A Technique for Tripartite Reconstruction of Fingertip Injuries Using the Thenar Flap With Bone and Nail Bed Grafts.

Fingertip amputation is the most common amputation encountered by hand surgeons. Treatment decisions are multifactorial, based on mechanism, level of injury, tissue loss, associated injuries, and patient preference, among others. In this article, we present use of the thenar flap in combination with bone graft and split-thickness nail bed graft to address the tripartite loss of distal phalanx, soft tissue, and nail bed. This method allows for a full-length and functional reconstructed fingertip that is aesthetically satisfactory and does not require microsurgical techniques.

Thumb fingertip reconstruction with palmar V-Y flaps combined with bone and nail bed grafts following amputation.

INTRODUCTION: The aim of treating thumb fingertip amputations with no indication for replantation is to reestablish functional and esthetic properties. MATERIALS AND METHODS: From March 2005 to October 2008, we treated 14 patients with thumb fingertip amputation using palmar V-Y flaps combined with bone and nail bed grafts. There were 10 men and 4 women, whose ages at surgery ranged from 19 to 63 years (mean 35.8 years). In all, 11 of the injuries occurred in the dominant hand. According to Allen's classification, two were type II, seven were type III, and five were type IV. All patients underwent emergency surgery, with a time delay after injury of 3-12 h (mean 6.4 h). In each case, the amputation was a crush or avulsion injury, making microsurgical replantation not feasible. RESULTS: All of the flaps survived. At 8-17 months (average 12.8 months) of follow-up, the average subjective satisfaction score was 8.64. All patients experienced cold intolerance, and none of the patients complained of dysesthesia. Favorable results (excellent or good) were found in 78.6%. Thin primary nails appeared on the grafted nail bed about 3 weeks after surgery, following which the newly formed nail thickened and developed a more natural appearance. In one case, the new nail plate showed abnormal thickening due to hyperkeratosis. The bone graft healed at 5 weeks. The mean two-point discrimination was 7.5 mm. Grip strength was 10% less than that in the unaffected hand. Metacarpophalangeal and proximal interphalangeal joint mobility losses were less than 10°. All patients returned to their jobs. No patients had postoperative complications. CONCLUSIONS: We believe that the combination of palmar V-Y flap and bone and nail bed grafts provides a distinct advantage over other choices. It improves function when replantation is not an option.

Human fingernail as interpositional graft material in the treatment of nasal septal perforations.

PURPOSE: The etiology of nasal septal perforations involves iatrogenic, traumatic, inflammatory, infectious, neoplastic, and caustic causes. To ensure successful closure, an appropriate interpositional graft material should be selected, and this graft material should be covered with healthy tissue. MATERIALS AND METHODS: The study included 18 New Zealand white rabbits weighing 2 to 2.5 kg. Nasal septal perforations were created in group 1. After the creation of defects in group 2, repair was performed with cartilage graft and bilateral mucoperichondrial advancement flaps. After septal nasal perforations in group 3, the defect was covered with fingernail and bilateral mucoperichondrial flaps. RESULTS: At week 12, the rabbits were sacrificed. The septum site that had been repaired with fingernail was intact. No nail exposition, wound site decomposition, or re-perforation was observed. No findings of a breach of the structural integrity of the fingernails or disintegration were encountered. CONCLUSION: Fingernails can be used as an interpositional graft material in place of cartilage in eligible cases for the repair of nasal septal perforations. Fingernails have several properties that enable their use in such cases, such as form preservation that is similar to cartilage, the lack of live cells, easy availability, and a lack of donor-site morbidity at removal.

Fingertip reconstruction with simultaneous flaps and nail bed grafts following amputation.

PURPOSE: To report our technique and results with treating fingertip amputations with flaps and simultaneous nailbed grafts. METHODS: We reconstructed 20 fingertip amputations with loss of bone and nail with flaps combined with nailbed grafts. We reconstructed the volar side of the fingertip with a flap, and the dorsal side of the fingertip with a nailbed grafted to the raw inner surface of the flap. We employed volar V-Y advancement flaps for transverse or dorsal oblique fingertip injuries and generally used abdominal flaps for volar oblique fingertip injuries. We harvested nailbeds from the amputated finger or from the patient's first toe. RESULTS: The length of the amputated fingertips was restored with the flaps, and the lost nailbeds were restored to their natural appearance with the nailbed grafts. We classified the results according to the length of the reconstructed fingertip and the appearance of the nail. Excellent or good results were achieved in 16 cases. Three cases had fair results and 1 had a poor result. We observed favorable results for distal fingertip amputations (Allen type II or III). In particular, most cases that were reconstructed with volar V-Y advancement flaps combined with nailbed grafts demonstrated favorable results. CONCLUSIONS: This method is useful for the restoration of dorsal oblique or transverse type fingertip amputations and is a good alternative when replantation is not an option.

