LETTERS AND COMMUNICATIONS
oxide for acute open wounds following pilonidal disease excision. Wound Repair Regen 2006;14:526–35. 5. Jeong SH, Kim HJ, Ryu HJ, Ryu WI, et al. ZnO nanoparticles induce TNF-a expression via ROS-ERK-Egr-1 pathway in human keratinocytes. J Dermatol Sci 2013;72:263–73.
Lilly Y. Zhu, BS Vanderbilt University School of Medicine Nashville, Tennessee
Sunaina S. Likhari, MD William G. Stebbins, MD Division of Dermatology, Department of Medicine Vanderbilt University Medical Center Nashville, Tennessee The authors have indicated no significant interest with commercial supporters.
Utilization of Mohs Micrographic Surgery in a Patient With Onychomatricoma Onychomatricoma (OM) is an uncommon benign tumor of nail matrix origin.1 Clinically, OM is distinguished by longitudinal bands of thickened yellow nail plate with transverse over curvature, distal cavities, occasional splinter hemorrhage, and presence of a papillary tumor protruding from the nail matrix.1 Standard treatment consists of nail plate avulsion with complete excision of the tumor back to the origin at the nail matrix.2,3 This report is a case of OM successfully treated with Mohs surgery in an effort to spare the unaffected nail matrix and prevent tumor recurrence. A 48-year-old woman presented with a 13-year history of an asymptomatic yellow band on the right second fingernail. The patient carried a previous diagnosis of onychomycosis, although prior nail clippings revealed no fungus, and treatment with oral and topical antifungals had failed. On physical examination, the nail demonstrated a yellowed roughened surface with longitudinal ridging, slight longitudinal over curvature, and splinter hemorrhages throughout (Figure 1). A 4-mm punch biopsy of the proximal nail matrix was performed showing fibroepithelial projections into the nail plate lined with papillomatous matrix epithelium consistent with OM (Figure 2). After discussion with the patient, a decision was made to treat the lesion with Mohs surgery for several reasons. The authors wanted to spare as much of the normal nail matrix as possible. In addition, the patient lived several hours from the clinic making staged traditional excision impractical. Finally, the patient was very anxious because of a history of lethal acral melanoma in her sibling and strongly desired complete removal
despite the benign diagnosis. The nail plate was avulsed, and the clinically apparent tumor, present as an ill-defined erythematous gelatinous papule, was removed by the Mohs technique with 2 mm lateral margins and extending to the periosteum on the deep margin. Microscopic examination revealed no evidence of residual tumor. The wound was allowed to heal by second intention. Periodic acid–Schiff histochemical stain of the nail plate was negative for fungal organisms. Nail regrowth occurred over the
Figure 1. Onychomatricoma demonstrating a yellowed roughened surface with longitudinal ridging and slight longitudinal over curvature and splinter hemorrhages throughout.
41:6:JUNE 2015
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© 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
LETTERS AND COMMUNICATIONS
Figure 2. Histopathology of OM demonstrating fibroepithelial projections into the nail plate lined with papillomatous matrix epithelium (H&E, original magnification ·40).
