Glomus tumor surgery

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Soujanya Thummathati, MBBS [2] Roukoz A. Karam, M.D.[3]

Surgery is the mainstay of treatment for glomus tumor. Surgical resection may be performed via several approaches including nail bed margin approach, Trap-door technique, Lee et al’s nail plate conservation, transungal, lateral subperiosteal, and Laterodigital Keyser-Littler approach.

• Surgery is the mainstay of treatment for glomus tumor.^[1]
• Surgical resection may be performed via several approaches:^[2]
  • Straightforward excision using a nail bed margin approach^[3]
    • Simple
    • Feasible
    • Low complication rate
    • Low recurrence rate
    • Can sufficiently expose and completely excise tumors at any subungual region
  • Trap-door technique^[4]
  • A technique described by Lee et al designed to conserve the nail plate itself^[5]
    • Better nail bed exposure
    • Easier tumor excision
    • Less damage to the nail bed
    • Less deformity of the nail
  • Transungual^[6]
    • The nail plate is removed and an incision is made on the nail bed.
    • The nail bed is elevated to expose the tumor adequately for removal.
    • It is then followed by extensive repair of the nail bed.
    • The transungual approach is the simplest and gives the best exposure of the nail bed.
  • Lateral subperiosteal^[7]
    • An incision is made dorsal to the mid-lateral line.
    • Dissection is performed to the distal phalanx and a dorsal flap consisting of skin, nail plate, nail bed and germinal matrix tissue is elevated in a single layer.
    • It may have a higher risk of incomplete excision.
  • Laterodigital Keyser-Littler approach^[8]
    • This is a high mid-lateral approach from below the paronychial fold.
    • The distal phalangeal ligament (which provides lateral support to the nail matrix and nail plate) is identified and retracted.
    • The nail matrix is elevated over the ligament and the dorsal cortex of the distal phalanx, followed by resection of the tumor.

• Removal of subungual glomus tumors has been reported to have recurrence rates of 2-13% (highest reported at 50%) and nail bed deformity rates of 0-19%.^[3]
• Some recurrence rates have been reported at 50%.
• Recurrence can be due to incomplete excision or development of a new lesion, with the probability of recurrence of glomus tumors in general being highest for subungual glomus tumors.^[4]