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14 Reconstruction ofNail Defects
14.2.1 Indications
The defect of nail bed with intact nail matrix, no injury of
phalanx, and good soft tissue in the palmar and distal end.
14.2.2 Surgical Design
The recipient site: The circumferential resection should be
carried out to the normal nail bed margin according to the
patient's ngernail condition (Fig.14.5).
The donor site: a transverse incision is made on the medial
side on the ipsilateral upper arm to facilitate the appearance
after suture (Fig.14.6).
14.2.3 Surgical Method
Anesthesia: Brachial plexus anesthesia or general anesthesia
should be selected.
After the anesthesia is stable, the patient is placed in the
supine position, and the affected side is driven by the tourniquet. First, the wound should be completely debrided.
Treatment of bone exposure: a 0.8 mm Kirschner wire is
used to drill holes on the dorsal side of the distal phalanx. All
the holes should be arranged into squares, and the distance of
each hole is 0.8mm. If accompanied by phalanx fracture, the
fracture site, and its distal end are not suitable for drilling, so
as not to cause local blood circulation disturbance, affecting
bone healing and graft survival. To measure the range of ngernail loss, the skin of the same size on the proximal medial
side of the upper arm of the patient is generally taken as
donor site. A transverse incision is made according to the
design. The epidermal layer of the skin is carefully removed
with a sharp knife to expose the dermis, and the graft is
removed along the subsupercial fascia. The donor site can
be sutured directly.
The tissue structure of the donor should be reversed, with
the supercial fascia layer on the top and the dermis layer
on the bottom to bury the bone of the phalanx on the wound
surface, and the donor is sutured intermittently with the skin
on the wound edge. Vaseline gauze pieces or cotton balls
wrapped with vaseline gauze are packed and compressed.
Use 4-0 mush thread intermittent suture, should not suture
too tight and dense, so as not to tear the tissue, affect the
blood supply and the survival rate of composite tissue.
Fig. 14.5 The situation of the nail defect and the appearance after
debridement
Fig. 14.6 The design for the incision of the donor site
14.2.4 Operation Characteristics
(a) Convenient sampling: the whole body can be sampled,
the method is simple, without special equipment or
technology;
(b) Less complications at the donor site: the donor site can
be sutured directly, with fast healing and no obvious
complications;
(c) Multi-purpose of “one skin”: the split skin of removed
skin can be used to cover the skin defect area;
(d) It can avoid the scar healing after the nail bed defect, keep
the length and appearance of the nger, and retain the integrity of the nail bed, without affecting the attachment ability
of the nail body, and without obvious local tenderness.
(e) Survival of the fascia layer restores the smooth surface
of the nail bed and gives the nail a more realistic
appearance.
14.2.5 Announcements
(a) The bone surface of nail bed defect should be drilled to
provide enough blood for nutrition and ensure dermal
survival.
(b) When removing the skin, the dermis should be of a cer-
tain thickness, which is equivalent to the thickness of the
nail bed. If it is too thick, it is not easy to survive, or it
may cause uneven nail growth.
14.3 Reconstruction ofNail Defect by Toenail Flap Transplantation
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217
(c) When the dermis covers the defect area, it should be
turned over and the Germanic layer should be outward to
ensure close adhesion with the new nail and prevent the
nail from separating.
(d) After suture, a pressure package should be made to make
the dermis closely adhere to the bone surface to ensure
the survival of the dermis.
(e) Reasonable use of antibiotics after the operation to pre-
vent wound infection and tissue necrosis;
(f) When the wound is infected or bleeding or hemoceles
under the wrap, the suture should be removed immediately, the wrap should be opened, the cause should be
checked and remedial treatment should be made in time.
(g) Local immobilization of the affected limb, such as plas-
ter external xation, which is prohibited to remove at
will to limit the movement of the affected nger.
