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TitleNail Surgery
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Total Pages206
Table of Contents
                            Contents
Preface
Chapter 1 Surgical anatomy of the nail apparatus
Chapter 2 Instrumentation
Chapter 3 General considerations
Chapter 4 Anesthesia of the nail apparatus
Chapter 5 Surgery of the nail plate
Chapter 6 Surgery of the proximal nail fold
Chapter 7 Surgery of the nail bed
Chapter 8 Surgery of the lateral nail folds
Chapter 9 Surgery of the distal fold
Chapter 10 Surgery of the matrix
Chapter 11 Surgery of the whole nail unit
Chapter 12 Surgery of the bony phalanx
Chapter 13 Surgery of the distal interphalangeal joint
Chapter 14 Acute trauma of the nail unit
Chapter 15 Cosmetic nail surgery for congenital nail abnormalities
Index
Back Cover
                        
Document Text Contents
Page 1

www.informahealthcare.com

Telephone House, 69-77 Paul Street, London EC2A 4LQ, UK

52 Vanderbilt Avenue, New York, NY 10017, USA

Bertrand RicheRt
Nilton Di chiacchio
Eckart haneke

R
ich

ert • D
i C

h
iacch

io
• H

an
eke

Cover design by Florence Richert
([email protected])

Bertrand Richert, MD, PhD
Clinical Professor, University of Liège
and Consultant Dermatologist, Université Libre de Bruxelles, Belgium
Second Vice President of the Council for Nail Disorders
Former Secretary of the European Nail Society
Author of L’ongle : de la clinique au traitement (2002; second edition, 2008),
50 cas de pathologie unguéale (2005), and a DVD on Basic Nail Surgery (2007)

Nilton Di Chiacchio, MD
Head of Dermatology Clinic, Hospital do Servidor Público Municipal de São Paulo, Brazil
Former Vice President of the Brazilian Society of Dermatologic Surgery
His previous publications include Doenças das Unhas (2007)

Eckart Haneke, MD, PhD
Department of Dermatology, University of Berne, Switzerland
Dermatology Practice Dermaticum, Freiburg, Germany
Centro de Dermatología Epidermis, Porto, Portugal
and Department of Dermatology, Academic Hospital, University of Ghent, Belgium
Former President, European Society for Dermatological Surgery
Former President, International Society for Dermatologic Surgery
Former President, European Society for Cosmetic and Aesthetic Dermatology
His previous publications include Nail Surgery (2000), Diseases of the Nails and their Management (2001), Text Atlas of Nail Disorders
(third edition, 2003), Onychomycosis (second edition, 2006), and The Nail in Differential Diagnosis (2007)

This text is a master-class for those wishing to perform nail surgery – a comprehensive practical guide to all types of nail surgery, including
some cosmetic procedures, with clear descriptions of each stage involved and of any complications and how to deal with them.

Contents:
Surgical anatomy of the nail apparatus * Instrumentation * General considerations * Anesthesia of the nail apparatus * Surgery of the
nail plate * Surgery of the proximal nail fold * Surgery of the nail bed * Surgery of the lateral nail folds * Surgery of the distal fold *
Surgery of the matrix * Surgery of the whole nail unit * Surgery of the bony phalanx * Surgery of the distal interphalangeal joint * Acute
trauma of the nail unit * Cosmetic nail surgery for congenital nail abnormalities

With over 500 color and black-and-white illustrations

Published in association with the Journal of Dermatological Treatment

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Nail Surgery

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Evolution
l Overall cosmetic results for all procedures are

excellent.
l In the Vandenbos’ and the Super U procedures,

healing by secondary intention may take up to 10
weeks.

l In Howard-Dubois’ and Noë l’s procedures, heal-
ing is quicker as it is first intention healing.

Complications and Management
l No complication has been reported yet for the

Vandenbos’ and Noë l’s procedures.
l Necrosis is a possible complication for Howard-

Dubois’s technique in case of overtightened
sutures.

HORN OF THE LATERAL SULCUS
Introduction
l This condition is mostly observed on the lateral

aspect of the fifth toe and in rare instances on the
fourth and affects almost exclusively women.

l The condition develops from the lateral rotation
of the fifth toe because of spread foot development
and precipitated by footwear (pointed shoes). The
toe is orientated such that the patient ambulates

on the lateral aspect of the nail plate. Friction
against the shoe box results in hyperkeratotic
reactions (9): it is usually benign and presents as
onychophosis (hyperkeratosis of the lateral nail
folds), but in some instances a real horn may
develop. The latter is very thick (Fig. 3A) and goes
deep down to the bone inducing excruciating pain
on pressure.

