Case and Research Letters
Periungual Acral Fibrokeratoma: Surgical Excision Using a Banner Flap
Fibroqueratoma acral periungueal: exéresis quirúrgica en bandera
O. Yélamos
, M. Alegre, J.R. Garcés, L. Puig
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Servicio de Dermatología, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
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Yélamos, M. Alegre, J.R. Garcés, L. Puig" "autores" => array:4 [ 0 => array:4 [ "nombre" => "O." "apellidos" => "Yélamos" "email" => array:1 [ 0 => "oyelamos@santpau.cat" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "M." "apellidos" => "Alegre" ] 2 => array:2 [ "nombre" => "J.R." "apellidos" => "Garcés" ] 3 => array:2 [ "nombre" => "L." "apellidos" => "Puig" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Dermatología, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Fibroqueratoma acral periungueal: exéresis quirúrgica en bandera" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1000 "Ancho" => 1333 "Tamanyo" => 178356 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Banner flap: 2 longitudinal incisions are made into the proximal nail fold, one on either side of the lesion.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The surgical treatment of periungual tumors is complicated by the risk of causing irreversible nail dystrophy. However, incomplete resection leads to a high risk of recurrence, and surgery must therefore eliminate the whole tumor while preserving the germinal cells of the nail matrix.</p><p id="par0010" class="elsevierStylePara elsevierViewall">We present the case of a 31-year-old man who was seen in outpatients for a firm, pink, digitiform tumor of about 5 × 3<span class="elsevierStyleHsp" style=""></span>mm that had been present on the fifth toe of the left foot for about 5 months (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The base of the lesion was beneath the eponychium but above the nail plate. The patient did not recall any history of trauma, and there was no family history or presence of other lesions suggestive of tuberous sclerosis. The clinical diagnosis was periungual fibroma and, as the patient reported discomfort due to friction against his footwear, it was decided to excise the lesion as an elective procedure.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The operation was performed under local anesthesia with 2% mepivacaine, and a glove was tied around the proximal part of the digit as a tourniquet to provide a bloodless surgical field. Two longitudinal incisions were then made into the proximal nail fold, one on each side of the lesion. The proximal nailfold was then elevated (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>), exposing the whole tumor and enabling us to dissect and excise the lesion completely. During the procedure, special care was taken not to damage the matrix.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">After resection, the flap was replaced to cover the defect and was sutured with interrupted 5/0 silk sutures, starting at the part closest to the cuticle. As the flap was narrow, the knots were placed outside its borders in order to prevent ischemia. Hemostasis was ensured by the application of Monsel solution with a swab onto the surgical wound, and there were no complications on removal of the torniquet. Finally, mupirocin ointment was applied and the area was covered with tulle gras, gauze, and an adhesive dressing. Histology of the surgical specimen revealed stromal fibrosis with vascular ectasia, compatible with fibrokeratoma. Follow-up at 1 year showed no nail dystrophy and no recurrence of the lesion.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Acral fibrokeratoma is a benign and typically solitary tumor. It is the color of normal skin and may be dome- or horn-shaped. This tumor may arise secondary to trauma.