Nail
Ingrown toenail is a common problem that causes significant morbidity. There are many options to treat it, from simple conservative approaches to surgical procedures. Conservative treatments are indicated in mild cases.1 Concerning surgical procedures, 2 different approaches are well established: narrowing of the nail plate and debulking of soft tissues. The physician assistant must choose the best technique on a careful clinical examination of each individual patient.2 In cases of ingrown toenail with hypertrophy of lateral and distal folds, the authors have been using a “super U” technique described by Dr. Rosa in 1989.3 In this technique, 2 parallel incisions forming a “letter U” are performed encompassing the hypertrophic tissue that will be removed.
the lateral nail groove up to the distal fold, 2 or 3 mm distally from the hyponychium, turning to the other side and ending at the beginning of the contralateral nail groove. The hypertrophic tissue between the 2 inverted U incision lines is removed, including the fat tissue on the lateral folds but not on the distal fold (Figure 1). The fat tissue on the distal fold is kept in place to avoid postoperative pain because of the proximity of the distal phalanx to the skin when the healing is complete. Hemostasis is achieved with a running locked suture. Healing is by second intention. The wound is covered with a nonadherent dressing, cotton and gauze, to avoid bleeding. Antibiotics and painkillers are prescribed. The affected limb should be elevated for 2 days. After the removal of the dressing, antiseptic soaks should be used twice a day until the wound is completely healed. The healing time is about 30 to 40 days.
The procedure starts with a proximal block anesthesia with 2% plain lidocaine. Then, a bilateral straight incision, perpendicular to the proximal nail fold, is performed beginning at the cuticle line and ending at the external limit of the hypertrophic tissue. A second incision starts at this point, running perpendicular to the first one and parallel to the bilateral distal lateral fold, continuing straight forward to the distal fold, and then turning to the contralateral side, ending at the same initial point, but on the other nail fold, forming a large “U.”
Another technique suggesting the debulking of soft tissues was described by Vandenbos and Bowers.4 The differences are that, in the super U, the most proximal part of the incision does not include the proximal nail fold, the distal fold is also removed, and hemostasis is achieved with a running locked suture.
To form the second parallel U line, a third incision begins at the same place as the first one and runs through
The authors have also used this technique in cases of ingrown nail of other toes than the hallux. In such
Figure 1. (A) Severe ingrowing nail with hypertrophy of lateral and distal nail folds. (B) Draft of incisions. (C) Surgical wound after removal of lateral and distal nail fold. (D) Outcome after 8 months.
652
DERMATOLOGIC SURGERY
© 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
LETTERS AND COMMUNICATIONS
cases, the surgical matricectomy, narrowing the nail plate, results in an unaesthetic nail. In children, when conservative treatments fail, the authors have performed this technique for the same reason.
Ival Peres Rosa, PhD Department of Dermatology Federal University of Sao Paulo São Paulo, Brazil
The authors consider the super U technique as the best treatment option for severe ingrown nails, with hypertrophy of lateral and distal nail folds.
Nilton Di Chiacchio, PhD Nilton Gioia Di Chiacchio, MD Department of Dermatology Hospital do Servidor Público Municipal São Paulo, Brazil
References 1. Richert B. Surgical management of ingrown toenails—an update overdue. Dermatol Ther 2012;25:498–509. 2. Haneke E, Richert B, Di Chiacchio N. Surgery of the whole nail unit. In: Richert B, Di Chiacchio N, Haneke E, editors. Nail surgery. London: Informa Heathcare; 2010;133–48. 3. Rosa IP, Garcia MLP, Mosca FZ. Tratamento cirúrgico da hipercurvatura do leito ungueal [in Portuguese]. An Bras Dermatol 1989;64:115–7. 4. Vandenbos KQ, Bowers WF. Ingrown toenail: a result of weight bearing on soft tissue. US Armed Forces Med J 1959;10:1168–73.
Livia Caetano, MD Department of Dermatology Federal University of Sao Paulo São Paulo, Brazil The authors have indicated no significant interest with commercial supporters.
“Yin–Yang” Graft: A Simple Technique for Maximal Tissue Conservation and Minimal Donor Site Defects Full- and split-thickness skin grafts have been used to reconstruct postsurgical defects for many years. One of the concerns when considering a graft is the creation of a large donor site defect. It is ideal to minimize excess wasted tissue, such as large standing cone deformities, when closing the defect. Although other mathematical approaches for devising the size of skin grafts have been used, they often incorporate complicated calculations that cannot be easily performed at the patient’s bedside. This method suggests a simplified calculation that minimizes both the size of the donor defect and the amount of tissue discarded.
Methods Patients were evaluated and treated surgically using Mohs micrographic surgery. The surgical defects after obtaining clear margins ranged from 2.5 to 6.5 cm. The defects in each case were circular in shape (Figure 1A). After reviewing closure options, each
patient elected to proceed with a full-thickness skin graft. The diameter of each defect was then measured. To obtain the correct measurements for the graft, the authors divided each defect’s width in half and doubled its length. Donor sites were chosen based on tissue similarity and available reservoir. In these patients, skin was taken from either the adjacent clavicle or posterior upper arm. The donor site dimensions were then mapped out on the patient with a 45 line transecting the width of each graft specimen (Figure 1B). The donor areas were appropriately prepared for surgery, and a full-thickness excision was performed. Excess subcutaneous fat was then trimmed appropriately to encourage graft survival. The 2 pieces of the donor graft were placed in the defect site, with the pieces side by side in a “Yin–yang” pattern (Figure 1C). The grafts were sutured into place with 5-0 fast absorbing gut on both the periphery and the center. A 3% bismuth tribromophenate-USP petrolatum gauze bolster was sutured overlying each graft to reduce the risk of hematoma formation. The donor sites were closed
41:5:MAY 2015
653
© 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
