For a want of a nail and plastic surgery

"For want of a nail, a Kingdom was lost" We have all read or are aware of this story. The nail I am talking about is different but it does carry a significant importance in the life of people. The human body is a result of a marvellous design. Even we, as plastic surgeons and hand surgeons know very little about the function of the nail. As any organ of the body it combines astounding aesthetics and function. To a young girl, looking after the nail is to have a set of beautiful nails - caring, trimming, painting and shaping to look good and even sometimes used as an effective weapon. Some of the real functions and which may look simple but astonishing is that the nail gives support for the ultraspecialised pulp against any object being held by the hand or the ground in the case of the feet. This is an important function. The ability to sense objects in the hand becomes half if he nail is lost. The sensitive tip just becomes limp and becomes less efficient to sense. The nail is also an important organ to do a large number of simple to complex assistive functions. Scratching is a very useful function. The junction between the nail and the skin is a specialised one and the transition is complex. The junction between the nail and the skin on the dorsum is extremely intricate and complex. Both these areas ,more so the dorsum is prone to a million stresses every time we use our hands. There are a million tears at this junction. Needless to say this junction has the largest number of WBC's per volume of tissue in the body than anywhere else combatting infection amazingly. No wonder then that nail biting and inadvertently biting, peeling of this skin seen sometimes damages this intricate balance, thus resulting in severe paronychia in some normal and in immunocompromised persons. The changes in the nail is also a window which can reflect several diseases. That is the forte of the physicians. Let me however confine myself to the plastic surgical aspects. While at a large hand surgery conference in the UK, which is attended by both the plastic surgeons and the orthopaedic surgeons, the orthopaedic surgeon sitting next to me commented- "what are you guys going to talk on the nail for half a day when all I can remember is just one procedure and that is to remove the nail in ingrowing toe nail". Such was my ignorance too as a young trainee who came to attend the rather large session on nails. It was however the most revealing. There are several things we do for the nail. Some of it has to do with the aesthetics of course which was dealt in detail by the cosmetic surgeon from Hollywood who showed some extraordinary reconstructions. Loss of nail, were reconstructed. Split nails have to be evaluated and a suitable procedure in a suitable patient can restore ugly looking nails to look beautiful. A snip here and there and a nail polish will make the nail so beautiful to be flashed with pride. Simple nail repairs, nail grafts and a whole gamut of procedures are done to restore function and great aesthetic form.

The topic today is however to create awareness about nail injuries at the time of injury. Injuries to the tip of the fingers and toes are very common among all age groups but is more seen among children. Patients and relatives often will ask and sometimes insist that the finger be treated and would request the first responders viz, the casualty doctors or the GPs to do something. It is now possible to reconstruct them at the time of the injury so that the long term physical, social ,psychological and also monetary distress these unfortunate patients go through can be avoided and normalcy restored. Seen below is injury in a 2 year old when the toe was crushed in the gate. Often the parents bring the child only without looking for the amputated part. On asking them to search for the missing part, they do succeed in finding it . The tip of the second toe often gets injured as it is the longest. Prompt expert reconstruction by an expert plastic surgeon works wonders. The joy of seeing the tip surviving and growing back is a joy worth its while not only for the surgeon but for the parents and patient. Next the growth of the nail is anticipated with much expectation and suspense. Once the nail grows, the final result though not good as the original is an achievement to be proud of. In this picture you can see the tip of the toe reconstructed successfully and the nail growing back in a month. In three to six months it will look almost normal.

In the event of an injury like this and the reconstruction not attempted at the time of injury, or if it was not possible, we do have a solution. Look at the deformed second toe seen in this young bride to be. She is extremely distressed with the appearance and the deformity. She wanted the toe to be presentable at the wedding during some of the ceremonies. The deformity was corrected and the toe straightened. Nail bed site had to be marked perfectly and a split nail bed graft from the big toe was harvested. Nail was successfully reconstructed to the joy and ecstasy of this young girl.

There is a saying in Plastic surgery - "There are no small operations in plastic surgery, only small surgeons". Remember there are no small procedures and no small tissue is useless.

Timing and expertise with appropriate technology and of course a little bit of imagination, which a plastic surgeon is required to have and prides himself to possess immensely is the key to create or recreate the perfect form and function in otherwise hopeless situations.

Article by Prof V. B. Narayanamurthy
Plastic and Reconstructive Surgeon
Kauvery Hospital, Chennai

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