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The term <span class="elsevierStyleItalic">acral fibrokeratoma</span> encompasses several entities, including acquired digital fibrokeratoma, acquired periungual fibrokeratoma, “garlic-clove” fibroma, and the subungual and periungual fibromas characteristic of tuberous sclerosis.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> These tumors should be excised when they cause symptoms or significant cosmetic problems.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Various surgical techniques can be used to resect these tumors, depending on whether they arise from above or below the nail plate. Lesions beneath the nail plate require partial or total removal of the nail. Lesions above the nail plate, on the other hand, can be removed by shaving followed by phenolization,<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> carbon-dioxide laser vaporization,<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> or, more usually, surgical resection after lifting the proximal nail fold as a banner flap.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Surgical resection is usually performed under nerve block anesthesia. Two oblique incisions are made in the proximal nail fold, one at each end of the eponychium; the whole proximal nail fold can then be lifted to expose the lesion. This allows the base of the lesion to be evaluated and complete excision performed, preventing future recurence, without damaging the nail matrix.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6–8</span></a> We used a simpler variant of this technique in which the 2 incisions were made along the borders of the tumor instead of making them at the medial and lateral ends of the eponychium.</p><p id="par0040" class="elsevierStylePara elsevierViewall">It is important to note that this type of lesion has a tendency to bleed despite suturing, and correct hemostasis is therefore essential. The use of vasoconstrictors is not recommended in acral regions due to the risk of distal ischemia; a simple digital torniquet will adequately control bleeding. In addition, Monsel solution—a ferric sulphate solution that has a high local hemostatic potential—can be used to ensure correct hemostasis.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Monsel solution is applied directly with a cotton bud or gauze swab after suturing.</p><p id="par0045" class="elsevierStylePara elsevierViewall">We thus propose this technique as a useful alternative to wedge or punch excision. These other procedures usually provide poorer visualization of the lesion, with a higher risk of recurrence due to incomplete excision of the lesion or nail dystrophy if the resection is too wide. In addition, the technique described preserves the supralesional skin of the proximal nail fold, which reduces tension in the scar and achieves excellent cosmetic results. The banner flap is therefore a simple and very practical technique for small periungual lesions.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Yélamos O, Alegre M, Garcés JR, Puig L. Fibroqueratoma acral periungueal: exéresis quirúrgica en bandera. Actas Dermosifiliogr. 2013;104:830–832.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1098 "Ancho" => 1334 "Tamanyo" => 250289 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Acral fibrokeratoma on the fifth toe of the left foot.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1000 "Ancho" => 1333 "Tamanyo" => 178356 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Banner flap: 2 longitudinal incisions are made into the proximal nail fold, one on either side of the lesion.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Acquired (digital) fibrokeratoma" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "P.J. 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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 24 | 6 | 30 |
| 2024 Octubre | 217 | 63 | 280 |
| 2024 Septiembre | 238 | 50 | 288 |
| 2024 Agosto | 269 | 72 | 341 |
| 2024 Julio | 246 | 64 | 310 |
| 2024 Junio | 288 | 85 | 373 |
| 2024 Mayo | 312 | 64 | 376 |
| 2024 Abril | 235 | 36 | 271 |
