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To evaluate the safety and efficacy of a novel bioabsorbable suspension device made of a polymer of polylactic acid and polyglycolic acid (Endotine Ribbon), we performed a retrospective multi-institutional case study of 21 patients who underwent minimally invasive or open rhytidectomy with the use of the device in an ambulatory surgery center setting. Twelve patients had an excellent result, 7 a good result, and 2 a fair result. Early complications were corrected with technical modifications. Patient satisfaction was high. The Ribbon is a safe and effective adjunct for performing both minimally invasive and open rhytidectomy and cervical lifting.

Background: Since the Endotine forehead fixation device (Coapt Systems, Palo Alto, CA) was introduced in 2003, a small percentage of surgeons and patients have complained of persistent palpability and sensitivity related to its 12- to 15-month absorption time. Therefore, a refinement of the original design, the Ultratine (Coapt Systems), consisting of a polymer blend altered for faster absorption and biodegradability, was introduced in 2006., Objective: The authors report early results of fixation using the Ultratine with respect to permanence of elevation and the duration of visibility, palpability, and sensitivity of the implant., Methods: The authors conducted a retrospective review of patients who had undergone brow lift with Ultratine forehead fixation, along with concomitant cosmetic procedures., Results: Ten patients were available for follow-up at 14 months postoperatively. In many cases, the implant biodegraded and absorbed at the 3- to 6-month intervals, and symptoms of visibility, palpability, and sensitivity were markedly improved over the original Endotine device., Conclusions: The Ultratine degradation profile produces secure, permanent fixation and elevation for endoscopic brow lifts while diminishing the long-lasting side effects of visibility, palpability, and sensitivity exhibited by a small proportion of patients with the original Endotine device. It is an option particularly for those patients who have thin scalps or fine hair. The Endotine may still be the best choice for patients with heavier brows; tighter, more immobile brows; and for secondary cases. It may also be preferable in cases of reverse brow procedures intended to lower the hairline.

Background: Aesthetic surgeons have become increasingly aware that elevation of the midface is a significant component of facial rejuvenation. However, adequate fixation remains a problem in midface lift procedures, regardless of the approach., Objective: The purpose of this study was to evaluate the efficacy and ease of application of the Endotine midface device (Coapt Systems, Palo Alto, CA), as well as patient and surgeon satisfaction with the results of treatment., Methods: The Endotine device consists of a polylactide polymer that incorporates 5 tines, each 4.5 mm long, to distribute tension over a wide area, maximizing fixation strength and holding power. After the cheek tissue is engaged, upward tension is applied to the anchoring leash, which is then sutured to the deep temporal fascia. Between October 2003 and October 2004, 31 patients underwent Endotine fixation for midface lift. The patient group comprised 7 men and 24 women ranging in age from 40 to 65 years (mean age, 49.25 years). Four patients had midface lifts as the sole procedure, and 27 had adjunctive facial cosmetic procedures. Results evaluated included ease of use/difficulty of insertion, postsurgical pain, adequacy and stability of fixation, side effects and complications, and patient and surgeon satisfaction., Results: All patients were judged to have satisfactory cheek elevation and enhanced contour without evidence of recurrent midface ptosis or loss of elevation/fixation. There were no postoperative complications of infection, hematoma, or dehiscence. In a subset of 11 patients, "pain in the treated area" averaged 2.7 (0 = no pain, 10 = extreme pain) at one month follow-up. Surgeon satisfaction with the fixation result averaged 4.9 (1 = very dissatisfied, 5 = very satisfied) at one month follow-up. Patient self-assessment of aesthetic outcome averaged 3.8 (1 = worse than baseline, 4 = dramatic improvement from baseline) at one month follow-up, and patient satisfaction assessment averaged 3.9 (1 = very dissatisfied, 4 = very satisfied) at one month follow-up., Conclusions: The midface Endotine device provided rapid, secure fixation in our small patient study group without complications, and eliminated the complicated and awkward suture techniques that have been an impediment to midface surgery. Larger clinical studies are in progress.

