Monday, February 11, 2008

Late Reconstruction of the Nail Bed

Recently I received the following e-mail:

"I came across your blog about fingertip injuries. When I was 4 years old I slammed a door on my pinky finger. The tip came off leaving me with what they call a hook nail. I have been trying to research any procedures that may improve the appearance of my finger. Do you have any suggestions or info on any procedures."

Secondary reconstruction is always less effective than "doing it right" at the time acute care is given to a nail bed injury. The appearance and shape of the nail improves during the first year after the injury so no attempts at reconstruction of the nail bed should be made until after the first year. You may want to refer back to my post on fingernail anatomy and fingertip injuries.

Typical nail deformities that require reconstruction include:

  • Non-adherent nails -- is the most common deformity of the nail plate after injury. It occurs due to scar tissue in the sterile matrix which prevents attachment of the nail plate to the nail bed. The non-adherent nail "sits" upwardly deviated from the nail bed. The lack of nail plate adherence becomes more of a functional than a cosmetic problem when more than one third of the distal nail is non-adherent. This allows it to catch on clothing and other articles putting the nail bed at risk for further injury. Dirt and other debris gather underneath the non-adherent nail and cause further irritation. Nail adherence on more than two thirds of the nail bed rarely results in a functional impairment.
  • Split nail deformities -- A longitudinal split in the nail is often the result of an underlying axial scar beginning in the germinal matrix of the nail bed. The scar divides the nail plate during formation. The nail plate grows out as 2 distinct plates.
  • Irregular contours -- The linear ridging deformity of the nail following a trauma is most often associated with an underlying bone or soft tissue abnormality. The ridging usually is more of a cosmetic problem more than a functional one.
  • Hook nail -- is usually the result of a fingertip amputation, with partial or complete loss of the supporting tuft of the distal phalanx (bone) and a loss of the distal nail bed and fingertip soft tissue. The regenerating nail plate follows the contour of the repaired fingertip amputation, angling in a dorsal (top) to volar (palm) direction. The hook-nail deformity is more than a cosmetic disfigurement to the patient's finger. The tip of the finger is often tender and chronically irritated, and sensibility may be impaired. The patient may also have difficulty grasping fine objects. Occasionally, the nail may catch on clothing or other utensils and become a constant source of trauma.

  • Pincer nail deformity -- represents a loss of the normal convex shape of the nail plate. The lateral edges of the nail plate have a marked convexity, turning acutely volarly (towards the palm) and taking on the characteristic shape of an omega sign when viewed head on at the distal phalanx. The exact etiology of this deformity is somewhat obscure, but a loss of the lateral integrity of the distal phalanx may occur, allowing this greater curvature of the nail plate. Paronychial infections may be more frequent with this type of nail irregularity.

  • Loss of the eponychium with synechiae -- Burns are the most common cause of loss of the eponychium. Other causes include friction avulsions, crush injuries, and complex lacerations. The eponychium contributes to the epidermoid keratinization of the nail, providing the characteristic sheen on a dorsal nail plate. So loss of the eponychium can result in an unsightly nail or notched deformity which can be a source of tenderness for the patient.

TREATMENT

Non-adherent Nail

  • Treatment involves trimming the nail back to normal sterile matrix. The scar in the nail bed is then excised and the defect is closed primarily or with split matrix grafts. Primary closure may be obtained with minimal nail bed undermining if the defect is less than 1-2 mm. The nail plate should adhere to the graft.
  • If the cause of non-adherence is due to hyperkeratosis of the nail bed, then the nail is removed. Then the hyperkeratosis is removed by scraping the sterile matrix with the edge of the scalpel blade down to the level of the normal nail bed. The nail either grows out completely or partially adheres to the nail bed. The procedure may be repeated if complete adherence is not achieved.

Split Nail Deformities

  • Treatment is determined by the underlying problem.
  • Longitudinal scars on the sterile matrix of the nail bed can usually be treated by excision and primary closure. Small Z-plasties (2 mm in length) can be used to alter the direction of the scar. Larger scars will require a split-thickness nail bed graft following excision. Loss of the central portion of the germinal matrix requires grafting with a full-thickness germinal matrix graft from the toe.
  • Adhesions within the eponychial fold are treated by removing the nail plate and dividing the synechia transversely. Upward traction on the open portion of the nail fold should allow visualization to perform the transverse incision. Any scar tissue of the germinal matrix and dorsal roof of the eponychium must be excised. A germinal matrix graft is then applied. Simple excision of the germinal matrix scar with primary approximation is less effective.
  • Reconstruction of the dorsal roof of the eponychium help restores the normal sheen to the regenerating nail. A silicone sheet (acts as a splint for the graft) should be placed in the nail fold to maintain the integrity of the eponychial fold until the grafts have "taken".

