FREE NAIL GRAFTING. By C. R. MCCASH, Ch.M., F.R.C.S.(Ed.) Plastic and Oral Surgery Centre, Rooksdown House, Basingstoke

Size: px

Start display at page:

Download "FREE NAIL GRAFTING. By C. R. MCCASH, Ch.M., F.R.C.S.(Ed.) Plastic and Oral Surgery Centre, Rooksdown House, Basingstoke"

Gerard Flowers
5 years ago
Views:

1 FREE NAIL GRAFTING By C. R. MCCASH, Ch.M., F.R.C.S.(Ed.) Plastic and Oral Surgery Centre, Rooksdown House, Basingstoke THE flattened form of the nail or ungula seen in man and certain of the higher mammals has been the subject of much controversy (Le Gros Clark, 1936). Some anatomists consider it to be a degenerate form of the claw or tegula and others consider that the reverse is true. A study of the functional values of the two types suggests rather that each is specialised to meet individual needs. For instance, furred animals use their curved and pointed claws for fighting, climbing, scratching, and combing the hair. In man and apes, on the other hand, the flattened ungula-type nails give suppolt to the tips of the long slender digits and, by exerting counter pressure on the pulp, add to the appreciation of touch and texture. This is borne out by the histology of the human nail bed, which reveals a complicated system of capillaries, non-medullated nerves, and lymph vessels, together with many Paccinian corpuscles. These latter are most numerous towards the finger-tip where the counter pressure of the nail would have its greatest effect. The tips of the fingers in man represent the tactile horizon of the body. As end organs designed for the appreciation of such fine differentiation as that of roughness or smoothness, softness or hardness, they should be anatomically perfect if they are to fulfil their functions. It has also been suggested by Castello (I94I) that the vascular systems under the nail play an important part in the regulation of peripheral circulation. Finally, the nail forms a protective shield over the ungual process which, unlike the rest of the terminal phalanx, ossifies in membrane. Apart from the value of the nails in relation to the rest of the body, their cosmetic importance remains the chief indication for our efforts as plastic surgeons to find a satisfactory technique to restore them. DEVELOPMENT The first evidence of nail formation in the human embryo is seen about the ninth week. It is described as a small area of hardening of the stratum lucidum near the tip of the finger and the formation of a groove behind and on each side. The primitive nail is covered at first by the eponychium. Soon with the growth of the digit the nail migrates back to its normal position on the dorsum and becomes harder by the deposition of eleidin in its cells. In the fourth month the soft eponychium which covers the nail is broken through, rather like the eruption of a tooth, and its remnants persist only in the perionyx at the nail root and the h yponychium beneath the free margin of the nail (Wood Jones, I946) (Fig. 1). The matrix from which the nail forms consists of a thickening of the stratum Iucidum. 19

20 BRITISH JOURNAL OF PLASTIC SURGERY GROWTH OF THE NAIL It has been proved that nail growth starts from root, and as the more superficial layers of cells in the matrix become cornified, they

2 20 BRITISH JOURNAL OF PLASTIC SURGERY GROWTH OF THE NAIL It has been proved that nail growth starts from root, and as the more superficial layers of cells in the matrix become cornified, they steadily migrate forwards toward the finger-tip. In its passage distally still more cells are added to the nail from the matrix beneath, and it consequently becomes thicker as it advances. The portion of the nail bed concerned with the growth and thickening of the nail known as the germinal matrix corresponds to the lunula. Distal to this lies the STERILE MATRIX OR NAiL BED ~ :? : : i : i [ LUNULA,,, A, L [ [~~':.~.:~-::~:'-;i:~:! ;.:V:ii:i:::~.'.'~":~:i:.:':"". " " GERa,NAL ~ :. " -~-4ATRIX " " FIG. I Anatomy of the nail bed. sterile matrix or nail bed proper which, though attached to the nail, is said to take no part in its formation. Proof of this is given by the fact that the keratohyaline granules which go to form the eleidin in the nail are found only in the cells of the germinal matrix and are absent in the nail bed (Castello, I94I). 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 (Figs. 2, 3, and 4). The peculiar property of forward growth in the nail matrix is not dependent upon its situation on the digit. This is exemplified in cases of accidental displacement of nail bed where an aberrant nail may grow in whatever direction it happens to be placed. Records of ectopic nails growing in new sites as a result of trauma have been made by Pribram (1912) and Deibert (1943). The latter describes a displaced nail growing over the distal interphalangeal joint in a proximal direction. An example of this is shown in the case of a boy of 16 (Fig. 5) who was treated for secondary deformity of fingers following operation for syndactyly in childhood. The aberrant nail is seen growing on the side of his thumb. An interesting investigation into nail growth was made by Le Gros Clark and Dudley Buxton in I938. File marks were made on the nails 2 mm. from the

FREE NAIL GRAFTING 2I FIG. 2 FIG. 3 Fig. 2.pTraumatic avulsion of part of the pulp of the right thumb. Fig. 3.--The same.