subsequent 3 years with ridging, thinning, and distal 1 to 2 mm onycholysis of the previously affected nail (Figure 3). At the patient’s request, a repeat biopsy was taken 1 year later, which revealed no further evidence of the tumor. Discussion Onychomatricoma is an uncommon benign tumor of the nail matrix that results in a distinctive pattern of
onychodystrophy. The tumor is more common in the fingernails than toenails with no gender predilection.2,3 Diagnosis can be supported with a clipping of the distal edge of the nail, which may also provide information determining extent of the lesion.4 The uncommon nature of this tumor may be due to incorrect or missed diagnosis of OM rather than true scarcity making proper diagnostic technique necessary for recognition and appropriate treatment of this tumor. On avulsion of the dystrophic nail plate, a filiform tumor may be seen arising proximally from the nail matrix. Histopathologically, OM is a pedunculated fibroepithelial tumor of the nail matrix with distal filamentous processes that form glove-finger projections into a highly thickened nail plate.3,5 The tumor is thought to be a mixed epithelial–mesenchymal tumor, with the mesenchymal component inducing epithelial onychogenic differentiation.5 No underlying bony involvement has been documented, making conservative surgical treatment an option for resolution. Given the benign nature of this entity, observation of the lesion may be sufficient. For symptomatic tumors or in the setting of an atypical clinical presentation, treatment is excision with clear margins. This surgery will include nail matrix and therefore may result in a split or deformed nail.3 Tangential excision may be preferable to prevent nail deformity but risks incomplete excision. Mohs micrographic surgery has been used in numerous clinical scenarios to remove tumors with minimal loss of surrounding normal tissue and to prevent recurrence. Given the complexity of the nail unit and potential cosmetic and functional impact of excision of the nail matrix with OM, Mohs micrographic surgery allows for clearance of the tumor with minimal removal of the unaffected nail matrix and conserved nail regeneration potential. References 1. Baran R, Kint A. Onychomatrixoma. Filamentous tufted tumour in the matrix of a funnel-shaped nail: a new entity (report of three cases). Br J Dermatol 1992;126:510. 2. Becerro de Bengoa R, Gates J, Losa Iglesias ME, Alija Martinez B. Rare toenail onychomatricoma: surgical resolution of five cases. Dermatol Surg 2011;37:709–11.
Figure 3. Nail regrowth 3 years after removal of OM by Mohs micrographic surgery.
754
3. Canueto J, Santos-Briz A, Garcia JL, Robledo C, et al. Onychomatricoma: genome wide analyses of a rare nail matrix tumor. J Am Acad Dermatol 2011;64:573–8.
DERMATOLOGIC SURGERY
© 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
LETTERS AND COMMUNICATIONS
4. Miteva M, de Farias DC, Zaiac M, Romanelli P, Tosti A. Nail clipping diagnosis of onychomatricoma. Arch Dermatol 2011;147: 1117–8.
Keith G. LeBlanc Jr, MD The Skin Surgery Centre Metairie, Louisiana
5. Perrin C, Langbien L, Schweizer J, Cannata G, et al. Onychomatricoma in the light of the microanatomy of the normal nail unit. Am J Dermatopath 2011;33:131–9.
Michael S. Graves, MD J. Kelly Anderson, BS Section of Dermatology Medical College of Georgia Georgia Regents University Augusta, Georgia
Daniel J. Sheehan, MD Section of Dermatology Medical College of Georgia Georgia Regents University Augusta, Georgia The authors have indicated no significant interest with commercial supporters.
A Novel Facial Rejuvenation Treatment Using Pneumatic Injection of Non–Cross-Linked Hyaluronic Acid and Hypertonic Glucose Solution Expectations for minimally invasive procedures have increased recently in the field of cosmetic surgery because of the large number of patients hoping to avoid invasive surgery. “Subdermal minimal surgery” technology, a computerized system that enables the targeted delivery of a jet of a solution by high pneumatic pressure through a tiny orifice, is a novel therapeutic modality for dermal remodeling procedures, such as those involving neck wrinkles, keloids, and depressed scars due to acne or herpes zoster.1–4 In previous clinical studies, it was suggested that pneumatically injected hyaluronic acid (HA) particles promote wound healing and induce neocollagenesis.1–4 The authors have applied this pneumatic technology to nonsurgical facial tightening, modifying the technology to suit the specific needs of this procedure.
solution (Fuso Pharmaceutical Industries, Osaka, Japan), which were compounded using a sterile 3-way stopcock and 2 syringes. The authors expected that the
Treatment Procedures The injection system (Enerjet; PerfAction Ltd., Rehovot, Israel) consisted of a central console, applicator, and sterile disposable kit mounted on an applicator. The applicator was filled with a mixed solution of 1 mL non–cross-linked HA (Artz; Seikagaku Corporation, Tokyo, Japan) and 9 mL 20% glucose
Figure 1. Placement of the pneumatic injections (white arrows). Temporal along the hairline, temporal within the main hair mass, supra-auricular, preauricular along the zygomatic arch, and malar prominence. SMAS, superficial musculoaponeurotic system.