Linear Ridging Deformity

  • As with the other deformities, the nail plate must be removed and the sterile matrix visualized. An incision is made over the ridge in a longitudinal fashion. The sterile nail bed is elevated from side to side (radially and ulnarly) to expose the underlying tissue. Scar tissue, foreign bodies, or bony exostosis must be removed. The nail bed is redraped and sutured with 7-0 chromic sutures. Any excessive scarring of the sterile matrix should be excised and replaced with a split-thickness nail bed graft. The nail plate or silicone sheeting is then placed over the repair and under the eponychial fold.

Hook Nail Deformity

  • Can be somewhat difficult because of the loss of bony and soft tissue support. Secondary reconstruction is centered on recreating the initial defect, then restoring the bony and/or soft tissue support.
  • Soft tissue support on the volar (palm-side) aspect of the finger can be accomplished with V-Y Atasoy/Kleinert flaps, lateral Kutler flaps, a cross-finger flap, or a thenar crease flap.
  • Split nail bed grafts (distal edge) are applied directly to the volar flaps, and the proximal edge is sutured to the native nail bed.
  • Restoring the bony support is less predictable. Distraction osteogenesis, bone grafting, and step cutting in the distal phalanx are likely to lead to a high rate of resorption.
  • Microvascular composite flaps of nail bed, bone, and soft tissue from the toe have been described with excellent results. A high level of microsurgical expertise is essential and the patient must be willing to sacrifice a toe for this procedure. This may be hard to justify as the local flaps mentioned above are easily and more reliably performed.
  • Revision amputation is an alternative to reconstructing a problematic hook-nail deformity.

Pincer Nail Deformity

  • Is corrected by using dermal grafts to "build up" the sides of the nail bed. This is done by first removing the nail plate. Then an incision is made in an oblique fashion in the pulp of the distal fingertip just distal to the end of the lateral nail folds. The nail bed is elevated off the distal phalanx by passing a Freer periosteal elevator into the wound gently pushing proximally. This will create a tunnel that is 2-3 mm wide and extends the full distance of the nail bed, including the germinal matrix. Care must be taken not to damage or buttonhole the overlying nail bed.
  • Nylon sutures (5-0) are then placed through the dorsal skin into the tunnel created between the distal phalanx and the lateral bed. The suture is carried out of the wound to capture the proximal end of a dermal graft. The suture is passed back through the tunnel and out the dorsal skin, exiting near the entrance of the previous suture. The dermal graft is advanced through the tunnel by pulling on the sutures. The suture is tied, securing the dermal graft in the tunnel. The excess length of the dermal graft is excised, and the wound is closed with a single nylon suture. Both sides (medial and lateral) of the nail plate are done in the same way.
  • A silastic sheet (the old nail won't work here--wrong shape) is introduced into the eponychial fold. The sheeting is removed in approximately 10 days. The procedure has had excellent results in restoring the nature contours of the nail plate.

Loss of the eponychium with synechiae

  • Entirely removing the nail plate is often necessary to see the remaining edges of the proximal nail fold. As with the other deformities, any scar tissue of the nail bed, matrix, etc must be removed.
  • Composite grafts can be obtained from the large or second toe. These composite grafts include the dorsal roof of the eponychial fold as well as the dorsal skin.
  • The composite graft is sutured in place with a 7-0 chromic and 6-0 nylon sutures, and the nail plate is replaced. The surgical site is then covered with sterile gauze and dressed as described previously.
  • The survival of the grafts can be precarious. The postoperative immobilization must be meticulous.
  • Occasionally enough skin is available on the dorsum (top) of the finger to rotate or transpose as local flaps to the eponychium. A split sterile matrix graft can then be sutured to the undersurface of the flap to restore the dorsal roof bed. The donor site of the flap is closed primarily or covered with a split-thickness skin graft.

COMPLICATIONS / OUTCOMES

The results of the initial repair are far better than reconstructive attempts.

Infections to the nail bed following repair are uncommon.

Split-thickness sterile matrix grafts are required for areas of nail bed loss. The excellent results obtained from split grafting the nail bed defects have made this procedure common practice for most hand surgeons. The donor site heals without difficulty with most authors reporting no residual deformities secondary to graft harvesting. Orientation of the split graft on the recipient bed does not affect adherence or nail plate morphology. Though most will have good results, some patients may have some nail plate irregularity with linear ridging or distal nonadherence (usually at the site of the initial avulsion and not at the site of donor harvesting).

