Modified VY-plasty for Traumatic Distal Nailbed Loss

M Satku, K Wan, Teoh LC

Department of Orthopaedic SurgeryHand and Microsurgery Surgery Section

Tan Tock Seng HospitalSingapore

Conflict of Interests: Nil

Introduction

• Fingertip injuries are relatively common in home and work-related injuries in Singapore.

• Injuries with nailbed

loss often result in a shortened nail complex, and cosmetically suboptimal outcome.

Left Ring Finger Tip Amputation

Aims

• To describe a relatively simple and easily reproducible method of treating volar favourable fingertip injuries with distal nailbed loss to achieve distal nailbed extension.

Methods

• Case series, Prospective• Adult patients > 21 years old• Traumatic fingertip injuries with distal nailbed loss• Isolated injuries• Volar favourable tip amputations• Amenable to VY-plasty

The Allen Classification of Fingertip Amputations

Example pictures

Volar favourable fingertip amputations amenable to VY-plasty

Procedure• Day procedure• Local anaesthesia

• Allen classification of fingertip amputation applied

• Measurement of nailbed remnant beyond eponychium and loss compared to contralateral digit

• Remnant nail avulsed or shortened

Pre-op Left Thumb

Modification• VY flap raised from volar

aspect

• Skin from distal end of flap cut back, leaving subcutaneous tisue

• Length of flap cut back determined by corresponding nailbed loss and available distal phalanx support

• Subcutanous tissue from VY flap cutback sutured to remnant nailbed Intra-op Left Thumb

Closure

• VY flap secured with nylon suture 5/0

• Absorbable suture 6/0 to nailbed

• Artificial nail inset

• Non-absorbable sutures removed after 2 weeks

Post-op Left ThumbPre-op Left Thumb

Management

• All patients had similar follow-up regime• Outpatient hand therapy• Post-operative photographs and direct

measurement of nailbed and nail growth

• Minimum follow-up 4 months

Results

• 7 patients– 2 female, 5 male

• All fulfilled wound criteria

• Allen type 2 or 3 amputations

• All flaps healthy• Minimum follow-up for

4 months

• Flap cutback limited by underlying distal phalanx support

• Measurements recorded

Patient Allen Type

Remnant (mm)

Defect (mm)

Flap Cutback (mm)

Growth (mm)

1 3 3 6 4 4

2 3 2 6 4 4

3 3 1 6 4 4

4 2 13 2 2 1

5 3 8 5 3 3

6 3 3 4 3 3

7 3 4 4 3 2

Case 1

Patient Allen Type

Remnant (mm)

Defect (mm)

Flap Cutback (mm)

Growth (mm)

6 3 3 4 3 3

Pre-op

Post-Op 2/12Post-Op 1/12

Post-op

Case 2

Pre-op Post-Op 5/12Post-Op

5/12

Patient Allen Type

Remnant (mm)

Defect (mm)

Flap Cutback (mm)

Growth (mm)

3 3 1 6 4 4

Discussion

• Many procedures described for nailbed injuries

• Nailbed grafting– Shepard GH. Treatment of nail bed avulsions with split-thickness nail bed grafts. J Hand Surg Am. 1983

Jan;8(1):49-54.

– Split thickness or Full thickness• Non-vascularised• From injured digit/great toe• Both for finger or toe nailbed• Donor site morbidity for full thickness grafts• Works well in presence of intact nail germinal matrix

• Local flap and nailbed graft combination– Palmar VY, Lateral VY– Moberg– Cross-finger flap– Thenar flap– Brown RE, Zook EG, Russell RC. Fingertip reconstruction with flaps and nail bed grafts. J Hand Surg Am. 1999 Mar;24(2):345-51.

• Microsurgical toenail transfer– From big or second toenail– Shibata M, Seki T, Yoshizu T, Saito H, Tajima T. Microsurgical toenail transfer to the hand. Plast Reconstr Surg. 1991

Jul;88(1):102-9; discussion 110.

• Hard palate mucosal graft– Hatoko M, Tanaka A, Kuwahara M, Yurugi S, Niitsuma K, Iioka H, Zook EG. Hard palate mucosal grafts for defects of the nail bed.

Ann Plast Surg. 2002 Oct;49(4):424-8; discussion 428-9.

• Full thickness skin graft– Applicable in malignancies– Lazar A, Abimelec P, Dumontier C. Full thickness skin graft for nail unit reconstruction. J Hand Surg Br. 2005 May;30(2):194-8.

Is nailbed tissue required?• Substitute tissue– Hard palate, Skin

• Nail growth pushes back skin graft or flap distally– 70% growth in amputation injuries– 90% growth with intact distal phalanx– Ogo K. Does the nail bed really regenerate? Plast Reconstr Surg. 1987 Sep;80(3):445-7.

• Nail splint without graft– Normal nail growth identical to contralateral nail– Ogunro O, Ogunro S. Avulsion injuries of the nail bed do not need nail bed graft. Tech Hand Up Extrem Surg.

2007 Jun;11(2):135-8.

Conclusion• Subcutaneous tissue can form nailbed• Balance between nailbed growth and re-epithilisation of

subcutaneous tissue determines which tissue will form• Nailbed growth length also determined by available distal

phalanx support

• Acceptable cosmetic result of nail unit• Recommend procedure for significant nailbed loss >3mm• Regeneration of nailbed in injuries <3mm may not have

significant cosmetic improvement

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