14.3 Reconstruction ofNail Defect by
Toenail Flap Transplantation
Nail is one of the important parts of the nger. The defect of the
nail will affect the appearance and function of the nger. Repair
and reconstruction of nail bed defects have always been a hot
topic in the clinical work of hand surgeons. Just the wound
repair is relatively simple. Various pedicled skin tubes, pedicled
skin aps, and adjacent nger aps can be used to cover the
wound surface in clinic, but that can only solve the problem of
the wound surface, while the repair and reconstruction of the
defect of the nail bed cannot meet the requirements of appearance and function. With the development of microsurgery, the
clinical use of free toenail ap transplantation to reconstruct the
defect of ngernails is satisfactory and has been a classic way
of repair, which has been gradually miniaturization after continuous improvement and development.
In 1988, Koshima designed a free toenail ap containing
blood vessels and nerves on the basis of great toenail ap for
nail defects or deformities. after the operation, it was found
that the nail was successfully reconstructed, with no deformities in appearance and good functional recovery. In 2002,
Chinese scholar Yuan Guanghai etal. designed a half toenail
ap for half or partial defect of the ngernail bed, which had
a good postoperative effect. The current clinical design for
nail bed defects is a kind of miniature toenail ap including
nail bed, blood vessels, and nerves, and its therapeutic effect
has been widely recognized clinically.
14.3.1 Indications
(a) Most or total (necrotic) defects in the ngernails; (b)
Patients have a strong desire for reconstruction and a high
requirement for the appearance of the nger; (c) The toenails
are normal, and the blood vessels have no obvious deformity;
(d) The optimal age is under 60 years old.
14.3.2 Surgical Design
According to the size of the ngernail defect, to determine
the removed toenail and range. For the reconstruction of
thumbnail defect, the ipsilateral great toenail is usually used.
For the reconstruction of other ngernails, the second toenail
can be selected. In addition, according to the defect area and
shape of the skin and nail on the dorsal side of the thumb or
the other nger, the great toe or the second toe on the ipsilateral or opposite side combined with the dorsal nail ap can
be designed to repair the corresponding thumb or ngernail
defects on the dorsal side. Arteries: the rst dorsal metatarsal
artery—the bular dorsal digitorum artery great toe or the
tibial dorsal digitorum artery of the second toe; veins: dorsal
digitorum vein—dorsal digitorum vein of the great toe; for
nerve defects, dorsal branch of deep peroneal nerve of great
toe can be grafted for repair (Fig.14.7).
Fig. 14.7 The defect of the
nail and the design for the
donor toe
218
14 Reconstruction ofNail Defects
14.3.3 Surgical Method
Preparation fortheRecipient Site
To retain healthy tissue as far as possible while debridement
is performed. Then emergency operation or scheduled transplantation 3–5 days later is selected according to the situation. The size and shape of the nail defect should be carefully
measured before operation, and whether there is bone defect
or skin defect.
Preparation fortheDonor Site
Appropriate great toenail aps, half-toenail aps, and toenail
aps are designed according to the defect in the recipient
site, and the donor site should be cleaned and prepared to
ensure that transplanted tissue is without local infection and
damage.
The Cutting oftheToe (Take theToenail Flap
oftheGreat Toe forExample)
The skin and subcutaneous incision are made on the bular
side of the great toe and the dorsal side of the rst toe web.
The plantar digitorum artery and dorsal digitorum vein of
the great toe are dissociated from distal to proximal. If necessary, it could be extended to the dorsal metatarsal vein
which should be cut off at an appropriate distance and
ligated at the proximal end. Cut open the skin at the toe pulp
according to the design, combined with subcutaneous tissue
of appropriate thickness is lifted to the bular side of the
bottom of the toe. At the deep surface of neurovascular bundle (The artery and nerve are included in the ap) dissociation is performed to the edge of nails, according to the
design line incision is made along the nails (from root to the
free edge) to the surface of the bone, and dissociate to the
bular side and merge with toe pulp ap. If the phalanges
need to be cut, the end of the extensor digitorum longus tendon of the great toe should be dissociated when the skin is
cut at the dorsal side. First, the half of the phalanx is cut
laterally far from the termination point, and then the toenail
and the deep part of the phalanx are cut longitudinally to
form the toenail (bone) ap pedicled with the bular artery
or plantar metatarsal artery and nerve of the great toe which
is dissociated proximally with appropriate length and cut off
for later use.