Repair of a degloving injury of the thumb with a combined dorsal great toenail flap and dorsalis pedis flap: a case report.

Many methods for the repair of degloving injuries of the thumb have been reported, but none are entirely satisfactory. Herein, we report a method in which the injury is divided into the dorsal and palmar area for repair. A great toenail flap is used to repair the dorsal injury to restore the nail defect, and a dorsalis pedis flap is used to repair the palmar injury. The described technique provides good restoration of morphology and aesthetic outcome, good functional and sensory recovery, and is associated with minimal donor-site morbidity.

Distraction osteogenesis and free nail graft after distal phalanx amputation.

PURPOSE: To describe the results in patients treated with distraction osteogenesis combined with free nail graft after distal phalanx amputation. METHODS: We analyzed 14 patients with distal phalanx amputation (13 women). Mean age was 35 years. There were 9 amputations of the index finger, 3 of the middle finger, and 1 each of the thumb and ring finger. We started bone distraction 7 days after surgery, with 1 mm distraction every 3 days. After bone elongation, we inserted a free composite nail graft at the dorsal tip of the distracted finger. We evaluated distraction length, consolidation time, aesthetic result (using the Foucher and Leclère score), and complications. RESULTS: The mean bone elongation was 17 mm and mean consolidation time was 149 days. Nail cosmetic results were satisfactory; the mean total Foucher score was 14 out of 20. Mean individual scores were patient's opinion (7.8 out of 10), adequate length (1.2 out of 2.5), adequate alignment (1 out of 1), adequate width (1.8 out of 4), and dorsal scar quality (2.2 out of 2.5). The mean total Leclère score was 14 out of 20. All patients retained sensibility in the grafted area and none had healing abnormalities. The mean opinion about the donor site was 7.5 out of 8. Nail growth less than 50% occurred in 2 patients. Mean follow-up was 62 months. CONCLUSIONS: Distraction osteogenesis combined with free nail graft is a therapeutic option when replantation is not an option or when it fails. However, treatment takes time and requires the involvement of the patient, family, and medical team.

Comparative analysis of the nail xenografts with cartilage autografts in eyelid reconstruction.

OBJECTIVE: The tarsal plate is the skeleton support system of the eyelids; therefore, repair during eyelid reconstruction is crucial. Many autogenous graft materials have been proposed for the tarsal reconstruction, such as nasal cartilage, palatal mucosa, upper eyelid tarsus, and auricular cartilage. Nail thickness and shape are similar to the tarsal plate with enough support for the eyelid. It also easily integrates with host tissues. The aim of this experimental study was to macroscopically and histopathologically compare nail xenografts with cartilage autografts when used in eyelid reconstruction in rabbits. METHODS: In total, 12 New Zealand rabbits were used in the experiment. Full-thickness defect with a 1-cm diameter was created in both upper eyelids. The right upper eyelids were used for cartilage autograft reconstruction, and the left upper eyelids were used for nail xenograft reconstruction. All animals were killed on week 12 after eyelid reconstruction. After the animals were killed, the upper eyelids of the rabbits were resected for macroscopic and histologic analysis. RESULTS: In histologic evaluation, moderate foreign body giant cell formation and moderate histiocytic, neutrophilic, basophilic, and lymphocytic infiltration were observed in both experimental group and control group. In addition, this marked fibrous capsule formation was observed around the nail xenograft, which was absent in the cartilage autograft group. CONCLUSIONS: Nail has some advantages such as being cost-effective, being easy to obtain, and having less rejection risk for being composed of dead cells. Nail xenografts can be taken into account instead of cartilage grafts in eyelid reconstruction.

Factors influencing the acceptance of toenail-to-fingernail transfer.

The aim of this study is to determine the factors influencing the acceptance of toenail-to-fingernail transfer. A total of 240 patients were divided into four groups according to severity of nail injury. Half (expensed informed [EI] group) were informed about the expenses (about $9,000) before the interview; the other half were not informed (the expense not-informed [ENI] group). The participants were asked to answer yes or no to the question "If you lose your fingernail and it can be reconstructed by transferring your toenail like this figure, will you undergo surgery? If you want it or not, please choose the reason for your choice." In the EI group, 68.3% accepted the surgery. In the ENI group, 85.0% accepted the surgery. There was a significant difference between the EI and ENI groups (p = 0.002). In the EI group, the age of the surgery acceptance group (36.9 ± 11.8) was significantly lower (p = 0.004) than that of the surgery rejection group (44.5 ± 15.5). The young age group wished to accept the surgery irrespective of the expenses, yet the old age group hesitated to have surgery when informed about the expenses. We think the risk acceptance for toenail-to-fingernail transfer mostly depends upon the expense.

