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Surgical Treatment

  • Bertrand Richert
  • Nilton Di Chiacchio
  • Marie Caucanas
  • Nilton Gioia Di Chiacchio
Chapter

Abstract

For decades, every year sees a wide number of articles in the podiatry, dermatology, general, and orthopedic literature about treatment of ingrown toenails. There is still a debate about the cause of ingrowing toenails. Some are convinced that the nail is responsible for the condition and thus will intervene on the plate itself; others are prone to the idea that the periungual soft tissues are at fault and favor a surgical procedure on them. The literature offers numerous studies showing the superiority of one technique over another, but none of them showed that the procedure is performed on the same type of ingrowing toenails. Many studies are open, non-randomized with short follow-up. Despite various trials, there is disagreement on which procedures give the most consistent results. Some do not hesitate to compare a conservative technique with an aggressive radical surgical procedure. And of course, comparing a surgical procedure you are used to, to another one with which you are not familiar, will skew the final results. One should also remember that mostly all surgical procedures are operator dependent, and that very easy ones to perform will certainly get higher success rates. There is indeed a no “cureall” technique for ingrowing toenails, but mainly two different approaches: narrowing the plate or debulking of soft tissues. Both excellent, as long as they are performed in appropriate cases. One should carefully examine each patient’s toe and decide which technique would suit best according to his/her skills. Sometimes, several types of procedures may be performed on the same ingrowing toenail to obtain best results. All procedures cited in this chapter have high cure rates as long as they are properly performed.

Keywords

Ingrowing nail Surgery Debulking Chemical cautery Pincer nail 

Avulsion

Nail avulsion consists in surgically removing the nail plate, partially or totally. This technique has been widely misused for the treatment of lateral ingrowing nails, with an unacceptable recurrence rate, together with high post operative pain and risk of nail dystrophy [1]. As soon as 1979, Palmer and Jones discouraged this procedure as a routine practice, after demonstrating that, out of 208 operated patients, partial and total avulsion led to respectively, 83 and 70 % recurrence rates. Except for the treatment of retronychia [2], avulsion is a useless and harmful procedure for the treatment of ingrowing nail [1].

Nail avulsion can be performed either by a distal or a proximal approach. Only the latter will be developed, as it is the only suitable surgical procedure for retronychia, due to distal abnormal adherences between the nail plate and its bed [3].

Indications

Treatment of retronychia.

Expectations

Normal regrowth of the nail plate.

Material

Basic nail ingrowing surgery tray, hemostatic solution (aluminium chloride 35 %).

Procedure

The proximal nail fold (PNF) is detached on its whole width, using anterior and posterior motions of the elevator (Fig. 4.1a). The elevator then reflects the PNF and is delicately inserted under the base of the nail plate where adherence to the matrix is weak. This is the most delicate motion of the procedure, which has to be repeated along the whole width of the plate (Fig. 4.1b). The avulsion progresses distally following the natural cleavage plane, until the nail plate is detached from the entire width of the nail bed (Fig. 4.1c). The nail plate is elevated or grasped with a sturdy hemostat, and its last distal subungual attachments are freed with scissors [4]. The surgeon must remove all successive nail plates [3] until reaching the matrix, which appears as a whitish opalescent structure and without hurting it. Compression for 10–20 s, with cotton-tipped applicators dipped into hemostatic solution suffices to stop any bleeding (Fig. 4.1d) [4].
Fig. 4.1

(a) The elevator detaches the proximal nail fold from the nail plate, with repeated back and forth motions (b) the elevator is inserted under the base of the plate (proximal avulsion); be cautious not to hurt the underlying matrix (c) the avulsion progresses proximal to distal until complete detachment of the plate (d) cotton-tipped applicators dipped into aluminium chloride suffice to stop any bleeding

Key Point

  • Inserting the elevator proximally and finding a cleavage plane without hurting the underlying matrix.

  • Removing all newly formed nail plates.

Post-op Care

  • Pain: moderate.

  • Greasy antiseptic dressings until complete healing.

Evolution

  • Healing takes between 14 and 21 days.

  • A complete regrowth of the nail is obtained in 12–18 months (Fig. 4.2a, b).
    Fig. 4.2

    (a) Retronychia (b) 1 year after simple proximal avulsion (patient from Fig. 4.1a, b)

Complications

  • Loss of counter pressure induced by the disappearance of the nail plate allows dorsal dislocation of the distal pulp and may promote distal embedding with a subsequent hyperkeratotic reaction (impacted nail). In mild cases, conservative measures include the reduction of the hyperkeratosis in front of the distal nail by using 50 % urea occlusive dressing at night, allowing debridement of the hyperkeratosis with a blade, and massaging back in a distal-plantar direction. Consistent taping is also a very valuable alternative. If there is severe pain, then surgery is mandatory to free the distal edge of the plate (see p. 97). As prevention of such a complication, an acrylic nail may be affixed to the new growing nail when it has reached one-third of its length. However, the upward force exerted by the pulp during gait often detaches the artificial nail.

  • Injuring the matrix or destroy the distal nail bed during the proximal avulsion with subsequent nail dystrophy or onycholysis.

