Split-thickness Nail Bed Graft Research Articles

Immediate Nail Bed Graft on Exposed Distal Phalanx in Fingertip Injury

Fingertip injuries with nail bed defects have traditionally been covered with full- or split-thickness nail bed grafts. However, it was widely understood, without sufficient evidence, that graft take is difficult if the nail bed is grafted directly on the distal phalanx. This study reports two successful cases of nail bed graft on sterile matrix defects with exposed bare cortical bone. Two patients suffered a crush injury on their fingers. While there was no fracture, the distal phalanx was exposed with a nailbed defect. As the defect was too large for primary closure and too small for flap coverage, a sterile matrix nailbed graft was performed using the ipsilateral big toe. In both cases, damaged nails have grown fully, identical to the contralateral finger with smooth and flat regrowth of the nail and adherence of the growing nail. Both outcomes were graded as excellent according to Zook’s criteria. No major complication was found except for a minor ingrown nail on donor site in both cases. Even if there is a nail bed defect with exposure of cortical bone, successful nail reconstruction could be obtained through immediate nailbed graft on the exposed distal phalanx.

Nail bed defect reconstruction using a thenar fascial flap and subsequent nail bed grafting.

BackgroundFull-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.MethodsFull-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. ResultsNine 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. ConclusionsWhen used in combination with a nail bed graft, the thenar fascial flap provides an excellent means of nail bed reconstruction.

Abstract: Nail Bed Defect Reconstruction Using Thenar Fascia Flap and Nail Bed Graft

INTRODUCTION: Split-thickness nail bed graft is the most preferred treatment option for covering nail bed defects.1 However, full-thickness loss of nail bed soft tissue precludes direct graft placement because there is no vascular wound bed for the graft to take.2 To cover such exposed distal phalanx and provide a graft bed, we used thin thenar fascial flaps. In this case series, we present our approach to such refractory defects using a two-stage operation. MATERIALS AND METHODS: Between 2014 and 2016, thenar fascial flaps and nail bed grafts were used in five patients. All the patients had full-thickness nail bed defects due to machines or door jamming incidents, and the sizes of the defects were more than half of the whole nail bed. We designed the flaps as general thenar flaps, performed suprafascial dissection, and elevated the dermal flaps proximally. We then performed subfascial dissection over the thenar muscle from the proximal to the distal direction and turned over the only fascial layer and inset onto the defects. After 2 weeks, the flap was divided, and a split-thickness nail bed graft was taken from the big toe. Tie-over dressings were performed, and the donor sites closed primarily. RESULTS: All flaps survived completely, and all split-thickness nail bed grafts were well taken. The mean follow-up period was 11 months. Nail growth was observed to the end of the distal nail bed without non-adherence, and the overall shape of the new nail was symmetrical to the corresponding finger nail of the contralateral hand. Cosmetic outcomes were excellent. The big toe nail showed partial non-adherence initially, but improved with time. None of the patients experienced any other complications. CONCLUSION: Full-thickness nail bed defects, especially with bony exposures, are difficult to operate with satisfactory results. The thenar fascia flap is extremely thin, yet performs admirably as a wound bed for split-thickness nail bed grafts. Morbidity is minimal at both the thenar and great toe donor sites. Functional and cosmetic outcomes are excellent. It could be an excellent treatment option for these kinds of cases. REFERENCES: 1. Brown RE, Zook EG, Russell RC. Fingertip reconstruction with flaps and nail bed grafts. J Hand Surg Am. 1999 Mar;24(2):345–51. 2. Zook EG. Anatomy and physiology of the perionychium. Hand Clin. 2002 Nov;18(4):553–9

Primary Reconstruction of Fingernail Injuries in Children with Split-Thickness Nail Bed Grafts

