Exposing the Hidden Nail: Matrix-Sparing Secondary Exposure After Adipofascial Flap Reconstruction of Distal Fingertips.

PURPOSE: To characterize delayed "hidden" nail regrowth after homodigital dorsal adipofascial reverse flap reconstruction of distal fingertips and to evaluate the outcomes of a standardized, matrix-sparing secondary exposure technique.

METHODS

A retrospective observational study was conducted on 40 fingertips reconstructed with the homodigital dorsal adipofascial reverse flap between January 2019 and March 2025. Patients who developed hidden nail requiring surgical revision were identified and analyzed. Inclusion criteria comprised localized inflammation, pain, drainage, or cystic swelling 3-4 months after initial reconstruction, with intraoperative confirmation of nail lamina growth beneath the flap. Revision procedures were performed in outpatient settings using a semilunar dorsal incision to excise the neoepithelium and expose the underlying nail plate while preserving the germinal matrix. Postoperative outcomes included healing time, symptom resolution, recurrence, nail appearance, and patient satisfaction at 12-month follow-up.

RESULTS

Eleven of 40 reconstructions (27.5%; 95% confidence interval, 16.1-42.8) developed delayed hidden nail at a mean of 3.5 months after surgery. All underwent brief, outpatient matrix-sparing exposure under digital anesthesia, with complete epithelialization achieved in approximately 15 days. No surgical site infections, hematomas, or recurrences occurred. At 12 months, all patients demonstrated ongoing, symmetrical nail growth with satisfactory cosmetic and functional outcomes, absence of hook-nail deformities, and full return to manual activities.

CONCLUSIONS

"Hidden nail" formation after homodigital dorsal adipofascial reverse flap is a predictable, biologically driven phenomenon reflecting the preservation of a viable nail matrix within a vascularized adipofascial bed rather than an infectious process. Early recognition and minimalist, matrix-sparing exposure reliably decompress the advancing plate, restore comfort, and allow normal nail regeneration. This approach transforms a perplexing late presentation into a reproducible, low-morbidity step within the fingertip reconstruction pathway.

TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.