Mimical Reconstruction And Aesthetic Repair of The Nail After Resection of Subungual Melanocytic Nevus

Abstract

Background: The purpose of this study is to report the outcomes of mimical reconstruction and aesthetic repair of the nail.
Methods: When the width of the pigmented bands was more than 1/2 of the whole nail width, the mimical reconstruction of the nail, the lateral toe pulp island flap covered the wound via the subcutaneous channel, was performed. If the width of the pigmented bands ranged from 1/4 to 2/5 of the entire nail, the aesthetic repair of the nail, the split-thickness excision under microscope, would be carried out.
Results: The average age at the time of surgery was 14.5 years. The lesions were located at the toes in 5 patients and fingers in 3 patients. No complications occurred postoperatively. In 5 patients with the mimical reconstruction of the nail, all of toenail showed well-settled flap. In three patients with the aesthetic repair of the nail, there was no nail malnutrition or deformity, and all nails have an aesthetic appearance.
Conclusions: Mimical reconstruction and aesthetic repair of the nail following resection of subungual melanocytic nevus is reliable and feasible. It seems to be satisfactory that “like tissue” repairs the complex nail defects. All patients obtain an excellent aesthetic outcome.
Level of Evidence: V

Full text

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Mimical Reconstruction And Aesthetic Repair of The Nail
After Resection of Subungual Melanocytic Nevus
Wenpeng Xu
Second Hospital of Shandong University
Xiucun Li
Second Hospital of Shandong University
Songhua Cao
Second Hospital of Shandong University
Ning Zhang
Second Hospital of Shandong University
Yong Hu (  handsurgeon@163.com )
Second Hospital of Shandong University
Research Article
Keywords: Mimical reconstruction, aesthetic repair, subungual melanocytic nevus, nail
Posted Date: November 3rd, 2021
DOI: https://doi.org/10.21203/rs.3.rs-279289/v2
License:   This work is licensed under a Creative Commons Attribution 4.0 International License.  Read Full
License

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Abstract
Background: The purpose of this study is to report the outcomes of mimical reconstruction and aesthetic repair of
the nail.
Methods: When the width of the pigmented bands was more than 1/2 of the whole nail width, the mimical
reconstruction of the nail, the lateral toe pulp island ap covered the wound via the subcutaneous channel, was
performed. If the width of the pigmented bands ranged from 1/4 to 2/5 of the entire nail, the aesthetic repair of the
nail, the split-thickness excision under microscope, would be carried out.
Results: The average age at the time of surgery was 14.5 years. The lesions were located at the toes in 5 patients
and ngers in 3 patients. No complications occurred postoperatively. In 5 patients with the mimical reconstruction
of the nail, all of toenail showed well-settled ap. In three patients with the aesthetic repair of the nail, there was no
nail malnutrition or deformity, and all nails have an aesthetic appearance.
Conclusions: Mimical reconstruction and aesthetic repair of the nail following resection of subungual melanocytic
nevus isreliable and feasible. It seems to be satisfactory that “like tissue” repairs the complex nail defects. All
patients obtain an excellent aesthetic outcome.
Level of Evidence: V
Introduction
Melanocytic nevi are benign tumor arising from the proliferation of melanocytes resulted from the BRAF(v-raf
murine sarcoma viral oncogene homolog B1)-activating mutations caused by various etiology such as ultraviolet
light, unidentied environmental mutagens [1]. Subungual melanocytic nevi, also known as melanonychia [2], are as
a result of the proliferation of melanocytes in the nail matrix and nail bed [3], being usually junctional nevi and rarely
compound nevi [4, 5].
According to the diagnostic criteria of the subungual melanoma [2, 6] and the consensus on melanonychia nail plate
dermoscopy [7], surgical resection of the subungual melanocytic nevi was performed when the width of the
subungual pigmented bands is greater than 3 mm. If subungual melanocytic nevi are not resected, there will be a
risk of malignant transformation [8, 9]. Also, they also cause great mental stress to the patient. Previous studies have
shown about 25% - 33% of cutaneous melanomas result from melanocytic nevi [8, 9], whereas this rate in high-risk
patients such as those with many nevi is possibly as high as 54.2% [10]. The Clarke model of melanoma
pathogenesis assumes that the evolvement process from normal melanocytes to melanoma may experience the
four stages of banal nevi, dysplastic nevi, melanoma in situ, and invasive melanoma, which is usually consider to
be driven by the gradual accumulation of pathogenic genetic/epigenetic changes [1, 11, 12]. However, some evidence
suggests that the progression in most melanomas is much more intricate and covers numerous different paths,
which may be partly determined by different carcinogenic hits [13].
Currently, there are no consensus on treatment of the subungual melanocytic nevi with the pigmented band width >
3mm. For the subungual melanocytic nevi with the pigmented band width of 3 to 6 mm, transverse elliptical matrix
excision or releasing ap method or tangential matrix excision was performed [2, 14]. For the subungual melanocytic
nevi with the pigmentation on lateral one‐third of nail, lateral longitudinal excision was carried out [2]. For the
subungual melanocytic nevi with the pigmentation on the whole nail, the whole nail was resected and then the

