Google Glass in my cosmetic surgery practice for approximately 8 weeks and have used it in a numerous ways. My most common usage has been taking pic-tures of patients and videos of my surgery. Again, I can do this automatically and seamlessly without inter-rupting the task at hand. Because the mini monitor sits above thefield of vision, the surgeon needs to only glance up to view the screen. I have also used the device to document patient consults or preoperative visits with their permission. I am working on a way to dis-play the patient’s vital signs on the computer so that I can observe this data during surgery with a quick glance. I can also answer the phone and listen to music (only if you purchase music from Google) (Figure 3).
One very interesting feature that is possible is remote video steaming, which enables a person or audience anywhere on the planet to“see what you see.” I am in the process of setting up a live surgery observation group with the residents at a local teaching institution. This is exciting to me that they
can observe the surgeon’s view live in real time through the Internet and converse.
The most intriguing thing to me is not what Google Glass does now, but rather what it will do in the future. I think dermatologists will use it to document lesions, take clinical photographs and videos, com-municate with other surgeons and patients, and to interact with electronic medical records. The tele-medicine advantages are obvious, and it is not that this technology does not presently exist, but this is the first “wearable” computer. I predict that a plethora of third party apps will develop to take Google Glass from a conversation piece novelty to a mainstream device that is a hybrid between cell phones and computers. The future is now.
Joe Niamtu, III Private Practice Cosmetic Facial Surgery Richmond, Virginia
Previous Nail Surgery Is a Risk Factor for Recurrence of Ingrown Nails
We apply nail braces to all types of ingrown nails, except in cases with proximally located granulation tissue because these nails do not benefit from our method.1,2Apart from these cases, all other locations
of granulation tissue and patients with signs of infection do benefit (Figures 1 and 2).
Matricectomy operations have been shown to be successful, but long-term follow-up considering recurrence of the symptoms on the new nail side is limited. We have been using braces for such recurrent patients as well, especially given that they are
extremely unwilling to undergo a second operation.
We always investigate the presence of previously defined risk factors for ingrown nails, that is, hyper-hidrosis, ill-fitting shoes, inappropriate trimming of the nail side, weight gain, pregnancy, and over-curvature of the nail. We also determine the curve of the nail, the thickness of the nail, the duration of the
ingrown nail, and the presence of granulation tissue for each patient.3Our aim was to determine the
recurrence rate after a course of successful conser-vative treatment and to define the risk factors asso-ciated with recurrence.
Figure 1. A case with bilateral granulation tissue that is not adjacent to the nail matrix.
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Materials and Methods
We followed up 88 patients with 123 ingrown nails that were successfully treated with braces. We checked the patients every 2 months for thefirst 6 months and every 3 months thereafter. If the patients had complaints, they immediately came in for re-evaluation. Recurrence was the ultimate end point of the study; otherwise, all patients were under control for at least 18 months.
We evaluated patients for certain variables, that is, gender, age, the duration of the complaint, family history, hyperhidrosis, lateral nail fold hypertrophy, nail thickness (thin, normal thickness, or thicker than 2 mm) and nail curve (defined as normal if the angle between the nail side and the nail bed was more than 90 and as overcurved if the angle was 90 or less). Additionally, the presence, duration and location of granulation tissue; signs of infection; the presence and type of previous operation; the type of shoe worn, such as high heeled, dressing, sport, or casual shoes; nail trimming style (V-shaped or square); weight gain; pregnancy; participation in sporting activities; and the history of a break on the nail side were evaluated. The last 6 variables were evaluated more than once to check their relationship with recurrence.
All variables collected were then assessed using gen-eralized estimating equations (GEEs) to detect inde-pendent risk factors for relapse. In patients with data on more than 1 nail, GEEs, an extension of the gen-eralized linear model, were selected. The results were
expressed as odds ratios and 95% confidence intervals.
Variables that were significantly associated with relapse at the 0.20 level in a univariate GEE analysis were considered in a multivariate GEE analysis. All analyses were performed using R 3.0.1 (R Develop-ment Team). A p <.05 is considered as statistically significant. The analysis was repeated while omitting previously operated cases to evaluate whether the results would have been different if we had never included those cases.
Results
Among 88 patients, 20 (21.4%) experienced a recur-rence of symptoms after an average duration of 22.266 7.69 months. Recurrence was not associ-ated with any of the previously described variables. The only significant variable affecting recurrence was the presence of a previous operation (p = .007). There were 31 previously operated cases (35%): 15 with nail avulsion alone and 16 with matricec-tomy. Once cases with a previous operation were removed from the group, there was no other factor associated with recurrence.
