Modified VY-plasty for Traumatic Distal Nailbed Loss M Satku, K Wan, Teoh LC Department of Orthopaedic Surgery Hand and Microsurgery Surgery Section Tan Tock Seng Hospital Singapore 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 PatientAllen Type Remnant (mm) Defect (mm) Flap Cutback (mm) Growth (mm)

Case 1 PatientAllen Type Remnant (mm) Defect (mm) Flap Cutback (mm) Growth (mm) Pre-op Post-Op 2/12 Post-Op 1/12 Post-op

Case 2 Pre-op Post-Op 5/12 PatientAllen Type Remnant (mm) Defect (mm) Flap Cutback (mm) Growth (mm)

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 Jan;8(1): – 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 Mar;24(2): 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 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 Oct;49(4):424-8; discussion 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 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 Sep;80(3): 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 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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