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Surgery and Cosmetics

Ival Peres Rosa, MD

Surgical Treatment of Transversal Overcurvature of the Nail Plate ("Pincer Nail")

Ival Rosa

Tuesday, December 05, 2006

The transverse overcurvature of the plate is the widening of the ungual plate across the finger. The increased ungual plate curvature can be slight or round, or even a 360º turn. Looking at the finger from the front, the pincer-shaped nail can be observed. Additionally, the ungual plate may be flat at the center and then abruptly curved at the lateral folds so that a 90º angle is formed.

Names such as incurved,1 reverse,2 endonychia constrictiva,2 tile,3 omega,3 trumpet,3 and plicated nails (90º on the sides)3 all refer to the overcurvatures of ungual beds as proposed by Samman.4

The term "pincer nail" was proposed by Cornelius and Shelley.5 They studied three cases whose common elements were the front aspect of the ungual plate pinching the bed, severe pain, and bone changes. The angle measurement, based on which a given nail is regarded as overcurved, is subjective. Our experience has been that the angle has never been less than 40º in any case.

Etiology

Hereditary6 and acquired cases have been disclosed. We have found no logical explanation for the appearance in the acquired cases, such as arteriovenous fistulas,7 medications,8 and Kawasaki disease.9 In such cases, the shape of the ungual plate returns to normal whenever the problem disappears.

The hereditary group represents almost all cases. The most consistent explanation for these cases is the bone change in the distal phalanx3 with reabsorption of the surrounding tissues. The most severe overcurvature cases show ungual plates that were virtually flat and then became convex, curving inward and creating a depression beside the lateral ungual folds. Ungual plates adhere more on the sides than at the center due to ligament-like structures.10 These structures become weaker and then tend to increase the ungual plate curvature in these regions. In some cases, ungual plates may detach from their beds, resulting in overcurvatures such as those found in onychomycosis,11 psoriasis,3 and tumors.12,13

Treatment

Many clinical and surgical treatments have been proposed. Among the clinical ones, ortheses14 and occlusive uric acid15 are not permanent as they do not correct the causes.

Surgical treatments can be divided, for didactic purposes, into three groups:

  1. Conservative, without bone correction:5,16-19
    These treatments include avulsion of the ungual plate,5 total destruction of the matrix,16,17 unilateral or bilateral matricectomy,17 dermal grafting,16 and CO2 laser use20,21
  2. Aggressive, with bone correction:
    These treatments can be associated with other procedures with no healing by second intention:
    • Ungual bed detached from the bone, bone correction, and re-placement of the bed with grafting, if necessary2,3,22,23
    • Ungual bed detached from the bone, bone correction with grafting if necessary,22,24 and the widening of the bed through the removal of the skin from the finger's lateral and front faces through the Dubois procedure

Such corrections may be aligned with unilateral or bilateral matricectomy.

  1. Highly aggressive: These treatments, proposed by us,26,27 include bone correction, bed widening through the removal of a large amount of wide "U"-shaped skin from the digit's lateral and front faces, with healing by second intention, including the portion removed from the bed

During this procedure, in addition to the removal of a wide strip of "U"-shaped skin, the distal portion of the ungual bed is removed, preserving the proximal portion, which goes 2 mm beyond the lunula. The bone correction of the distal phalanx is carried out with a Joseph knife. The distal phalanx bone becomes exposed and hemostasis is conducted by separate stitches on the free skin border and pressure dressing. The healing by second intention takes about 40 days for lateral folds and 2-3 months for the bed.

Figure 1. 360º turn (trumpet nail)

360º turn (trumpet nail)

Figure 2. Same patient featured in Figure 1

Same patient featured in Figure 1

Figure 3. Same patient, after highly aggressive treatment

Same patient, after highly aggressive treatment

Figure 4. Same patient, after recovery

Same patient, after recovery

Pros and Cons of Treatment Options

All procedures have their own pros and cons. For cases that are diagnosed early, less aggressive treatments may be successful. For more severe cases with large angle changes, however, more aggressive treatments are appropriate.

Among the less aggressive treatments, dermal grafting18 underneath the bed is very useful - except in the most acute cases, which require a more aggressive treatment.

All the surgical procedures mentioned are appropriate for intermediate cases.

Several procedures are intended to widen the ungual bed by removing the skin from the digit's front and lateral faces under the Dubois procedure, in which the formed defect is sutured. In our opinion, the widening of the ungual bed resulting from such a procedure is smaller28 than that with the healing by second intention, as the suture causes the skin of the plantar region to rise. Our procedure does not produce a large bed widening.

Grafts are used whenever one does not want the corrected bone to be exposed, yet their results are unpredictable. The most common complication is the non-adherence of the ungual plate to the hyponychium region. The question is whether the distal phalanx healed by second intention will allow the bed to advance or not. The answer is yes. We noticed the bed moves forward adhered to the ungual plate and will move forward over the healed tissue if no dystrophy occurs in the bed-generating matrix. Our observation is that the ungual plate adhered to the bed fails to move beyond the grafted region in some cases, particularly in the distal third. With our method, the healing by second intention allows the ungual plate to move forward adhered to the totality of the bed. This tissue healed by second intention does not induce adherence to the bone as firmly as grafts.

