Correction of transverse overcurvature of the nail using autologous dermal graft

Abstract

Introduction: Transverse over curvature is a commoninaes the tic and pain ful deformity of the nail plate. There are several conservative and surgical techniques for trea ting this condition. We describe a simple and cost effective techni que using auto logous dermal grafts.

Keywords: NAIL DISEASES, NAILS, NAILS, MALFORMED, NAILS, INGROWN, AMBULATORY SURGICAL PROCEDURES

INTRODUCTION

Transverse over-curvature of the nail can be classified into 3 types: pincer nail, tile nail and folded nail. 1,2 Although the eti- ology is uncertain, it has been attributed to conditions such as tumors, psoriasis, exostosis and others. 3,4 Although the big toe is frequently affected, this deformity can occur in other digits. 5 The curvature increases distally, pinching the soft tissue beneath the nail plate, causing severe pain and sometimes secondary infection. Treatment is recommended if the patient has pain, inflammation, difficulty wearing shoes or cosmetic complaints. This condition usually affects a patient''''''''s daily activities and qual- ity of life. 4

Several surgical treatments have been reported, but until now there has not been a universally accepted technique. 4 Zook suggested placing dermal grafts under the lateral nail beds between the paronychial fold and the phalanx to flatten the nail bed. Removal of hypertrophy of lateral and distal nail folds using Howard-Dubois s technique or U shape techniques 6 are described as a surgical correction, especially when an osteophyte of the distal phalanx is removed and the nail bed must be flat- tened. This article describes a procedure that combines both of these techniques to flatten and widen the nail bed and correct the dense adherence of the nail bed to the periosteum, in order to prevent a reattachment of the nail bed to the distal phalanx and preserve the nail matrix.

METHODS

The nail plate is removed after a distal block anesthesia and the placement of a tourniquet (Figures 1 and 2). An elliptical wedge of soft tissue, approximately 5 mm wide, is excised with- in the distal lateral wall and removed down to the bone, as in Howard-Dubois s technique. The dermal graft is performed after the epidermis and fat tissues have been removed using scis- sors. The graft is then divided into two fragments of about 15 mm each (Figure 3). The lateral paronychial attachments to the bone are longitudinally freed with a blunt spatula, creating a tunnel from the open wound to the matrix on both sides (Figure 4). The dermal grafts are placed inside these tunnels to flatten the nail bed, as in Zook''''''''s technique. Finally the incision is closed with mononylon 4-0 (Figure 5). After the procedure, analgesics are prescribed and the suture stitches are removed after 7 to 14 days.

RESULTS

Immediately after the procedure it is possible to note the flattened nail bed due to the elevation of the nail matrix in the places where the grafts were placed. The pain is light to moder- ate in the first days, being more intense when there is necessity of osseous rectification. The use of closed shoes is allowed after approximately 4 weeks, with clear improvement of the pain when walking, as compared to the period before the procedure. The new nail grows with a flattened plate and an elongated bed, with excellent esthetical and functional results. (Figure 6 and 7).

DISCUSSION/CONCLUSION

The transverse over-curvature of the nail is a nail appara- tus alteration considerable prevalent in the population, leading to esthetical and functional problems. A number of correction techniques are described in the literature. The present method is aimed at combining two diverse techniques by excising the hal- lux''''''''s hypertrophy (according to the Howard-Dubois tech- nique), using that material as a dermal graft (according to the Zook''''''''s technique), rather than discarding it. With the synergy generated from the combined techniques, this procedure takes less time, less anesthesia and avoids an unattractive scar in the donor area for the dermal graft.

References

1 . Baran R, Dawber RPR, De Berker AR, Haneke E, Tosti A. Transverse overcurvature of the nail. In: Baran & Dawber''s Diseases of the nails and their management. 3rd ed.New York: Blackwell Science; 2001. pp. 54-5.

2 . Di Chiacchio N, Kadunc BV, de Almeida ART. Treatment of transverse overcurvature of the nail with a plastic device: Measurement of response. J Am Acad Dermatol. 2006;55(6): 1081-84.

3 . Baran R, Haneke E, Richert B. Pincer nails: definition and surgical treatment.Dermatol Surg. 2001;27(3):261–6.

4 . Mutaf M, Sunay M, Isik D. A New Surgical Technique for the Correction of Pincer Nail Deformity. Ann Plast Surg. 2007;58(5):496-500.

5 . Plusje LG. Pincer nails: a new surgical treatment. Dermatol Surg. 2001;27(1):41– 43.

6 . Rosa IP. Hipercurvatura transversa da lamina ungueal (pincer nail) e lamina ungueal que não cresce. Tratamento cirúrgico: Remoção do "U" largo de pele, osteocorreção do leito e cicatrização por segunda intenção. (Tese). São Paulo. Universidade Federal de São Paulo. Escola Paulista de Medicina. 2005. 156 p.