Transplantation
After the toenail ap is cut, the subcutaneous fat should be
removed under the operating microscope. The brous tissue
between the ap and toenail is cut off to make the ap fully
open so as to accommodate the phalanx. When moving to the
hand, the toenail is rst xed to the residual phalanx with a
Kirschner wire. Dissociate the proximal nail margin and lift
it up to x the surrounding tissue to form a bilateral symmetry of the semi-arc. Then, the free edge of the toe is removed
about 0.2 cm, and the epidermis is inverted with the edge of
the nail bed. If there is still some residual soft tissue on one
side of the affected nger, the nail fold will be reconstructed
by a mattress suture. If there is just residual nail fold on the
affected nger, the toenail will be disengaged and repaired,
and inserted into it. If there is still some residual nail bed on
the affected nger, the nail plates of about 0.3cm on both
sides of the nail bed will be removed respectively. The
exposed nail bed is sutured distally from the methyl with a
5-0 noninvasive suture. Trim the distal free edge of toenail to
make both sides symmetrical. Anastomosis of digital and
digitorum vessels and nerves is performed (Figs.14.8, 14.9,
and 14.10).
Fig. 14.8 The blood vessels
and nerves
14.3 Reconstruction ofNail Defect by Toenail Flap Transplantation
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Fig. 14.9 The dissection of the donor toe nail and the blood vessels
and nerves for anatomosis
Fig. 14.10 The appearance after the transplantation
Postoperative Treatment
(a) Strengthen nursing, closely observe the blood supply for
the nail; (b) Postoperative “three anti” and other routine tissue transplantation therapy should be carried out; (c) Heat
preservation should be carried out; (d) No smoking during
the perioperative period.
14.3.4 Operation Characteristics
(a) The defect of ngernail itself has little effect on the
function of nger. The main purpose of the reconstruc-
219
tive operation is to solve the aesthetic problem.
Therefore, this operation has a higher requirement for
appearance and requires a ne design to meet the
requirements of the patient;
(b) The risk of operation is high, and the requirement for
microsurgical technique is higher;
(c) The appearance of reconstructed nails after the operation
is realistic and the effect is good;
(d) It is suitable for the whole nail bed, part of the nail bed
defect, and also for patients with phalanx and skin
defects.
14.3.5 Announcements
(a) Precise surgical method is designed to protect the donor
site and reduce damage to the great toe. If phalanges
were needed, iatrogenic fractures should be avoided.
(b) When cutting the nail bed, try to leave a thin layer of the
nail bed to facilitate the re-growth of the toenail bed. A
little skin should be attached around the nail to facilitate
the suture and xation with the ngertips.
(c) Protect the connection between the nail bed and the
artery. After the pedicle is cut off, the nail ap should be
trimmed under a microscope to remove the excess toe
bone and soft tissue. At the same time, pay attention to
maintaining the integrity of the nail bed when the nail
bed is separated from the toe bone.
(d) To ensure the anastomosis quality of blood vessels, be
careful not to be too long or rotated or twist, 8 needles of
11-0 sitch is appropriate while the ratio of arteriovenous
can be 1:1 or 1:2.
(e) The arteries and veins of the donor site should be appro-
priately longer when cutting in order to have a larger
diameter and healthier blood vessels for anastomosis.
(f) The tunnel where the toenail ap is xed with the vascu-
lar nerve pedicle should be loose, which even can be
opened if necessary;
(g) Avoid injuring the nail matrix when cutting, otherwise, it
will lead to the development of deformity of the reconstructed nail and affect the appearance.
(h) After the operation, lie in bed absolutely for a week and
pay attention to indoor heat preservation, a quiet and
smoke-free environment is also required.
