• Archives of Plastic Surgery
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• v.46 no.1
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• pp.57-62
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• 2019

Background Full-thickness nail bed defects with significant exposure of the distal phalanx are typically challenging to reconstruct. We describe a novel method of nail bed defect reconstruction using a thenar fascial flap combined with nail bed grafting. Methods Full-thickness nail bed defects were reconstructed in a 2-stage operation involving the placement of a thenar fascial flap and subsequent nail bed grafting. A proximally-based skin flap was designed on the thenar eminence. The flap was elevated distally to proximally, and the fascial layer covering the thenar muscle was dissected proximally to distally. The skin flap was then closed and the dissected fascial flap was turned over (proximal to distal) and inset onto the defect. The finger was immobilized for 2 weeks, and the flap was dressed with wet and ointment dressings. After 2 weeks, the flap was divided and covered with a split-thickness nail bed graft from the great toe. Subsequent nail growth was evaluated on follow-up. Results Nine patients (9 fingers) treated with the novel procedure were evaluated at follow-up examinations. Complete flap survival was noted in all cases, and all nail bed grafts took successfully. Five outcomes (55.6%) were graded as excellent, three (33.3%) as very good, and one (11.1%) as fair. No donor site morbidities of the thenar area or great toe were observed. Conclusions When used in combination with a nail bed graft, the thenar fascial flap provides an excellent means of nail bed reconstruction.

• Archives of Plastic Surgery
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• v.32 no.6
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• pp.763-766
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• 2005

The restoration of the fingernail is not simple in case of amputated distal fingertip which involved the pulp and nail. The nail should maintain a length of at least 2 mm from the eponychium for an adequate grip and decent appearance. Various methods to reconstruct the fingernail bed are available. The nail bed graft from amputated finger or great toe, and free onychocutaneous flap are commonly used. The nail bed of the injured tip tends to be atrophied, deformed and failed as a graft. And the great toe is often turned down as a donor. We have restored satisfactorily the nail beds of three injured finger tips with eponychial cutaneous flaps. The pulps were reconstructed with either a reverse dorsal digital island flap or free pulp graft. Repeated again. A mean follow- up was six months. The nail grew up to the average of 3.7 mm. All patients were satisfied with the length of the nail and met with good cosmetic results. An eponychial cutaneous flap is useful to restore the nail of the distal fingertip amputation. The procedure is relatively simple and morbidity is minimum.

• Archives of Plastic Surgery
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• v.38 no.1
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• pp.113-116
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• 2011

Purpose: Many fingertip injuries are associated with nail injury and it is hard to repair to original shape due to its unique characteristic. Mucosal graft is used for a defect of the nail bed injury. Hereby, we introduce a DAP flap and buccal mucosal graft, with which we could reduce the defect size of the injured fingertip and donor site morbidity at the same time, without any need for harvesting additional skin from other part of hand. Also, mucosal graft makes good cosmetic and functional outcome of nail. Methods: This method was performed in a 56-year-old man with fingertip injury on dorsal side of left thumb due to electrical saw. First, DAP flap was performed on the injured finger to reduce the size of the defect of fingertip and cover the bone exposure. Second, nail bed part of the DAP flap was de-epithelized and buccal mucosal graft was done from left side of intraoral cavity wall. Results: Flap and graft survived without any necrosis but some nail bed could not be covered with flap due to insufficient flap size. All wounds healed well and did not present any severe adversary symptoms. Conclusion: DAP flap with mucosal graft is an effective method that we can easily apply in reconstruction of fingertip injury. We suggest that the combination of the two procedures makes good functional and cosmetic outcome compared to the usual manner, especially in cases of nail bed injury without distal phalanx bone defect.

• Archives of Plastic Surgery
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• v.49 no.1
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• pp.70-75
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• 2022

Background Fingertip injuries are very common; however, the reconstruction of volar pulp defects with nail bed defects is challenging in the absence of the amputated segment. We reconstructed fingertip amputations with nail bed defects using a new surgical approach: a subcutaneous flap and composite graft. Methods We treated 10 fingertip amputation patients without an amputated segment, with exposed distal phalangeal bone and full-thickness nail bed defects between February 2018 and December 2020. All patients underwent two-stage surgery: in the first stage, a subcutaneous flap was performed to cover the exposed distal phalanx, and in the second stage, a composite graft, consisting of nail bed, hyponychium, and volar pulp skin, was applied over the subcutaneous flap. Results All flaps survived and all composite grafts were successful. The wounds healed without any significant complications, including the donor site. The average follow-up duration was 11.2 months (range, 3-27 months). The new nail and the shape of the volar pulp were evaluated during follow-up. All patients were satisfied with their natural fingertip shapes and the new nails did not have any serious deformities. Conclusions A subcutaneous flap in combination with a composite graft fitting the shape of the defect could be another option for fingertip injuries without amputated segments.

