CARACTERÍSTICAS
REEMPLAZO DE LA BOMBILLA
Eckart Haneke, Bertrand Richert, and Nilton Di Chiacchio
Some surgical procedures involve the whole nail apparatus, either for biopsy purposes (removal of a thin strip containing all its structures) or detachment of the whole nail apparatus with subsequent rotation (realignment of a misdirected nail) or section and removal (malignant process).
LATERAL LONGITUDINAL BIOPSY Introduction
l Lateral longitudinal biopsy allows the study of
all components of the nail unit including the matrix, the bed, the proximal nail fold and the hyponychium (Fig. 1). It is the most useful biopsy technique for the pathologist (1–4). It gives information over the entire period of the growth of the biopsied nail.
l It is indicated:
in inflammatory disorders with alteration of the surface of the nail plate resulting from involvement of the proximal matrix,
in excision of tumors, located in the lateral third of the plate,
in excision of longitudinal melanonychia up to 4 mm wide affecting the lateral part of the plate, and
as an independent technique to narrow a nail, for example, in a racquet nail (see pp. 178–180).
Anesthesia
l Proximal or distal digital block
Tools
l Tourniquet
l Basic nail surgery tray
l Blade No. 15C or No. 64 Beaver blades l Skin hooks (simple or double)
l 4/0 or 3/0 nonabsorbable sutures
Surgical Procedure Technique: difficult
l A tourniquet is placed.
l The incision starts halfway between the cuticle
and the distal interphalangeal crease and progresses distally through the proximal nail fold where the nail is the softest, and continues through the nail plate and its bed to the hyponychium. It may be hard to cut through the plate: repeated up and down movements with the blade with distal progression (as cutting a tart) helps greatly. Proximally, the incision takes a laterally curved direction that extends about halfway on the lateral aspect of the finger, up to the distal interphalangeal crease. This allows complete removal of the lateral horn of the matrix and ensures a more anatomical closure at the junction of the proximal and lateral nail folds. A second incision, starting from the distal extremity of the previous one, runs from the hyponychium into the lateral sulcus and joins the proximal end of the previous incision. It parallels the first one ensuring a sigmoid excision (Figs. 1 and 2A).
l The biopsy reaches a width of 2 to 3 mm at its
widest point. For resection en bloc of a longitu- dinal melanonychia this width may be much larger but closure should be performed with a flap (see pp. 92–95).
l All incisions are carried down to bone contact. l The specimen is then removed distally to
proximally. Holding the specimen should be very cautious, using either a skin hook or delicate forceps (Fig. 2B). Another option is to grasp the free edge of the nail plate with a
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hemostat. This is especially useful at the great toenail, where the nail is thick. Using fine sharp curved scissors with “tips down” (5), the spec- imen is detached from the periosteum. At the proximal tip of the biopsy, great care must be taken, as the matrix should be part of the biopsy (Fig. 2C), and one should avoid coming up with scissors too soon and foreshortening the speci- men (6). Another option, very smooth and easy, is to detach the whole specimen with a No. 64 Beaver blade pushed proximally and slide on the sides. The blade has to shave the specimen from the bone.
l The wound should be then reviewed to avoid
leaving small remnants of matrix.
l Proximal nail fold and hyponychium are closed
with single suture using nylon 4/0.
l A half-buried horizontal mattress suture with 3/
0 nylon, starting in the lateral nail fold and through the nail plate is will recreate a lateral nail fold (Fig. 2D, E).
l The tourniquet is removed.
Key Point
l Before surgery the digit should be soaked for
about 10 minutes in antiseptic solution or even saline solution to soften the nail plate. Another option is to ask the patient to soften the nail by nightly application of a 30% to 40% urea paste the three to four nights prior to surgery.
l The nail plate is a hard structure and it requires
some force to cut through it. Be careful when reaching the hyponychium as the blade may come out abruptly from the plate.
l Take extra care when removing the specimen in
its most proximal part. Beginners most often come up too soon with the scissors leaving the matrix on site.
l The lateral nail fold should not be included in
this type of biopsy. It will be included for excision of a tumor (see pp. 91–92).
l Be sure to have removed the whole lateral horn. l Suturing should not be too tight as the digit is
prone to swelling and tight sutures produce pain and can result in local ischemia (6).
