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Aesthetic and Functional Results From Nailfold Recession Following Fingertip Amputations

Published:November 04, 2014DOI:https://doi.org/10.1016/j.jhsa.2014.09.010

      Purpose

      To analyze the aesthetic and functional results of a technique for nail salvage by recessing the nailfold to increase the exposed nail matrix after fingertip amputation.

      Methods

      Thirty cases of fingertip amputation with distal partial nail bed defects underwent nailfold recession and pulp reconstruction. We increased nail bed exposure by recessing a rectangle flap of eponychium and reconstructed the pulp with different local flaps depending on the injury geometry. A 0.3- to 0.4-cm–wide rectangular strip of eponychium was de-epithelialized. The eponychial flap was separated from the nail matrix and slid proximally to expose more nail matrix, thereby effectively lengthening the exposed nail bed.

      Results

      The flaps survived in all patients. The exposed nail beds were lengthened 0.3 to 0.4 cm and enlarged 38% to 100%. The fingertips had smooth and natural nail plates with inconspicuous scars on both the eponychium and pulp and no deformities. The sensation and mobility of injured and uninjured contralateral fingers did not differ statistically. All patients were satisfied with the appearance and function of the reconstructed fingertips.

      Conclusions

      Nailfold recession combined with different local flaps provided for the aesthetic and functional restoration of the fingertip after amputation with partial nail bed defect.

      Type of study/level of evidence

      Therapeutic IV.

      Key words

      Nail salvage after complex trauma affecting both the pulp and the nail bed is not easy, especially if treatment aims to restore nail length and appearance. The nail bed has a role in both the function and appearance of the fingertip.
      • Adani R.
      • Marcoccio I.
      • Tarallo L.
      Nail lengthening and fingertip amputations.
      Nail bed matrices (sterile and germinal) are specialized tissues, and attempts to replace them with skin or dermal graft are rarely successful.
      • Shepard G.H.
      Perionychial grafts in trauma and reconstruction.
      Numerous techniques of nail matrix transfer have been described, but each has its drawbacks.
      • Rai A.
      • Jha M.K.
      • Makhija L.K.
      • et al.
      An algorithmic approach to posttraumatic nail deformities based on anatomical classification.
      The rectangle recession flap is a good choice for increasing nail bed exposure to remedy the injured nail bed. We have implemented a technique for nail bed reconstruction that can be used at the same time as pulp reconstruction, with the aim of achieving both aesthetic and functional restoration. In this study, we present our clinical experience with application of nailfold recession for fingertip amputations.

      Patients and Methods

      Patients

      We evaluated 41 consecutive cases of fingertip amputation with nail bed involvement from January 2007 to October 2013. Thirty patients (18 men and 12 women, age 19–53 y, mean 34 y; defect size ranging from 0.9 to 2.0 cm2) underwent nailfold recession and fingertip reconstruction. We excluded 11 cases in which residual nail beds measured less than 0.2 cm or the lunula was destroyed.

      Methods

      Digit-specific radiographs were performed to show associated phalangeal fractures and foreign bodies. Evaluation of the amputation included the size of the nail bed and the pulp defect, the presence of exposed bone, and the geometry of the injury. All cases underwent a nailfold recession operation, which was performed with a rectangle flap. Pulp reconstruction was carried out with different local flaps according to the angle of injury geometry, including V–Y advancement flaps, Kutler flaps, and homodigital neurovascular island flaps. We performed operations with local anesthesia or brachial plexus block in the emergency operating room. Our institutional review board approved this study.