A new surgical strategy for reconstruction of claw nail deformity.

Claw nail deformity is common in patients with fingertip injury. The optimal reconstruction remains unclear. We devised a unique strategy for reconstruction of claw nail deformity. We divided the approach into three parts: soft tissue reconstruction, bone graft and nail bed graft. In the soft-tissue reconstruction, a reverse digital arterial finger flap for the finger or an extended palmar flap advancement with V-Y plasty for the thumb was selected. A part of the distal phalanx of the second toe including periosteum was harvested as a bone graft. A nail bed graft from the big toe was performed. We reconstructed in 11 cases of claw nail deformity using our strategy. All cases achieved significant improvement with no recurrence of the claw nail deformity. Moreover, there was no donor site morbidity.

Arterial anatomy of the second toe nail bed related to toenail transfer.

The aim of this study was to elucidate the exact course of the terminal branches of the plantar digital artery (PDA) to the nail bed of the second toe. Thirteen second toes from seven fresh Korean cadavers were dissected (age range 74-92 years, four men and three women). The terminal segmental branches (TSB) branched off from the PDA at 7.6 ± 0.7 mm proximal to the nail fold. The fibro-osseous hiatus branch (FHB) branched off from the PDA at 3.3 ± 0.7 mm from the nail fold. They were 3.8 ± 1.0 mm lateral to the paronychium. Diameters of TSB and FHB were 0.8 ± 0.2 mm and 0.7 ± 0.1 mm, respectively. Diameter of PDA was 1.4 ± 0.2 mm. Surgeons should stay at least 4 mm proximal to the nail fold to avoid injury to the terminal branch. We believe that second toenail with minimum amount of soft tissue may be transferred using FHB-based vascularized toenail flap. Perfusion study and clinical application should be followed.

Preliminary study on durability of nail as xenograft.

In reconstructive surgery, many autograft/allograft/xenograft and synthetic materials are being used for repairing congenital or acquired tissue and skeletal deformities. Compatibility of the graft or the material to the tissue, the risk or rejection, toxicity, and morbidity affect the preference. With the aim of searching the usability of human cadaver nail being used as xenograft instead of cartilage graft on small and composite defects, 60 rats were separated into 3 groups, each of which was composed of 20 rats. One hundred twenty nail samples of 1 × 1-cm size, whose epithelium tissue was shaved 2-sided, were prepared for the purpose of placing 2 of them into the back of rats. They were placed under the dorsal skin of rats as naked in the first group, as fascia-wrapped in the second group, and as amnion membrane-wrapped in the third group. It has been stated as a result of the pathologic surveys performed in 2, 4, 12, and 24 weeks from rats in all groups that all the nails were available; acute and chronic inflammatory signs that were observed in early stages regressed, and in late stages, histopathologic signs of all groups were similar. Nail has some advantages such as being cost-effective, being easy to obtain, and having less rejection risk for being composed of dead cells. Application of nail xenograft eroded 2-sided can be taken into account instead of cartilage graft in small-size areas needing support tissue.

Repair of thumb defect by using the toenail flap: biomechanical analysis of donor foot-a retrospective cohort study.

BACKGROUND: The thumb accounts for 50% of the total hand function. This study reports the functional outcomes and complications of people with traumatic thumb amputations who underwent toe-to-thumb reconstruction. METHODS: From January 2013 to January 2018, 29 patients with second-degree thumb defect underwent thumb reconstruction with distal phalangeal braided toenail flap. The footscan foot pressure gait analysis system was used to measure the index changes of the same foot before and after 1, 3 and 6 months. The contact area, peak pressure, impulse value, contact time of each gait phase, centre of gravity coordinate and foot balance were analysed statistically. RESULTS: Twenty-nine cases of thumb reconstruction recovered well. After following up for 6-15 months, the appearance of the reconstructed thumb was close to normal, and the sensation was restored to S3+. The two-point discrimination was 6-8 mm, and the function of the thumb was good. The function of the donor foot was well restored, and no skin ulceration, pain and claudication were noted during walking. Compared with that before the operation, the biomechanical indices of the donor foot were basically restored to normal 6 months after the operation. Only the stress and impulse values of the third metatarsal head were significantly increased, forming a stress concentration area centred on the third metatarsal head. CONCLUSIONS: This study confirmed that the toenail flap with distal phalangeal bone restored the second-degree thumb defect without destroying the main functional structure of the sole. The biomechanical indices of the donor foot were basically restored to normal 6 months after the operation. Only the stress concentration area centred on the third metatarsal head, and the pain on the forefoot was induced after the operation. Discomfort, callus formation, metatarsal fasciitis, etc., can lead to fatigue fracture of the third metatarsal bone in severe cases, which requires further follow-up and observation. TRIAL REGISTRATION: Clinicaltrials.gov , NCT03879941; registered on 10 March 2019, retrospectively.