Figure 2 (A-E) (A) Incisions in a lateral longitudinal biopsy. Note how the most proximal part of the incisions curve to ensure removal of the lateral horn of the matrix. (B) Dissection of the specimen from the periosteum. (C) Removing the most proximal portion of the biopsy is the toughest part: be sure to remove the matrix by staying on the periosteum at all times. (D) Suture recreating a lateral nail fold. (E) Closer view.
Postoperative Care Postoperative Pain: moderate
l Greasy nonadherent bulky dressing. l Give potent pain killers.
l Ask to keep the limb elevated.
l Removal of the dressing at 48 hours, soakings in
antiseptics twice daily for two weeks. Another option especially in patients frightened to do their wound care is to leave the new dressing in place for the next five to six days.
Evolution
l Suture removal is performed at 14 days. l Healing is fast (Fig. 2F and 3A, B).
l Long-term cosmetic outcome is great (Fig. 2G).
Complications and Management
l If the width of the biopsy or excision specimen is
wider than 3 mm, lateral deviation toward the site of biopsy should be expected (7).
l Postoperative cysts and spicules (8) are a com-
mon complication of such a biopsy. It may be avoided by careful examination of the most proximal aspect of the wound after removal of the specimen, checking that there is no remain- ing fragment of matrix. In case of doubt, the lateral matrix pocket should be debrided with fine forceps and scissors.
UNGUEODERMAL FLAP FOR CONGENITAL MALALIGNMENT OF THE GREAT TOENAIL Introduction
l Congenital malignment of the big toenail
(CMBT) is a relatively common condition (9–19). It may have a genetic background as it is seen both in homozygous twins as well as siblings (12–15).
l The cause of CMBT is not correctly known. It
was proposed that a hypertrophy of the dorsal expansion of the lateral ligament (20) exerts a pull on the lateral matrix horn of the hallux nail thus causing a malalignment of the matrix with consecutive oblique growth toward the lateral side of the foot (21–23). Elongation of the dorsolateral extension of the dorsal ligament has been recommended; however, its long-term effects were disappointing (23). There is more often than not also a deviation of the distal hallux phalanx in relation to the axis of the proximal phalanx and a widening of the base of the distal phalanx that is more pronounced medially pushing the medial matrix horn for- ward distally and thus the entire nail organ into an oblique position. This is later also seen in radiographs, which show a slightly oblique position of the epiphysis line.
l Clinically, CMBT is characterized by a lateral
deviation of the axis of the nail often aggravated by an additional lateral longitudinal curvature of the nail in itself, a marked degree of onycholysis usually allowing probing back to the matrix border, thickening of the nail with an oyster shell–like aspect, marked yellowish-greenish dirty discoloration (Fig. 3A), a sharp bend at its medial margin, and an overall triangular shape (Fig. 3B).
Figure 2 (F–G) (F) Aspect of the nail four weeks after a lateral longitudinal biopsy. (G) Long-term aspect. Seven years after a lateral longitudinal biopsy for lichen planus.
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l The toe(s) is shorter and often bulbous. The
hyponychium is retracted proximally and a distal nail wall has developed, which is, how- ever, usually hidden under the nail. The medial aspect of the distal nail wall is more pronounced.
l In some cases, a spontaneous resolution is
observed till the age of two (to five) years (12,13,17,18). This apparently depends on the degree of onycholysis: the more severe the onycholysis the less likely is spontaneous improvement.
l The best chances for a successful operation are
when this is done before the age of two to five years; however, an absolute age cannot be given (23,24). When there is no tendency toward improvement until the age of two (13) surgery is recommended.
l In patients older than two to five years, the nail
bed has often irreversibly shrunk and a distal nail wall formed. The rest of the nail field is epidermized obviating the potential to retrans- form into normal nail bed epithelium, which is unique in its property to firmly attach the nail (Fig. 3C). Without nail attachment, a normal nail cannot grow. Personal experience of one author (Eckart Haneke) suggests a positive effect on consistent massage of the nail bed with 20% azelaic acid cream (Skinoren1); however, no systematic trial has ever been performed with this drug.
l Untreated CMBT develops into onychogryphosis
at older age.
Anesthesia
l General anesthesia is preferred in little children.
We combine this with a proximal digital block
with either ropivacaine 1% or bupivacaine 0.5%, which allows the general anesthesia to be very light and guarantees a pain-free period of 12 to 24 hours.
