From the Orthopaedic Department, St. George's Hospital Medical School, London S.W.I.

Transcription

1 TRANSPLANTATION OF THE NAIL: A CASE REPORT By NICHOLAS P. PAPAVASSlI.IOU, M.D. 1 From the Orthopaedic Department, St. George's Hospital Medical School, London S.W.I. THE loss of a finger nail may be of as much concern to a patient as the loss of part of a digit. Often the use of an artificial nail is recommended (Buncke and Gonzalez, I962) and the alternative of transplantation not offered. Indeed there are few publications dealing with nail transplantation (Sheehan, I929 ; Berson, I95 o ; McCash, I956) whereas techniques for reconstruction or construction of digits are numerous. In this case report, the transplantation of a nail to damaged digits was done at the patient's specific request, and at a time when the work of others was not known. Material and Methods.--M.E., a married woman of 42 years, had lost the thumb of the left hand at the level of the metacarpophalangeal joint and the ring finger at the level of the base of the middle phalanx, from a severe pyogenic infection 2o years before. There was a fair amount of loose skin over the thumb remnant, and so this was lengthened to the level of the index metacarpophalangeal joint, using a block of bone from the ulna pegged into the metacarpal. Healing was uneventful. Eight weeks later a nail transplant to the ring finger was successful and so a similar transplant was performed to the thumb a month later. A. Transplantation of third right toe nail to left ring finger.rathe third toe was chosen because it had the better looking nail even though it was somewhat small for the finger. Under general anesthesia, the toe was prepared and a small rubber tourniquet placed around the digit. An incision on each side of the nail matrix, extended proximally for about r½ cm., allowed a flap to be raised (Fig. ia). A curved incision, just distal andbeneath the nail bed, allowed the nail to be detached fr0m theunderlying periostem. The skin edges of the donor site were undermined and the wound was closed by interrupted silk s u t u r e s.. :-.... With the nail as a template, a piece of skin of similar size was excised from the dorsum of the stump of the ring finger. Two small parallel incisions, made proximally, allowed a small skin flap to be raised (Fig.IC). The nail was placed on the fibro-fatty bed and the.flap used :to cover,the exposed nail matrix. The:! transplanvwa~ held in position by interrupted 3/o silk sutures (Fig. 2a), and covered b3~i a Conapressi0h d,ressing of tulle gi:as and dry gauze. No splint: Was used. i ~ ::~ : ~:~i:i B. Transplantation of right great toe nail to left,tbumb.'--+again und~rg~neral anesthesia, a pneumatic tourniquet on the thigh was" used' to cbhtroi bieediflg and allow greater precision in removing the donor nail. The method of removing the nail was similar to that of the previous operation but a frill of skin, forming the normal cuticle of the nail, was removed with the transplant. It was hoped that this would improve the appearance of the nail in its new position (Fig. 3b). A small portion of the phalanx of the great toe was removed to allow closure of the donor site without tension (Fig. 3a). Because the toe nail appeared rather broad on the thumb it was trimmed on each side and sutured into position as before. 1 Present address: the Unit for Experimental Plastic Surgery, Department of Surgery, Royal Postgraduate Medical School, (University of London), Ducane Road, London, W.I2. 274

2 TRANSPLANTATION OF THE NAIL Results.--The after-care of both nail transplantations behaved differently. 275 was the same but they Ring finger.--the nail, examined eight days after operation, was found to be pale and mobile, indicating that it had not yet taken. On the twelfth day the stitches were removed and an attempt was made to raise the nail ; the periphery had not taken but FIG. I A, The donor third toe. A skin flap has been raised to facilitate the removal of the matrix. B, The ring finger stump. C, Drawing of the incision on the dorsum of the ring finger stump. The skin inside the circle was removed ; the two extensions of the incision proximally were used for a flap to be raised under which the nail matrix was placed. its centre was attached to its new position. The finger was re-bandaged, and on the eighteenth day the nail was soundly attached to its new bed and entirely alive. The patient was seen regularly every two weeks. At the end of the eighth week, the nail exfoliated revealing a pink thin plate of nail. This gradually thickened and moved forwards. Four months after the transplantation it was an almost normal-looking nail (Fig. 2b). Thumb.mFifteen days after,operation the stitches were removed and the nail appeared to have taken completely. During the third week there was a minor infection

3 276 BRITISH JOURNAL OF PLASTIC SURGERY FIG. 2 A, The third toe nail on its new position on the ring finger stump. B, The transplanted nail four months after the operation. C, The same nail one year after the operation.