Avulsion injuries of the nail bed do not need nail bed graft.

From 1985 to 1992, 12 cases of severe avulsion injuries of the nail bed were treated by allowing the nail bed to regenerate naturally, without a nail bed graft irrespective of the extent of nail bed loss. This involved simply covering the residual nail bed with the nail splint for a period of approximately 6 weeks or until the nail bed was observed to be fully regenerated. The patients were then followed up until full nail growth. It was observed that the nail bed regenerated spontaneously, followed by a normal nail growth identical to the contralateral uninjured nail.Proper coverage of the nail bed protected the culture milieu conducive to natural nail bed regeneration, and nail bed grafting was not necessary irrespective of the extent of tissue loss.

[Free grafting of big toe nail bed repairing defects of fingernail bed].

Objective: To investigate the feasibility and indication of free grafting of split big toe nail bed for defects of fingernail bed. Methods: From September 2008 to September 2011,13 cases (4 females and 9 males) with fingernail bed defects(aged 17-38,average,32) were treated with split big toe nail bed. The split big toe nail was harvested according to the defects size without bone exposure at donor site. Results: Three grafted nail beds were necrotic completely and reconstructed with flaps. The 2 grafted nail bed was partial loss and healed after dressing. All the other grafted nail bed survived completely with primarily healing both in donor sites and recipient sites. The patients were followed up for 6-30 months(average,14 months).The therapeutic effect was graded as excellent in 8 cases, good in 2 cases and poor in 14 cases(good rate,76.9％).The nail matrix was excellent in 8 cases,good in 1 case and poor in 1 case(good rate,90％).The toe nails in donor sites grew well. Conclusions: The single fingernail defect with intact nail matrix can be reconstructed by split toe nail bed graft with good cosmetic and functional effect. There is no malfunction at donor site. The indication should be selected.

[Use of autotransplants and implants in ossiculoplasty].

The paper presents a comparative analysis of efficacy of ossiculoplasty (OP) using different transplants. A total of 202 operations were performed. Prostheses made of the fragments of the auditory ossicles, or a cortical layer of the temporal bone (n=81), of nail plate (n=56), titanium implants (n=65) were applied. A satisfactory result was achieved in 72-87% ossiculoplasties. Functional outcomes of OP did not vary significantly with type and material of the prosthesis. Main causes of poor OP results were fixation or displacement of the prosthesis with fibrous tissue; in case of titanium prostheses -- perforation of the tympanic membrane with prosthesis extrusion.

Use of human nail for reconstruction of the orbital floor: an experimental study in rabbits.

The orbital floor is the thinnest part of the orbital wall, and in 20% of all maxillofacial injuries it is fractured. Autografts, allografts, and alloplastic materials are used in reconstruction, but there is no consensus about which material is the most appropriate. Nail is a semirigid material that is easy to reshape and is not antigenic. Alloplastic materials, which are used in reconstructions of the orbital floor, have various complications and are expensive. Autografts have donor-site problems, high rates of resorption, and take a long time to do. We created bilateral 10mm defects in the orbital floors in 18 New Zealand rabbits. We reconstructed the left orbital floors with double-ground human nail while the right orbital floors were left open as controls. The orbital floors were examined macroscopically and microscopically at 4, 8, and 12 weeks postoperatively, and there were no macroscopic signs of infection, inflammation, or extrusion. Forced duction tests showed that it was possible to induce movement of the eyeball for all 18 of the reconstructed sides throughout the observation period, and in 14 of the 18 rabbits on the control sides. Positive forced duction test shows us that orbital muscles are trapped in orbital floor defect and due to this movement of eyeball is restricted. Acute and chronic inflammation, fibrosis, vascularisation, and the presence of foreign body giant cells were evaluated microscopically. Acute inflammation and the presence of foreign body giant cells were recorded as mild, whereas fibrosis, chronic inflammation, and vascularisation were severe, as were epithelialisation on the maxillary sinus side of the nails, calcification, and progression of collagen. We found no signs of resorption of the nails.

Microvascular reconstruction of the distal digits by partial toe transfer.

Advances in microsurgery have provided multiple options for reconstruction of distal digital deficit using various parts of the finger. These relatively minor microsurgical procedures always lead to a great patient satisfaction both in function and appearance.