Background: No single technique for fixation of the scalp after endoscopic forehead lift is universally accepted, and complications such as alopecia and regression of elevation have been reported with all techniques., Objective: This report describes the preliminary results of a study of the Endotine 3.5 forehead device (Coapt Systems, Inc, Palo Alto, CA), a new biodegradable fixation device., Methods: The Endotine 3.5 device consists of a post on the deep side for anchoring it in the skull and five tines on the superior side for engaging the deep scalp tissues. It was tested in 9 patients, with postoperative follow-up ranging from 6 to 8 months. The surgeon evaluated the device for difficulty/ease of use, palpability, postsurgical pain, and wound healing., Results: The Endotine 3.5 device produced a secure fixation without problems or complications, although it was often palpable with moderate degrees of sensitivity. It could be applied in less than 2 minutes per side., Conclusions: Our preliminary findings indicate that the Endotine 3.5 forehead device provides rapid, secure fixation without the complications associated with other fixation techniques. After patients reported that it was still palpable up to 24 weeks after implantation, a second-generation polymer that dissolves more rapidly was fabricated. Further studies are under way to evaluate long-term efficacy. (Aesthetic Surg J 2003;23:103-107.).

Histologic data describing the depth of penetration that occurs with the CO2 laser using variations in delivered energy, number of passes, and density settings have been limited. Most of the initial studies used a 3-mm collimated handpiece; few studies used the computerized pattern generator, which is now standard in treatment. This study examined histologic depth of thermal damage with varying density settings and number of passes using the computerized pattern generator. The Coherent UltraPulse 5000 CO2 laser with a computerized pattern generator was used. Preauricular (sun-exposed) and postauricular (sun-protected) facial skin samples were used from seven rhytidectomy patients aged 37 to 68 years. Preoperative skin treatment regimen included Retin-A and hydroquinone application for 3 weeks before the procedure. Three adjacent sites from the preauricular and postauricular regions were chosen from each ear (12 sites per patient). A density setting of 5 (30 percent overlap) was chosen for the right ear, and a density setting of 9 (60 percent overlap) was used for the left ear. Each region was subjected to one, two, and three passes. The laser delivers approximately 7.5 J/cm2 of fluence at a spot size of 2.25 mm and 300 mJ. Excisional biopsies were performed at the time of cervicofacial flap redraping. All specimens were evaluated for depth of thermal damage by a dermatopathologist who was blinded to the treatment parameters for each test site. Histologic examination of the treated test sites consistently demonstrated that one pass at these settings obliterated most or all of the epidermis, with minimal invasion into the papillary dermis. Test sites treated with two or three passes resulted in increased cumulative depth of penetration and thermal injury into the papillary dermis. Only one sample site showed any thermal injury extending into the reticular dermis. Depth of penetration was greater at the postauricular sites. Additionally, depth of penetration was greater with a density of 9 (60 percent overlap) than one of 5 (30 percent overlap) in both the preauricular and postauricular sites. Our study supported previous observations that the cumulative depth of penetration is greater with increasing levels of energy and additional passes. Additionally, we saw a greater average depth of penetration as density overlap increased, as one would predict. However, at these settings, fewer passes at a higher density setting did not achieve the same depth of penetration as more passes at a lower density setting. Furthermore, we found that the margin of safety using these settings is high: only 1 of 84 sites extended into the reticular dermis.

Background: The short pulse duration high-energy carbon dioxide (CO2) lasers have been used in the past for treating cutaneous pathology and more recently for cosmetic improvements of rhytids, photo-aging, and acne., Objective: This study was undertaken to determine the benefits of CO2 laser resurfacing on the severe peri-oral rhytidosis commonly seen in patients with systemic scleroderma., Methods: Three patients were studied and evaluated for satisfactory wound healing, improved cosmetic result, and lack of complications., Results: All three patients experienced significant improvement following laser resurfacing., Conclusion: The study demonstrated the safe and effective treatment for peri-oral rhytidosis in patients with generalized scleroderma utilizing CO2 laser resurfacing.

The reader is presumed to have a broad understanding of plastic surgery procedures and concepts. After studying this article, the participant should be able to: Physicians may earn 1 hour of Category 1 CME credit by successfully completing the examination based on material covered in this article. The examination begins on page 373. The benefits of laser resurfacing are now well-known and-documented. As larger series of patients are being treated and followed, a typical pattern of side effects and complications is being observed. Normal sequelae or side effects include temporary skin problems such as erythema, tightness, or drying of the skin. Milia or acne may occur at the 2- to 4-week interval. Inadequate removal of rhytids may necessitate touch-up treatment, as may the appearance of telangiectasia or rosacea. Hyperpigmentation and lines of demarcation often disappear with time and conservative treatment. Complications include infection by bacterial, viral, yeast, or fungal organisms and may result in hypertrophic or keloid scarring. Unusual hypersensitivity reactions are not uncommon. Hypopigmentation is permanent. Ectropion and tooth enamel injury may also be permanent.