4 TRANSPLANTATION Fro. 3 OF T H E NAIL 277

5 278 BRITISH JOURNAL OF PLASTIC SURGERY in the distal half of the nail bed (Fig. 3c), which was treated with dressings and further immobilisation. Ten weeks after the operation the nail exfoliated revealing a pink thin nail-plate covering the distal half of the nail bed, and a thicker semi-rigid nail on the proximal half, which had a lunula. The rate of growth of this nail was very slow, so that by the end of six menths only two-thirds of the nail bed had been covered by keratinised firm nail (Fig. 3d). Eleven months after operation on the ring finger the appearance of the nail was almost normal. But when the nail grew beyond its soft tissue bed, which was curved, it tended to follow the same track and so grow into the skin of the pulp of the finger ; the patient, therefore, had to keep the free border short. The rate of growth appeared to be normal (Fig. 2c). The nail on the thumb, unfortunately, failed to grow normally, and, as Call be seen from the photograph (Fig. 4d), it is irregular and thickened. At the free border the plate turns downwards towards the skin. The forward growth has been slow. DISCUSSION The grafting of a nail may be performed by three different techniques (McCash, 1956) : the partial, the composite, and the complete graft. The present patient comes into the third category of complete grafting. Splinting of the recipient finger, as used by some authors (Sheehan, 1929 ; Swanker, 1947 ; McCash, i956), does not appear to be necessary. Sheehan (1929) and McCash (I 956) have described the histology and growth of the nail. Two points only should be mentioned here, namely the importance of the nail bed and the forward movement of the nail. As McCash has pointed out, the nail bed "does appear to be of importance in controlling the shape and smooth form of the nail, because scarring or irregularity of this area may lead to distortion of the nail itself ". As far as this forward movement is concerned, Wolf and Hanusova (1966) have studied the statics, dynamics and mechanics of the conditions existing in the nail root. They believe that it is the proliferation of epithelial cells of the root, enclosed as they are in a" fibrous pocket "with only one exit to the front, which drives the nail plate forwards. Hence, any hindrance to the forward movement of the nail plate will result in deformity of the nail and in an increase of its thickness. It would appear that the nail bed is responsible for the shape and direction of growth of the nail plate, because the latter must follow the direction of its bed. Hence, if the bed changes shape, for any reason, the nail must also do so. When the nail plate reaches the border of its bed, it will continue to grow at a tangent from the bed. If the nail bed, for any reason, has been destroyed (e.g. infection as in the thumb graft), this must be a barrier to the forward growth of the nail plate: the root cells will continue to proliferate, but additional cells are added at the periphery making the nail grow in thickness rather than in length. The support beneath the nail bed is at least partly responsible for its shape and, consequently, of the nail itself. Therefore, when there is no firm support (such as occurs normally at the terminal phalanx on the finger), the nail bed will follow the curved direction of the pulp, as will the nail plate. The nail seems able to change its characteristics when it is transplanted, for both of the two nails transplanted from the toes to the fingers have grown to look like finger nails.

6 TRANSPLANTATION OF THE NAIL 279 /,a %, FIG. 4 A comparison of the nails of the normal ring finger and t h u m b on the right hand with the transplanted ones on the left hand. A, Normal ring finger nail. B, Transplanted nail on ring finger stump. C, Normal t h u m b nail. D, Transplanted nail on the t h u m b stump one year after the operation.

7 280 BRITISH JOURNAL OF PLASTIC SURGERY CONCLUSIONS I. The nail tissue is very delicate and therefore has to be treated with great care. 2. After transplantation, the epithelial cells of the root pass into a stage of" shock" when no growth appears. This may last for about ten days before proliferation starts again. Stitches therefore should be removed at about this time (Io to 15 days), for otherwise they could obstruct the forward movement of the nail plate, possibly resulting in a deformity. 3. Complete immobilisation of the digit does not appear to be necessary. 4- The transplanted nail alters its previous shape to conform to the shape of the new bed on which it is placed. I would like to thank Mr. J. S. Calnan, Reader in Plastic and Reconstructive Surgery, for his help and guidance in writing this paper, and Mrs. ~, Underhill, Photographic Department, St. George's Hospital, for the excellent photographs she has taken. REFERENCES BERSON, M. I. (I95o). Surgery, 27, 594. BtrNcI ~, H. J. and GONZALEZ, R. I. (I962). Plastic reconstr. Surg. 3o, 452. McC^SH, C. R. (x956). Br. J. plast. Surg. 8, 19. SHEEHAN, J. E. (I929). J. Am. med. Ass. 92, SWANIO~R, A. W. (x947). Am. J. Surg. 74, 34 L WOLF, J. and HANUSOVA, S. (I966). Folia morph. I4, 283.