Introduction Clinical definition scar that produces an 'empty' or 'blank' longitudinal area of nail between two normal regions of nail Etiology Pathophysiology caused by scar in the germinal matrix that causes absence of nail production can occur as a sequelae of nail bed injuries infections (i.e. paronychia) Anatomy Perionychium consists of nail bed soft tissue beneath the nail includes germinal matrix (proximal) produces 90% of the nail scarring causes absence sterile matrix (distal) keeps nail adherent to nail bed injury causes deformity nail fold most proximal portion of the perionychium consists of ventral floor - germinal matrix portion of the nail bed dorsal roof eponychium skin proximal to the nail that covers the nail fold paronychium skin on each side of the nail hyponychium skin distal to the nail bed Presentation History patient will report fingertip injury in the form of trauma or infection in the past Symptoms common symptoms painless complaint is typically cosmetic in nature Physical exam careful inspection of the nail to identify any 'blank' areas of nail Imaging Radiographs not typically warranted obtain if suspicious of underlying bony etiology Treatment Nonoperative observation alone indications majority of patients not concerned about cosmesis Operative scar resection and primary closure indications size < 2mm patients have strong desire to improve cosmesis scar resection and full thickness nail bed graft from second toe indications germinal matrix and size >2mm sterile matrix, any size resection and primary closure rarely successful patients have strong desire to improves cosmesis Techniques Scar resection and primary closure indicated for germinal matrix if size <2mm Scar resection and full thickness nail bed graft from second toe preferred for geminal matrix if size > 2mm Complications Recurrence of split nail Persistent cosmetic deformity Donor site morbidity