Eleven female patients are reported who underwent full-face resurfacing. Three patients were treated for cosmetic rhytids, five for residual acne scarring, and three for photoaging. There were no complications or side effects in this group of patients. Reepithelialization was achieved in an average of 9.3 days, and erythema disappeared in an average of 8.9 weeks. The UltraPulse carbon dioxide laser with computerized pattern generator (CPG) scanner allows a rapid, uniform laserbrasion. The sequence of the procedure involves close application of adjacent squares at 60 W, 200 to 300 ml, at moderate density. Skin preparation with Retin-A and bleaching agents is important for best wound healing. Postoperative wound care includes maintenance of a moist environment and Zovirax for herpes prophylaxis.

The UltraPulse carbon dioxide laser with CPG scanner was utilized to deepithelialize dermal pedicles in breast reduction inferior pedicle flaps. Clinical advantages include lack of bleeding, markedly shortened time of dissection, and excellent wound healing. Histologic studies confirm that the laser removes epidermis and papillary dermis but leaves undamaged the superficial vascular plexus and reticular dermis.

Thirteen patients with mild and severe acne scarring have been treated with the Ultra Pulse carbon dioxide laser over a 24-month period. Nine patients had full-face and 4 patients had regional reurfacing. All patients were pretreated with a Retin-A preparation. The patients healed in an average of 7.3 days and erythema was gone in an average of 7.6 weeks. Eight patients with mild acne experienced a good (1 patient) or excellent (7 patients) result. Of the 5 patients with severe acne characterized by marked irregularity, deep defects, and atrophy, 2 patients experienced fair results and 2 experienced good results (1 patient was lost to follow-up). Thus, laser resurfacing for severe atrophic acne achieves only moderate results, while treatment for mild acne can provide excellent results.

Fifty-one patients underwent a study approved by the Food and Drug Administration for laser-assisted liposuction in five plastic surgery centers. The YAG laser fiber is contained within the cannula, shears off the fat cleanly, and coagulates blood vessels as the fat is drawn into the cannula. Hemoglobin decrease was relatively modest after surgery, and patients were able to return to work at 6 days and light exercise at 7 days. Contralateral studies showed a slight benefit for the laser side at both 1 and 8 weeks for ecchymosis, pain and discomfort, and edema. Lipocrit studies were inconsistent. The investigators concluded that no clear benefit was demonstrated with the laser. The Food and Drug Administration did not approve the technique, and the sponsoring laser company has not pursued the study.

The ultrapulse carbon dioxide laser has been used in 110 patients for resurfacing and 50 patients for facelift, eyelid, and forehead surgery. Skin resurfacing is able to remove layers of skin of 100 microns without bleeding. Use of the computer pattern generator automatic scanning device allows a very rapid, uniform treatment in a variety of geometric patterns, sizes, and densities. Hemostatic incision is possible for cosmetic surgery. Sequence of the laserbrasion procedure as well as patient preparation, selection for surgery, and postoperative care are detailed. Laser lower blepharoplasty through the transconjunctival approach is commonly done concurrently with skin resurfacing to smooth out fine rhytides and extra skin.

A total of 22 patients--19 children, 3 adults--with a variety of hemangiomas and vascular malformations of the nose were treated over a 5-year period. Various laser modalities were used. Some lesions could be photocoagulated by the argon or the yttrium-aluminum-garnet (YAG) laser. Larger lesions were resected with the YAG laser and sapphire tips. Preliminary arteriography with superselective embolization was necessary in 1 patient. Total removal was possible in 13 patients, and no complications or side effects were noted.

Massive hemangiomas and vascular malformations have been treated with lasers and adjunctive measures. Intralesional laser photocoagulation involves the direct penetration of a tumor by a yttrium-aluminum-garnet laser fiber with photocoagulation at various depths and levels to produce thromboses and controlled coagulation necrosis, thus shrinking and blanching the malformation. Seven children have benefited from intralesional laser photocoagulation as well as steroids, embolization, and excisional surgery. Intralesional laser photocoagulation has contributed to the initial shrinkage and fibrosis of these massive vascular tumors in preparation for surgery or as the only treatment in some cases.