      Nailfold recession technique

      A skin rectangle as wide as the remaining portion of the nail is drawn 0.5 to 0.6 cm proximal to the distal border of the eponychium. The remaining portion of the nail plate is not removed. A small retractor is used to separate the eponychium gently along its entire width from the nail matrix so that the rectangle’s longitudinal dimension (about 0.3 to 0.4 cm) can be evaluated. The rectangle is then de-epithelialized, with care taken to protect the underlying subcutaneous vascular network. Two longitudinal periungual incisions are then made. At this point, the eponychial flap can be delicately lifted, slid proximally, and folded, and its edges sutured. Two stitches are made on the medial and lateral borders. If the nail plate is detached or destroyed, the sterilized remaining part of the nail plate or an artificial (polypropylene) plate is reset and fixed on the medial and lateral borders. The distal edge of the flap used for pulp reconstruction is anchored to the residual (sterilized/artificial) plate (Figure 1, Figure 2).
      Figure thumbnail gr1
      Figure 1Diagram of nailfold recession. The abcd rectangle depicts the de-epithelialized area. Side ab is slid proximally and sutured to side cd; a should touch c and b should touch d.
      (Modified from Adani R, Marcoccio I, Tarallo L. Nail lengthening and fingertip amputations. Plast Reconst Surg. 2003;112(5):1287–1294. © 2003 Wolters Kluwer Health. Used with permission.
      • Adani R.
      • Marcoccio I.
      • Tarallo L.
      Nail lengthening and fingertip amputations.
      )
      Figure thumbnail gr2
      Figure 2Clinical example. A A skin rectangle as wide as the nail bed is designed. B The skin rectangle is de-epithelialized and the remaining portion of nail plate is preserved with its distal edge anchoring the edge of the pulp flap. C Separating and lifting the eponychial flap ensures that it slides smoothly. D The nail fold recession is accomplished and the visible nail bed is lengthened.

      Evaluation of outcomes

      We evaluated outcomes for fingertip appearance, fingertip sensation, distal interphalangeal (DIP) and interphalangeal (IP) joint mobility, and patient satisfaction with hand function. Fingertip appearance included nail and pulp, such as the nail bed size, scar, and deformity. We measured the nail bed size using a ruler and calculated it with AutoCAD 2008 (Autodesk, San Rafael, CA). The scar was evaluated with the Vancouver scar scale. The flap sensation was quantified using Semmes-Weinstein monofilaments. We measured static 2-point discrimination (s-2PD) of the treated fingertip with a ruler and compass and used goniometry to determine the active range of motion of the finger’s DIP and IP joints. The contralateral uninjured finger was used as a control. We employed paired t test to test for significant differences in DIP and IP joint mobility and s-2PD between the treated finger and the contralateral counterpart. P < .05 was considered statistically significant. The sixth section of the Michigan Hand Outcomes Questionnaire was completed to evaluate patient satisfaction with hand function. Another medical team that was independent of the study performed the evaluation.

