CARACTERÍSTICAS
BIENNO SE RECOMIENDA
Bertrand Richert
Nails play an important esthetic and functional role in our society. Nowadays, esthetic improvements become increasingly common. Some nail dystrophies may bother patients in daily life: denial of wearing sandals, hiding a finger by keeping their hands in pockets, clenching their fists in public, etc. Physicians should be aware that some congenital and acquired nail dystrophies might benefit from surgical cures allowing a nice cosmetic outcome when performed by skilled surgeons. Here will be reviewed some of the most common nail dystrophies that may be improved by surgery: malalignment of the big toenail, trapezoi- dal nails, racquet thumbs, vertical implantation and duplication of the nail on the fifth toe. For more complex dysplasias and malformations, involvement of hand surgeons is recommended.
MALALIGNMENT OF THE GREAT TOENAIL This congenital disease is discussed in “Ungueoder- mal Flap for Congenital Malalignment of the Great Toenail,“ pp. 135–137.
This condition should be operated before the age of six to obtain the best cosmetic outcome. However, as there is no alternative treatment it may be indicated to try to improve the aspect of a severely distorted and thickened nail by surgically rotating the whole nail unit as described for children. This usually results in a correctly orientated nail, much thinner and shorter as the nail bed has been epithelialized in its distal part (Fig. 1A). In some instances, an almost normal nail may even grow out (Fig. 1B). A number of so-called onychogryphoses in nondebilitated persons are in fact due to an untreated congenital malalignment of the big toenail.
TRAPEZOIDAL NAILS Introduction
l Trapezoidal nails are a congenital nail abnormal-
ity where the nail plate appears to widen distally as its proximal part remains hidden by the proximal portion of the lateral nail folds (Fig. 2A). The plate may look too wide for its bed, but in fact the PNF-LNF junction is too medial.
l The condition is always symmetrical and affects
both great toenails. Unlike racquet thumbs, no bony alteration is associated (1).
l This affection would only be a curiosity if the
imbalance between the width of the nail plate and that of the nail bed would not promote distal lateral onychocryptosis in some patients (Fig. 2B), the distal borders of the nail plate pushing laterally on the nail folds. With time, this may promote the development of a hyper- trophic lip.
Figure 1 (A) Cosmetic outcome of reaxation of the great toenail in a young adult. Compare with the contralateral nail. The new nail is thinner and normally oriented and exhibits a nicer hue. In summertime, an acrylic nail may be stuck on it. (B) Almost complete recovery of a normal nail after surgery (compare with the contralateral nail). Note the scar from surgery (see arrow).
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l The trapezoidal appearance of the nail may
appear “too masculine” for some women seek- ing a cosmetic surgical improvement.
Anesthesia
l Bilateral distal digital block
Tools
l Nail avulsion tray
l 88% phenol, 10% sodium hydroxyde, or 100%
trichloracetic acid
l Cotton-tipped applicator
Surgical Procedure Technique: easy
l The goal of the treatment is the permanent
narrowing of the nail plate either for achieving a cure of ingrowing toenail or for cosmetic reasons.
l Chemical cautery is the best choice (see “Narrow-
ing the Matrix with Chemocautery,” pp. 106–108). This treatment is simple, time honored, cheap, and reproducible and produces a permanent cure with low recurrence rate.
l The lateral fifth of the nail plate is detached from
the nail bed and from the proximal nail fold using an elevator.
l The detached nail portion is split down under the
proximal nail fold with thin nail nippers and then avulsed in a rotating motion with a hemostat.
l This procedure allows the lateral nail folds to
flatten. They fill the space previously occupied by the avulsed nail strip.
l A cotton-tipped applicator or the elevator itself
(if the lateral avulsion is narrow) dipped into the cauterant is pushed under the proximal nail fold and rubbed onto the exposed lateral horns of the matrix (1).
Key Point
l This procedure has to be performed in a blood-
less field (tourniquet) as blood neutralizes the phenol (2).
Postoperative Care Pain: very little
l Oozing from the chemical burn will last for
about two to six weeks according to the type of cauterant.
l Soakings with antiseptic soaps twice per day,
followed by application of antiseptic solution is mandatory during that time.
Evolution
l Cosmetic results are dramatic (Fig. 3).
Complications and Management
l The same as for chemical cautery (see p. 108).
