Clinical Example: Nail complex reconstruction with nail bed grafts and reverse partially deepithelialized dorsal cross finger flaps for eponychial reconstruction

Fingernail anatomy is complicated. Even more complicated is the task of reconstructing components of this area. One of the trickier issues is the eponychial fold, which has skin on both sides. One technique for replacing this area is a reversed deepithelialized dorsal cross finger flap, which is demonstrated with this case.
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This 40 year old man on insulin for diabetes sustained loss of the dorsal soft tissues of his dominant index and middle fingers in a rotating blade injury. The central nail beds and central  eponychial skin were partially lost, as was the dorsal DIP joint capsule and terminal tendon of the middle finger.
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The nail beds were reconstructed with nail bed grafts from the adjacent fingers. the middle finger terminal tendon was reconstructed with a slip of lateral band used as a graft inserted distally with a bone anchor. Dorsal flaps were elevated and partially deepithelialized, leaving distal areas undisturbed to reconstruct the undersurface of the eponychial skin fold (yellow arrows).
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Donor sites and flaps were closed with a full thickness skin graft from the medial proximal forearm. Nail beds were dressed with Gelfilm.
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Two weeks postop, immediately prior to flap division.
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Two weeks after flap division.
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One year postop, after debulking flap revisions.
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reverse dorsal cross finger flap
eponychium reconstruction

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