Twenty patients with nevus of Ota have been treated with the argon laser, Q-switched yttrium-aluminum-garnet (YAG) laser, or a combination of both lasers. The argon laser was originally used from 1975 to 1993 and has now been replaced by the Q-switched YAG laser. The Q-switched YAG laser mechanism of action is selective photothermolysis in which the pulse width of the laser beam is very short, thus allowing the melanocyte chromophore target to dissipate its heat without burning adjacent normal tissue. Satisfactory fading without skin scar or texture change was observed in 10 patients in this series who had completed treatment; treatment is in progress in the remaining 10 patients. Six patients who were initially treated with argon and then subsequently were treated with Q-switched YAG laser demonstrated improved results.

Twenty-eight patients have undergone facelift and blepharoplasty in which the YAG laser scalpel was used. The laser is able to produce an incision with excellent hemostasis. The patients in this series demonstrated markedly diminished blood loss during surgery and reduced bruising, swelling, pain, and discomfort postoperatively. Contralateral procedures done with the laser on one side and conventional surgery on the other side demonstrated greater benefit on the laser side.

Fifty-one patients underwent an FDA-approved study of laser-assisted liposuction in five plastic surgery centers. The YAG laser fiber is contained within the cannula and shears off the fat cleanly and coagulates blood vessels as the fat is drawn into the cannula. The drop in hemoglobin was relatively modest after surgery. Patients were able to return to work at six days and to light exercise at seven days. Contralateral studies showed a slight benefit for the laser side at both one and eight weeks for ecchymosis, pain/discomfort, and edema. Lipocrit studies were inconsistent.

The argon-pumped tunable dye laser (APTDL) is useful in the treatment of a wide variety of superficial vascular and melanocytic lesions. Safety is enhanced by the use of a computerized scanning device--the Hexascan. Over a 1-year period, 140 patients (33 patients under the age of 21, and 21 patients from 0 to 10 years of age) were treated. Facial rosacea/telangiectasia was the most frequently treated lesion, followed by port-wine stain. Although multiple treatments were often necessary, fading was successfully achieved in most patients without scarring or other complications.

Infantile (juvenile) capillary hemangiomas are vascular neoplasms which can appear quite infiltrative histologically and are characterized by cords of cells with areas of marked cellularity. While vessels can be distinguished in most cases, there are many cells which do not appear to be endothelial in origin. We labeled 5 such cases with antibodies directed against factor VIII-related antigen, CD34, alpha actin, factor XIIIa and PC-10. Anti-factor VIII-related antigen labeled all endothelial cells and did not label cells away from vessels. Anti-CD34 recognized similar cells and also stained a subset of interstitial cells. Anti-alpha muscle defined pericytes and stained few interstitial cells and none of the endothelial cells. Many of the interstitial spindled and cuboidal cells stained strongly with anti-factor XIIIa. The majority of the mitotic activity was concentrated in the interstitial cells. These observations lend support to the concept that infantile (juvenile) capillary hemangioma is a tumor of primitive cells with capabilities for differentiating toward endothelial cells and pericytes. It is not clear whether a similar stem cell population gives rise to dermal dendrocytes, or whether these represent an immune response to the neoplasm.

This histological study demonstrates that the Hexascan device combined with a continuous tunable dye laser at either 514 nm or 577 nm is able to effectively treat port wine hemangiomas. Both 514 nm and 577 nm were effective in producing almost normal looking skin histologically after treatment in some patients. Other patients demonstrated a minor number of residual vessels or no significant change. In this small series, it appeared that the 514 nm and 577 nm wavelengths were similar histologically.

Laser therapy of port wine stains (PWS) is well established. However, the application of lasers to PWS treatment over the last decade has resulted in the use of many laser systems. The goal of this study is to describe the different laser parameters, treatment techniques, and delivery systems. Two methods, coagulation and microvaporization, are used to destroy the abnormal blood vessels. The coagulation method results in excellent treatment, but it requires careful control of laser parameters during the treatment process. Scanning devices can be utilized for this purpose. The microvaporization method, obtained with a pulsed dye laser, is restricted to PWS composed of small vessels since it is difficult to obtain a pulse longer than 450 microseconds. In addition, numerous retreatments are needed with the pulsed dye method. The initial assessment of the patient should contribute to an improvement in the choice of laser parameters and the outcome of treatment.