• Archives of Plastic Surgery
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• v.49 no.6
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• pp.764-768
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• 2022

The wrap-around flap (WAF) has become a popular approach to thumb reconstruction because the results are functionally and cosmetically excellent. By modifying to a partial toenail transfer, the WAF can also be used for finger reconstruction. However, performing cosmetically superior finger reconstruction is a significant challenge because it is difficult to reconstruct the natural nailfold by partial nail transplantation, although partial nail transplantation is required to reconstruct a narrow fingernail. One side of the reconstructed lateral nailfold tends to be a missing nail margin, and one side of the proximal nailfold angle tends to be retracted. Based on the rationale that loss of the lateral nailfold volume due to the postoperative tension of the volar flap would result in a missing nail margin, the volume of the lateral nailfold was maintained with a single thread that was passed from the nail to the volar flap. Additionally, half of the proximal nailfold from the nail plate was elevated to advance it forward. The results indicated that a cosmetically natural nailfold was achieved with the WAF approach to finger reconstruction. These easy and simple techniques enable reconstruction of a cosmetically natural nailfold using WAF for finger reconstruction.

• Archives of Plastic Surgery
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• v.50 no.3
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• pp.274-278
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• 2023

Ingrown toenails are most common among school-age children and adolescents though they can be observed at any age. Causes of ingrown toenails are increased curvature, trauma, and external pressure. Treatment of ingrown toenails can be broadly characterized as conservative and surgical. Conservative treatment can be performed using various methods, such as a gutter splint, dental floss, and cotton. Surgical treatments may be divided into two main approaches; narrowing of the nail plate and debulking of periungual tissues. However, these various conservative and surgical treatments have high recurrence rates, and thus, the author used a permanent surgical method based on the use of a paronychium flap to treat a 15-year-old male adolescent with excessive periungual tissues and curved ingrown toenails who did not improve despite conservative and several surgical treatments over 4 years. Subsequently, toenail shape was maintained without recurrence 22 months after surgery, and there were no complaints of inflammation or pain while walking. This simple surgical method can be performed on patients with advanced ingrown toenails due to excessive periungual tissues and nail curvature and can be expected to have permanent effects.

• Archives of Plastic Surgery
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• v.46 no.6
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• pp.580-588
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• 2019

Background There are various reconstructive options for nail bed defects. However, it is challenging not to leave a deformity. In this study, we investigated differences in outcomes depending on the reconstruction method, attempted to determine which method was better, and analyzed other factors that may affect outcomes. Methods The long-term outcomes of nail bed reconstruction were reviewed retrospectively. We performed three types of reconstruction depending on the defect type: composite grafts of severed segments, nail bed grafts from the big toe, and two-stage surgery (flap coverage first, followed by a nail bed graft). Subsequent nail growth was evaluated during follow-up, and each outcome was graded based on Zook's criteria. The reconstruction methods were statistically analyzed. Other factors that could contribute to the outcomes, including age, the timing of surgery, germinal matrix involvement, defect size, and the presence of bone injuries, were also compared. Results Twenty-one patients (22 digits) who underwent nail bed reconstruction were evaluated. The type of reconstruction method did not show a significant relationship with the outcomes. However, patients who sustained injuries in the germinal matrix and patients with a defect larger than half the size of the nail bed had significantly worse outcomes than the comparison groups. Conclusions The results suggest that no operative method was superior to another in terms of the outcomes of nail bed reconstruction. Nevertheless, involvement of the germinal matrix and defect size affected the outcomes.