      Results

      Table 1 lists patients’ data. All procedures were performed within 4 hours of injury. The mean follow-up period was 15 months (range, 12–36 mo) and no patients were lost to follow-up. The skin flaps survived in all patients. Compared with the preoperative residual nail, the postoperative visible nail length increased by 0.3 to 0.4 cm and the visible area increased by 38% (eg, patient 18) to 100% (eg, patient 2) (average, 47%). We did not remove the residual plates during the operation in 12 patients (eg, patients 2 and 8). Sterilized and artificial nail plates were reset in 14 patients (eg, patient 11) and 4 patients (eg, patient 18), respectively, because the nail plate was detached or destroyed.
      Table 1Nailfold Recession in Patients
      PatientSex/Age, yMechanism of InjuryInjured FingerInjury ClassificationFlap Type (Pulp)Nail Bed Size, cm2Rate of Enlargement (%)Scar (VSS Score)
      PreoperativelyPostoperativelyDorsalVolar
      1M/22CrushL/middleDorsal obliqueV–Y0.771.104301
      2M/40CrushL/indexDorsal obliqueV–Y0.601.2010001
      3F/35CutL/middleVolar obliqueKutler0.601.006600
      4F/25CrushR/littleTransverseV–Y0.500.806000
      5M/36CrushR/indexTransverseKutler0.771.104301
      6M/29CrushR/indexLateral obliqueHNI0.961.323802
      7M/53SawR/middleVolar obliqueKutler0.550.886001
      8F/30CrushR/middleTransverseV–Y0.601.006601
      9M/42CutL/middleDorsal obliqueV–Y0.961.323801
      10M/45CrushR/ringVolar obliqueKutler0.771.104301
      11M/33CrushL/middleVolar obliqueKutler0.841.224500
      12F/26CrushR/indexTransverseV–Y0.600.905000
      13M/40SawL/indexLateral obliqueHNI0.881.213803
      14F/34CrushR/middleDorsal obliqueV–Y0.841.204301
      15M/23CrushL/middleDorsal obliqueV–Y0.961.323800
      16M/33CutL/middleTransverseKutler0.771.104301
      17F/31CutR/littleTransverseV–Y0.600.905001
      18F/45CrushL/thumbLateral obliqueHNI1.201.653801
      19M/37CrushR/ringTransverseKutler0.771.104301
      20M/52CrushR/middleLateral obliqueHNI1.081.443302
      21F/19CrushL/indexVolar obliqueKutler0.771.104301
      22F/23SawR/indexVolar obliqueKutler0.771.104301
      23M/43CrushL/middleDorsal obliqueV–Y0.721.085500
      24F/28CrushR/middleLateral obliqueHNI0.911.304302
      25M/47CutR/littleDorsal obliqueV–Y0.600.905001
      26M/32CrushL/thumbDorsal obliqueV–Y1.121.543800
      27F/25CrushR/indexTransverseKutler0.801.103801
      28M/38CrushR/middleVolar obliqueKutler0.841.204301
      29M/35CrushL/middleDorsal obliqueV–Y0.961.323601
      30F/24CutR/indexLateral obliqueHNI0.721.24802
      HNI, homodigital neurovascular island flap.
      All incisions healed with inconspicuous scars (Vancouver scar scale score, 0–3) especially in the perionychium (Figure 3, Figure 4, Figure 5, Figure 6). No patients had parrot beak deformities or other disorders of the nail or pulp.
      Figure thumbnail gr3
      Figure 3Patient 2 in . A Fingertip with dorsal oblique pulp defect in pulp and 0.4-cm nail bed remnant. B, C The treated fingertip attained good appearance and function 26 months later. Static 2-PD was 3 mm, and full motion was present.
      Figure thumbnail gr4
      Figure 4Patient 8 in . A Fingertip with transverse defect in pulp and 0.6-cm nail bed remnant. B, C The exposed nail bed was smaller than its healthy counterpart but no parrot beak deformity was present 13 months later. Sensation was restored to 3 mm on s-2PD. The mobility of the DIP joint of the treated finger was normal.
      Figure thumbnail gr5
      Figure 5Patient 11 in . A The injured fingertip with a 0.8-cm nail bed remnant to undergo nail fold recession and Kutler flap surgery. B, C There was an inconspicuous scar and no parrot beak deformity 28 months later. The s-2PD was 4 mm. There was no difference in mobility between the treated finger and its counterpart.
      Figure thumbnail gr6
      Figure 6Patient 18 in . A The injured fingertip ready to receive nail fold recession and homodigital neurovascular island flap surgery. B, C The size of the nail and the contour of the pulp was almost the same as the uninjured counterpart 22 months later. Static 2PD was 4 mm. The IP joint moved freely.
      Patients regained sensation in the proximal half of the flap within 2 to 3 weeks. All of them reported returning to normal daily activities in 8 weeks and to work in 10 weeks. Mild hypersensitivity of the reconstructed pulp was reported in 25 patients 6 months after surgery, but it subsided 1 year later in 17 of them. The remaining 8 patients still felt subtle discomfort. The hypersensitivity did not adversely affect daily activities and work. The mean motion arc of the DIP joint and IP joint (thumb) were equal to the same digit on the opposite hand. The mean s-2PD of the treated fingertips and the contralateral counterparts was 4.3 mm (range, 3–6 mm) and 4.1 mm (range, 3–5.6 mm), respectively. There were no significant differences in the s-2PD of the fingertip between the treated and contralateral fingers. According to the Michigan Hand Outcomes questionnaire, 27 patients were strongly satisfied (score, 5 of 5) and 3 patients were satisfied (score, 4 of 5) with the function of the reconstructed fingertips.