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wound was covered by skin grafts, llet ap with the phalanx shortening, and free ap [2, 15–17]. Importantly, these
options change post-operative nail appearance and cannot obtain a well aesthetic outcomes. To maintain the
aesthetic contour of the nail, the methods of mimical reconstruction and aesthetic repair of the nail were performed
in patients with the subungual melanocytic nevi. Thus, the purpose of this study is to report the outcomes of
mimical reconstruction and aesthetic repair of the nail.
Patients And Methods
Inclusion and exclusion criteria
This clinical retrospective study was approved by the Research Ethical Committee of the Second Hospital of
Shandong University (KYLL-2021(LW)017). Written informed consent was obtained from each patient. All methods
were performed in accordance with the declaration of Helsinki - ethical principles for medical research involving
human subjects. In our series, inclusion criteria of the patients with the subungual pigmented lesion were given
below: (1) more than 3mm or 1/4 of the whole nail of the pigmented bands width, (2) dark brown to black color, (3)
greater than one year interval from onset to surgical resection, (4) progressive increasing in pigmented bands width
within one year, (5) presence or absence of pigmentation on the adjacent skin (Hutchinson’s sign). The patients who
presented with the broad bands of pigment < 3mm, or blurred surrounding borders, or nail dystrophy and/or
ulceration were excluded in this study. Accordingly, we reviewed hospital medical records from August 2013 to
September 2020, and found that 8 patients underwent the mimical reconstruction and aesthetic repair of the nail
following the nail resection, and were diagnosed as the subungual melanocytic nevus by pathology.
Microsurgical technique
Based on the width of the pigmented bands, two different microsurgical methods were selected. When the width of
the pigmented bands was more than 1/2 of the whole nail width, the mimical reconstruction of the nail was
performed, namely, the lateral toe pulp island ap covered the wound via the subcutaneous channel following the
resection of the whole nail. If the width of the pigmented bands ranged from more than 3mm or 1/4 of the whole
nail to 2/5 of the whole nail, the aesthetic repair of the nail, the split-thickness excision of the pigmented nail matrix
and nail bed lesions under microscope, would be carried out.
Mimical reconstruction of the nail
The mimical reconstruction of the nail was dened as the reconstruction of the nail using the lateral toe pulp island
ap after the resection of the whole nail. After removing the nail plate, the whole nail bed including germinal matrix
and sterile matrix was resected. Also, the whole nail folds were kept intact during resection of the nail bed (Fig. 1A).
Lateral toe pulp island ap based on the plantar digital artery was design according to the size of the total nail bed
(Fig. 1B). A rhombic incision was made. Flap was dissected from the distal to the proximal side, including the
plantar digital nerve (Fig. 1C). The ap was transferred to the defect region of the nail bed via the subcutaneous
channel (Fig. 1D), and covered the wound (Fig. 1E). Finally, the ap donor site was closed primarily.
Aesthetic repair of the nail
The aesthetic repair of the nail was regarded as the split-thickness excision of the pigmented nail matrix and nail
bed lesions under microscope (Video 1). After removing the nail plate, the origin and location of the pigmented
lesions of the nail was identied. The longitudinal incision was made at the junction of the proximal nail fold and
pigmented lesions (Fig. 2A). The pigmented lesions of the nail matrix and nail bed was exposed thoroughly. The