RACQUET NAILS Introduction
l This term refers to a hereditary malformation of
the thumbs resulting in brachyonychia, the width of the nail plate and nail bed being greater than their length. Clinically, the thumb exhibits a gross, short and broad terminal phalanx that usually lacks the lateral nail fold (Fig. 4A).
l Racquet thumbs are inherited as an autosomal
dominant trait with variable penetrance and expression; females are three times more affected than men (3).
l It affects symmetrically the thumbs. Some cases
may be asymmetrical and involve only one thumb, rarely another finger or even a toe. Exceptionally, all fingernails are affected.
Figure 2 (A) Trapezoidal nail. The nail seems to wide distally. The lateral nail folds are pushed laterally. The contralateral nail benefited from bilateral chemical cautery eight weeks before. (B) Acute paronychia in a trapezoidal nail.
l This deformity is caused by an early obliteration
of the epiphyseal line of the thumbs, while the periosteal growth continues, leading to a wider and shorter bony phalanx covered with a nail plate of a similar shape (3).
l Narrowing the nail plate and recreating lateral
nail folds may improve esthetic appearance. Anesthesia
l Bilateral distal digital block
Tools
l Standard nail surgery tray
Surgical Procedure Technique: difficult
l Lateral longitudinal nail excisions in the shape of
a so-called “lazy S” are performed on both sides of the thumbnail exactly as performed for the lateral longitudinal biopsy.
l The lateral soft aspects of the distal phalanx are
dissected from the bone almost down to the volar aspect.
l Back stitches (nonabsorbable 3/0 suture) are
used to create lateral nail folds. The needle is run into the lateral aspect about 2 to 3 mm volar
Figure 4 (A) Racquet thumb. (B) Narrowing the nail and the soft tissues in raquet nails. The longitudinal excision is a “lazy S” as described for lateral longitudinal biopsy.
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to the plane of the nail bed-bone interface, through the nail bed and plate, and back again through the lateral thumb skin, which, upon knotting, will be elevated, thus forming a lateral nail fold (Fig. 4B) (4,5).
l Nail groove epithelium develops by secondary
intention.
l It might be interesting in some cases to try to give
a longer shape to the plate by removing a crescent of the proximal nail fold as performed in chronic paronychia (see “Chronic Paronychia,” pp. 43–46).
Key Point
l Removal of enough soft tissues to avoid the
appearance of a narrow nail on a short broad extremity.
l Back stitches are most important as to recreate
the lateral nail folds.
Postoperative Care Pain: severe
l Injecting bupivacaine postoperatively as a distal
wing block is two folds: (i) bleeding is severe after removal of the tourniquet; the volume of anesthetic will press onto the lateral digital arteries, thus reducing bleeding; (ii) this is a painful surgery from the large removal of tissue and traction from suture.
l Give strong painkillers (opioids are recom-
mended) (see “Postoperative Pain Management, Pain Killers,” pp. 20–21).
l Bulky dressing is a must with renewal after
24 hours, not later.
Evolution
l Healing is complete within three weeks. l Early mobilization is mandatory.
Complications and Management
l As for lateral longitudinal biopsy, incomplete
removal of the lateral horn of the matrix will result in the growth of spicules. It starts with inflammation of the most proximal part of the lateral nail fold, with sometimes some purulent discharge. While the spicule has pierced the skin, inflammation lessens and healing occurs, leaving a horn popping out from the lateral sulcus or from the lateral aspect of the finger.
VERTICAL IMPLANTATION OF THE FIFTH TOENAIL
Introduction
l In this rare disorder the aberrant implantation of
the matrix of the fifth toenail is responsible for its vertical growth (Fig. 5A, B).
l In addition to the esthetic inconvenience, it
generates a real discomfort especially when pulling on stockings or socks, the nail being pushed backward. Ladies mostly complain of running their stockings.
l Treatment is total nail ablation.
Anesthesia
l Bilateral distal digital block
Tools
l Basic nail surgery tray
Figure 5 (A) Vertical implantation of the fifth toenail. (B) Histological aspect. (C) Vertically implanted fifth toenail before surgery. (D) Cosmetic and functional outcome of a vertically implanted fifth toenail. Source: Part B: Collection of J. Andre´, Brussels, Belgium.
