Wei Zhang, MD

Practice Gap

Longitudinal melanonychia (LM) is characterized by the presence of a dark brown, longitudinal, pigmented band on the nail unit, often caused by melanocytic activation or melanocytic hyperplasia in the nail matrix. Distinguishing between benign and early malignant LM is crucial due to their similar clinical presentations.¹ Hence, surgical excision of the pigmented nail matrix followed by histopathologic examination is a common procedure aimed at managing LM and reducing the risk for delayed diagnosis of subungual melanoma.

Tangential matrix excision combined with the nail window technique has emerged as a common and favored surgical strategy for managing LM.² This method is highly valued for its ability to minimize the risk for severe permanent nail dystrophy and effectively reduce postsurgical pigmentation recurrence.

The procedure begins with the creation of a matrix window along the lateral edge of the pigmented band followed by 1 lateral incision carefully made on each side of the nail fold. This meticulous approach allows for the complete exposure of the pigmented lesion. Subsequently, the nail fold is separated from the dorsal surface of the nail plate to facilitate access to the pigmented nail matrix. Finally, the target pigmented area is excised using a scalpel.

Despite the recognized efficacy of this procedure, challenges do arise, particularly when the width of the pigmented matrix lesion is narrow. Holding the scalpel horizontally to ensure precise excision can prove to be demanding, leading to difficulty achieving complete lesion removal and obtaining the desired cosmetic outcomes. As such, there is a clear need to explore alternative tools that can effectively address these challenges while ensuring optimal surgical outcomes for patients with LM. We propose the use of the customized dermal curette.

The Technique

An improved curette tool is a practical solution for complete removal of the pigmented nail matrix. This enhanced instrument is crafted from a sterile disposable dermal curette with its top flattened using a needle holder(Figure 1). Termed the customized dermal curette, this device is a simple yet accurate tool for the precise excision of pigmented lesions within the nail matrix. Importantly, it offers versatility by accommodating different widths of pigmented lesions through the availability of various sizes of dermal curettes (Figure 2).

Histopathologically, we have found that the scalpel technique may lead to variable tissue removal, resulting in differences in tissue thickness, fragility, and completeness (Figure 3A). Conversely, the customized dermal curette consistently provides more accurate tissue excision, resulting in uniform tissue thickness and integrity (Figure 3B).

Practice Implications

Compared to the traditional scalpel, this modified tool offers distinct advantages. Specifically, the customized dermal curette provides enhanced maneuverability and control during the procedure, thereby improving the overall efficacy of the excision process. It also offers a more accurate approach to completely remove pigmented bands, which reduces the risk for postoperative recurrence. The simplicity, affordability, and ease of operation associated with customized dermal curettes holds promise as an effective alternative for tissue shaving, especially in cases involving narrow pigmented matrix lesions, thereby addressing a notable practice gap and enhancing patient care.

Practice Gap

Longitudinal melanonychia (LM) is characterized by the presence of a dark brown, longitudinal, pigmented band on the nail unit, often caused by melanocytic activation or melanocytic hyperplasia in the nail matrix. Distinguishing between benign and early malignant LM is crucial due to their similar clinical presentations.¹ Hence, surgical excision of the pigmented nail matrix followed by histopathologic examination is a common procedure aimed at managing LM and reducing the risk for delayed diagnosis of subungual melanoma.

Tangential matrix excision combined with the nail window technique has emerged as a common and favored surgical strategy for managing LM.² This method is highly valued for its ability to minimize the risk for severe permanent nail dystrophy and effectively reduce postsurgical pigmentation recurrence.

The procedure begins with the creation of a matrix window along the lateral edge of the pigmented band followed by 1 lateral incision carefully made on each side of the nail fold. This meticulous approach allows for the complete exposure of the pigmented lesion. Subsequently, the nail fold is separated from the dorsal surface of the nail plate to facilitate access to the pigmented nail matrix. Finally, the target pigmented area is excised using a scalpel.

Despite the recognized efficacy of this procedure, challenges do arise, particularly when the width of the pigmented matrix lesion is narrow. Holding the scalpel horizontally to ensure precise excision can prove to be demanding, leading to difficulty achieving complete lesion removal and obtaining the desired cosmetic outcomes. As such, there is a clear need to explore alternative tools that can effectively address these challenges while ensuring optimal surgical outcomes for patients with LM. We propose the use of the customized dermal curette.

The Technique

An improved curette tool is a practical solution for complete removal of the pigmented nail matrix. This enhanced instrument is crafted from a sterile disposable dermal curette with its top flattened using a needle holder(Figure 1). Termed the customized dermal curette, this device is a simple yet accurate tool for the precise excision of pigmented lesions within the nail matrix. Importantly, it offers versatility by accommodating different widths of pigmented lesions through the availability of various sizes of dermal curettes (Figure 2).

Histopathologically, we have found that the scalpel technique may lead to variable tissue removal, resulting in differences in tissue thickness, fragility, and completeness (Figure 3A). Conversely, the customized dermal curette consistently provides more accurate tissue excision, resulting in uniform tissue thickness and integrity (Figure 3B).

