Nail Surgery: General Principles, Fundamental Techniques, and Practical Applications

Abstract

Despite being an integral part of dermatologic surgery, nail surgery is infrequently performed in daily practice. Indeed, it is frequently considered difficult, time-consuming, and the results take a long time to be observed. Nonetheless, nail pathology is a frequent cause of dermatology consultation, so dermatologists should be familiar with its diagnosis and therapeutic approach, which often involves surgical procedures. This article provides a review of nail surgery, focusing on the anatomy of this region, anesthesia of the ungual apparatus, common surgical techniques, reconstruction of defects in these locations, and a general approach to the most frequently encountered conditions in clinical practice.

Keywords: Dermatologic surgery; nail diseases; nail surgery.

Figure 1

Anatomy of the nail apparatus: (A) front view and (B) lateral view

Figure 2

Vascular supply of the nail apparatus. (A) frontal view with the three arcades that give rise to longitudinally running fine vessels for the proximal nail fold, matrix, and nail bed. (B) Lateral view highlighting the palmar artery, which supplies most of the blood to the nail apparatus and anastomoses with the thinner dorsal artery

Figure 3

Innervation of the nail apparatus. (A) The thumb and fifth finger are innervated mainly by the dorsal proper digital nerve. (B ) The remaining fingers are innervated mainly by the volar proper digital nerves

Figure 4

Anesthesia of the nail apparatus. (A) Distal digital block. (B) Distal anesthesia through the proximal nail fold. (C) Distal anesthesia through the hyponychium. (D) Traditional digital anesthesia

Figure 5

Nail dystrophy after incomplete removal of the lateral matrix horn. A separated lamina of nail plate is observed laterally and separated from the main one, originating from one lateral matrix horn, which was not completely removed during previous matricectomy

Figure 6

Segmental phenolization: (A) Ingrown nail before surgery, (B) unilateral 3-mm longitudinal avulsion of the nail plate, and (C) phenol application

Figure 7

Schernberg flap: (A) paramedian longitudinal lesion involving all sections of the nail unit; (B) flap design, (C) flap is cut and advanced into the defect, and (D) flap sutured in place

Figure 8

Unguodermal flap: (A) congenital malalignment of the great toenail, (B) flap design, (C) flap is cut and rotated into a normal orientation (as the nail unit is very firmly attached to the base of the distal phalangeal bone, dissection must be performed in this plan in order to enable rotation of the nail apparatus), and (D) flap sutured in place

Figure 9

Cross finger flap: (A) large lesion occupying most of the nail unit, (B and C) the entire nail apparatus is removed, (C) flap is cut as a “U” from an adjacent digit, and (D) flap sutured in place

Figure 10

Bilateral advancement flap: (A) lesion on the proximal nail fold, (B) flap design, (C) flap is cut and advanced into the defect, (D) flap sutured in place (if the secondary defects cannot be closed directly, they are left to heal by secondary intention)

Figure 11

V–Y rotation advancement flap: (A) large lesion on the proximal nail fold, (B) flap design, (C) flap is cut, rotated, and advanced into the defect, and (D) flap sutured in place

Figure 12

Bipedicle lateral nail fold flap: (A) lesion on the lateral nail fold, (B) flap design, (C) flap is cut and advanced into the defect, retaining its proximal and distal attachments, and (D) flap sutured in place

Figure 13

Matrix bipedicle flap: (A) midline lesion arising from the nail matrix, (B) flap design, (C) flap is cut and advanced into the defect, retaining its proximal and distal attachments, and (D) flap sutured in place

Figure 14

Bilateral sliding (advancement and rotation) flap: (A) lesion arising from the mid to distal nail matrix, (B) flap design, (C) flap is cut, rotated, and advanced into the defect, and (D) flap sutured in place

Figure 15

Bilateral A-to-T advancement flap: (A) lesion arising from the proximal nail matrix, (B) flap design, (C) flap is cut, rotated, and advanced into the defect, and (D) flap sutured in place

Figure 16

Onychogryphosis of the first toenail

Figure 17

Performance of a fish-mouth incision parallel to the distal groove on the tip of the toe, such that its closure pulls the distal nail wall down

Figure 18

Retronychia: (A) initial appearance, (B) appearance of the nail apparatus after removal of the first nail plate, (C) appearance of the nail apparatus after removal of another nail plate and curettage of granulation tissue, (D) nail plate avulsion complete, (E) plasty of the digital pulp using Howard Dubois technique, (F) result by the end of the surgery, (G) image of some of the nail plates removed, and (H) follow-up six months later, with satisfying cosmetic and functional results

Figure 19

Digital myxoid pseudocyst. Simple excision with ligation of the pedicle in the distal interphalangeal joint

Figure 20

Subungual exostoses. (A) A lesion is observed under the distal nail plate; B: bone consistency is perceived after removing part of the nail plate. (C and D) Overlying skin is incised and the exostosis is dissected and clipped off at its base. (E) Result by the end of the surgery. (F) Result two weeks after surgery