1. 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

2. 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

3. 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.

4. 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

5. Example pictures Volar favourable fingertip amputations amenable to VY-plasty

6. 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

7. 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

8. 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 Pre-op Left Thumb Post-op Left Thumb

9. 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

10. 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

11. Case 1 Pre-op Post-Op 1/12 Post-Op 2/12 Post-op

12. Case 2 Post-Op 5/12 Pre-op Post-Op 5/12

13. 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

14. 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.

15. 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.

16. 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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