Late reconstruction of

nail problems
Christian Dumontier, MD, PhD
Hand Center, Guadeloupe, FWI
(with the help of Drs Braga Silva and Carmès)

A-1189 FESSH MEETING ROTTERDAM 2024/6/27

We will focus on (some) post-traumatic nail problems

• Hook-nail deformity

• Nail dystrophies

• Nail bed injuries (onycholysis, nail

splitting, nail cracking Onycholysis,
onychoschizis)

• Nail matrix injuries (anonychy,

pterygion)

• Soft-tissues problems

• Hyponychial scars

• Nail fold dystrophies

 Hook-Nail deformity

• Volar inclination of the nail is secondary

to:

• Bone loss

• Pulp retraction/loss

• 50% in the injury is in the distal 2/3 of

the ngertip

• Treatment can only be surgical

• Many techniques have been published

• With very few cases and short follow-

up usually

• Low level of evidence !

Chow SP and Ho E. Open treatment of ngertip injuries in adults. J Hand Surg Am 1982;7(5):470-6.
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Surgical
Technical principles Variants Authors Number of cases

Nail removal Verdan [29] Non Available

techniques Soft-tissues addition Local flaps

Advancement flap
Onizuka [18]

Kojima [26]
3?

5 cases

homodigital advancement flap Dumontier [6] 18 cases

Reverse island flaps Kaji [27] Non Available

Antenna + Cross-finger flaps Atasoy [21] 4 cases

Antenna + Cross-finger flaps or thenard flaps Strick [22] 6 cases

Antenna + skin graft Harvey [23] 1 case

• Support with soft- Antenna + palmar pedicled flap Macionis [24] 1 case

tissues Eponychial flap Cambon-Binder [25] 4 cases

Bone grafting /lengthening Non vascularized Tubiana [30] 2 cases

Non vascularized Verdan [29] Non Available

• Bony support Non vascularized bone graft from the iliac crest Lee [16] 10 cases

Vascularized bone and skin flap Saffar [34] Non Available

• Toe transfer Vascularized bone and skin flap Gargollo [35] 12 cases

Vascularized bone and skin flap Garcia-Lopez [36] 1 case

Osteotomy of the phalanx + advancement flap Shepard [41] 7 cases

Distraction lengthening Kim [40] 10 cases

Nail recession + local flaps Dufourmentel [15] Non Available

+ local flaps Dumontier [9] 16 cases

Caterpillar flap Cantero [19] Non Available

Escalator flap Foucher [20] 4 cases

Composite grafts composite graft from the toe Bubak [42] 9 cases

Toe phalanx graft + reverse pedicled finger flap Yagishita [32] 10 cases

Toe transfer Koshima [44] 2 cases

 Antenna’s procedure

• Described in 1983

• K-wires are used to sustain the nail bed, the loss

os substance is ful lled with a cross- nger ap

• 4 cases (« happy or very happy with the results »,

TPD was 4 mm)

• 7 cases reported in children with 5 good and 2

fair results; « In all seven patients the deformity
was noticeably improved in the opinion of the
reviewer and patient »

• Different aps have been used in other

publications

Atasoy E, Godfrey A, Kalisman M. The « antenna » procedure for the « hook-nail » deformity. J Hand Surg 1983; 8:55-8.
Strick MJ, Bremner-Smith AT, Tonkin MA. Antenna procedure for the correction of hook nail deformity. J Hand Surg Eur
2004;29B: 1: 3–7
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 Two personal series
• Nail recession technique (in Nancy)

• 11/16 cases, 50% good results

• Quality of results was correlated to the

importance of bone loss

• Homodigital ap after nail apparatus

attening (In Paris)

