'Onion' flap

Background Nail fold deformities from burn injury frequently result in eponychial retraction, proximal nail exposure, pain, and distal phalangeal function impairment. Secondary nail abnormalities including longitudinal ridges, surface cracks, and fragility are common sequelae to nail fold deformities. Surgical management of postburn nail fold deformity is challenging because of scar contractures involving the dorsum of digits and lack of surrounding healthy tissues that can be used as source of soft tissue for reconstruction. Previous reports have discussed several methods for reconstruction of these deformities. However, all of these methods are associated with significant donor site morbidities. Methods From August 2008 to January 2010, "onion" flap reconstruction was performed for postburn nail fold contractures and deformities on 32 fingers of eight patients (five men and three women; average age, 44.4 years; age range, 23-54 years). This novel technique was used to release scar contractures in the eponychial area and allow soft tissue restoration by redraping the eponychium in a single-step procedure. All 32 fingers received single-stage "onion" flap reconstruction for their nail fold deformities at least 6 months after the initial injury. Results The follow-up period, with an average of 7.8 months, revealed that all nails had good esthetic and functional results. All experienced amelioration of nail abnormalities. The "onion" advancement flap had effectively released the scar contracture around the nail fold and simultaneously restored the eponychial fold. Conclusions The "onion" flap technique provides superior results compared with those from conventional techniques. We recommend it as the mainstay of treatment for reconstruction of the postburn eponychial deformities. Level of evidence V, therapeutic study.