FULL THICKNESS SKIN GRAFT FOR NAIL UNIT RECONSTRUCTION A. LAZAR, P. ABIMELEC and C. DUMONTIER Ã From the Institut de la Main, 6 square Jouvenet, and Hoˆpital Saint Antoine, 184 Rue du Faubourg Saint Antoine, Paris, France A retrospective study of 13 patients assessed the use of a full thickness skin graft for nail unit reconstruction after total nail unit removal for nail bed malignancies. No failures of the graft were observed and no patient had recurrence of the malignant tumour at 4 year follow-up. Full thickness skin grafting is a simple procedure which provides a good cosmetic outcome and does not produce significant donor site morbidity. Journal of Hand Surgery (British and European Volume, 2005) 30B: 2: 194–198 Keywords: nail unit reconstruction, full thickness skin graft, nail tumour, malignant melanoma, epidermoid carcinoma INTRODUCTION Thenailunithasdistinctivefeaturesthataredifficultto restore. From a functional point of view, the nail protectsthedorsalaspectofthedistalphalanx,provides stability to the fingertip during pinch and increases sensibility.Thenailplatealsoactsasastabilizerforthe pulp (Dumontier and Legre´, 2000; Iselin et al., 1963; Kleinert et al., 1967; Zook and Brown, 1999). As an organ of first contact with the environment, the appearance of the hand (especially its dorsal aspect) has a huge psychological impact (Dawber et al., 1995; Dumontier and Legre´, 2000). Reconstructionofthedorsalsurfaceofthefingertipis difficultbecauseofitsuniqueanatomyandtheneedfor aperfectcosmeticresult.Whenitisnecessarytoremove most (50% or more), or all of the nail matrix or the completenailunit,distalphalanxcoverageismandatory to avoid the need for a fingertip amputation. In this situation, free nail grafts and vascularized nail transfers have been used. Free nail grafting was proposed by Shepard (1990) buthasdrawbacksincludingthelimited size of the donor toe nail beds, unless the great toe is used. Good results have been obtained for traumatic injuries (Sellah et al., 2000)butShepardreportedalow (50%) success rate for nail reconstructive surgery (Shepard,1990).Freevascularizednailtransferhasalso been used but it is technically difficult to perform and thecosmeticresultisnotalwaysgood(Endoetal.,1997; FoucherandPajardi,2000).Bothfreenailgraftandfree vascularized nail transfer require the sacrifice of a healthy nail, while cross finger and other flaps leave the donor finger with a cosmetic defect. Theuseoffullthicknessskingraftstocovernailbed defects has been thought to produce unacceptable cosmetic and functional results and cause altered sensibility at the fingertip. Most books devoted to the naildonotevenmentionfullthicknessskingraftingasa treatmentoption(BaranandDawber,1995; Krulletal., 2001; Zook and Brown, 1999). Wereportourexperiencewithfullthicknessskingrafts to cover the distal phalanx following nail unit excision. PATIENTS AND METHOD Patients who had undergone a total nail unit excision followed by a full thickness skin graft reconstruction were identified from the operative records of the senior authors (CD and PA). Traumatic avulsions and partial nail removals treated by local flap reconstruction were excluded. The pre-operative diagnosis and clinical find- ings (including fingertip static two-point discrimination sensation and distal interphalangeal joint mobility), the pathology records and the cosmetic and functional outcomes from the patient’s point of view, as well as thepresenceofpostoperativecomplicationshadallbeen carefullyrecordedinpatients’files.Absenceofrecurrence of the resected malignancies and the presence of late complications were confirmed by telephone interview. SURGICAL TECHNIQUE The surgery is performed under axillary block anaes- thesia with a tourniquet on the upper arm. We do not performexsanguinationifthesurgeryisforamalignant tumour, so as to avoid the risk of tumour cell embolisation. The margins of resection depended on the initial pathology report. We advise a 5mm margin for malignant melanoma in situ and epidermoid carcinoma. Excision is performed down to the bony phalanx which is then curetted. A transverse incision is made at least 2mm distal to the hyponychium down to the underlying distal phalanx. On each side, the incision is prolonged by a lateral incision which includes the lateral nail folds. A transverse incision is then made proximal to the nail matrix,usuallyatthedistalinterphalangealjointcrease. Care must be taken to prevent a distal extensor tendon injury. The lateral incisions join with the ends of the proximal transverse incision so that the whole nail unit is circumscribed. Distal to proximal sharp dissection of thenailbedisthenperformed,ensuringthattheplaneof dissection is directly onto the distal phalanx, so as to ensureanadequatedepthofexcision.Thematricalhorn ARTICLE IN PRESS 194