Failure to detect and treat partial or complete avulsions of the nail bed may lead to severe nail deformity that predisposes to repeat injuries and is cosmetically inacceptable. Treatment of these injuries with split-thickness nail bed grafts (STNBGs) is controversial and no pediatric series has been published. A retrospective, single center case series of nine fingers with complex nail bed injuries that were reconstructed primarily with STNBGs was performed. Surgical outcome and patient satisfaction were assessed. For six nail bed reconstructions, the nail bed graft was harvested from the injured finger, and for the remaining three from the great toe. Harvesting of the great toe's nail bed could be performed without removal of the nail plate by only lifting it up distally. Insufficient vascularization required primary flap coverage in six cases with three Moberg flaps, two palmar V-Y flaps, and one thenar flap. No flap was lost and all nail bed grafts had a 100% take. Only one patient required reoperation due to a hook- and split-nail deformity. All other patients were satisfied or very satisfied and the surgical outcome was least satisfactory in all but two patients. Primary reconstruction of complex nail bed injuries with STNBGs usually gives good cosmetic and functional results in children and prevents secondary nail growth disturbances reliably.

Radical resection of a venous malformation in middle finger and immediate reconstruction using medial plantar artery perforator flap: A case report

Reconstruction of complex defects resulting from radical resection of venous malformation occurring in other digits except the thumb is challenging because a thin and durable flap is required to achieve optimal reconstruction without functional impairment. Here, we describe an alternative reconstruction technique in a young patient. A 15-year-old female patient with venous malformation of the left 3rd finger was treated by radical excision of the tumor including involved skin, distal phalanx, and nail bed followed by reconstruction with free medial plantar artery perforator flap and split thickness nail bed graft from the great toe. Twenty-nine months after surgery, the reconstructed finger showed a acceptable aesthetic result without tumor recurrence and excellent restoration of motor function. This method can be considered as an useful alternative option for management of the digital venous malformation in other digits except the thumb. Indications and technical aspects of this method are discussed in this report.

Subungual exostosis treated with an in situ thin split-thickness toenail bed graft

Subungual exostosis is a slow-growing, benign outgrowth of normal bone or calcified cartilaginous remains of the distal phalanx. Complete surgical excision of lesions, including the cartilaginous cap, is a unique curative method. An 18-year-old male presented with a protruding papule on the right great toenail. Diagnosis of subungual exostosis had been established and complete excision was performed. In addition, an in situ thin split-thickness toenail bed graft was used to cover the defect. At 6 months after excision, the patient had no complaint of recurrence or pain. We report on a unique trial case of subungual exostosis treated with thin split-thickness nail bed grafts taken from the adjacent normal nail bed of the affected toe.

Primary repair of degloving injury of the distal fingers with nail bed defect

Objective To introduce the operative methods of digital artery island flap with additional fascia flap combining split-thickness nail bed graft for repair of degloving injury of the distal finger, and evaluate the treatment outcomes. Methods From June 2005 to October 2008, three types of digital artery island flap with additional fascia flap combining split-thickness nail bed graft were clinically applied to repair degloving injury of the distal finger in 9 cases. The reversed island flap from the proximal phalanx of the same finger was applied in 6 cases. The forward island flap from the middle phalanx of the adjacent finger was applied in 2 cases, while the reversed island flap from the adjacent finger with ligation of the common digital artery was applied in 1 case.Nail bed grafts were taken from the great toe in 7 cases, the second toe in 1 case, and the avulsed nail bed in 1 case. Results All flaps and nail bed grafts survived. Postoperative follow-up period ranged from 3 months to 2 years. The appearance of the repaired pulps were well-stacked, with 2-PD recovered to 6 to 12 mm. The newly grown nail was flat and smooth, with complete coverage in 3 cases. In 2 cases coverage of the nail bed by the newly grown nail surpassed 4/5, while the coverage was over 1/2 in another 3 cases. All these newly grown nails attached to the nail bed closely. There was only 1 case that had incomplete nail. The range of motion of the distal interphalangeal joint was 30° to 60°. The nail of donor toe grew well, and the function of walking was normal.Conclusion Digital artery island flap with additional fascia flap combining split-thickness nail bed graft is good method in repair of degloving injury of the distal finger. Key words: Surgical flaps; Fingers; Reconstructive; Surgical procedures,operative; Degloving injury