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oblique incision was made proximally and bilaterally on the lesions, respectively. The excisional split-thickness nail
matrix and nail bed was designed according to the lesion size under the microscope (Fig. 2B). The nail matrix and
nail bed lesion were completely removed under the microscope. In other words, the nail matrix and nail bed invaded
by the lesion was completely removed, and the uninvaded nail matrix and nail bed was kept. The invaded supercial
half of the nail matrix and nail bed depth was removed under the microscope (Fig. 2C). Finally, the residual nail bed
was atted under the microscope (Fig. 2D). The incision at the proximal nail fold was sutured.
Post-operative Management
Post-operative care and monitoring were performed for the rst two post-operative days. No anticoagulant was
used. Patients were ambulated on the third post-operative day but were instructed to avoid any strenuous exercise
for two weeks. The skin sutures were removed at post-operative two weeks.
Results
Of eight patients, two patients were females and six patients were males. The average age at the time of surgery
was 14.5 years (range, 1 to 41 years). The mean interval from onset to surgical resection was 2.9 years (range, 1 to
5 years). The lesions were located at the toes in 5 patients and ngers in 3 patients. In ve out of 8 patients, the
width of the pigment bands was more than 1/2 of the nail width. Among them, ve patients underwent the mimical
reconstruction of the nail. In addition, the aesthetic repairof the nail was carried out in 3 patients. The basic
information of the ten patients with thesubungual melanocytic nevuswas shown in Table 1.
No complications such as wound infection, wound dehiscence, nail bed and/or fold necrosis, ap necrosis occurred
postoperatively. Eight patients were followed up, and the follow-up time ranged from 5 months to 55 months (mean,
19.6 months). There was no hypertrophic scar at the incision wound. In 5 patients with the mimical reconstruction
of the nail, all of toenail showed well-settled ap; these ve patients can wear shoes and walk normally, and were
satised with the outcomes. Moreover, in three patients with the aesthetic repair of the nail, there was no nail
malnutrition, recurrence or deformity, and all nails have an aesthetic appearance. Finally, all patients (8 patients)
obtained a satisfactory outcome.
Table 1. The basic information of the eight patients with the subungual melanocytic nevus.

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Patient Sex Age
(Years) Interval
from
onset to
surgical
resection
(years)
Laterality Site Width
of
pigment
bands
Colours
of
pigment
bands
Hutchinson’s
sign Treatment
1 M 13 4 Right
foot Great
toe More
than
1/2 of
the
whole
nail
width
Black No MR
2 M 4 4 Right
foot 5th
toe
The
whole
nail
Dark
brown No MR
3 F 41 3 Right
foot 4th
toe
More
than
1/2 of
the
whole
nail
width
Dark
brown No MR
4 M 3 2 Left Foot 4th
toe
The
whole
nail
Dark
brown No MR
5 F 5 2 Right
foot 5th
toe
The
whole
nail
Black No MR
6 M 1 1 Right
hand Index
nger About
1/4 of
the
whole
nail
width
Black No AR
7 M 19 5 Left
hand Little
nger About
2/5 of
the
whole
nail
width
Dark
brown No AR
8 M 30 2 Left
hand Index
nger About
1/3 of
the
whole
nail
width
Dark
brown No AR
M: male. F: female. MR: Mimical reconstruction of the nail bed. AR: Aesthetic repair of the nail bed.
Case 1 (Patient 1)
A 13-year-old male patient had a history of progressive subungual melanosis for over 4 year in the hallux of right
foot but not pseudo-Hutchinson sign (Fig.3A). After the resection of the tumor, it was pathologically diagnosed as