Surgical Procedure
Technique: easy to intermediate
l The best cosmetic option is the definitive
removal of the nail apparatus in one block in a transverse ellipse, down to the bone and half way down the lateral aspect of the toe to remove the lateral horns of the matrix, and suturing of the defect.
l In some instances, a relaxing incision at the tip of
the toe is mandatory to free a flap from the hyponychium that is pulled dorsally to allow primary closure.
l This leaves a “naked” toe cosmetically very
acceptable (Fig. 5C, D).
l If the patient is not willing to undergo such a
surgery, chemical cautery of the whole nail matrix is the best alternative (1).
Key Point
l Complete removal of the lateral horn of the
matrix with a wide lateral excision, reaching the midline of the lateral aspect of the toe.
Postoperative Care Pain: intermediate
l Greasy dressings
l Soakings and antiseptics until removal of the
stitches
Evolution
l Primary closure heals rapidly.
l The defect left by the relaxing incision may take
more time (up to three weeks depending on its size).
DUPLICATION OF THE FIFTH TOENAIL (DOUBLE LITTLE TOENAIL)
Introduction
l This condition is quite common and may prob-
ably be genetically determined (6).
l Pain is promoted by the lateral rotation of the
fifth toe in spread foot when the patients walk on the lateral aspect of the fifth toe (Fig. 6A).
Figure 5 (Continued )
Figure 6 (A) Scheme explaining the etiology of the duplication of the fifth toenail. (B) Clinical appearance of double little toe. (C) Preoperative aspect. (D) Immediate postoperative aspect.
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l It presents as a horn filling the lateral sulcus
(Fig. 6B, C).
l Patients search medical advice because the con-
dition may be very painful. However, often it is just a chance observation.
Anesthesia
l Distal digital block
Tools
l Basic surgery tray
Surgical Procedure Technique: intermediate
l Excision in the shape of a so-called lazy S exactly
as performed for lateral longitudinal biopsy (Fig. 6D)
Key Point
l Complete removal of the lateral horn of the
matrix, with a lateral excision reaching the midline of the lateral aspect of the toe
Postoperative Care Pain: intermediate
l Greasy dressing until healing.
l Unfortunately, pressure will occur on the wound
from walking on it because of the forefoot alteration and may render the postoperation
quite uncomfortable. Try to perform this surgery in summertime when footwear is looser.
Evolution
l If the precipiting factors are not corrected, pain
will recur. Podiatric support is a must with specific insoles. Orthopedic surgery is exception- ally indicated.
Complications and Management
l Inflammatory reaction postoperatively is frequent
from rubbing of the wound against the shoe.
l Infection is possible.
REFERENCES
1. Richert B, Choffray A, de la Brassinne M. Cosmetic surgery for congenital nail dystrophies. J Cosmet Dermatol 2008; 7:304–308.
2. Baran R, Haneke E. Matricectomy and nail ablation. Hand Clin 2002; 18:693–696.
3. Ronchese F. The racket thumbnails. Dermatologica 1973; 146:199–202.
4. Haneke E. Reconstruction of the lateral nail fold after lateral longitudinal nail biopsy. In: Robins P, ed. Surgical Gems in Dermatology. New York: Journal Publ Group, 1988:91–93.
5. Haneke E, Baran R. Nails: surgical aspects. In: Parish LC, Lash GP, eds. Aesthetic Dermatology. New York: Mc Graw Hill, 1991:236–247.
6. Haneke E. Therapie von Nagelfehlbildungen. In: Land- thaler M, Hohenleutner U, eds. Fortschritte der Operativen Dermatologie. Vol. 12. Berlin, Wien: Black- well Wiss-Verl, 1997:180–187.