      Discussion

      During fingertip reconstruction, both appearance and function should be taken into consideration. Although there are many ways to obtain soft tissue coverage of an injured digital pulp,
      • Turner A.
      • Ragowannsi J.
      • Hanna J.
      • et al.
      Microvascular soft tissue reconstruction of the digits.
      • Joshua A.L.
      • Jeffrey E.J.
      • Rod J.R.
      Soft-tissue injuries of the fingertip: methods of evaluation and treatment. An algorithmic approach.
      • Koshima I.
      • Inagawa K.
      • Urishibara K.
      • et al.
      Fingertip reconstruction using partial-toe transfers.
      • Raja Sabapathi S.
      • Vankatramani H.
      • Bharathi R.
      • et al.
      Reconstruction of fingertip amputations with advancement flap and free nail bed graft.
      the fingernail is often overlooked in the reconstructive effort. To optimize the outcome of the reconstructed fingertip, we treated cases of fingertip amputation with partial nail bed defect by nailfold recession and different local flaps depending on the geometry of the injury.
      The dorsal skin over the nailfold, the nail wall,
      • Fassler P.R.
      Fingertip injuries: evaluation and treatment.
      covers most of the germinal matrix and a portion of the nail plate. Some authors suggested that if less than 0.5 cm or less than half of the original nail bed remains, the nail bed should be ablated.
      • Fassler P.R.
      Fingertip injuries: evaluation and treatment.
      • Zachary S.V.
      • Peimer C.A.
      Salvaging the “unsalvageable” digit.
      In a normal finger, the nail plate should protrude from the eponychium by at least 0.2 cm for a precise grip and good appearance.
      • Brown R.E.
      • Zook E.G.
      • Russel R.C.
      Fingertip reconstruction with flaps and bed grafts.
      Our experience suggests that if the residual nail bed is more than 0.2 cm or if the lunula is intact, the residual nail matrix should be kept and exposed for aesthetics and function. Defects in the sterile matrix have been treated with split-thickness nail bed graft or a free osteo-onycho-cutaneous flap from an adjacent digit or the great toe.
      • Koshima I.
      • Inagawa K.
      • Urishibara K.
      • et al.
      Fingertip reconstruction using partial-toe transfers.
      • Raja Sabapathi S.
      • Vankatramani H.
      • Bharathi R.
      • et al.
      Reconstruction of fingertip amputations with advancement flap and free nail bed graft.
      • Hsieh S.C.
      • Chen S.L.
      • Chen T.M.
      • et al.
      Thin split-thickness toenail bed grafts for avulsed nail bed defects.
      The results of these methods are unreliable, and nail deformities may occur at both the donor and injury sites. Furthermore, a nail bed graft cannot address the loss of distal phalanx support, as was the case for most of our patients.
      Recession of the nailfold is a simple and practical method. There is about a 0.4- to 0.6-cm-long nail bed covered by the nail wall (Figure 1, Figure 2).The residual nail bed can be exposed and effectively enlarged to look more acceptable.
      • Bakhach J.
      Eponychial flap.
      This rectangle flap can exteriorize the uninjured nail bed by sliding and folding without destroying the margin of the eponychium.
      • Atasoy E.
      • Ioakimidis E.
      • Kasdan M.L.
      • et al.
      Reconstruction of the amputated finger tip with a triangular volar flap: a new surgical procedure.
      Moreover, this method avoids donor site injury. The residual (sterilized/artificial) nail plate’s distal edge resists a tendency to lift. Therefore, the flap is inset in a tension-free manner, making postoperative nail deformities rare. The residual nail plate can provide more natural and stronger support than the sterilized (artificial) nail plate owing to its adherence to the sterile matrix. If the nail plate were detached or destroyed, the sterilized (artificial) plate could substitute for the native plate, flattening the nail bed, avoiding the formation of hematoma, and preventing the formation of parrot beak deformity. Because of the abundant subcutaneous vascular network, the eponychium remains intact during de-epithelialization. The dorsal incision heals well with inconspicuous scarring.

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        • Marcoccio I.
        • Tarallo L.
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        Perionychial grafts in trauma and reconstruction.
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        • et al.
        An algorithmic approach to posttraumatic nail deformities based on anatomical classification.
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        • Ragowannsi J.
        • Hanna J.
        • et al.
        Microvascular soft tissue reconstruction of the digits.
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        • Jeffrey E.J.
        • Rod J.R.
        Soft-tissue injuries of the fingertip: methods of evaluation and treatment. An algorithmic approach.
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