Conclusion
In this study, the recurrence rate was 21%, and more than one-third of patients experienced postoperative recurrences. Recurrence, however, seems to be inde-pendent of all risk factors, except for the presence of a previous operation.
In a previous study, we observed granulation tissue in thin-thickness and normal-thickness nails, generally in thefirst 6 months of complaint and in relatively young patients, whereas patients with thickened nails usually had a longer duration of complaint and no granulation tissue formation.4This observation led us
to believe that juvenile-onset and adult-onset cases may be different in etiology, clinical presentation, and, most likely, risk factors for recurrence.
However, because 4 of 5 patients did not experience recurrence after a single treatment with braces, an
Figure 2. The same nail in 10 days with potassium per-manganate foot bath, nail brace, and silver nitrate application.
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ingrown nail may be considered as a relatively benign condition that might not have a tendency to recur in most patients. Therefore, ceasing the edema and inflammation of the skin under the nail may be tried before removing the nail plate indefinitely because operations lead to resistance to conservative treatments.
The factors previously described as being associated with ingrown nails seem not to be responsible for recurrences. In future studies, cases should be evalu-ated as traumatic, juvenile onset, or adult onset, and recurrences should be evaluated in light of new vari-ables defined for each group.5
We believe that ceasing the inflammation of the skin irritated by the nail by slightly pulling the nail upward, relieving the edema, and preventing further trauma can be triedfirst; in resistant cases, operations can be considered as a second step.
If all ingrown nails are treated using this method, there may be fewer recurrences given that the number of operated cases would also decrease.
References
1. Erdogan FG, Erdogan G. Long term results of nail brace application in diabetic patients with ingrown nails. Dermatol Surg 2008;34:84–6.
2. Erdogan FG. A simple, pain free treatment for ingrown toenails complicated with granulation tissue. Dermatol Surg 2006;32:1388–90. 3. Heidelbaugh JJ, Lee H. Management of ingrown toenail. Am Fam
Physician 2009;79:303–8.
4. Erdogan FG, Guven M, Elhan AH, Gurler A. Efficacy of nail brace treatment for ingrown nails [in Turkish]. Turkderm 2010;44:88–91. 5. Erdogan FG, Tufan A, Guven M, Goker B, et al. Association of
hypermobility and ingrown nails. Clin Rheumatol 2012;31: 1319–22.
Fatma G. Erdogan, MD, MPH Munevver Guven, MD Department of Dermatology, Faculty of Medicine Ufuk University, Ankara, Turkey
Beyza D. Erdogan, PhD Department of Biostatistics, Faculty of Medicine Ankara University, Ankara, Turkey
Aysel Gurler, MD Department of Dermatology, Faculty of Medicine Ufuk University, Ankara, Turkey
In Situ Melanoma of the Nail Unit Presenting as a Rapid Growing Longitudinal Melanonychia in
a 9-Year-Old White Boy
Longitudinal melanonychia (LM) is a pigmented lon-gitudinal band of the nail unit, which results from pigment deposition, generally melanin, in the nail plate.1Such lesion is frequently observed in specific
ethnic groups, such as Asians and African Americans, typically affecting multiple nails. When LM involves a single nail plate, it may be the sign of a benign lesion within the matrix, such as a melanocytic nevus, simple lentigo, or nail matrix melanocyte activation. However, the possibility of melanoma must be con-sidered.1Nail melanoma in children is exceptionally
rare and only 2 cases have been reported in fair-skinned Caucasian individuals.2
A 9-year-old Italian boy came to our attention with LM of the leftfifth fingernail, which had been present since the age of 2 and had allegedly expanded from a single
longitudinal streak up to a diffuse pigmentation of the nail plate over a few years. The child was in good health, had fair skin (phototype 2), and a nevus count less than 10 with no clinically suspicious melanocytic nevi. Family history of skin tumors was negative.
Clinically, the pigmented lesion involved most of the nail plate and was pale to richer brown (Figure 1). Dermoscopy showed irregularly spaced and variably thick light to deeper brown longitudinal bands, involving two thirds of the nail, but sparing lateral nail margin. A darker area at the medial edge was evident, as was the extension of pigmentation to the proximal nail fold (positive Hutchinson sign) (Figure 2).
A 3-mm punch biopsy of the medial end of the nail matrix showed intraepithelial melanocyte hyperplasia
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