| 2024 Marzo | 303 | 38 | 341 |
| 2024 Febrero | 252 | 35 | 287 |
| 2024 Enero | 308 | 43 | 351 |
| 2023 Diciembre | 353 | 53 | 406 |
| 2023 Noviembre | 216 | 41 | 257 |
| 2023 Octubre | 250 | 54 | 304 |
| 2023 Septiembre | 230 | 43 | 273 |
| 2023 Agosto | 202 | 36 | 238 |
| 2023 Julio | 212 | 41 | 253 |
| 2023 Junio | 184 | 19 | 203 |
| 2023 Mayo | 188 | 46 | 234 |
| 2023 Abril | 154 | 20 | 174 |
| 2023 Marzo | 127 | 58 | 185 |
| 2023 Febrero | 135 | 32 | 167 |
| 2023 Enero | 153 | 40 | 193 |
| 2022 Diciembre | 112 | 50 | 162 |
| 2022 Noviembre | 90 | 26 | 116 |
| 2022 Octubre | 92 | 27 | 119 |
| 2022 Septiembre | 68 | 49 | 117 |
| 2022 Agosto | 55 | 33 | 88 |
| 2022 Julio | 58 | 37 | 95 |
| 2022 Junio | 53 | 26 | 79 |
| 2022 Mayo | 146 | 32 | 178 |
| 2022 Abril | 128 | 34 | 162 |
| 2022 Marzo | 101 | 52 | 153 |
| 2022 Febrero | 129 | 25 | 154 |
| 2022 Enero | 147 | 62 | 209 |
| 2021 Diciembre | 85 | 49 | 134 |
| 2021 Noviembre | 160 | 67 | 227 |
| 2021 Octubre | 216 | 41 | 257 |
| 2021 Septiembre | 136 | 58 | 194 |
| 2021 Agosto | 159 | 35 | 194 |
| 2021 Julio | 168 | 42 | 210 |
| 2021 Junio | 160 | 32 | 192 |
| 2021 Mayo | 102 | 37 | 139 |
| 2021 Abril | 277 | 59 | 336 |
| 2021 Marzo | 138 | 45 | 183 |
| 2021 Febrero | 96 | 40 | 136 |
| 2021 Enero | 99 | 22 | 121 |
| 2020 Diciembre | 92 | 24 | 116 |
| 2020 Noviembre | 62 | 20 | 82 |
| 2020 Octubre | 72 | 31 | 103 |
| 2020 Septiembre | 93 | 13 | 106 |
| 2020 Agosto | 61 | 35 | 96 |
| 2020 Julio | 67 | 19 | 86 |
| 2020 Junio | 70 | 40 | 110 |
| 2020 Mayo | 35 | 37 | 72 |
| 2020 Abril | 52 | 35 | 87 |
| 2020 Marzo | 28 | 23 | 51 |
| 2020 Febrero | 2 | 12 | 14 |
| 2020 Enero | 0 | 11 | 11 |
| 2019 Diciembre | 3 | 10 | 13 |
| 2019 Noviembre | 0 | 11 | 11 |
| 2019 Octubre | 0 | 7 | 7 |
| 2019 Septiembre | 4 | 6 | 10 |
| 2019 Agosto | 0 | 4 | 4 |
| 2019 Julio | 0 | 6 | 6 |
| 2019 Junio | 2 | 30 | 32 |
| 2019 Mayo | 2 | 14 | 16 |
| 2019 Abril | 0 | 26 | 26 |
| 2019 Marzo | 2 | 14 | 16 |
| 2019 Febrero | 2 | 11 | 13 |
| 2019 Enero | 3 | 5 | 8 |
| 2018 Diciembre | 0 | 18 | 18 |
| 2018 Noviembre | 5 | 0 | 5 |
| 2018 Octubre | 2 | 0 | 2 |
| 2018 Septiembre | 4 | 8 | 12 |
| 2018 Agosto | 0 | 13 | 13 |
| 2018 Julio | 0 | 14 | 14 |
| 2018 Junio | 0 | 13 | 13 |
| 2018 Mayo | 0 | 6 | 6 |
| 2018 Abril | 0 | 7 | 7 |
| 2018 Marzo | 28 | 6 | 34 |
| 2018 Febrero | 169 | 8 | 177 |
| 2018 Enero | 171 | 14 | 185 |
| 2017 Diciembre | 123 | 7 | 130 |
| 2017 Noviembre | 139 | 29 | 168 |
| 2017 Octubre | 153 | 6 | 159 |
| 2017 Septiembre | 165 | 38 | 203 |
| 2017 Agosto | 153 | 32 | 185 |
| 2017 Julio | 195 | 19 | 214 |
| 2017 Junio | 178 | 39 | 217 |
| 2017 Mayo | 162 | 29 | 191 |
| 2017 Abril | 103 | 33 | 136 |
| 2017 Marzo | 119 | 37 | 156 |
| 2017 Febrero | 326 | 10 | 336 |
| 2017 Enero | 145 | 36 | 181 |
| 2016 Diciembre | 201 | 22 | 223 |
| 2016 Noviembre | 282 | 32 | 314 |
| 2016 Octubre | 273 | 27 | 300 |
| 2016 Septiembre | 355 | 35 | 390 |
| 2016 Agosto | 308 | 37 | 345 |
| 2016 Julio | 163 | 20 | 183 |
| 2016 Junio | 7 | 24 | 31 |
| 2016 Mayo | 4 | 23 | 27 |
| 2016 Abril | 5 | 30 | 35 |
| 2016 Marzo | 6 | 21 | 27 |
| 2016 Febrero | 13 | 27 | 40 |
| 2016 Enero | 8 | 1 | 9 |
| 2015 Diciembre | 10 | 1 | 11 |
| 2015 Noviembre | 7 | 15 | 22 |
| 2015 Octubre | 1 | 15 | 16 |
| 2015 Septiembre | 4 | 18 | 22 |
| 2015 Agosto | 4 | 1 | 5 |
| 2015 Julio | 217 | 15 | 232 |
| 2015 Junio | 174 | 12 | 186 |
| 2015 Mayo | 126 | 22 | 148 |
| 2015 Abril | 142 | 14 | 156 |
| 2015 Marzo | 127 | 4 | 131 |
| 2015 Febrero | 123 | 9 | 132 |
| 2015 Enero | 88 | 8 | 96 |
| 2014 Diciembre | 86 | 6 | 92 |
| 2014 Noviembre | 75 | 3 | 78 |
| 2014 Octubre | 85 | 13 | 98 |
| 2014 Septiembre | 76 | 7 | 83 |
| 2014 Agosto | 69 | 2 | 71 |
| 2014 Julio | 62 | 8 | 70 |
| 2014 Junio | 61 | 7 | 68 |
| 2014 Mayo | 82 | 10 | 92 |
| 2014 Abril | 46 | 5 | 51 |
| 2014 Marzo | 46 | 3 | 49 |
| 2014 Febrero | 36 | 7 | 43 |
| 2014 Enero | 34 | 7 | 41 |
| 2013 Diciembre | 25 | 4 | 29 |
| 2013 Noviembre | 14 | 4 | 18 |
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