The pressure of the flap on the sterile matrix has temporarily distorted the nail. Fig. 4.--The same.

4 margin of the lunule and recordings of the rate of growth made at regular intervals using a micrometer scale.

3 FREE NAIL GRAFTING 2I FIG. 2 FIG. 3 Fig. 2.pTraumatic avulsion of part of the pulp of the right thumb. Fig. 3.--The same. Eight weeks after repair by cross-finger flap. The pressure of the flap on the sterile matrix has temporarily distorted the nail. Fig. 4.--The same. Five months after repair the flap has shrunk and the nail has returned to its original contour. FIG. 4 margin of the lunule and recordings of the rate of growth made at regular intervals using a micrometer scale. The following conclusions were reached :- The rate of growth is the same in children and adults between the ages of Io and 23 years. The nails on the longest digits grow fastest and the thumb is slower than the index and ring fingers. Nail biting accelerates growth. Nails grow faster in summer than in winter. There is no difference in rate of growth between the sexes. IB* Fie. 5 Ectopic nail growing on the side of the thumb.

22 BRITISH JOURNAL OF PLASTIC SURGERY REVIEW OF LITERATURE ON NAIL GRAFTING A perusal of the literature on nail grafting reveals comparatively few records of this procedure.

4 22 BRITISH JOURNAL OF PLASTIC SURGERY REVIEW OF LITERATURE ON NAIL GRAFTING A perusal of the literature on nail grafting reveals comparatively few records of this procedure. In 1929 Eastman Sheehan described a case of successful transfer of part of one thumb nail to the other. A boy of 16 had lost a thumb nail from an injury two years previously and the digit was scarred from attempts at restoration. A partial graft was taken from the opposite thumb consisting of the central two-thirds of nail and matrix along with part of the lunula but not extending as far as the root. The bed prepared for reception of the graft was excavated to the level of the periosteum. The transferred nail was gradually exfoliated by the new nail growing beneath it. Four months later the patient had well formed nails on both thumbs. In 1936 Ko, in a Japanese journal, described with illustrations the transfer of the skin on the dorsal surface of the fourth toe along with nail and nail bed to the little finger as a two-stage flap procedure. The final photograph is not sufficiently distinct to show the end result clearly. In 1938 Barrett Brown recorded a successful replacement following traumatic amputation. The end of a digit with the entire nail, finger pulp, and " possibly a very small piece of bone" was sliced off with a bread-cutting machine. The detached portion was replaced one hour later and survived in toto. Exfoliation of the nail occurred, followed by the growth of a new one. The author remarks that free grafts of nails have not been successful enough to report. In 1946 Rivas and Tucillo, in the Argentine, reported a case of total graft of finger nail and nail bed. In 1947 Swanker described a technique similar to Sheehan for partial nail transfer fixing the new nail in position with plasma and thrombin and pressure dressing over a tantalum plate resting on the nail. No actual cases are recorded. In 1949 Maurice Rupin (Switzerland) recorded the free grafting of one of the lesser toe nails to a thumb. In 195 Morton Berson described a case of partial nail graft to a reconstructed finger. He had carried out a restoration of a woman's index finger which had been amputated through the proximal interphalangeal joint. A submammary tubed pedicle was used as cover, and into this a stored piece of cartilage was inserted. The flexor and extensor tendons were attached to the cartilage. Two months after the completion of the finger restoration, a partial nail graft from the centre of the great toe nail was imbedded in the finger. Three years later the cosmetic result was described as being very good, as indeed is borne out by the photograph. The new nail had continued to grow, and the finger could be actively flexed from full extension to 9o degrees at the proximal interphalangeal joint. PRESENT SERIES In the present series of ten cases carried out personally, three different meth~ods of free grafting have been employed (Fig. 6) :-- x. The Partial Nall Graft.bSimilar to the technique described by Eastman Sheehan using the central section of the great toe nail with nail bed and matrix, but with one difference that the graft extends right back to the root of the donor nail to include all the germinal matrix available.