41:6:JUNE 2015
755
© 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
oxide for acute open wounds following pilonidal disease excision. Wound Repair Regen 2006;14:526–35. 5. Jeong SH, Kim HJ, Ryu HJ, Ryu WI, et al. ZnO nanoparticles induce TNF-a expression via ROS-ERK-Egr-1 pathway in human keratinocytes. J Dermatol Sci 2013;72:263–73.
Lilly Y. Zhu, BS Vanderbilt University School of Medicine Nashville, Tennessee
Sunaina S. Likhari, MD William G. Stebbins, MD Division of Dermatology, Department of Medicine Vanderbilt University Medical Center Nashville, Tennessee The authors have indicated no significant interest with commercial supporters.
Utilization of Mohs Micrographic Surgery in a Patient With Onychomatricoma Onychomatricoma (OM) is an uncommon benign tumor of nail matrix origin.1 Clinically, OM is distinguished by longitudinal bands of thickened yellow nail plate with transverse over curvature, distal cavities, occasional splinter hemorrhage, and presence of a papillary tumor protruding from the nail matrix.1 Standard treatment consists of nail plate avulsion with complete excision of the tumor back to the origin at the nail matrix.2,3 This report is a case of OM successfully treated with Mohs surgery in an effort to spare the unaffected nail matrix and prevent tumor recurrence. A 48-year-old woman presented with a 13-year history of an asymptomatic yellow band on the right second fingernail. The patient carried a previous diagnosis of onychomycosis, although prior nail clippings revealed no fungus, and treatment with oral and topical antifungals had failed. On physical examination, the nail demonstrated a yellowed roughened surface with longitudinal ridging, slight longitudinal over curvature, and splinter hemorrhages throughout (Figure 1). A 4-mm punch biopsy of the proximal nail matrix was performed showing fibroepithelial projections into the nail plate lined with papillomatous matrix epithelium consistent with OM (Figure 2). After discussion with the patient, a decision was made to treat the lesion with Mohs surgery for several reasons. The authors wanted to spare as much of the normal nail matrix as possible. In addition, the patient lived several hours from the clinic making staged traditional excision impractical. Finally, the patient was very anxious because of a history of lethal acral melanoma in her sibling and strongly desired complete removal
despite the benign diagnosis. The nail plate was avulsed, and the clinically apparent tumor, present as an ill-defined erythematous gelatinous papule, was removed by the Mohs technique with 2 mm lateral margins and extending to the periosteum on the deep margin. Microscopic examination revealed no evidence of residual tumor. The wound was allowed to heal by second intention. Periodic acid–Schiff histochemical stain of the nail plate was negative for fungal organisms. Nail regrowth occurred over the
Figure 1. Onychomatricoma demonstrating a yellowed roughened surface with longitudinal ridging and slight longitudinal over curvature and splinter hemorrhages throughout.
41:6:JUNE 2015
753
© 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
LETTERS AND COMMUNICATIONS
Figure 2. Histopathology of OM demonstrating fibroepithelial projections into the nail plate lined with papillomatous matrix epithelium (H&E, original magnification ·40).