Tools
l Basic nail surgery tray
l Bone rongeur or sturdy nail clipper
Surgical Procedure Technique: very difficult
l An incision is carried around the tip of the toe
approximately 5 mm below the level of the nail bed. Another incision is performed at the toe tip such as to yield a crescentic wedge of soft tissue that is slightly wider on the anteromedial aspect (Fig. 3D).
l The nail organ is meticulously dissected from the
phalanx, which at this age is not yet fully mature, while remaining directly on the bone. In most instances, the distal dorsal tuft of the distal phalanx is hypertrophic pointing upward (dorsally). It has then to be removed to give a straight surface of the distal phalanx. Care has to be taken not to perforate the nail bed while dissecting the nail bed and matrix from the underlying bone. The dissection has to be extended up to the joint without damaging the extensor tendon and the joint (Fig. 3E).
l The entire nail apparatus can be elevated as an
unguodermal flap and rotated into the correct axis of the toe. Slight overcorrection is sometimes advisable. Whether or not Burow’s triangles are taken to facilitate rotation depends on the degree of malalignment. Avoiding removal of Burow’s
Figure 3 (A–C) (A) Congenital malaligment of the great toenail. Note the oyster shell–like aspect and the greyish green color. (B) Congenital malaligment of the great toenail. Note the triangular shape and the bulky distal edge of the toe. (C) Congenital malalignment of the great toenail. Note the severe onycholysis and overcurvature indicating poor prognosis and the necessity of surgery.
triangles may avoid to further damage the arterial blood supply. The unguodermal flap is then sutured in its correct position with 4/0 stitches (Fig. 3F).
Key Point
l Detaching the entire nail apparatus as a whole
without perforating the bed of injuring the extensor tendon.
l Ensure enough rotation of the flap, if necessary
with Burrow triangles.
Peri- and Postoperative Care Postoperative pain: very painful
l The irregular nail plate as well as the onycho-
lytic area of the nail harbor a tremendous amount of bacteria, of which staphylococci, enterococci and other gram-negative enterobac- teria are the most important pathogens. Even with vigorous disinfection, the surgical field cannot be made sterile. We therefore give perioperative antibiotic prophylaxis: the anes- thesiologist gives our little patients an intrave- nous injection of an antibiotic that covers these potential bacteria, for example, a second-gener- ation cepholosporin (cefuroxim, cefotiam), before the surgery starts.
l It is advisable to elevate the foot for about
48 hours, which may be a real problem is some children.
l The dressing is changed the next day in a lukewarm
foot bath with some povidone-iodine soap.
Evolution
l The results of the unguodermal flap rotation are
usually good in little children. The older the patient, however, the less likely is a good nail growth after surgery. However, a new smooth well aligned nail may grow out but that will remain short from the long-standing onycholysis with epithelialization of the bed (Fig. 3G). This is nevertheless much more comfortable for the patient during footwear. Acrylic nails may be stuck on it during summertime.
Complications and Management
l Complications are partial flap necrosis, infection
and insufficient recovery of the nail bed.
l In young children, flap necrosis is exceptional. In
older children and adolescents, tip necrosis may develop depending on the degree of tension necessary to rotate the unguodermal flap.
l Infection may occur up to five days later and has
to be vigorously treated with antibiotics accord- ing to bacterial sensitivity; until the results of an antibiogram are known a staphylococcus-fast antibiotic is recommended.
REMOVAL OF THE WHOLE NAIL UNIT Introduction
l The nail apparatus is fully excised for two main
reasons: malignant tumor and severe posttrau- matic nail dystrophy.
Figure 3 (D–G) (D) U-shaped incision all around the toe tip. (E) After complete elevation of the whole nail apparatus. Note the shiny porcelain color of the terminal extensions of the extensor tendon. (F) After realignment and suture. Compare with Figure 3C. (G) This young lady had realignment of the right great toenail. The new nail is properly aligned, thin and nicely pinkish. Compare with the contralateral toenail not yet operated.
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l Amputation remains necessary in case of any
suspicion of bone involvement for squamous cell carcinoma (25,26) and for invasive melanoma (27–29).
Anesthesia
l This surgery is performed under local block,
usually a proximal or distal digital block.