Figure 6 (Continued )
Index
Page numbers followed by f and t indicate figures and tables, respectively. Acquired fibrokeratoma anesthesia, 50 complications of, 50 evolution of, 50 key point, 50 management of, 50 overview, 49–50 postoperative care, 50 procedure for, 50 tools of, 50 Acute paronychia, 42–43, 43f anesthesia, 42 complications of, 43 differential diagnosis of, 42 evolution of, 43
key points, 42 management of, 43 overview, 42
postoperative care, 43 surgical procedure for, 42 tools for, 42
Analgesics
in nail surgery, 21 Anesthesia
Bowen’s disease lateral nail folds, 92 nail bed, 72 complications
from anesthetic, 29 from technique, 29 management, 29 distal fold, tumors of, 102 distal nail embedding, 98 evolution of, 28
fibrokeratomas lateral nail folds, 92 nail bed, 66 for chondroma, 153
for closure by reversed dermal graft, 143 for cross-finger flap, 144
for duplication of fifth toenail, 182 for enchondroma, 154
for exostosis, 149
for graft, closure with, 141 for inclusion cyst, 155
for lacerating and crush lesions, 173
[Anesthesia]
for lateral longitudinal biopsy, 133 for myxoid cysts, 165
for nail plate biopsy, 31
for nail removal, whole unit, 138 for osteochondroma, 149 for osteoid osteoma, 157 for partial nail plate avulsion, 38
longitudinal, 40 proximal, 39 for racquet nails, 179
for subungual hematoma, 172 for total nail plate avulsion
distal approach, 32 proximal approach, 34 for trapezoidal nails, 178
for unguodermal flap for CMBT, 136 for vertical implantation of fifth toenail, 180 glomus tumor, 70
heloma, 74
horn of the lateral sulcus, 90
hypertrophic lateral walls, ingrowing nail with, 87 hypertrophic lip, 85 implantation cyst, 95 key points, 28 materials in, 25 nail bed biopsies, 55
elongation for larger defects, 76 grafting, 80
of nail apparatus, 24–29
pachyonychia congenita (PC), 76 procedures, 25–28
distal digital block/wing block, 26–27, 26f hyponychial block, 28
matricial block, 27, 27f
proximal digital block, 25–26, 25f transthecal digital block, 27–28, 27f products, 24 pyogenic granulomas, 62 SUKA, 64 superficial fibromyxoma, 69 tips, 28–29 Antibiotics, prophylactic, 16–17 Avulsion of matrix, 174–175
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Avulsion, of nail plate, 31–41 partial, 38–41, 39f–41f total, 32–38, 33f–37f
Beaver blade, 103 No. 64, 128
Beaver blade system, 14, 14f Biopsy, of nail plate, 31
anesthesia for, 31 complications, 31 indication for, 31 procedure for, 31 surgical tools for, 31
Blood thinners, discontinuation of, 18 Blood vessels, of nails, 3–4
Bone rongeur, 14
Bowen’s disease, lateral nail folds, 92–95, 93f, 94f anesthesia, 92 complications, 94–95 evolution, 94 key point, 94 management, 94–95 postoperative care, 94 surgical procedure, 93–94 surgical tools, 92
Bowen’s disease, nail bed, 72–74, 73f anesthesia, 73
key point, 74
surgical procedure, 74 surgical tools, 73 Bowen’s disease
and curled nail avulsion, 37f Bupivacaine, 24
for racquet nails, 180
Candida albicans, 43 Cardiac disease
local anesthesia and, 24 Chemocautery, 106–108, 107f, 108f anesthesia for, 106 complications of, 108 evolution of, 108 key point, 107 management of, 108 of whole nail matrix, 113 overview, 106 postoperative care, 107 procedure for, 106–107 tools of, 106 Chondroma, 152–153 anesthesia for, 153 complications of, 153 evolution, 153 key point of, 153 management of, 153 postoperative care, 153 surgical procedure for, 153 tools for, 153
Chronic paronychia, 43–46, 43f, 44f anesthesia of, 44
complication of, 46 en bloc excision of, 44 evolution of, 46 key points of, 45 management of, 46 overview, 43–44 postoperative care, 45
surgical procedure for, 44–45, 45f tools of, 44
Cicatricial pterygium trauma and, 175
Cleaning, of surgical site, 17 Closure
by reversed dermal graft, 143–144. See also Reversed dermal graft, closure by
with graft, 140–143, 142f. See also Graft, closure with with secondary intention healing, 138f, 139–140,
139f–141f. See also Secondary intention healing, closure with
