With careful attention to anatomic repair and by replacing missing tissue with similar tissue, corrections in emergency situations can be accomplished with predictably good results. Even in the most complex of injuries, normal nails are the expectation rather than the surprise endpoint of surgical repair. Improved results in the treatment of chronic nail deformities encourage a bolder surgical stance when patients present with nail deformities. Although more work needs to be done in the field of total nail replacement, a well-performed full-thickness composite graft in carefully selected and prepared patients may be an appropriate solution to a problem that has been ignored too often.