14.3.6 Case Description
Case 1 The 20-year-old female patient was admitted to the
hospital for more than 2 h due to pain and bleeding of the
right index and middle ngers with movement limitation
caused by the heavy objection. Physical examination: She
was in good general condition, with stable vital signs. The
contusion of the right index nger was serious, with the trau-
220
abc
14 Reconstruction ofNail Defects
d
e f
g
Fig. 14.11 Reconstruction of the right index ngernail defect by free
great toenail ap transplantation. (a) Preoperative condition of the nger defect. (b) Preoperative design. (c) Dissociation of the great toenail
ap. (d) The dorsal view of the reconstructed nger after the operation.
(e) The palmar view of the reconstructed nger after the operation. (f)
The dorsal view of the donor site. (g) The plantar view of the donor site
matic loss of the nail plate and nail bed, phalanx exposed,
uneven wound margin, slow bleeding, serious soft tissue
contusion of the dorsal end of the wound, blue on the nger
pulp, general in capillary reaction, numbness of feeling;
Open injury was on the dorsal side of the right middle nger,
with the traumatic loss of the nail plate, oblique crack nail
bed exposed, slow bleeding, general in peripheral blood supply. After admission, routine preoperative preparation for
reconstruction was given, and surgical contraindications
were excluded. After complete debridement, the index nger
was reconstructed by the toenail ap transplantation of the
right great toe. Debridement and suture of right middle nger were performed and the defect in the donor site was
repaired with ipsilateral dorsal metatarsal ap. The operation
was successful, after the tourniquet relaxed, the reconstructed ngers were ruddy with moderate tension, wrapped
with the sterile cotton, bulked, and stuffed with the broken
cotton gauze around, and she returned to the ward safely.
Routine reconstruction treatment was given after the opera-
tion. Two weeks after the operation, the reconstructed nail
ap survived successfully. Regular follow-up was conducted
to guide functional exercise. The appearance and function of
the reconstructed nger were satisfactory (Fig.14.11).
Case 2 The 23-year-old male patient was admitted to the
hospital in emergency for 1 h due to pain and bleeding of the
right thumb defect caused by mould injury. Physical examination: he was in good general condition, with stable vital
signs, traumatic loss of the thumb from the nail root, irregular skin of the stump, exposed bone, and active bleeding. And
the other ngers were normal. After admission, routine preoperative preparation for reconstruction was given, and surgical contraindications were excluded. After complete
debridement, the thumb was reconstructed by half toenail
ap transplantation of the left great toe under general anesthesia in emergency, and the donor site was covered by transposition of the local ap. The operation was successful, after
the tourniquet relaxed, the reconstructed ngers were ruddy
ef
14.3 Reconstruction ofNail Defect by Toenail Flap Transplantation
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ab c
d
gh
221
Fig. 14.12 Reconstruction of the right thumbnail defect by free great
toenail ap transplantation. (a) Preoperative condition of the nger
defect. (b) Preoperative design. (c) Dissociation of the great toenail
ap. (d) The condition of the reconstructed nger after the operation.
with moderate tension, wrapped with the sterile cotton,
bulked, and stuffed with the broken cotton gauze around, and
he returned to the ward safely. Routine reconstruction treatment was given after the operation. Two weeks after the
operation, the reconstructed nger survived successfully.
Regular follow-up was conducted to guide functional exercise. The appearance and function of the reconstructed nger
were satisfactory. The donor site healed in the rst stage, and
the patient was satised with the appearance and function
(Fig.14.12).
Case 3
The 39-year-old male patient was admitted to hospi-
tal in emergency for 1.5 h due to pain and bleeding of the left
thumb and index nger defect caused by punch injury.