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the subungual melanocytic nevus. The defect of the nail matrix was reconstructed using the lateral toe pulp island
ap based on the plantar digital artery (Fig.3B and 3C). The patient was followed up for 16 months and made a well
recovery after surgery (Fig.3D, 3E and 3F).
Case 2 (Patient 5)
A ve-year-old female patient had a history of progressive subungual melanosis for greater than two years and
intermittent pain for more than half a year in the fth toe of right foot (Fig.4A). After the resection of the tumor (total
nail matrix), it was pathologically diagnosed as the subungual melanocytic nevus of the fth toe. The defect of the
total nail matrix was reconstructed using the lateral toe pulp island ap based on the plantar digital artery (Figs.4B
and 4C). The patient was followed up for 5 months and obtained a satisfactory outcome (Figs.4D and 4E).
Case 3 (Patient 6)
The subungual melanocytic nevus of the index nger of the right hand was pathologically diagnosed in a 1-year-old
boy (Fig.5A). It had a history of progressive subungual melanosis for over half a year. After removing the nail plate,
the split-thickness excision of the pigmented nail bed lesions under microscope was performed (Fig.5B and 5C).
Also, the residual nail bed was atted under the microscope(Fig.5D). The patient was followed up for 20 months
and gained a satisfactory outcome (Fig.5E).
Discussion
In this study, the technique on mimical reconstruction and aesthetic repair of the nail following resection of
subungual melanocytic nevus is a reliable and feasible, all patients obtained a satisfactory appearance.
Although melanocytes are the normal pigment-producing cells in the skin [1], the density of melanocytes in the nail
matrix (200/mm2) and nail bed (absent to 50/mm2) is much smaller than in normal skin (1150/mm2) [3, 5]. These
also explains why some of subungual melanocytic nevi tend to be not black. Therefore, it is not reliable to evaluate
the malignant degree of pigmented lesions through the color alone.
However, the thickness of the normal nail bed in healthy individuals was approximately 1.17 mm [18].
Histopathologically, melanocytes in nail matrix were usually found in suprabasal position between the second layer
and the fourth layer; in the nail bed, all melanocytes were situated in the rst and second layers [3, 5, 19]. Di et al.
reported that the average thickness (depth) for subungual pigmented lesions was 0.08mm (range, 0.04 to 0.12 mm),
and the thickness of subungual melanocytic nevi ranged from 0.04 to 0.07mm (mean, 0.05 mm) [20]. In our series,
there are 5 patients with the width of the pigmented bands ranged from 1/4 to 2/5 of the whole nail, these ve
patients underwent the aesthetic repair on split-thickness excision of the pigmented nail matrix and nail bed lesions
under microscope. No patients recur in a follow-up of over one year. Thus, the aesthetic repair on split-thickness
excision of the pigmented nail matrix and nail bed lesions under microscope is reliable and feasible. When the width
of the pigmented bands was more than 1/2 of the whole nail width, the split-thickness excision of the pigmented
nail matrix and nail bed lesions under microscope can lead to the nail malnutrition or deformity. Thus, the whole nail
resection is an option.
The absence of nail may not only inuence the appearance and function of the injured foot/hand but also give rise
to a psychological burden on the patients due to the poor appearance of the toe/nger. In addition to improving the
sensitivity and stability of the toe pulp, the nail also has an aesthetic effect [21–23]. To date, the attention on the