5 FREE NAIL GRAFTING The Composite Nail Graft.--Taken from one of the lesser toes and consisting of the complete nail, nail bed, and matrix, the nail fold on each side and at the root, and a thin shaving of the upper surface of the terminal phalanx. 3" The Complete Nail Graft.--Taken from one of the lesser toes and consisting of the nail, nail bed, and matrix only without bone or surrounding skin. I 2 3 FIG. 6 Three methods of free nail grafting. NAIL ~MATRIX NAIL S ln ATRIX BONE NAIL "MATRIX PARTIAL COMPOSITE COMPLETE NAIL GRAFT NAIL GRAFT NAIL GRAFT TO.~E - ~ T LI N E OF ~ ~ SECTION THE COMPOSITE GRAFT ~ INGER Case I. FIG. 7 Technique of composite nail graft. OOT S.OW,NG!// A CESSOR / {33 Case x.--in I95 x a girl of 8 years was referred to me on account of a supernumerary toe which interfered with her wearing shoes. On examination it was found that the left foot showed fusion of first, second, and third toes with absence of nails. A small rudimentary segment of toe bearing a nail and containing a phalanx was attached to the dorsum by skin only. The middle finger of her left hand showed fusion of middle and distal phalanges and no nail was present, though the other fingers were normal. It was decided to remove the accessory toe segment and at the same time as an experiment transfer its nail to the finger.

24 BRITISH JOURNAL OF PLASTIC SURGERY June I95I--Operation : Composite Nail Graft (Experimental) (Fig. 7).

A suitable elliptical defect was created on the middle finger by a curved incision corresponding to the position of the nail fold. The U-shaped FIG. 8 FIG. 9 Fig. 8.--Case I.

io flap was raised and turned distally to increase the length of the finger and give bulk to the tip. The dorsal surface of the phalanx was removed and the graft fitted into the defect.

6 24 BRITISH JOURNAL OF PLASTIC SURGERY June I95I--Operation : Composite Nail Graft (Experimental) (Fig. 7).--From the rudimentary toe segment the nail, nail bed, and upper surface of the phalanx were excised as one composite graft. A suitable elliptical defect was created on the middle finger by a curved incision corresponding to the position of the nail fold. The U-shaped FIG. 8 FIG. 9 Fig. 8.--Case I. Foot showing rudimentary toe. Fig. 9.--Case I. Graft ten days after operation. Fig. io.--case I. Graft fifteen months after operation. FIG. io flap was raised and turned distally to increase the length of the finger and give bulk to the tip. The dorsal surface of the phalanx was removed and the graft fitted into the defect. Marginal sutures, a light pressure dressing, and a plaster of Paris slab completed the fixation. Sixth Day.--First dressing. Graft appeared perfectly healthy. Seventh Week.--Nail growing, 3 mm. long. Thirty-second Week.mNail 5 mm. long. The nail did not exfoliate and continued to grow normally from the base. As an experimental composite free graft it was a success, but it remained much too small in relation to the increasing size of the growing finger (Figs. 8, 9, and IO). For this reason two years after the first operation it was decided to replace it by a " partial nail graft " from the great toe. J~une I953--Operation : Partial Nail Graft.--The previous nail graft was excised

7 FREE NAIL GRAFTING 2 5 and a free graft consisting of the central section of the great toe nail with its matrix was removed and fitted into the defect created in the recipient finger (Fig. I I). The graft was secured by two sutures, one across the base of the nail and another through its distal extremity and the pulp of the finger (Fig. I2). Ribbon gauze dipped in Whitehead's varnish was applied as a dressing. When examined at the first dressing a week later the graft appeared perfectly healthy. Protective dressings were retained for a further two weeks, after which the nail was left exposed. No exfoliation occurred. Ten months after the operation the nail was cosmetically satisfactory and growing at the normal rate, and the same held true at eighteen months. FIc. ii Technique of partial nail graft. Case 2.--J. M., girl, aged I8.--Burns of the right hand three years previously had resulted in loss of nails and nail beds on ring and little fingers. On the thumb only nail-bed remnants were present. The whole of the dorsal surface of the hand had been repaired by stamp grafts but was still disfigured by scarring. The ungual processes of the terminal phalanges had been lost in the affected digits. September Operation.--The following nail grafts were carried out (Fig. 13) :- To the thumb--a "partial graft" from the central portion of the great toe nail. To the ring finger--a " complete graft," entire nail of the second toe with its matrix but without surrounding skin or the shaving of bone. To the little finger--the entire nail of the third toe with matrix in the same manner. In implanting the grafts some difficulty was experienced owing to the tightness of the scarred skin on the tips of the fingers. In order to get sufficient depth the upper

8 26 BRITISH JOURNAL OF PLASTIC SURGERY A C D E G FIG. I 2 A-D, E, F, G, Case I. Operative technique of partial nail graft. Three weeks after operation. Two months after operation. Ten months after operation. F

FREE NAIL / Case 2. 27 GRAFTING I ' FIG.