Treatment of post-traumatic nail bed deformities with split-thickness nail bed grafts

Split-thickness nail bed graft have been proposed for treatment of post-traumatic nail bed dystrophies. Only three papers reported good results in 60 to 90% of cases. We report our experience. We reviewed 18 cases of split-thickness nail bed grafts from operative and consultation files and photographs. Evaluation was made using criteria as the nail plate shape, its adhesion on the nail bed, patient satisfaction and possible sequelae on the donor finger. RESULTANTS: Thirteen patients have been reviewed with a sufficient follow-up to assess the results. In 13 cases, the graft was taken from the hallux. The nail-bed graft was used for hallux reconstruction two times, the thumb six times, index six times, middle and ring finger one each, and the little finger two times. In every patient the graft was molded using either the patient nail or the nail plate from the donor finger. Clinical results were excellent in five cases, good in three and poor in five cases. Five failures were due to wrong indications in three cases in which matrix problem has been underestimated, and infectious failures in two cases. Fifteen per cent of our patients had some sequelae on the donor finger.

Nail bed reconstruction with split-thickness nail bed grafts

The results of reconstruction of chronic post-traumatic nail deformities are thought to be unpredictable. We have reviewed eight patients treated by split-thickness nail bed grafts for deformities arising from defects in the sterile matrix. Appearance, adherence and function were improved in all cases, with no significant morbidity of the donor area.

The repair of nail deformities with the nonvascularized nail bed graft: Indications and results

Twenty-four cases of nonvascularized nail bed grafting to correct nail deformities were reviewed. The highest success rate in improving the appearance of the deformed nail, 86%, was achieved when the split-thickness nail bed graft of sterile matrix was used to correct a nail deformity caused by a sterile matrix injury; the same procedure used to correct a nail deformity caused by a germinal matrix injury had a 0% success rate. Donor site morbidity occurred in 25% of split-thickness nail bed grafts and 100% of full-thickness nail bed grafts. The split-thickness nail bed graft of sterile matrix, if used in properly selected patients, will consistently improve the appearance of the deformed nail.

Tratment of the Nail Bed Avulsion Injury with Split-thickness Nail Bed Graft

Tratment of the Nail Bed Avulsion Injury with Split-thickness Nail Bed Graft

Treatment of nail bed avulsions with split-thickness nail bed grafts

Experimental studies with squirrel monkeys indicated the feasibility of split-thickness grafting of segments of the nail bed. Thin grafts, when taken from the nail bed, achieved excellent take over of the avulsed areas. Thirty-one patients with avulsion of segments of the nail bed were treated with split-thickness nail bed grafts. The injured nail bed had sufficient residual nail bed to serve as a donor site in 24 patients. The remaining seven patients required split-thickness grafts from the lateral one third of the great toe. Of the 31 treated nail beds, there was a total of five deformities in which there was either nonadherence of the nail or irregularity of the nail surface. Twenty-six had nails with no deformity. No deformities occurred in the graft donor area. The split-thickness nail bed graft offers the advantage of frequent availability of tissue on the same injured digit and the absence of donor site deformity, whether on the same injured digit or a donor great toe.

Treatment of nail bed avulsions with split-thickness nail bed grafts

Experimental studies with squirrel monkeys indicated the feasibility of split-thickness grafting of segments of the nail bed. Thin grafts, when taken from the nail bed, achieved excellent take over of the avulsed areas. Thirty-one patients with avulsion of segments of the nail bed were treated with split-thickness nail bed grafts. The injured nail bed had sufficient residual nail bed to serve as a donor site in 24 patients. The remaining seven patients required split-thickness grafts from the lateral one third of the great toe. Of the 31 treated nail beds, there was a total of five deformities in which there was either nonadherence of the nail or irregularity of the nail surface. Twenty-six had nails with no deformity. No deformities occurred in the graft donor area. The split-thickness nail bed graft offers the advantage of frequent availability of tissue on the same injured digit and the absence of donor site deformity, whether on the same injured digit or a donor great toe.