• 28 patients, 1/3 excellent, 1/3 good,

1/3 fair

• Results were correlated to bone loss, the

cutting edge being 50% bone loss

• It is important to over-estimate the skin

loss to prevent recurrence due to
secondary ap retraction

Dumontier et al. 1989; 1995

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 Bony support

• Bone grafting tends to absorb with

time

• Vascularized bone ap are of limited

size

• Bone elongation with mini ex- x

• Composite toe graft from the toe or

reversed island ap

Yagishita M, Hirase Y and Onozawa H. A new surgical strategy for reconstruction of claw nail deformity. J Plast Surg Hand
Surg 2022;56(3):127-132
Garcia-Lopez A, Laredo C and Rojas A. Oblique triangular neurovascular osteocutaneous ap for hook nail deformity
correction. J Hand Surg Am 2014;39(7):1415-8.
Kim JY and Kwon ST. Correction of contracted nail deformity by distraction lengthening. Ann Plast Surg 2008;61(2):153-6.
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 Toe transfer

• The most logical solution

• Only 2 cases reported in 40

years…
 In my opinion: indication for hook-
nail deformity correction depends of
• Bone loss: < 50% (soft-tissue or bony support),

• Bone loss > 50% consider microsurgery if:

• Pulp loss Whatever the technique chosen,

we can improve patients but we
• Thumb (> nger)
are not yet able to give them a
• Local vascularity (Age +++, smoker)
normal nail AND fingertip
• Functional needs (Musicians, ...)

Take home message: Best treatment relies on prevention:

reconstruction in emergency of the supportive structures of the nail plate
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 Dystrophies of the nail
bed (sterile matrix)

matrix nail bed

• Absence of adhesion (onycholysis)

• +/- ridges

• +/- furrows

• +/- ungueal fragility

(onychoschyzy)
Split nail
• If nail bed loss is limited (2-3
mm):

• Central loss: Undermine the

nail bed from the phalanx and
bring the two edges together.
If necessary, a contra incision
can be made at the junction of
the lateral nail wall and nail
bed

• Lateral loss: resect the

proximal matrix and shorten
nail width
 Split nail
• If loss is > 2-3 mm: consider Nail bed
grafting

• 4 published series (< 10 cas)

• 60-70% good results 1 yr

• Failures were due to:

• Unknown (secondary) infection

2 years
• Associated matrix involvement
 Nail matrix destruction matrix
nail bed

• No matrix = No nail

• Split nail

• Limited, central nail matrix

loss ➜ Translation aps

• Large matrix loss ➜ Partial

nail matrix grafts (including
proximal nail fold)
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Nail matrix destruction
• Pterygion

• Nail matrix reconstruction

• Plus nail fold reconstruction

with a split thickness nail
bed graft under the fold
Split-thickness graft of a nail wall
for treatment of a pterygium
PARTIAL NAIL MATRIX GRAFT at 3 YEARS FU
Nail (apparatus)
grafts

• According to Flint, partial nail matrix always fail (not exactly true)

• Shepard reported of 8 cases of «en bloc» nail unit graft

• Sellah (2000) reported of 14 cases without late resorbtion and 11

good results
 Bone
lengthening
and grafting

Secondary nail
apparatus graft
 Hyponychial Scar

• After distal pulp loss (i.e. ngertip

amputation w/wo reconstruction with a
ap)

• Loss of hyponychium is responsible for

a painful scar with nail adhesion. Patient
complains of pain when pulling on their
pulp or when trying to cut their nails

• Prevention during ap reconstruction

by extending the ap

• Secondary treatment with FTSG

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 Nail fold late problems

• Loss of lateral nail fold induces

nail malrotation deformity and/or
painful pinch and/or ingrowing
nail

• Lateral skin aps is the only

solution. Few are available

• Proximal nail fold: Many skin aps

mostly designed for burn injuries

• Two tricks: graft the donor site +

nail bed graft on the inferior part
of the nail fold +++
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 As a conclusion for post-traumatic dystrophies

• Best treatment is prevention at the time of

accident

• Take care of the nail apparatus +++

• Secondary reconstruction may improve

patients but rarely give them a normal nail
and ngertip

• Even so most patients feel embarrassed

with a nail dystrophy and will be happy if
you can help them

• Do not neglect the nails

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Many thanks to the
FESSH organisation
committee