A, Nail destruction in three digits resulting from burns three years previously.

9 FREE NAIL / Case GRAFTING I ' FIG. 13 Indicating donor and recipient digits. A B C D FIG. 14 Case 2. A, Nail destruction in three digits resulting from burns three years previously. B, Partial graft to thumb. Complete grafts to ring and little fingers. C, One month after operation. D, Six months after operation.

28 BRITISH JOURNAL OF PLASTIC SURGERY surfaces of the terminal phalanges had to be removed to allow the convex under-surfaces of the grafts to bed in easily (Fig. I4). Eighth Day.--First dressing.

At four weeks ring finger nail exfoliated. Little finger nail still firmly attached. At three months thumb nail 5 ram. long and well defined. Ring finger--no true nail present. Little finger-- 5 mm.

10 28 BRITISH JOURNAL OF PLASTIC SURGERY surfaces of the terminal phalanges had to be removed to allow the convex under-surfaces of the grafts to bed in easily (Fig. I4). Eighth Day.--First dressing. Small h~ematomata at the base of the ring and little finger grafts which may have been caused by the patient having had a fall on her hand. At three weeks thumb nail exfoliated. Nail bed is hardening. At four weeks ring finger nail exfoliated. Little finger nail still firmly attached. At three months thumb nail 5 ram. long and well defined. Ring finger--no true nail present. Little finger-- 5 mm. long and well defined. Attire months thumb nail well established but rather thick and rough. Ring finger-- no nail. Little finger--cosmetically good, nail 8 ram. long. FIG. I5 FIG. I6 Fig. I5.--Index and middle fingers in girl aged :t6 showing destruction of nails from burns in infancy. Fig. i6.--the same case showing index finger one year after composite graft and middle finger six months after partial graft. Both are unsatisfactory results owing to the failure of the sterile matrix of the nail bed to take. In addition to the cases described, five other free grafts have been carried out, making a total of ten in all (see table). Two of these were composite grafts from the second and third toes, two were partial grafts from the great toe nails, and one a recent complete graft. All took well, but the end results in three have not been cosmetically satisfactory, and one failed to grow a new nail after exfoliation. The fact that a graft appears to take well and become vascularised in the first two weeks does not necessarily guarantee a good end result. Exfoliation may take place any time between the third and eighth weeks, and the new nail may be only a thin plate lacking in character or it may become coarse and horny (Figs. I5 and I6). POINTS IN TECHNIQUE OF OPERATION The operation can be carried out under local or general anaesthesia with a rubber tubing tourniquet at the bases of the digits.

11 FREE NAIL GRAFTING 2 9 o~0 ~_ ~: ~..~ o o o 888 o o o o o o o bl) ~..~,9, ~ F ~ o ~

12 30 BRITISH JOURNAL OF PLASTIC SURGERY Whichever method is used, careful dissection and atraumatic handling are essential. The recipient bed must be contoured to correspond to the concave or convex under-surface of the graft. In taking a composite graft the terminal phalanx must be cleanly cut with a sharp chisel as also must be the recipient phalanx. A wire mattress suture placed vertically through the phalanx and centre of the graft and tied over two buttons ensures intimate contact between the bony surfaces (Fig. 17). The one button DRILLING HOLE cl,..~ ~ I NEEDLE PASSES wrr..and ~ I / EYE F,RST OR,LL U'I', Fm. x7 Technique of wire fixation. rests on the nail and the other on the finger pulp as shown in the diagram. This method is also suitable for " complete grafts " and has the advantage that should the tension prove too great between the buttons this can be eased by untwisting the ends of the mattress suture. The fewer sutures which have to be inserted the better. Exposure of composite grafts at too early a stage may lead to drying up of the skin edges and an ischa:mic necrosis. This is seen on the middle finger graft in Fig. 18. A greasy protective dressing is therefore advisable for two weeks at least after the first dressing. CHOICE OF DONOR NAIL The partial grafts from the great toe have the advantage that any desired size can be cut. Where the lesser toes have suitable nails the composite graft is the most likely to produce a good result because the nail bed and matrix are not interfeled with at the operation and are splinted as it were in the post-operative period between the nail and the shaving of bone.