Anesthesia
l Hemi distal digital block

Tools
l Basic nail surgery tray

Surgical Procedure
Technique: intermediate

l The lesion is removed in an ellipse oriented
longitudinally and deep to the bone. There is no
reason to curve the proximal part of the incision,
as there is no removal of the matrix horn here.
One horizontal mattress suture, starting from the
lateral nail fold toward the plate will usually
suffice on the fifth toenail (Fig. 3B).

Figure 3 (A) Painful thick horn of the lateral sulcus of the fifth toe. (B) The lesion is excised in a straight incision and the lateral
edges reapproximated with one horizontal mattress stitch. (C) Very thick horn of the distal aspect of the lateral nail fold. (D) Closure of
the defect with a wide relaxing incision.

90 NAIL SURGERY

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l As the skin of the lateral aspect of the toe is thick
it is almost always impossible to close the defect,
even with large undermining. To help the
closure, a relaxing incision made 1 cm laterally
may suffice to help closing small defects (Fig. 3C,
D). This relaxing incision will usually run over
the pulp of the fifth toe.

l If the relaxing incision is not sufficient, a trans-
lation bridge flap is freed by inserting fine
pointed scissors in the excisional defect, which
are pushed down and laterally to emerge within
the relaxing incision. Repeated openings and
closures of the scissors will free the flap. The flap
is grasped with fine Adson forceps or better skin
hooks to check its mobility and its ability to be
lifted up to the lateral aspect of the nail. If not,
the flap has to be extended either proximally of
distally.

l Using nonabsorbable 3/0 suture, the flap is
affixed to the lateral edge of the plate with one
horizontal mattress suture, starting from the flap
toward the plate. One such stitch will usually
suffice on the fifth toenail. For hemostatic
purposes, one simple stitch may be added at
each extremities of the incision.

l The lower defect is not sutured and will heal by
secondary intention (10,11).

Key Point
l Freeing the flap from the underlying tissues. As

the surgery is performed on a thick skin with
few fat padding, mobility is quite limited.

Postoperative Care
Pain: severe

l Bleeding is the rule! After removal of the
tourniquet, inject some extra anesthetic (ropiva-
caine or buvipacaine) as a distal digital block to
press onto the digital arteries.

l Apply a large amount of greasy antiseptic
ointment and Tulle Gras on the wound and
pad with several layers of gauze. Apply firmly,
but not too tight, an elastic band around the
whole foot and secure to the ankle.

l Keep the patient with the limb elevated for about
half an hour before returning home.

l This surgery is painful. Prescribe potent pain
killers for two days.

l Remove the stitches within two to three weeks
according to healing.

Evolution
l Healing is quite fast and the defect will close in

about three weeks.
l It has been shown that semiocclusive dressings

may enhance healing (10). Silicone dressings
(Mepitel1) are very effective (11).

l No infection is observed with the secondary
intention healing if proper care is performed
(12).

l Some patients may complain about pain in the
secondary intention healing area than elsewhere.
This may be due to the wound retraction
observed in such healing.

l After recovery, proper footwear is a must and
podiatric examination to correct any imbalance
with insole is especially useful. Otherwise,
recurrence is the rule.

Complications and Management
l Necrosis of the flap is exceptional. Beware of

heavy smokers and patients with impaired
vascular flow at the extremities.

l No dystrophy or retraction is observed at this
location as the defect remains of small size.

FIBROKERATOMA
Introduction
l At this location acquired periungual fibroker-

atomas (FK) are identical to the digital acquired
FK (13). They may present as flat to dome
shaped, or tall and hyperkeratotic flesh-colored
asymptomatic nodules with a hyperkeratotic tip
(Fig. 4). Trauma is thought to be an causative
factor.

Figure 4 Digital fibrokeratoma.