Germinal matrix defects must be treated with a full-thickness germinal matrix graft. The type of material (silicone sheet, nail plate, sterile petroleum jelly-impregnated gauze) placed in the eponychial fold does not appear to influence the final outcome and appearance of the regenerating nail plate.

It can not be said enough:

Careful initial repair has a better outcome than secondary reconstructive surgery.

REFERENCES

Nail Pathology; Michael Neumeister MD and Dimitrios Danikas MD; eMedicine Article, October 27, 2004

The Perionychium; Zook EG, Brown RE; In: Green DP, ed. Operative Hand Surgery. 4th ed. New York, NY: Churchill Livingstone; 1999.

Nailfold Reconstruction for Correction of Burn Fingernail Deformity; Plastic & Reconstructive Surgery, 117(7):2303-2308, June 2006; Donelan, Matthias B. M.D.; Garcia, Jesus A. M.D., Ph.D.

Nail Transfer: Evolution of the Reconstructive Procedure; Plastic & Reconstructive Surgery. 100(4) Supplement 1:907-913, September 1997; Endo, Takashi M.D.; Nakayama, Yoshio M.D.; Soeda, Shougo M.D.

Nail Lengthening and Fingertip Amputations; Plastic & Reconstructive Surgery. 112(5):1287-1294, October 2003; Adani, Roberto M.D.; Marcoccio, Ignazio M.D.; Tarallo, Luigi M.D.

Nail Regeneration by Elongation of the Partially Destroyed Nail Bed; Plastic & Reconstructive Surgery. 111(1):167-172, January 2003; Lemperle, Gottfried M.D., Ph.D.; Schwarz, Martin M.D.; Lemperle, Stefan M. M.D.

Nail Surgery; Neh Onumah MD and Richard Scher MD; eMedicine Article, September 18, 2006

33 comments:

BassoonJedi said...

Please tell me how I can avoid a non-adherent nail. Two weeks ago I cut a "corner" of my thumb off, which was surgically re-attached (the cut portion of nail was removed). My nail bed has developed thickened yellowish/whitish "skin" (more like scales) which will eventually be covered by the growing nail. Can I debride the scaly skin myself? The injury did not extend all the way down into the germinal matrix. Thank you for your thoughts.

rlbates said...

BassoonJedi, I can't replace your treating physician. It may be best to see your physician and have him/her do it.

"If the cause of non-adherence is due to hyperkeratosis of the nail bed, then the hyperkeratosis is removed by scraping the sterile matrix with the edge of the scalpel blade down to the level of the normal nail bed. The nail either grows out completely or partially adheres to the nail bed. The procedure may be repeated if complete adherence is not achieved."

BassoonJedi said...

Thanks for your thoughts -- my doc is out of town for a week, and his nurse refuses to allow me to see any of his five colleagues "because they've never seen you before." I explained to her what I'm experiencing and she doesn't get it: "oh, you've got a nail rent." "No, it's hyperkeratosis of the sterile matrix." "Oh, well, I don't remember that you had anything done to your nail bed, so you must be thinking of something else." "No, the ER took off part of my nail." "Well, you must be confused." Aaargghh!!! I am calling around town but every doc has a waiting list of at least a week, and it's been growing out over the top of the "scab" for two weeks now. I liked the pictures on your site. Thank you again.

Anonymous said...

And my doctors sais there was no way to fix my nail bed. My issue is the loss of the eponychium with synechiae, I cruched my left big toenail when I was about 4 or 5 & it got deformed like the picture shown above, & it was so embarrassing I couldn't ever wear flip flops till later in high school! People would just stare at it & today when I do wear sandals, I will catch some one staring at it. I think I'll show this article to my doctor now. Thanks for the info

Anonymous said...

hi i had an accident since i was 7 years old and my toe nail was divided into 2 and there was a lump in between of two divided nails. im now 28 i decided to have my surgeon remove my nail and thinking that my nail would come back in normal. the operation held last april 13, 2009 but until now the nail is not growing yet when i read your article i got scared that maybe my nail will not grow at all... please educate me on this...
my name is irish of the philippines

rlbates said...

Irish, if your surgeon did not destroy the nail matrix then your nail should grow back. Toe nails grow back very slowly. Give it more time.

leah said...

I finally know what this is called! Thank you.
What's the ball-park cost for surgery for a non-adherent fingernail? Would any insurance cover this?
If it makes a difference, my left index fingernail has partial non-adherence and also a vertical split close to the side of the finger -- the split bothers me less than the non-adherence, which is in the larger 'half' of the nail. The larger half also seems thicker. I've had this since I was around 11 and slammed my finger in the door, I'm in my late 20s now.

rlbates said...