subsequent 3 years with ridging, thinning, and distal 1 to 2 mm onycholysis of the previously affected nail (Figure 3). At the patient’s request, a repeat biopsy was taken 1 year later, which revealed no further evidence of the tumor. Discussion Onychomatricoma is an uncommon benign tumor of the nail matrix that results in a distinctive pattern of
onychodystrophy. The tumor is more common in the fingernails than toenails with no gender predilection.2,3 Diagnosis can be supported with a clipping of the distal edge of the nail, which may also provide information determining extent of the lesion.4 The uncommon nature of this tumor may be due to incorrect or missed diagnosis of OM rather than true scarcity making proper diagnostic technique necessary for recognition and appropriate treatment of this tumor. On avulsion of the dystrophic nail plate, a filiform tumor may be seen arising proximally from the nail matrix. Histopathologically, OM is a pedunculated fibroepithelial tumor of the nail matrix with distal filamentous processes that form glove-finger projections into a highly thickened nail plate.3,5 The tumor is thought to be a mixed epithelial–mesenchymal tumor, with the mesenchymal component inducing epithelial onychogenic differentiation.5 No underlying bony involvement has been documented, making conservative surgical treatment an option for resolution. Given the benign nature of this entity, observation of the lesion may be sufficient. For symptomatic tumors or in the setting of an atypical clinical presentation, treatment is excision with clear margins. This surgery will include nail matrix and therefore may result in a split or deformed nail.3 Tangential excision may be preferable to prevent nail deformity but risks incomplete excision. Mohs micrographic surgery has been used in numerous clinical scenarios to remove tumors with minimal loss of surrounding normal tissue and to prevent recurrence. Given the complexity of the nail unit and potential cosmetic and functional impact of excision of the nail matrix with OM, Mohs micrographic surgery allows for clearance of the tumor with minimal removal of the unaffected nail matrix and conserved nail regeneration potential. References 1. Baran R, Kint A. Onychomatrixoma. Filamentous tufted tumour in the matrix of a funnel-shaped nail: a new entity (report of three cases). Br J Dermatol 1992;126:510. 2. Becerro de Bengoa R, Gates J, Losa Iglesias ME, Alija Martinez B. Rare toenail onychomatricoma: surgical resolution of five cases. Dermatol Surg 2011;37:709–11.
Figure 3. Nail regrowth 3 years after removal of OM by Mohs micrographic surgery.
754
3. Canueto J, Santos-Briz A, Garcia JL, Robledo C, et al. Onychomatricoma: genome wide analyses of a rare nail matrix tumor. J Am Acad Dermatol 2011;64:573–8.
DERMATOLOGIC SURGERY
© 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
LETTERS AND COMMUNICATIONS
4. Miteva M, de Farias DC, Zaiac M, Romanelli P, Tosti A. Nail clipping diagnosis of onychomatricoma. Arch Dermatol 2011;147: 1117–8.
Keith G. LeBlanc Jr, MD The Skin Surgery Centre Metairie, Louisiana
5. Perrin C, Langbien L, Schweizer J, Cannata G, et al. Onychomatricoma in the light of the microanatomy of the normal nail unit. Am J Dermatopath 2011;33:131–9.
Michael S. Graves, MD J. Kelly Anderson, BS Section of Dermatology Medical College of Georgia Georgia Regents University Augusta, Georgia
Daniel J. Sheehan, MD Section of Dermatology Medical College of Georgia Georgia Regents University Augusta, Georgia The authors have indicated no significant interest with commercial supporters.
A Novel Facial Rejuvenation Treatment Using Pneumatic Injection of Non–Cross-Linked Hyaluronic Acid and Hypertonic Glucose Solution Expectations for minimally invasive procedures have increased recently in the field of cosmetic surgery because of the large number of patients hoping to avoid invasive surgery. “Subdermal minimal surgery” technology, a computerized system that enables the targeted delivery of a jet of a solution by high pneumatic pressure through a tiny orifice, is a novel therapeutic modality for dermal remodeling procedures, such as those involving neck wrinkles, keloids, and depressed scars due to acne or herpes zoster.1–4 In previous clinical studies, it was suggested that pneumatically injected hyaluronic acid (HA) particles promote wound healing and induce neocollagenesis.1–4 The authors have applied this pneumatic technology to nonsurgical facial tightening, modifying the technology to suit the specific needs of this procedure.
solution (Fuso Pharmaceutical Industries, Osaka, Japan), which were compounded using a sterile 3-way stopcock and 2 syringes. The authors expected that the
Treatment Procedures The injection system (Enerjet; PerfAction Ltd., Rehovot, Israel) consisted of a central console, applicator, and sterile disposable kit mounted on an applicator. The applicator was filled with a mixed solution of 1 mL non–cross-linked HA (Artz; Seikagaku Corporation, Tokyo, Japan) and 9 mL 20% glucose
Figure 1. Placement of the pneumatic injections (white arrows). Temporal along the hairline, temporal within the main hair mass, supra-auricular, preauricular along the zygomatic arch, and malar prominence. SMAS, superficial musculoaponeurotic system.
41:6:JUNE 2015
755
© 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