Physical examination: He was in good general condition,
with stable vital signs, soft tissue defect on the dorsal side of
the distal segment of the thumb, exposed bone, in irregular
(e) The appearance of the reconstructed nger 23 months after the operation. (f) The opponents function of the reconstructed nger 23 months
after the operation. (g) The holding function of the reconstructed nger
23 months after the operation. (h) The situation of the donor site
skin of the stump; soft tissue defect on the nger pulp of the
index nger, exposed bone, in irregular skin of the stump,
seriously polluted. After admission, routine preoperative
preparation for reconstruction was given, and surgical contraindications were excluded. After complete debridement,
the thumb was reconstructed by toenail ap transplantation
of the left great toe under general anesthesia in emergency,
and the donor site was covered by transposition of the lateral
tarsal ap. Debridement and skin graft were also performed
on the index nger. The operation was successful, after the
tourniquet relaxed, the reconstructed ngers were ruddy with
moderate tension, wrapped with the sterile cotton, bulked,
and stuffed with the broken cotton gauze around, and he
returned to the ward safely. Routine reconstruction treatment
was given after the operation. Regular follow-up was conducted to guide functional exercise. The appearance and
function of the reconstructed nger were satisfactory. The
222
ef
abc
d
g h
14 Reconstruction ofNail Defects
Fig. 14.13 Reconstruction of the left thumbnail defect by free great
toenail ap transplantation. (a) Preoperative condition of the nger
defect. (b) The condition of nail defect after debridement. (c)
Preoperative design. (d) Dissociation of the pedicle. (e) Dissociation of
donor site healed in the rst stage, and the patient was satised with the appearance and function (Fig.14.13).
Case 4 The 26-year-old female patient was admitted to
hospital in an emergency for 1.5 h due to pain and bleeding
of the left thumb caused by punch injury. Physical examination: she was in good general condition, with stable vital
signs, type III defect of the thumb, exposed bone, in irregular wound, seriously polluted. After admission, routine preoperative preparation for reconstruction was given, and
surgical contraindications were excluded. After complete
debridement, the thumb was reconstructed by toenail ap
transplantation of the left great toe combined with the second phalangeal bone and joint composite tissue transplantation under general anesthesia in emergency. The foot
donor site was designed to be repaired by the residual composite tissue ap of the second toe, and the second toe
donor area was directly sutured. The operation was suc-
the lateral tarsal ap. (f) The appearance of the reconstructed nger
after the operation. (g) The appearance of the reconstructed nger 1
month after the operation. (h) The appearance of the donor site 1 month
after the operation
cessful, after the tourniquet relaxed, the reconstructed ngers were ruddy with moderate tension, wrapped with the
sterile cotton, bulked, and stuffed with the broken cotton
gauze around, and she returned to the ward safely. Routine
reconstruction treatment was given after the operation.
Regular follow-up was conducted to guide functional exercise. The appearance and function of the reconstructed nger were satisfactory. The donor site healed in the rst
stage, and the patient was satised with the appearance and
function (Fig.14.14).
Case 5 The 21-year-old male patient was admitted to hospital in emergency for 2 h due to pain and bleeding of the right
thumb defect caused by punch injury. Physical examination:
he was in good general condition, with stable vital signs, nail
defect and soft tissue defect of the nger pulp of the thumb,
exposed bone, in irregular wound, and seriously polluted.
After admission, routine preoperative preparation for recon-
ef
14.3 Reconstruction ofNail Defect by Toenail Flap Transplantation
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ab c
d
223
g
j
k
Fig. 14.14 Reconstruction of the left thumbnail defect by free great
toenail ap transplantation. (a) Preoperative dorsal condition of the nger defect. (b) Preoperative palmar condition of the nger defect. (c)
Preoperative X-ray. (d) Preoperative design (the dorsal side). (e)
Preoperative design (the plantar side). (f) Dissociation of the composite
tissue ap. (g) Transplantation of the ap. (h) The palmar appearance of
ih
l
the reconstructed nger after the operation. (i) The dorsal appearance of
the reconstructed nger after the operation. (j) The situation of the
donor site. (k) The dorsal appearance of the reconstructed nger 14
months after the operation. (l) The palmar appearance of the reconstructed nger 14 months after the operation
struction was given, and surgical contraindications were
excluded. After complete debridement, the thumb was reconstructed by toenail ap transplantation of the right great toe
combined with the bular ap of the great toe transplantation
under general anesthesia in emergency. The foot donor site
was covered by the dorsal ap of foot. The operation was
successful, after the tourniquet relaxed, the reconstructed
ngers were ruddy with moderate tension, wrapped with the
sterile cotton, bulked, and stuffed with the broken cotton
gauze around, and she returned to the ward safely. Routine
reconstruction treatment was given after the operation.