Thirteen patients have been treated over a 2-year period utilizing a team approach between the radiology and surgical services. Initial diagnostic evaluation is directed at determining the size and anatomic extent of the hemangioma; clinical assessment of coagulation and hemodynamic status is also performed. Arteriography with superselective embolization precedes the surgical procedure, usually by 24 hours. The YAG laser with contact sapphire-tip scalpels is then utilized for resection and reconstruction of the hemangioma. Total removal of hemangioma was achieved in 9 of 13 patients, and partial or subtotal removal was achieved in the remainder. Blood loss and complications were minimal.

Complicated hemangiomas of the hand or upper extremity have been resected in eight patients with use of the YAG laser with sapphire scalpels. This laser allows excellent hemostasis and precise surgery, thus allowing resection of complicated problems. Many of the patients have had preoperative arteriography with selective embolization, which has aided in hemostasis. Almost complete but subtotal resection of hemangioma was possible in four of the eight patients with well localized lesions. Three patients had only partial resections of hemangiomas and one lesion was considered unresectable.

Twenty patients with capillary/cavernous hemangiomas of the periorbital area (eyelid, eyebrow, nose extending to canthus) have been treated with a variety of techniques. Six patients were treated by yttrium-aluminum-garnet (YAG) laser photocoagulation and direct injection of steroids. Rapid shrinkage of the hemangiomas occurred in all patients, and 2 infants whose eye was totally occluded by the hemangioma had their eyes rapidly opened. YAG laser excision with or without previous photocoagulation plus injection and with arteriogram plus superselective embolization was performed in the other 14 patients. Results were satisfactory in all patients.

Ten patients underwent upper eyelid blepharoplasty using the carbon dioxide laser on one eyelid and a conventional technique on the other. Administrative factors, safety considerations, ease of procedure, and short- and long-term results were evaluated. The carbon dioxide laser added considerable administrative, equipment, personnel, and organizational requirements to the procedure. The possibility of adverse safety factors or accidents was increased with the laser. Immediate and late postoperative results of pain, swelling, ecchymosis, and scarring were not significantly different on the two sides. No clear benefit other than a positive marketing factor could be demonstrated with use of the carbon dioxide laser for blepharoplasty.

A massive cavernous hemangioma of the face in an 11 month old child has been successfully resected utilizing a combination of laser and non-laser techniques. The hemangioma was initially treated twice with YAG laser photocoagulation plus direct injection of steroids. This treatment promptly stopped the rapid growth and induced blanching as well as a 25% shrinkage with each treatment. Arteriogram with superselective embolization produced a further shrinkage of the hemangioma. Finally, the contact YAG laser with sapphire scalpel tips was utilized for complete and cosmetically satisfactory hemangioma resection. The treatment of a massive cavernous hemangioma by a combination of modalities is discussed.

The acute or emergency treatment of traumatic tattoos has been based on the principles of immediate and thorough removal of all particles. The delayed treatment of traumatic tattoos has classically been with overgrafting or dermabrasion. We developed an animal model for traumatic tattoos. Two levels of wounds were made (shallow and deep). Each group consisted of five guinea pigs with one consistent level of wounding. Four treatment methods were applied: carbon dioxide laser, argon laser, overgrafting, and dermabrasion. The results were evaluated by trained observers on a gross basis. Although no statistically significant differences were found within these small groups, clinical experience in a small group of patients suggests that carbon dioxide laser may prove to be useful in the delayed treatment of traumatic tattoos. Eight patients have been treated over a 4-year period. Satisfactory total or subtotal foreign body removal of various agents (road tar, cement, cooper particles) has been achieved.

Preliminary investigation of a frequency-doubled YAG laser (KTP 532 nm) manufactured by Laserscope of Santa Clara was undertaken. Twenty-five patients with either port wine hemangiomas or decorative tattoos were treated with a 532-nm light and the results compared to argon laser at identical power settings. Clinical and histological results were identical between the two lasers.

One hundred six cutaneous vascular abnormalities were treated over a 3-year period by the argon laser. Absorption of light energy causes heat coagulation of the hemangioma with sparing of the overlying skin and secondary skin appendages. Patients with port wine hemangiomas, capillary/cavernous hemangiomas, and telangiectasia showed good response to argon laser treatment. Superficial varicosities of the lower extremity proved to be relatively insensitive to laser treatment. The argon laser shows promise as an effective clinical tool in the treatment of hemangiomas; however, further clinical and laboratory investigation will be necessary to establish the laser as the modality of choice in the treatment of such lesions.