SURGERY OF THE LATERAL NAIL FOLDS 91

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Total nail avulsion
distal approach, 32–34, 33f
proximal approach, 34–36, 35f
with plate replacement, 36–38

curled nail avulsion, 37–38
trap door avulsion, 36–37, 36f

Tourniquet, 11, 13f, 106
Transthecal block procedure, 29
Transthecal digital block procedure, 27–28, 27f
Trap door avulsion, 36–37, 36f

complications and management, 37
evolution, 37
indications for, 36
key point, 37
postoperative care, 37
procedure, 36–37, 36f
surgical tools for, 36

Trapezoidal nails, cosmetic surgery for, 177–178,
178f, 179f

anesthesia for, 178
complications of, 178
evolution, 178, 179f
key point of, 178
management of, 178
postoperative care, 178
surgical procedure for, 178
tools for, 178

Traumas, acute, 171–176, 171f–176f
division of

avulsion of matrix, 174–175
severe crush injury, 174, 175f
simple laceration, 173–174, 174f
stellate laceration, 174

[Traumas, acute]
lacerating and crush lesions, 173–176, 174f–176f.

See also Crush lesions; Laceration
subungual hematoma, 171–172, 171f–172f, 173f.

See also Subungual hematoma
Tumors of distal fold, 100–102

anesthesia, 102
complications, 102
evolution, 102
key point, 102
management, 102
postoperative care, 102
surgical procedure, 101f, 102, 102f
surgical tools, 102

Ulnar nerve, in hand, 4, 4f
Unguodermal flap, for CMBT, 135–137, 136f–137f

Vater-Pacini bodies, 9, 9f
Ventral nail, 8, 9f
Vertical implantation of fifth toenail, 180–181, 180f–181f.

See also Toenail, fifth, vertical implantation of
Vibrating frog, 28, 28f

Warfarin, 29f
discontinuation, 18

Wedge excision, for matrix, 103–104
Wing block procedure, 26–27, 26f
Work disruption, information on, 16

Zip-tie tourniquet, 11, 13f

192 INDEX

Page 206

www.informahealthcare.com

Telephone House, 69-77 Paul Street, London EC2A 4LQ, UK

52 Vanderbilt Avenue, New York, NY 10017, USA

Bertrand RicheRt
Nilton Di chiacchio
Eckart haneke

R
ich

ert • D
i C

h
iacch

io
• H

an
eke

Cover design by Florence Richert
([email protected])

Bertrand Richert, MD, PhD
Clinical Professor, University of Liège
and Consultant Dermatologist, Université Libre de Bruxelles, Belgium
Second Vice President of the Council for Nail Disorders
Former Secretary of the European Nail Society
Author of L’ongle : de la clinique au traitement (2002; second edition, 2008),
50 cas de pathologie unguéale (2005), and a DVD on Basic Nail Surgery (2007)

Nilton Di Chiacchio, MD
Head of Dermatology Clinic, Hospital do Servidor Público Municipal de São Paulo, Brazil
Former Vice President of the Brazilian Society of Dermatologic Surgery
His previous publications include Doenças das Unhas (2007)

Eckart Haneke, MD, PhD
Department of Dermatology, University of Berne, Switzerland
Dermatology Practice Dermaticum, Freiburg, Germany
Centro de Dermatología Epidermis, Porto, Portugal
and Department of Dermatology, Academic Hospital, University of Ghent, Belgium
Former President, European Society for Dermatological Surgery
Former President, International Society for Dermatologic Surgery
Former President, European Society for Cosmetic and Aesthetic Dermatology
His previous publications include Nail Surgery (2000), Diseases of the Nails and their Management (2001), Text Atlas of Nail Disorders
(third edition, 2003), Onychomycosis (second edition, 2006), and The Nail in Differential Diagnosis (2007)

This text is a master-class for those wishing to perform nail surgery – a comprehensive practical guide to all types of nail surgery, including
some cosmetic procedures, with clear descriptions of each stage involved and of any complications and how to deal with them.

Contents:
Surgical anatomy of the nail apparatus * Instrumentation * General considerations * Anesthesia of the nail apparatus * Surgery of the
nail plate * Surgery of the proximal nail fold * Surgery of the nail bed * Surgery of the lateral nail folds * Surgery of the distal fold *
Surgery of the matrix * Surgery of the whole nail unit * Surgery of the bony phalanx * Surgery of the distal interphalangeal joint * Acute
trauma of the nail unit * Cosmetic nail surgery for congenital nail abnormalities

With over 500 color and black-and-white illustrations

Published in association with the Journal of Dermatological Treatment

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