Nail Reconstruction

Yotsuya Medical Cube, Chiyoda-ku, Tokyo, Japan


Basic Principles

  1. 1.

    Clinical Principles of Thumb Reconstruction

    • Nail bed level amputation (nail matrix intact)

      • Volar flap + nail bed graft

    • Distal phalanx amputation (Including IP joint amputation)

      • Wrap-around flap (+ volar flap)

    • Basal phalanx amputation (distal to MP joint) Refer to Chap. 9

      • Great toe transfer

      • Twisted wrap-around flap (TWA) flap

    • Metacarpal level amputation (loss of MP joint)

      • Second toe transfer

      • Pollicization

    • Degloving injury

      Twisted wrap-around flap (+ dorsal pedis flap)

      Refer to Chap. 4


  2. 2.

    Clinical Principles of Finger Reconstruction

    • Nail bed level amputation (nail matrix intact)

      • Split-thickness nail bed graft and digital artery flap (distal phalanx bone graft from second toe)

      • Vascularized nail bed graft (with bone)

    • Nail matrix graft

      • Wrap-around flap (+ volar flap)

      • Twisted wrap-around flap

      • Second toe transfer


Selectable Flaps and Surgical Procedures
Spilt-thickness nail bed graft and digital arterial flapVascularized nail bed graftWrap-around flapDigital arterial flap + partial toe transferTwisted wrap-around flapVenous nail graftToe transfer

The difficulty level of each surgical procedure is shown subsequent to the procedure title (e.g., Level of Difficulty: 2). The levels range from 1 to 5, with level 1 indicating a preliminary level and level 5 indicating a very advanced level.


10.1 Split-Thickness Nail Bed Graft (Level of Difficulty: 1)


Caution Start harvest from great toe, harvesting from center to the surrounding area so that a normal nail bed is retained. To avoid nail deformity, it is necessary to harvest from the toe tip. Harvest a thick split-thickness skin graft, making sure that it doesn’t become too thin. In the case that a full-thickness nail bed is required, harvest from the paronychium in accordance with the surgery method for ingrown toenails.


10.1.1 Operation Procedures


Fig. 10.1
Procedure 1: Thumb with nail bed defect


Fig. 10.2
Procedure 2: Leaving the bilateral paronychium intact, the center of the nail is cut and reflected. The required size nail bed is designed from the center of the donor nail bed


Harvesting of the nail bed must be conducted from the center. If harvested from the toe tip the nail will not regenerate, causing it to become deformed.


Fig. 10.3
Procedure 3: The nail bed is split using a No. 11 blade scalpel. It is possible to harvest a slightly thick section if the nail bed of the donor site is intact on all sides, and as long as the periosteum is not exposed


Fig. 10.4
Procedure 4: The reflected nail is returned to its original position and bandaged. This can be left as it is for 1 week. Shoes may be worn from the following day


Fig. 10.5
Procedure 5: Nail bed is sutured to surrounding area using fine absorbable suture thread


Fig. 10.6
Procedure 6: A tie-over bolster dressing is applied using a cotton ball


Once the nail bed takes, a dry crust gradually forms, which is replaced by a normal nail

The transplanted nail bed forms a dry crust as the nail grows, that eventually peels off and is replaced by a normal nail.


10.2 Split-Thickness Nail Bed Graft and Digital Arterial Flap (Graft-on Flap Method) (Level of Difficulty: 3)


The most effective finger flap for combining with a nail bed graft in the case of a thumb, is a volar advancement flap, and in the case of a finger is either an oblique triangular flap or a reverse vascular pedicled digital arterial flap


10.2.1 Operation Procedures


Fig. 10.7
Procedure 1: Amputated at base of nail bed of thumb. Nail matrix is intact. Loss of 1/3 of distal end of distal phalanx


Fig. 10.8
Procedure 2: An extended volar advancement flap is designed all the way to the thenar region. A multiple Z plasty is added that cuts across the joint crease area


The solid line in the photo represents the incision line, the dotted line represents the expected position after advancement of the flap, with Z plasty conducted based on these. Another Z plasty is added on the proximal end of the flap.

“Reconstruction of distal finger area/Extended palmar flap advancement with V-Y and Z plasty” in Chap. 8


Fig. 10.9
Procedure 3: The flap margin is cut and dissected above the tendon sheath. Although not essential for the thumb, if it is possible to remain the dorsal branch from the digital artery, it should be retained


Fig. 10.10
Procedure 4: The flap is advanced and Z plasty conducted along the margin, with wire inserted from the fingertip, fixing the flap in place. At the tip of the flap, a suture is made with both sides rotated, creating a bulge at the finger tip from the resultant dog ear


Fig. 10.11
Procedure 5: The nail bed is harvested from the great toe


Fig. 10.12
Procedure 6: The harvested nail bed is transplanted onto the defect nail bed on the transferred flap and sutured using an absorbable suture thread


Fig. 10.13
Procedure 7: A tie-over bolster dressing is applied to the nail bed


Fig. 10.14
Procedure 8: Regeneration of the nail is observed over a 6 month period. The nail bed forms a dry crust and eventually peels off due to the formation of a normal nail. (Some photos reproduced from “Injuries to distal finger area and nail/Trauma Cosmetic Surgery” by Yuichi Hirase, edited by Masaki Ando, p.115–119, Kokuseido Publishing, Tokyo, 2007; “Injuries to distal finger area (6) Treatment Using Tissue Flaps” by Yuichi Hirase, MB Orthop 20: 81–87, 2007; “Reconstruction of distal finger area using Graft-on flap method” by Yuichi Hirase; The Japanese Journal of Plastic Surgery 50: 743–748, 2007)


Why is extended volar advancement flap the first choice for volar reconstruction of the thumb?

For advancement flap of other fingers, the vascular pedicle runs parallel with the movement direction of the flap and expansion of the blood vessel is limited. In the case of an extended volar advancement flap, the vascular pedicle enters from the lateral ulnar side of the flap, so there is little expansion of the vascular pedicle due to advancement of the flap. Therefore, the larger the flap, the greater the range of coverage from the stretching of the flap, and if a VY plasty is conducted on the base flap, the flap movement distance as an island flap increases considerably. If a VY plasty is conducted on an extended volar advancement flap, it is possible for the flap to move 3 cm.

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Oct 18, 2017 | Posted by in Reconstructive surgery | Comments Off on Nail Reconstruction
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