CMBT. See Congenital malalignment of the big toenail (CMBT)
Congenital abnormalities, cosmetic surgery for, 177–182, 177f–182f
malalignment of great toenail, 177, 177f
racquet nails, 178–180, 179f. See also Racquet nails trapezoidal nails, 177–178, 178f, 179f. See also Trapezoidal
nails, cosmetic surgery for
vertical implantation of fifth toenail, 180–181, 180f–181f. See also Toenail, fifth, vertical implantation of Congenital malalignment of the big toenail (CMBT)
cause of, 135
characteristics of, 135, 136f
unguodermal flap for, 135–137, 136f–137f anesthesia for, 136
complications, 137 evolution, 137, 137f key point of, 137 peri-operative care, 137 postoperative care, 137 procedure for, 136–137, 137f tools for, 136
Connective tissue
matrix, with Vater-Pacini body, 9f subungual, neural structures in, 9f Cosmetic surgery
for congenital abnormalities, 177–182, 177f–182f for vertical implantation of fifth toenail, 180–181,
180f–181f. See also Toenail, fifth, vertical implantation of
malalignment of great toenail, 177, 177f
racquet nails, 178–180, 179f. See also Racquet nails trapezoidal nails, 177–178, 178f, 179f. See also
Trapezoidal nails, cosmetic surgery for Crescent excision, 46f, 128–129, 128f
anesthesia, 46, 128 complication of, 47, 129 evolution of, 47, 129
[Crescent excision] key point, 47, 128 management of, 47, 129 overview, 46, 127 postoperative care, 47, 128–129 procedure for, 47, 128, 128f tools for, 47, 128 Cross-finger flap, 144–147, 145f–146f anesthesia for, 144 complications of, 147 evolution, 145f, 146f, 147 key point of, 147 postoperative care, 147 procedure for, 144–146, 145f–146f tools for, 144 Crush lesions, 173–176, 174f–176f anesthesia for, 173 complications of, 175–176, 176f evolution, 175
perioperative antibiotics for, 173 postoperative care, 175
procedure for, 173–175, 174f–175f severe injury, 174, 175f
tools for, 173
Curled nail avulsion, 37–38
complications and management, 38 evolution, 38
indications for, 37 key points, 38 postoperative care, 38 procedure for, 37–38, 37f surgical tools for, 37 Cuticle, formation of, 7, 7f Cyst, nail
trauma and, 175
Dental spatula elevator, 11, 12f Dental syringes, 25, 25f
Digital myxoid cysts (DMC), 165–169 anesthesia for, 165
complications of, 169, 169f evolution, 167f, 169 key point of, 168, 168f management of, 169, 169f postoperative care, 169
surgical procedure, 165–168, 166f–168f tools for, 165
Discontinuation, of systemic treatments, 17–18 Disinfection, of surgical field, 18
Distal approach, for nail plate avulsion, 32–34 anesthesia for, 32
complications and management, 32, 34 indication for, 32
key point, 32
postoperative care, 32 procedure for, 32, 33f surgical tools for, 32
Distal digital block procedure, 26–27, 26f complications, 29, 29f Distal embedding, 32, 34, 34f, 36 Distal fold distal embedding, 97–100 tumors of, 100–102 anesthesia, 102 evolution, 102 key point, 102 postoperative care, 102 surgical procedure, 101f, 102, 102f surgical tools, 102
Distal interphalangeal joint, surgery of, 165–169, 166f–169f Distal lateral subungual onychomycosis (DLSO), 31 Distal matrix. See Nail bed
Distal nail embedding, 97–100 anesthesia, 98, 100 complications, 99, 100, 100f evolution, 99, 100 Howard-Dubois’ procedure, 98, 98f, 99f key point, 99, 100 management, 99, 100 postoperative care, 99, 100 shaving procedure, 99–100, 100f surgical tools, 98, 100
DLSO. See Distal lateral subungual onychomycosis (DLSO) DMC. See Digital myxoid cysts (DMC)
Dorsal digital nerves, in distal phalanxes, 4, 4f Double little toenail, 181–182, 181f–182f Dressings, 18–19, 18f–19f absorbent, 19 nonadherent, 18–19, 19f removal, 21, 21f replacement, 21, 22f securing, 19, 19f
Dual action nail nipper, 11, 12f Dura mater elevator, 11, 12f Dystrophy, nail
subungual hematoma and, 173
Elevator, 11, 12f Elliptical excision, 126–127, 127f EMLA cream, 28 Enchondroma, 153–155, 154f anesthesia for, 154 complications of, 155 evolution, 155 key point of, 154 management of, 155 postoperative care, 155 surgical procedure, 154 tools for, 154
