Chapter 23 - Basic and Advanced Nail Surgery (Part 1: Principles and Techniques)

We sought to assess the shave biopsy technique, which is a new surgical procedure for complete removal of longitudinal melanonychia. We evaluated the quality of the specimen submitted for pathological examination, assessed the postoperative outcome, and ascertained its indication between the other types of matrix biopsies.

This was a retrospective study performed at the dermatologic departments of the Universities of Liège and Brussels, Belgium, of 30 patients with longitudinal or total melanonychia.

Pathological diagnosis was made in all cases; 23 patients were followed up during a period of 6 to 40 months. Seventeen patients had no postoperative nail plate dystrophy (74%) but 16 patients had recurrence of pigmentation (70%).

This was a retrospective study.

Shave biopsy is an effective technique for dealing with nail matrix lesions that cause longitudinal melanonychia over 4 mm wide. Recurrence of pigmentation is the main drawback of the procedure.

Longitudinal erythronychia is a frequent nail presentation with a limited differential diagnosis. This clinical entity may be divided into cases that involve one (localized) or multiple (polydactylous) nails. The different presentations have distinct differential diagnoses and workups yet often share a common pathogenesis. Localized longitudinal erythronychia most commonly represents onychopapilloma, yet malignancies may present identically. Therefore biopsy may be required. Polydactylous longitudinal erythronychia usually coincides with a regional or systemic cause. Occasionally, it may herald an important underlying disease. A thorough understanding of the pathogenesis, clinical presentations, and possible diagnoses is necessary for successful evaluation and management.

Surgical evaluation of longitudinal melanonychia requires biopsy of the nail matrix. Previous publications have presented detailed surgical approaches to this problem. However, discussion of longitudinal excision with local matrix flap reconstruction is documented sparsely in the literature.

To describe the indications for and technique of performing a longitudinal, full-thickness excision for longitudinal melanonychia; as this surgery poses a high risk of postoperative split nail, reconstruction is essential. Three local matrix flaps are detailed to maximize functional and cosmetic results.

The authors detail the different procedures, with several illustrations and clinical photographs highlighting the techniques.

These techniques provide the surgeon with additional approaches to excise lesions of longitudinal melanonychia and reconstruct the surgical defects.

All surgeries of the nail matrix pose a risk of postoperative nail dystrophy and/or split nail.

The different flaps provide elegant local alternatives to second-intention healing and maximize cosmetic and functional results after matrix excision with narrow margins for longitudinal melanonychia.

Successful nail surgery requires exposure of the underlying tissues. In many cases, partial nail plate avulsion is preferable compared with traditional total distal and proximal plate avulsions. The techniques described herein include partial distal, lateral, proximal, and window techniques, and two variation of the total plate avulsion termed the trap door and lateral nail plate curl avulsion. By using these methods, the surgeon is able to access the targeted nail unit while minimizing trauma to adjacent, uninvolved tissue.

Longitudinal melanonychia (LM) may represent nail matrix melanocyte activation (defined as a normal number of melanocytes with increased production of melanin), benign hyperplasia, or melanoma, in addition to multiple nonmelanocyte pathologies, including hemorrhage and infection. This article details an algorithmic approach to LM, including a careful history and physical examination, dermoscopy, and ability to sample the matrix using 3 biopsy techniques, a 3-mm punch excision, a lateral longitudinal excision, and a matrix shave biopsy. Facility with all 3 techniques will allow the physician to procure appropriate nail matrix specimens for diagnosis.