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aesthetic reconstruction of the ngernail defects continues to be paid[21, 23, 24], whereas the emulational repair and
aesthetic reconstruction of the toenail defects has been neglected for a long time. With the popularity of
increasingly aesthetic knowledge, aesthetic reconstruction of toenail soft tissue defects possesses increasingly
requirements. Therefore, the reconstruction of the toenail soft tissue defects poses a severe challenge for surgeon.
The wound repair following the resection of the whole nail is also a brainteaser. In clinical practice, skin grafts for
repairing the nail soft tissue defects with phalanx exposure often presented with the hypertrophic scar at recipient
site [16]. The llet ap with the phalanx shortening often requires the sacrice of the distal phalanx [15]. Free ap has
some disadvantages of long operative time and microsurgical microvascular anastomosis [17]. Currently, few
studies focus on the toe pulp aps for reconstructing the nail defects. Cheng et al reported a lateral toe pulp ap for
repairing the dorsal toe defect [25]. Tashiro et al reported a second-toe lateral hemipulp ap transfer to cover a third-
toe pulp defect [26]. In our series, mimical reconstruction of the nail following the resection of the whole nail was
performed using the lateral toe pulp island ap. All patients obtained the excellent function and aesthetic outcomes,
and all patients were satised. The lateral toe pulp island ap provides several merits over the use of conventional
aps[15–17], including short operation time, simple ap dissection, minimal donor site morbidities, and outstanding
functional and aesthetic outcomes. In addition, the texture and color of the toe pulp is similar to that of the toenail
because the toe pulp has a thicker cuticle. This ap can mimic the unique original characteristics of the toenail to
minimize deformities. The toe pulp can provide a glabrous skin ap suitable for resurfacing toenail soft tissue
defect, realizing sensate reconstruction via “replacing like with like”.
Conclusions
Mimical reconstruction and aesthetic repair of the nail following resection of subungual melanocytic nevus is a
reliable and feasible. It seems to be satisfactory that “like tissue” repairs the complex nail defects. All patients
obtain an excellent aesthetic outcome.
Abbreviations
BRAF: v-raf murine sarcoma viral oncogene homolog B1
MR: Mimical reconstruction of the nail bed
AR: Aesthetic repair of the nail bed
Declarations
Ethics approval and consent to participate:The experimental protocol was established, according to the ethical
guidelines of the Helsinki Declaration and was approved by the Human Ethics Committee of the second hospital of
Shandong university. Written informed consent was obtained from individual or guardian participants.. Approval
number:KYLL-2021LW1017.
Consent to publication: Not applicable. No informed consent was required, because the data are anonymized.
Authors' contributions:

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N.Z collected the patient data. WP. X and XC. L analyzed and interpreted the patient data . SH. C and Y. H performed
the operation. XC. L was a major contributor in writing the manuscript.
All authors read and approved the nal manuscript.
Funding: Not applicable.
Competing Interests: The authors declare that they have no competing interests.
Availability of data and materials: The datasets used and/or analysed during the current study available from the
corresponding author on reasonable request.
Source of Funding:Not applicable
Conict of Interest:Not applicable.
Acknowledgements: The authors will thank all the colleagues of Department of foot and ankle surgery of the
second hospital of Shandong University for their great help.
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Figures

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Figure 1
The surgical procedure of mimical reconstruction of the nail. (A) removing nail plate and resecting the whole nail
bed and matrix, (B) Lateral toe pulp island ap design, (C) Flap dissection, (D) The ap was transferred to the defect
region of the nail bed via the subcutaneous channel, (E) The ap covered the wound.
Figure 2
The surgical procedure of aesthetic repair of the nail. (A) Longitudinal incision, (B and C) Split-thickness excision
procedure of the pigmented nail matrix and nail bed lesions under microscope, (D) The residual nail matrix and nail
bed was atted under microscope.
Figure 3
The pre-, intra- and post-operative results of case 1. (A) Subungual melanocytic nevus of hallux of right foot. (B and
C) The defect of the nail matrix after the resection of tumor was repaired with the lateral toe pulp island ap based
on the plantar digital artery. (D, E and F) The result after 16 months.
Figure 4
The pre-, intra- and post-operative results of case 2. (A) subungual melanocytic nevus of the fth toe of right foot. (B
and C) the defect of the nail matrix after the resection of tumor was repaired with the lateral toe pulp island ap
based on the plantar digital artery. (D and E) the result after 5 months.
Figure 5
The pre-, intra-, and post-operative results of case 3. (A) subungual melanocytic nevus of the index nger of the right
hand. (B and C) the split-thickness excision of the pigmented nail bed lesions under microscope. (D) the residual
nail bed was atted. (E) the result after 20 months.