Regular follow-up was conducted to guide functional exercise. The appearance and function of the reconstructed nger
were satisfactory. The donor site healed in the rst stage, and
the patient was satised with the appearance and function
(Fig.14.15).
224
abc
def
14 Reconstruction ofNail Defects
Fig. 14.15 Reconstruction of the right thumbnail defect by free great
toenail ap transplantation. (a) Preoperative condition of the nger
defect. (b) Preoperative design. (c) Dissociation of the ap. (d) The
appearance of the reconstructed nger after the operation. (e) The
appearance of the reconstructed nger 2 years after the operation. (f)
The function of the reconstructed nger 2 years after the operation
Reconstruction ofFinger Pulp Defects
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15
Abstract
The nger pulp defect of thumb and other ngers is common in clinic, which affects the integrity of ngertip and
the holding function. Traditional local aps, reverse aps,
and free aps can all be used to repair the wound surface,
but the function and appearance are difcult to satisfy
patients. The reason is that the nger pulp has its special
structure: the skin surface of the nger pulp has a large
number of ne skin lines; the dermis of the nger pulp is
composed of dense connective tissue; the deep dermis of
the nger pulp is closely connected with the subcutaneous
tissue, and the deep subcutaneous fat tissue is separated
by many vertical ber bundles which attach to the deep
fascia. Therefore, when the nger pulp is to be reconstructed, the above structures need to be reconstructed.
Obviously, only the toe pulp is the ideal donor site. At
present, the commonly used donor sites in clinical practice include bular ap of the great toe and tibial ap of
the second toe. The former one has larger soft tissue volume, and the donor site is easy to be sutured directly
which is focused on in this chapter.
Keywords
Finger reconstruction · Finger pulp defect
that surgeons can use this technology to complete the reconstruction of the nger pulp defect better.
The palmar nger ap is a skin ap containing bilateral
palmar proper arteries and nerve bundles, which can be dissociated and moved forward to repair and reconstruct the
nger pulp defect. Due to the dense skin structure on the
palm of the nger, the postoperative nger pulp is plump and
wear resistant, and the feeling is good.
15.1.1 Indications
(a) Simple nger pulp defect caused by trauma or nger pulp
ischemic necrosis, the range is not more than 1.5 cm; (b) The
defect in the distal segment of the nger.
15.1.2 Surgical Design
Longitudinal lines are drawn in the middle of both sides of
the affected nger, and the proper neurovascular bundles of
both sides should be included in the palmar ap.
15.1.3 Surgical Method
(a) The position of patients: In supine position, the affected
limb is abducted on the operating table.
15.1 Reconstruction ofFinger Pulp Defect
by Local ThumbFlap
Finger pulp is the most sensitive part of hand touch, the
touch function of the hand completely depends on the nger
pulp to complete. Therefore, the nger pulp defect needs to
be repaired with high quality as far as possible, especially to
restore the tactile function and good appearance. The development of microsurgery has also created good technical conditions for the repair and reconstruction of the nger pulp, so
© Springer Nature Singapore Pte Ltd. 2023
J. Lin et al., Atlas of Finger Reconstruction, https://doi.org/10.1007/978-981-19-9612-2_15
(b) Anesthesia: Brachial plexus block, digital nerve block,
or exor tendon sheath anesthesia can be used.
(c) The design of the ap: A line should be drawn along the
middle line on both sides of the nger stump wound to
the root of the nger.
(d) Surgical steps: The operation is performed under the
control of a tourniquet. After debridement of the nger
stump, the skin is cut along the midline incision line on
both sides, and the skin is sharply separated from the
distal end to the proximal end on the supercial surface
225
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