Nail bed defect reconstruction using a thenar fascial flap and subsequent nail bed grafting

BACKGROUND: Full-thickness nail bed defects with significant exposure of the distal phalanx are typically challenging to reconstruct. We describe a novel method of nail bed defect reconstruction using a thenar fascial flap combined with nail bed grafting. METHODS: Full-thickness nail bed defects were reconstructed in a 2-stage operation involving the placement of a thenar fascial flap and subsequent nail bed grafting. A proximally-based skin flap was designed on the thenar eminence. The flap was elevated distally to proximally, and the fascial layer covering the thenar muscle was dissected proximally to distally. The skin flap was then closed and the dissected fascial flap was turned over (proximal to distal) and inset onto the defect. The finger was immobilized for 2 weeks, and the flap was dressed with wet and ointment dressings. After 2 weeks, the flap was divided and covered with a split-thickness nail bed graft from the great toe. Subsequent nail growth was evaluated on follow-up. RESULTS: Nine patients (9 fingers) treated with the novel procedure were evaluated at follow-up examinations. Complete flap survival was noted in all cases, and all nail bed grafts took successfully. Five outcomes (55.6%) were graded as excellent, three (33.3%) as very good, and one (11.1%) as fair. No donor site morbidities of the thenar area or great toe were observed. CONCLUSIONS: When used in combination with a nail bed graft, the thenar fascial flap provides an excellent means of nail bed reconstruction.