• Archives of Plastic Surgery
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• v.33 no.3
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• pp.347-352
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• 2006

Ingrowing toenail has been treated conventionally by various surgical treatment modlities. However, none of these procedures are perfect to achieve esthetic results with low cost, recurrence, and complication rates. Although mild cases can be treated conservatively, in severe recurrent cases, surgical treatment is preferred. The purpose of this study is to evaluate the effectiveness and safety of using partial matricectomy and paronychial advancement flap for correction of recurrent ingrowing toenail. Eight patients suffering from recurrent ingrowing toenail were operated using partial matricectomy and paronychial advancement flap in our department from August 2004 to August 2005. The number of recurrent episodes ranged from 2 to 5. With digital nerve block, the excision area was marked on nailplate and inflammed lateral nail fold. The horizontally designed paronychial flap considering defect size was effective for wide exposure of the neighboring germinal matrix, which is later to be completely excised or cauterized because remnant germinal matrix made postoperative spicule formation. The nailplate on the affected side was removed about 3-5 mm width longitudinally, being cautious not to damage the proximal dorsal nail fold. The same width of the sterile matrix including germinal matrix was excised longitudinally with inflammed granulation tissue and partial lateral nail fold on the affected side. The subcutaneously elevated paronychial flap was advanced to cover the defect and was anatomically sutured with 5-0 nylon sutures. We evaluated our procedure's effectiveness by examining some factors such as cosmetic results, recurrence, spicule formation, postoperative pain and duration of return to normal activities. In eight patients, no complication was observed such as recurrence, severe pain and spicule formation except for 1 case of infection. Postoperative discomfort was minimal. Average duration of return to normal activities was 12 days. Cosmetically the results were acceptable in all patients. The partial matricectomy and paronychial advancement flap for correction of recurrent ingrowing toenail were found to be technically simple, efficient procedure with a relative low recurrence rate and better cosmetic results.

• Archives of Plastic Surgery
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• v.42 no.2
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• pp.207-213
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• 2015

Background Pincer nail deformity is a transverse overcurvature of the nail. This study aimed to define the anatomical characteristics of pincer nail deformity and to evaluate the surgical outcomes. Methods A retrospective review was conducted on 20 cases of pincer nail deformity of the great toe. Thirty subjects without pincer nail deformity or history of trauma of the feet were selected as the control group. Width and height indices were calculated, and interphalangeal angles and base widths of the distal phalanx were measured with radiography. We chose the surgical treatment methods considering perfusion-related factors such as age, diabetes mellitus, kidney disease, and peripheral vascular disease. The zigzag nail bed flap method (n=9) and the inverted T incision method (n=11) were used to repair deformities. The outcomes were evaluated 6 months after surgery. Results The interphalangeal angle was significantly greater in the preoperative patient group ($14.0^{\circ}{\pm}3.6^{\circ}$) than in the control group ($7.9^{\circ}{\pm}3.0^{\circ}$) (P<0.05). The postoperative width and height indices were very close to the measurements in the control group, and most patients were satisfied with the outcomes. Conclusions We believe that the width and height indices are useful for evaluating the deformity and outcomes of surgical treatments. We used two different surgical methods for the two patient groups with respect to the perfusion-related factors and found that the outcomes were all satisfactory. Consequently, we recommend taking into consideration the circulatory condition of the foot when deciding upon the surgical method for pincer nail deformity.

• Archives of Reconstructive Microsurgery
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• v.16 no.2
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• pp.75-81
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• 2007

Introduction: Microsurgical replantation of amputated digit have become common procedure in recent years. However replantation of fingertip amputation, Zone I by Yamano classification, is still difficult because digital arteries branch into small arteries and also digital veins are hard to separate from the immobile soft tissue. So, fingertip amputation was covered by volar V-Y flap, composite graft, cross finger flap and groin flap. But patients who have been treated by these methods experience shortening of digit, nail deformity, excessive tenderness and persistent pain. Replantation could solve most of these problems. Material & Methods: In our department, from March 2004 to August 2007, 36 digits in 32 patients with complete amputation at distal to nail base were replanted using a microsurgical technique. Results: The overall survival rate of the replanted finger was 75%. Venous anastomosis was possible in 8 cases and impossible in 28 cases. In latter cases external bleeding technique was applied with medical leech. Conclusion: After replantation, a few patient complained decreased sensibility, nail deformity and cold intolerance. But most of patients were satisfied with the functional and cosmetic appearance of the viable replanted digits. We believe the replantation should be the first choice in fingertip amputation.