A new computerized suction aspirator monitor is described. This device offers the benefits of instantaneous and concurrent scientifically accurate readout of aspirate contents in five separate bodily areas. Thus knowledge of amounts of blood versus fat can be immediately known without resorting to guess, estimate, or cumbersome lipocrit determination by centrifuging. Advantages of such a device include better accuracy in determination of fat removal from each area, with improvement of symmetrical fat removal. More exact determination of blood loss with improved hemodynamic replacement is also more easily and safely accomplished. In an area of mystique, experience, artistry, and aesthetic appreciation which has cloaked the initial enthusiasm for suction lipectomy, a new generation of scientific accuracy is now possible. Thus accurate determination of aspirate content vis-a-vis fat and blood can now transform this procedure into a more sophisticated and scientifically accurate operation which traditionally is desired by most practitioners of suction lipectomy.

Twenty-two patients with cutaneous vascular malformations were treated with an argon laser. Promising results were obtained in patients with port-wine stains, hemangiomas, telangiectasia and varicose veins. The argon laser shows promise as an effective clinical tool in the treatment of all such cutaneous vascular abnormalities. However, further study of clinical as well as laboratory data is necessary over a long period of time before this modality can be definitely recommended as the treatment of choice for vascular deformities of the skin.

The use of the carbon dioxide laser for minor hand problems is reviewed, and the physiological effects of laser treatment are discussed. Forty-one patients have been treated during a one-year period for warts, nail disorders, and a variety of benign neoplasms. Results of CO2 laser treatment are equivalent to those of other methods with less pain and disability. Future applications of the CO2 laser are discussed.

In an attempt to limit scarring, 51 patients have been treated over a period of 2 years with the argon laser in a dot or pointillistic fashion. One- to 2-mm dots are blanched at intervals of 1-2 mm with minimal power, and the interspaces are filled in at 12 weeks. Scar-prone areas of the face such as the upper lip, nasolabial fold, nose, and lower lip have been successfully treated with minimal scarring and good fading. Lesions of the trunk and extremity have also been successfully treated.

Pathophysiology and clinical usage of the carbon dioxide laser is reviewed. The unique light is capable of relatively bloodless excision when finely focused or vaporization and cautery when defocused. Malignant and infectious lesions can be resected and sterilized by the laser's heat. "Laserbrasion" can remove superficial lesions such as tattoos, xanthelasma, warts and other similar lesions.

Argon and CO2 lasers have been used to treat 13 patients with well-established keloid scars of the trunk or earlobe. Multiple-bore-hole argon technique and total excision with the CO2 laser were attempted. One patient with an earlobe keloid responded to treatment, all other patients had no improvement.

Twenty-one patients with small localized oral cavity hemangiomas of the lips, tongue, and buccal mucosa are reported in this series. Although the lesions were not massive or high-flow/high-pressure vascular tumors, the simultaneous cutting and coagulation capabilities of the CO2 laser were demonstrated, rendering such excisional surgery more precisely and easily accomplished with a great deal less bleeding and a marked reduction in postoperative pain and edema. Many of the patients in this series were done as outpatients under local anesthesia. Results were acceptable and complications were minimal. Thus this laser is recommended both for the patient care and comfort aspects and the ability to render oral cavity hemangioma excisional surgery much more safely and easily done with a significant decrease in hospital utilization and overall medical expenses.

We have had a substantial decrease in the number of postoperative hematomas following face lifts since we started putting the patients in extreme Trendelenburg position after all the cutting was done, to reveal any potential bleeding points. These are then coagulated or ligated to obtain more complete hemostasis.

Subungual osteochondroma, a rare disorder of the fingers and toes, occurred in five patients. Clinical features of the condition include nail deformation, history of long, slow growth, and characteristic radiologic features. Surgery is directed toward total tumor resection with preservation of the nailbed to achieve normal nail growth. Differential diagnosis included bony, cartilagionous, and soft tissue tumors as well as cystic lesions. Malignant tumor should be suspected by not confused with this benign disorder. Roentgenologic examination is indicated in the differential clinical diagnosis of any subungual mass.