Leah, I'm not sure what to tell you about cost. You'll have to ask your surgeon. Whether insurance will cover yours will depend on why it is done -- ie problems vs looks. You can call your insurance company and ask them.

Phillothea@aol.com said...

When I was 10 my big toenails on both feet were removed surgically due to chronic ingrown toenails. Through the years I always had to wear a closed shoe. Now I glue fake toenails on, but they don't stay on long. Is there anything that can be done to correct this problem?

rlbates said...

Phillothea, not without sacrificiing another nail for a graft.

Anonymous said...

Hi, thanks for your article. My issue is similar to Pillotheas above. When I was 15, I had ingrown toenails on both sides of my right big toe due to playing a sport. It wasn't a long-term issue, but an unexpected one. I was young and with the pain I opted for permanent removal on both sides of the toe. It's been difficult for me, but now 28 I have tried to research ways of nail regrowth through surgery. I believe you explained and I've read somewhat through germinal matrix grafting of a donor nail. It's difficult to find much more info on this other than in medical books and articles online. I'm curious, who would perform such procedure, and what type of doctor could best be talked to further about this issue.

rlbates said...

Anon (Sept 20), you will most likely have to do some searching for a doctor. Try plastic surgeons and orthopedic hand & or foot specialists.

Anonymous said...

Hi!

thank you so much for this post.

When I was twelve I injured my toenail. During past 20 years I had 3-4 procedures to remove this toenail, but it continues to grow irregular, so I believe (after reading ur article) that this is due to Pincer Nail Deformity. So, I was wondering if you know who can treat it and may be you can refer me to an MD from NY state?

Thnx,
Nataliya

rlbates said...

Nataliya, I'm sorry but I don't know the doctors in NY State. I would look for either a good podiatrist or an orthopedic foot doctor.

Harmeet said...

Hi, my 2 big toenails keep falling off (left one since I was 17 & the right one past 5yrs; am 36 now & live in Malaysia; both from trauma). I did not have fungus, had it tested many times but did take itraconazole 200mg twice/day x 1wk every mth for 1yr (just completed last mth). Everytime they'd start to grow back, they'd start to lift and fall off again. It is very embarrassing but I don't wear closed shoes as I feel it would add to the prob ie. not help the nails grow. I'm wondering if you can help me find a clinician that does toe nail transplants/ grafting in Malaysia? I have no known med illnesses.

rlbates said...

Sorry, Harmeet, I don't know any physicians in Malaysia.

Hyesun, LEe said...

Hi,
My name is Hyesun and Korean.
i have a son and he is one
year old,
he has a divied nail by nature
the index finger his left hand.
i thought if he will grow, the nail is also get together..then
not yet..when he was 3month i saw a doctor at quiet a big general hospital but they couldn't any help. my english is not enought to explanation well...pleas let me know what can i do for my son.
sola-1@hanmail.net

rlbates said...

Hyesun, it may well be that your son has a partial thumb duplication. You should ask for him to be seen by a hand surgeon.

Maisie said...

I have a special case with a fingernail, and I'm really wondering if you have any suggestions whatsoever on how or if I could fix it...

When I was about 8 years old, a mole began to form under my nail bed. It was there for 2 years before doctors finally decided to remove the entire nail bed (after have taken off the nail several times). The plastic surgeon who did it did a good job, and used skin from my hip to heal the wound. They did, however, scrape right down to the bone. There is now a small layer of skin between where my nail would have been, and where my bone is. I have now gone 7 years with my finger like this.

I'm wondering if there is ANYTHING that can be done for this. One of the plastic surgeons I talked to when this surgery was going on said that they might be able to use one of the nailbeds from my toes and transplant it onto my finger. While this is not the ideal solution, I'm wondering if it's possible to somehow reconstruct my finger so I will one day have a nail?

Thank you for your time!

rlbates said...

Maisie, I don't know of anything other than a nailbed graft/transplant from a toe as your plastic surgeon suggested.

Anonymous said...

Hi Dr. Bates,

Thanks for your informative post.

I am Harish. I used to have fungal problem(discoloration, thick and non-adherent nail) on my toenail.

After using alternative medicine(Homeopathy) for 1 year the fungal problem seems to be cured because there is no discoloration anymore but my discolored toenail came-off and the new nail has grown only upto 75% of the full size nail - it is not growing anymore.

