Surgical correction of severe bilateral thumb pincer-nail deformity.

A53-year-old woman presented to the office with a complaint of severe bilateral thumb nail pain and deformity (Fig. 1). She denied previous trauma to the thumb nails and had no history of previous bacterial or fungal infections of the nails. Based on the curvature of the nails, which increased from proximal to distal, a diagnosis of bilateral thumb pincer-nail deformity was made. The patient was scheduled for surgical correction by modification of previously described techniques. Beginning with the left thumb a digital block was performed and the affected digit was exsanguinated. The nail plate was sharply removed without damaging the underlying sterile and germinal matrix. The curved nail bed then was elevated off of the underlying distal phalanx (Fig. 2). On the left side a dermal graft was obtained from the hypothenar eminence that was closed primarily. This was harvested as a full-thickness graft that then was de-epithelialized (Figs. 3, 4). The dermal graft was divided into 2 equal pieces and placed in the area of the lateral nail folds, filling in the defects that had been present. The nail bed was sutured back over the graft to the lateral nail folds with 5-0 chromic suture. The nail bed now had a less curved and more natural flattened appearance (Fig. 5). The curved nail plate was discarded and silicone sheeting was placed into the nail fold as a stent. On the right side a similar procedure was performed; however, instead of harvesting dermal grafting from the patient, a suitably sized piece of collagen graft (Integra LifeSciences Corporation, Plainsboro, NJ) was used in place of the dermal graft. This was accomplished by removing the silicone membrane layer of the collagen graft bilaminate and using only the collagen-glycosaminoglycan matrix component (Fig. 6). This allows the collagen matrix component of the graft to be wholly implanted. This then was positioned as the dermal graft had been into the lateral nail defects. The remainder of the procedure was performed as previously described. The patient reported resolution of the pain and soft-tissue pinching sensation that she had before surgery. The thumb nails have regrown and appear more normal and have a flattened appearance (Fig. 7). There was good adherence between the nail plate and the underlying nail bed. Figure 1. Bilateral thumb nails. Figure 2. Nail bed elevated off the distal phalanx.