Practice Implications

Compared to the traditional scalpel, this modified tool offers distinct advantages. Specifically, the customized dermal curette provides enhanced maneuverability and control during the procedure, thereby improving the overall efficacy of the excision process. It also offers a more accurate approach to completely remove pigmented bands, which reduces the risk for postoperative recurrence. The simplicity, affordability, and ease of operation associated with customized dermal curettes holds promise as an effective alternative for tissue shaving, especially in cases involving narrow pigmented matrix lesions, thereby addressing a notable practice gap and enhancing patient care.

Practice Gap

Longitudinal melanonychia (LM) is characterized by the presence of a dark brown, longitudinal, pigmented band on the nail unit, often caused by melanocytic activation or melanocytic hyperplasia in the nail matrix. Distinguishing between benign and early malignant LM is crucial due to their similar clinical presentations.¹ Hence, surgical excision of the pigmented nail matrix followed by histopathologic examination is a common procedure aimed at managing LM and reducing the risk for delayed diagnosis of subungual melanoma.

Tangential matrix excision combined with the nail window technique has emerged as a common and favored surgical strategy for managing LM.² This method is highly valued for its ability to minimize the risk for severe permanent nail dystrophy and effectively reduce postsurgical pigmentation recurrence.

The procedure begins with the creation of a matrix window along the lateral edge of the pigmented band followed by 1 lateral incision carefully made on each side of the nail fold. This meticulous approach allows for the complete exposure of the pigmented lesion. Subsequently, the nail fold is separated from the dorsal surface of the nail plate to facilitate access to the pigmented nail matrix. Finally, the target pigmented area is excised using a scalpel.

Despite the recognized efficacy of this procedure, challenges do arise, particularly when the width of the pigmented matrix lesion is narrow. Holding the scalpel horizontally to ensure precise excision can prove to be demanding, leading to difficulty achieving complete lesion removal and obtaining the desired cosmetic outcomes. As such, there is a clear need to explore alternative tools that can effectively address these challenges while ensuring optimal surgical outcomes for patients with LM. We propose the use of the customized dermal curette.

The Technique

An improved curette tool is a practical solution for complete removal of the pigmented nail matrix. This enhanced instrument is crafted from a sterile disposable dermal curette with its top flattened using a needle holder(Figure 1). Termed the customized dermal curette, this device is a simple yet accurate tool for the precise excision of pigmented lesions within the nail matrix. Importantly, it offers versatility by accommodating different widths of pigmented lesions through the availability of various sizes of dermal curettes (Figure 2).

Histopathologically, we have found that the scalpel technique may lead to variable tissue removal, resulting in differences in tissue thickness, fragility, and completeness (Figure 3A). Conversely, the customized dermal curette consistently provides more accurate tissue excision, resulting in uniform tissue thickness and integrity (Figure 3B).

Practice Implications

Compared to the traditional scalpel, this modified tool offers distinct advantages. Specifically, the customized dermal curette provides enhanced maneuverability and control during the procedure, thereby improving the overall efficacy of the excision process. It also offers a more accurate approach to completely remove pigmented bands, which reduces the risk for postoperative recurrence. The simplicity, affordability, and ease of operation associated with customized dermal curettes holds promise as an effective alternative for tissue shaving, especially in cases involving narrow pigmented matrix lesions, thereby addressing a notable practice gap and enhancing patient care.

Practice Gap

Wound dressings protect the skin and prevent contamination. The hair often makes it difficult to affix a dressing after a minor scalp trauma or local surgery on the head. Traditional approaches for fastening a dressing on the head include bandage winding or adhesive tape, but these methods often affect aesthetics or cause discomfort—bandage winding can make it inconvenient for the patient to move their head, and adhesive tape can cause pain by pulling the hair during removal.

To better position a scalp dressing, tie-over dressings, braid dressings, and paper clips have been used as fixators.^1-3 These methods have benefits and disadvantages.

Tie-over Dressing—The dressing is clasped with long sutures that were reserved during wound closure. This method is sturdy, can slightly compress the wound, and is applicable to any part of the scalp. However, it requires more sutures, and more careful wound care may be required due to the edge of the dressing being close to the wound.

Braid Dressing—Tape, a rubber band, or braided hair is used to bind the gauze pad. This dressing is simple and inexpensive. However, it is limited to patients with long hair; even then, it often is difficult to anchor the dressing by braiding hair. Moreover, removal of the rubber band and tape can cause discomfort or pain.

Paper Clip—This is a simple scalp dressing fixator. However, due to the short and circular structure of the clip, it is not conducive to affixing a gauze dressing for patients with short hair, and it often hooks the gauze and hair, making it inconvenient for the physician and a source of discomfort for the patient when the paper clip is being removed.

The Technique

To address shortcomings of traditional methods, we encourage the use of hairpins to affix a dressing after a scalp wound is sutured. Two steps are required:

• Position the gauze to cover the wound and press the gauze down with your hand.
• Clamp the 4 corners of the dressing and adjacent hair with hairpins (Figure, A).