Also, there is a red mark at the end of the nail that looks like a blood clot, my doctor said that this was a ingrown toenail and when it tried to grow under another nail due to pressure it has thickened and discolored.

My question is - can a surgery help to have a normal fully grown nail back and is there a chance to get the slim nail back.

I know its your old post but I am desperate to know the answer.

Thanks

rlbates said...

Harish, it may be possible. You would need to see your surgeon so they could exam your nail/nailbed and see.

Anonymous said...

Hi Dr. Bates and others,

Thank you for this information, I thought I was the only one who worried about the appearance of my nails! About 6 years ago my GP noticed a severely dysplastic Nevis on the nail bed of my left thumb which needed to be removed and would not bare another nail. My surgeon advised me to have a tissue transplant from both of my big toes, taking half of each to use towards reconstructing the nail in my thumb. Unfortunately the graph got infected and did not take. All of it had to be removed. So the result is two "half" big toe nails and no thumb nail. I have come to accept my feet and my hand (the results are a lot better than if my GP had never noticed the growth!) But I have recently got engaged and would love nothing more than having a nail on my thumb for the big day! As I have used the best donors for my graph already, I don't think another transplant is an option for me. So my question is (if I don't sounds too crazy!) is there any way I can have something surgically inserted into surface of my thumb which would support an artificial nail? I have tried acrylic/ gel nails but obviously the glue or gel won't stay secured to skin alone, it needs something more solid. If you could make any suggestion at all I would really appreciate it! Thanks a lot, Linda, Australia

rlbates said...

Anon (11/3/11), congratulations on your engagement. Best wishes to a long and happy marriage/life together.

As for your suggestion, I don't know of anything though love your thinking.

Anonymous said...

8 weeks ago my 3 year old daughter amputated her fingertip completely at the lunula. She had a composite graft done, which went completely black like a large scab. The scab itself has not come off although we were expecting it to. I am told that the scab may not come off by itself if there was insufficient covering of the bone. I am also told that to remedy this the bone may need to shortened. How long does it usually take for a scabbed composite graft to fall off and is there an alternative to bone shortening?

rlbates said...

Anon (1/26/12), check out this post on fingertip injuries. It discusses flap options that a hand surgeon can often use to maintain length of the finger.

Anonymous said...

Hi! i am so excited to find someone who seems to regularly have answers for people, that is hugely awesome.

ok, so jumping right in - i wanted to ask if it would be possible to graft part of the matrix from one toe to another, & if it was would it be likely to join together to form one solid nail on the recieving toe?

my right big toenail was recently (jan. 21st) ripped off and about 1/3 of the germinal matrix on the far right side was pulled out from under the cuticle... if i knew then what i know now i would have cleaned the area and re-inserted it... but i didn't. so now i seem to have just 2/3 (maybe less, too early to tell) of a toenail on that toe... i am not worried about the look, but i hate open toed shoes & love socks, i am scared to wear closed toed shoes for fear of fungal infections in the exposed nail bed, or socks pulling up the remaining toenail... would it be possible/advisable to graft 1/4 inch of toenail from the far right of my left big toenail onto my right big toenail to leave me with 2 suitable (albeit smaller) toenails?

.....sorry, that's a bit long ^^;

-Friday N

rlbates said...

Anon (2/29/12),
It is possible to graft matrix from one toe to another and it might join together. It will leave the donor nail smaller. There is always risk of infection and graft loss, so it is never a guarantee. Take you questions to a foot surgeon or a hand surgeon. Then decide if the risks are worth it for you.

Anonymous said...

thanks so much for that little bit of good news!
-fri

Lisa said...

I think I have Linear Ridging Deformity from peeling up a layer of my right thumb nail about 13 years ago when i noticed a tiny crack around the nail bed and the same on my left hand maybe 5 years ago. I always thought this would go away if I could just stop picking at/filing the ugly nails in a false attempt to make them look better. I have let them be for a few months now and they haven't gotten better at all. In fact, very pronounced vertical cracks have started near the cuticle on both nails in the last few days. Now, after reading this and other information online, I am afraid this damage will never be repaired. I am so ashamed of these hideous nails. Do you know of any specialists who could treat such old injuries in New York?

Thank you so much for your help.

rlbates said...

Lisa, I'm sorry but I don't. Look for a good hand surgeon in your area

Anonymous said...

Hello ,I had my left thumb nail complectly remove, Since the nail will never grow back ,how or what can be done to protct the thumb ??

rlbates said...

Anon (Oct 29, 2013), the fingertip can be protected with a band-aid or a strip of Coban wrapped around it. Over time, the skin where the nail bed was should get "tougher" and not need as much if any protection.