English nail splitter, 11, 12f Epinephrine, 24
Eponychial flap, 47–49, 48f anesthesia, 47
complications of, 49 evolution of, 49 key points of, 49 management of, 49 overview, 47
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surgical procedure, 150–151, 150f–153f tools for, 150
Extensor tendon, insertion, 1, 2f, 5, 6
Fibrokeratomas (FK), 49–50, 120
Fibrokeratomas (FK), lateral nail folds, 91–92, 91f anesthesia, 92 complications, 92 evolution, 92 postoperative care, 92 surgical procedure, 92 surgical tools, 92
Fibrokeratomas (FK), nail bed, 66–69, 66f anesthesia, 66 complications, 69 evolution, 69 key point, 69 management, 69 postoperative care, 69 surgical procedure, 66–69, 67f–68f surgical tools, 66 Fingernails
shape and size of, 3, 3f FK. See Fibrokeratomas (FK) Flexor tendon, 2f, 4, 5, 5f Freer septum elevator, 11, 12f Fungal contamination
subungual hematoma and, 173, 173f
Ganglion cyst. See Digital myxoid cysts (DMC) Germinative matrix. See Nail matrix
Gillies skin hooks, 14, 15f Glomus tumor, 70–72, 71f anesthesia, 70 complications, 72 evolution, 72 key point, 72 management, 72 postoperative care, 72 surgical procedure, 72 surgical tools, 70 Glove tourniquet, 11, 13f
Graft, closure with, 140–143, 142f. See also Closure anesthesia for, 141
complications of, 142f, 143 evolution, 143
key point of, 142 management of, 142f, 143
[Graft, closure with]
postoperative care, 142–143, 142f surgical procedure for, 141–142, 142f tools for, 141
Hair, and nail, 6, 6f Hand, innervation, 4, 4f
Healing by second intention, for larger defects, 78–79, 79f Heloma, 74–75, 75f anesthesia, 74 complications, 75 evolution, 74–75 key point, 74 management, 75 postoperative care, 74 surgical procedure, 74 surgical tools, 74
Hematoma, subungual, 171–173, 171f–172f, 173f. See also Subungual hematoma
Hook nail
trauma and, 176, 176f
Horn of the lateral sulcus, 90–91, 90f anesthesia, 90 complications, 91 evolution, 91 key point, 91 management, 91 postoperative care, 91 surgical procedure, 90–91, 90f surgical tools, 90 Howard-Dubois’ procedure
for distal nail embedding, 98–99, 98f, 99f
for ingrowing nail with hypertrophic lateral walls, 89, 89f Hydroxyzine
for nail procedures, 16 Hypertrophic hyponychium
trauma and, 176
Hypertrophic lateral walls, ingrowing nail with, 87–90 anesthesia, 87 complications, 90 evolution, 90 Howard-Dubois’ procedure, 89, 89f key point, 89 Noe¨l’s procedure, 88, 88f postoperative care, 89 super U procedure, 88, 88f surgical tools, 87 Vandenbos’ procedure, 87, 87f Hypertrophic lip, 85–87 anesthesia, 85 complications, 87 evolution, 86 key point, 85, 86 management, 87 postoperative care, 86 surgical procedure, 85, 86f surgical tools, 85
Hyponychial block procedure, 28 Hyponychium, 2, 7, 9, 9f
Imaging, medical in preoperative assessment, 16 Implantation cyst, 95–96, 95f anesthesia, 95 complications, 96 evolution, 96 key point, 95 management, 96 postoperative care, 95 surgical procedure, 95 surgical tools, 95 Inclusion cyst, 155 anesthesia for, 155 complications of, 155 key point of, 155 management of, 155 postoperative care, 155, 156f surgical procedure for, 155, 156f tools for, 155
Ingrowing nail with hypertrophic lateral walls, 87–90 anesthesia, 87 complications, 90 evolution, 90 Howard-Dubois’ procedure, 89, 89f key point, 89 Noe¨l’s procedure, 88, 88f postoperative care, 89 super U procedure, 88, 88f surgical tools, 87 Vandenbos’ procedure, 87, 87f Intermediate matrix. See Nail matrix Interphalangeal joint, distal, 3, 5 Intraungual fibrokeratoma, 120 Irritation
digital myxoid cysts and, 169, 169f
Keratins, 9
Keratoacanthoma, 64–66, 65f. See also Subungual keratoa- canthoma (SUKA) Koenen tumors, 49–50 Laceration, 173–176, 174f–176f anesthesia for, 173 complications of, 175–176, 176f evolution, 175
perioperative antibiotics for, 173 postoperative care, 175 procedure for, 173–175, 174f–175f simple, 173–174, 174f stellate, 174 tools for, 173 Laser anesthesia, 108 complications of, 109 evolution of, 109 key point of, 109