Tools
l Basic nail surgery tray
Surgical Procedure Technique: intermediate
l First, the incision lines are drawn on the tip of
the digit according to the admitted safety margins: 6 mm minimum all around the nail apparatus (27). The incision starts at the tip of the finger or toe, 6 mm ahead of the hypo- nychium, and is prolonged on both sides, paralleling the lateral nail sulcus, 6 mm laterally, until the junction proximal-lateral nail fold. Here, it is mandatory to curve the incision line down and laterally to reach about the midline of the lateral aspect of the finger/toe, as the lateral horn of the matrix may extend that low, espe- cially on the great toenail. This will avoid any spicule formation or recurrence of the tumor (Fig. 4A). The two lateral incision lines join with a transverse cut over the distal interphalangeal joint.
l The nail bed is dissected from the bony phalanx
with sharp pointed scissors progressing proxi-
mally. Using a Beaver blade No. 64 renders the task easier. Always stick to the bone, the periosteum should ideally be removed during the procedure. Elevation of the bed is difficult as the unit of the bed and plate are unbendable. Grasp the distal end of the nail apparatus with a sturdy haemostat and use it as a lever (Fig. 4B). When reaching the matrix area, be very delicate and be sure to detach the whole matrix from the bone, especially laterally. Again, this is much easier with the Beaver blade. When the whole matrix area is fully detached lifting of the whole nail apparatus becomes very easy.
l Progress proximally until reaching the most
proximal incision over the distal interphalangeal joint. Take care of the extensor tendon that appears as a shiny whitish structure (Fig. 3E).
l Cut transversally the remaining attachments
with scissors. Key Point
l Removing the whole matrix and avoiding to
leave any remnant of it.
l Care must be taken to prevent a distal extensor
tendon injury. This event remains extremely rare as this structure is hard and easily recognizable. However in old patients this structure may be fragile and more easily torn up.
Evolution
l Closure of the defect may be done by secondary
intention healing or skin grafting.
l Usually, secondary intention healing is preferred
on toes and grafting on fingers.
Figure 4 (A) Complete removal of the nail apparatus for extensive Bowen’s disease. Note how the most proximal part of the incision curves to remove the most lateral part of the matrix horns. (B) Elevation of the bed using a hemostat. (C) A running locked suture around the wound will dramatically decrease postoperative bleeding after removal of the tourniquet.
CLOSURE WITH SECONDARY INTENTION HEALING
Introduction
l Secondary intention healing allows excellent
functional results. It is a simple and cost-effec- tive method for reconstruction (30): granulation tissue will develop and cover the defect.
l Second intention healing has several advantages
(31):
As safety margins are not known during surgery of the tumor, the wound can be left open until histological results are known (Mohs’ surgery). Then, if necessary, a new excision may be performed until margins are clear. Afterward, the surgical site may go on with the secondary intention healing or shift for grafting.
Surgical time is much shortened compared with closure with skin grafting.
No new wound is performed on the donor site.
l Repair time is longer (up to eight weeks) than
closure with grafts and instructions must be given to patients accordingly.
Surgical Procedure
l After complete removal of the nail unit, if
secondary intention healing is planned, a run- ning locked suture is performed all around the wound to avoid bleeding (Fig. 4C).
Postoperative Care Pain: very little
l If dealing with a high risk patient (diabetic,
impaired limb vascularization) prophylatic anti- biotics should be prescribed.
l The first dressing is left in place for 48 hours and
then gently removed. If adherent, soak until complete detachment. Never pull.
l The wound is thereafter soaked twice daily in
lukewarm water with antiseptic soap, tapped dry and covered with a large amount of greasy antibiotic ointment.
l A nonadherent dressing (Telfa1, Tulle Gras1,
Mepitel1) is placed over it, covered with a layer of cotton gauze and secured with an elastic bandage.
l The wound must be kept very clean. Patients are
orientated to wash the wound with saline solu- tion twice a day and hydrogel is placed into the wound. The wound should never dry out.
l Absorbent silver coated dressing can also be
used and changed weekly until complete heal- ing. These dressings are more expensive, but some patients will appreciate them as they will not have to check and clean the wound. More- over this type of dressing prevents infection.
Key Points
l Following the patient at regular intervals to
adapt the local treatment accordingly.
l Remove fibrous tissue with a curette if needed.
This is painless.
Evolution
l If proper care is performed and the patient is in
good general health, healing time will take from four to eight weeks (Figs. 5A–C, 6A–E, and 7A–D).
Figure 5 (A) Melanoma of the thumb. (B) Removal of the whole nail unit revealed an in situ melanoma. (C) Results at eight months postoperatively.
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l In diabetics, smokers and other person at risk
healing may take up to 12 weeks.
Complications and Management
l Infection is unusual but remains a serious
complication especially because of the naked bone at the very beginning. Therefore some practioners prefer to cover the first week with prophylactic antibiotics.
l Overgranulation may occur in young adults. Stop
the greasy ointments. Compressive dressings associated with drying lotion (i.e., povidone-