References

  1. Frost L. Root resection for incurvated nail. J Natl Assoc Chirop. 1950;40(3):19-28.
  2. Fosnaugh RP. Surgery of the nail. In: Epstein E, ed. Skin surgery. Springfield: Charles C. Thomas;1970:604-28.
  3. Baran R, Haneke E, Richert B. Pincer nails: definition and surgical treatment. Dermatol Surg. 2001 Mar;27(3):261-6.
  4. Samman PD. The nails in disease. London: William Heinemann;1965.
  5. Cornelius CE 3rd, Shelley WB. Pincer nail syndrome. Arch Surg. 1968 Feb;96(2):321-2.
  6. Mimouni D, Ben-Amitai D. Hereditary pincer nail. Cutis. 2002 Jan;69(1):51-3.
  7. Hwang SM, Lee SH, Ahn SK. Pincer nail deformity and pseudo-Kaposi's sarcoma: complications of an artificial arteriovenous fistula for haemodialysis. Br J Dermatol. 1999 Dec;141(6):1129-32.
  8. Greiner D, Shöfer H, Milbradt R. Reversible transverse overcurvature of the nails (pincer nails) after treatment with a beta-blocker. J Am Acad Dermatol.1998 Sep;39(3):486-7.
  9. Vanderhooft SL, Vanderhooft JE. Pincer nail deformity after Kawasaki's disease. J Am Acad Dermatol. 1999 Aug;41(2 Pt 2):341-2.
  10. Guéro S, Guichard S, Fraitag SR. Ligamentary structure of the base of the nail. Surg Radiol Anat. 1994;16(1):47-52.
  11. Plusje LG. Pincer nails: a new surgical treatment. Dermatol Surg. 2001 Jan;27(1):41-3.
  12. Gourdin FW, Lang PG Jr. Cylindrical deformity of the nail plate secondary to subungual myxoma. J Am Acad Dermatol. 1996 Nov;35(5 Pt 2):846-8.
  13. Theunis A, André J, Forton F, et al. A case of subungual reactive eccrine syringofibroadenoma. Dermatology. 2001;203(2):185-7.
  14. Effendy I, Ossowski B, Happle R. Zangennagel Konservative Korrektur durch Aufkleben einer Kunststoffspange. Hautarzt. 1993;44(12):800-2.
  15. El-Gammal S, Altmeyer P. Erfolgreiche Konservative Therapie des Pincer-Nail-Syndroms. Hautarzt. 1993;44(8):535-7.
  16. Zadik F. Obliteration of the nail bed of the great toe without shortening the terminal phalanx. J Bone Joint Surg. 1950;32:66-7.
  17. Iida N, Ohsumi N. Treatment of severe deformities of the toenails by the modified Zadik method with artificial skin. Scand J Plast Reconstr Surg Hand Surg. 2004;38(3):155-9.
  18. Brown RE, Zook EG, Williams J. Correction of pincer-nail deformity using dermal grafting. Plast Reconstr Surg. 2000 Apr;105(5):1658-61.
  19. Aksakal AB, Akar A, Erbil H, et al. A new surgical therapeutic approach to pincer nail deformity. Dermatol Surg. 2001 Jan;27(1):55-7.
  20. Kim KD, Sim WY. Surgical pearl: nail plate separation and splint fixation - a new noninvasive treatment for pincer nails. J Am Acad Dermatol. 2003 May;48(5):791-2.
  21. Lane JE, Peterson CM, Ratz JL. Avulsion and partial matricectomy with the carbon dioxide laser for pincer nail deformity. Dermatol Surg. 2004 Mar;30(3):456-8.
  22. Suzuki K, Yagi I, Kondo M. Surgical treatment of pincer nail syndrome. Plast Reconstr Surg. 1979 Apr;63(4):570-3.
  23. Kosaka M, Kamiishi H. New strategy for the treatment and assessment of pincer nail. Plast Reconstr Surg. 2003 May;111(6):2014-9.
  24. Hatoko M, Iioka H, Tanaka A, et al. Hard-palate mucosal graft in the management of severe pincer-nail deformity. Plast Reconstr Surg. 2003 Sep;112(3):835-9.
  25. Dubois JPH. Un traitment de l'ongle incarné. Nouv Presse Méd. 1974;31(3):1939-40.
  26. Rosa IP. Tratamento da hipercurvatura transversa da lâmina ungueal: tratamento cirúrgico. In: XIX Congress of the International Society for Dermatologic Surgery; 1998; Salvador.
  27. Rosa IP, Garcia MLP, Mosca FZ. Tratamento cirúrgico da hipercurvatura do leito ungueal. An Bras Dermatol. 1989;64(2):115-7.
  28. Ozawa T, Yabe T, Ohashi N, et al. A splint for pincer nail surgery: a convenient splinting device made of an aspiration tube. Dermatol Surg. 2005 Jan;31(1):94-8.
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