Practical Implications

Hairpins are common for fixing hairstyles and decorating hair. They are inexpensive, easy to obtain, simple in structure, convenient to use without additional discomfort, and easy to remove (Figure, B). Because most hairpins have a powerful clamping force, they can affix dressings in short hair (Figure, A). All medical staff can use hairpins to anchor the scalp dressing. Even a patient’s family members can carry out simple dressing replacement and wound cleaning using this method. Patients also have many options for hairpin styles, which is especially useful in easing the apprehension of surgery in pediatric patients.

Practice Gap

Wound dressings protect the skin and prevent contamination. The hair often makes it difficult to affix a dressing after a minor scalp trauma or local surgery on the head. Traditional approaches for fastening a dressing on the head include bandage winding or adhesive tape, but these methods often affect aesthetics or cause discomfort—bandage winding can make it inconvenient for the patient to move their head, and adhesive tape can cause pain by pulling the hair during removal.

To better position a scalp dressing, tie-over dressings, braid dressings, and paper clips have been used as fixators.^1-3 These methods have benefits and disadvantages.

Tie-over Dressing—The dressing is clasped with long sutures that were reserved during wound closure. This method is sturdy, can slightly compress the wound, and is applicable to any part of the scalp. However, it requires more sutures, and more careful wound care may be required due to the edge of the dressing being close to the wound.

Braid Dressing—Tape, a rubber band, or braided hair is used to bind the gauze pad. This dressing is simple and inexpensive. However, it is limited to patients with long hair; even then, it often is difficult to anchor the dressing by braiding hair. Moreover, removal of the rubber band and tape can cause discomfort or pain.

Paper Clip—This is a simple scalp dressing fixator. However, due to the short and circular structure of the clip, it is not conducive to affixing a gauze dressing for patients with short hair, and it often hooks the gauze and hair, making it inconvenient for the physician and a source of discomfort for the patient when the paper clip is being removed.

The Technique

To address shortcomings of traditional methods, we encourage the use of hairpins to affix a dressing after a scalp wound is sutured. Two steps are required:

• Position the gauze to cover the wound and press the gauze down with your hand.
• Clamp the 4 corners of the dressing and adjacent hair with hairpins (Figure, A).

Practical Implications

Hairpins are common for fixing hairstyles and decorating hair. They are inexpensive, easy to obtain, simple in structure, convenient to use without additional discomfort, and easy to remove (Figure, B). Because most hairpins have a powerful clamping force, they can affix dressings in short hair (Figure, A). All medical staff can use hairpins to anchor the scalp dressing. Even a patient’s family members can carry out simple dressing replacement and wound cleaning using this method. Patients also have many options for hairpin styles, which is especially useful in easing the apprehension of surgery in pediatric patients.

Practice Gap

Wound dressings protect the skin and prevent contamination. The hair often makes it difficult to affix a dressing after a minor scalp trauma or local surgery on the head. Traditional approaches for fastening a dressing on the head include bandage winding or adhesive tape, but these methods often affect aesthetics or cause discomfort—bandage winding can make it inconvenient for the patient to move their head, and adhesive tape can cause pain by pulling the hair during removal.

To better position a scalp dressing, tie-over dressings, braid dressings, and paper clips have been used as fixators.^1-3 These methods have benefits and disadvantages.

Tie-over Dressing—The dressing is clasped with long sutures that were reserved during wound closure. This method is sturdy, can slightly compress the wound, and is applicable to any part of the scalp. However, it requires more sutures, and more careful wound care may be required due to the edge of the dressing being close to the wound.

Braid Dressing—Tape, a rubber band, or braided hair is used to bind the gauze pad. This dressing is simple and inexpensive. However, it is limited to patients with long hair; even then, it often is difficult to anchor the dressing by braiding hair. Moreover, removal of the rubber band and tape can cause discomfort or pain.

Paper Clip—This is a simple scalp dressing fixator. However, due to the short and circular structure of the clip, it is not conducive to affixing a gauze dressing for patients with short hair, and it often hooks the gauze and hair, making it inconvenient for the physician and a source of discomfort for the patient when the paper clip is being removed.

The Technique

To address shortcomings of traditional methods, we encourage the use of hairpins to affix a dressing after a scalp wound is sutured. Two steps are required:

• Position the gauze to cover the wound and press the gauze down with your hand.
• Clamp the 4 corners of the dressing and adjacent hair with hairpins (Figure, A).

Practical Implications

Hairpins are common for fixing hairstyles and decorating hair. They are inexpensive, easy to obtain, simple in structure, convenient to use without additional discomfort, and easy to remove (Figure, B). Because most hairpins have a powerful clamping force, they can affix dressings in short hair (Figure, A). All medical staff can use hairpins to anchor the scalp dressing. Even a patient’s family members can carry out simple dressing replacement and wound cleaning using this method. Patients also have many options for hairpin styles, which is especially useful in easing the apprehension of surgery in pediatric patients.