FREE NAIL GRAFTING 31 Burnt fingers make poor recipient sites for grafting, but even here there has been one really good result (Fig, 14, D).

The middle finger shows ischmmic necrosis of the skin edges resulting from too early exposure to the air. The nail matrix survived, but the new nail was not cosmetically satisfactory.

TREATMENT OF DONOR DIGITS In the case of composite grafts from second or third toes, the terminal phalanx was shortened and the plantar skin sewn to the base of the defect.

13 FREE NAIL GRAFTING 31 Burnt fingers make poor recipient sites for grafting, but even here there has been one really good result (Fig, 14, D). Generally speaking, the deeper a graft can be imbedded the better, and burnt scarring renders this difficult to achieve. FIG. 18 Index and middle fingers, composite grafts. The middle finger shows ischmmic necrosis of the skin edges resulting from too early exposure to the air. The nail matrix survived, but the new nail was not cosmetically satisfactory. FIG. 19 Donor digit. Three weeks after composite graft from second toe. TREATMENT OF DONOR DIGITS In the case of composite grafts from second or third toes, the terminal phalanx was shortened and the plantar skin sewn to the base of the defect. This healed normally and the slight shortening of the toes was not unsightly (Fig. I9). In complete grafts remnants of the nail bed apparently left behind have resulted in a regrowth of the nail (Fig. 20), In the partial grafts from the great toe there is some deformity, as the new nail which grows forward to fill the defect fails to fuse with the lateral elements

--Donor digits. Fig. 2i.mDonor digit. FIG. 20 FIG. 2I Six months after complete grafts from second and third toes and partial graft from great toe. Great toe one year after a partial graft.

14 32 BRITISH JOURNAL OF PLASTIC SURGERY of old nail, and a fissure down the centre of the nail persists (Fig. 21). This has not, however, caused any discomfort, and might be avoided, as in Eastman Sheehan's case, by leaving a small portion of the root of the donor nail with its matrix behind. Fig Donor digits. Fig. 2i.mDonor digit. FIG. 20 FIG. 2I Six months after complete grafts from second and third toes and partial graft from great toe. Great toe one year after a partial graft. CONCLUSION The results obtained from this small series of experiments indicate that the nail with its germinal matrix behaves like any other epidermal structure, being freely transferable on the same individual~ and can retain in its new site its peculiar property of forward growth. In every i~ase the graft took well initially, becoming vascularised within the first two weeks. Of the three methods of grafting employed, each yielded one really good end result, and it is of interest to note that these were the cases in which exfoliation did not occur. Although in all but one case a new nail grew after exfoliation, some were brittle~and fragmented and others horny in character. The ultimate success from a cosmetic standpoint appears to depend upon a complete take of both the germinal and sterile matrix along with a good digital blood supply and a smooth surface beneath the graft. A careful contouring of the recipient bed is therefore important, combined with firm fixation. The method described of wire mattress suture passing through the end of the finger has been used in recent cases with satisfactory results. My thanks are due to Professor T. Pomfret Kilner for assistance in tracing the references, to Mr E, Ferrill for the photographs, and to Mr Sibson Drury for the drawings.

15 FREE NAIL GRAFTING 33 REFERENCES BERSON, M. I. (1950). Surgery, 27, 594. BROWN, J- BARRETT (I938)- Ann. Surg., Io7, 952. CASTELLO, V. PARDO (1941). " Diseases of the Nails," 2nd ed. Springfield, Illinois: C. C. Thomas. CLARK, W. E. LE GROS (1936). Proc. zool. Soc. Lond., xo6. CLARK, W. E. LE GROS, and BUXTON, L. H. D. (1938). Brit. J. Derm., 5o, 221. DEIBERT, G. A. H. (I943). Amer. J. Surg., 62, 142. JONES, F. WOOD (1946). " The Principles of Anatomy as seen in the Hand," p. 121, 2nd ed. London : Bailli6re, Tindall & Cox. Ko, C. (1936)- Taiwan Igakkai Zasshi, 35, lo72. PRIBRAM, E. E. (I912). Arch. Derm. Syph., Wien, 112, 657. RIVAS, C. I., and TUClLLO, O. J. (1946). Bol. Acad. argent. Cirug., 9,453- RupIN, M. (1949)- " Reconstitution d'un Ponce." Thesis, Universit6 de Lausanne. SHEEHAN, J. E. (1929). J. Amer. reed. Ass., 92, (1938). "A Manual of Reparative Plastic Surgery," p London: Oxford University Press. SWANKER, W. A. (1947). Amer..7. Surg., 74, 34I- IC

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

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