  • Nail dystrophy may be observed in about 30 % of patients. The nail is thickened and yellowish and grows very slowly [5].

Author’s Point of View

  • It is astonishing to see how many surgeons still believe that simple nail avulsion (even repeated) is the first treatment option of ingrowing toenail.

  • And on the contrary, retronychia is considered as an infection whereas avulsion is curative in this condition!

Surgical Resection of the Matrix Horns

Classical Wedge Resection

Partial and total cold steel matricectomies are various and numerous. In the literature, the reader will find the names of Winograd, Zadik, Suppan, Frost, Kaplan and Syme. They are all surgical matricectomies developed for ingrowing nails [6]. A summary of the procedures is listed below and Table 4.1 represents the procedures schematically:
Table 4.1

Schematic representation of the various partial and total cold steel matricectomies

  • Winograd’s procedure is a partial matricectomy and involves a “D”-shaped excision, removing at the same time the lateral part of the matrix and a portion of the lateral wall.

  • Frost’s procedure, one of the older “sharp” partial matricectomy procedures, involves an “L”-shaped incision, allowing reclining the proximal fold to expose and excise the nail matrix selectively.

  • Suppan’s procedure associates the avulsion of a lateral strip of nail with curettage of matrix horn and bed exposed. It is a partial matricectomy.

  • Zadik’s procedure is also a complete matricectomy. Two incisions at 45° are performed at the junction proximal lateral nail folds allowing reclining the proximal nail fold and exposing the whole matrix area. The latter is excised with the blade and the proximal nail fold is put back in place and sutured.

  • Kaplan’s procedure involves an “H”-shaped incision allowing complete removal of both the nail matrix and nail bed. This is a complete matricectomy that is almost abandoned, even for removal of tumours. It was formerly indicated for onychogryphosis or permanent nail dystrophy. Now the preference goes to chemical cautery which is much less aggressive and much more comfortable for the patients.

  • Syme’s procedure, also called the terminal Syme operation is basically an amputation of the tip of the toe. It has nowadays no indication ever in the treatment of ingrowing toenails.

In Germany, the “Emmert plasty” is still the intervention most commonly performed by surgeons for the treatment of ingrown nails [7]. In Germany and Switzerland, it is called the Kocher’s surgery, although Kocher had explicitly warned against this method! [1]. Emmert, a Bernese surgeon, proposed the wedge excision of the lateral nail wall, groove, adjacent nail and corresponding matrix [8], which is in fact the method first described by the French military surgeon Baudens (from the Val de Grâce) in 1850 [9], which is indeed a…. Winograd’s procedure!

Indications

  • When both narrowing the nail plate along with removal of hypertrophic lateral nail fold is needed.

  • The procedure is identical to the one used in lateral longitudinal biopsy for lateral longitudinal melanonychias and inflammatory diseases.

Expectations

This procedure works at the same time on the matrix and surrounding tissues. As there are stitches, fast healing is expected.

Material

Full ingrowing nail surgery tray

Procedure

  • To facilitate the resection of soft tissue, the procedure starts with the avulsion of a 2–3 mm wide lateral strip of nail plate (Fig. 4.3a, b). The later is detached from its bed and from the PNF using an elevator and cut longitudinally with a nail clipper.
    Fig. 4.3

    (a) Ingrown toenail with pyogenic granuloma (grade III – Heifetz). (b) Removal of a lateral portion of nail, bed and matrix (Winograd’s procedure) with curving the incision proximally to ensure complete removal of the lateral horn of the matrix (c) Immediately after suturing the defect. (d) Aspect four months post operatively

  • An incision is carried out starting at the hyponychium with the blade sticking vertically to the lateral part of the clipped nail, and progresses proximally along the bed and through the PNF until it reaches a point halfway between the cuticle and distal interphalangeal crease. The incision then takes on a laterally curved direction (Fig. 4.3b). It is extended until the most lateral part of the nail plate is visualized [1].

  • Bone contact is mandatory all time.

  • The second incision starts at the same point and extends laterally through the lateral fold, removing the excess tissue, parallels the first incision and curves laterally at the most proximal part to ensure section of the lateral horn of the matrix to meet the end point of the first incision.

  • The wedge of tissue is then removed distally to proximally, sticking to the bone, working with fine-tipped curved scissors “tips down” or with a No. 64 Beaver blade shaving the periosteum (Fig. 4.3c).

  • Proximal nail fold and hyponychium are closed with single suture using nylon 4-0. Half-buried horizontal mattress sutures from the lateral nail fold through the nail plate are best to re-create the lateral fold.

Key Point

  • Avulsing the lateral part of nail eases greatly the medial incision through nail bed and nail matrix.

  • Extending the incision proximally enough and curving proximally ensures to remove of the lateral horn of the matrix, otherwise recurrence is expected.

  • Always check that there are no remnants of matrix left. If any structure looks suspicious, remove it with scissors.

Post Op Care

  • Antiseptic ointment is applied on the surgical wound and covered with non-adherent gauze and a bulky dressing.

  • Potent painkillers should be prescribed, as the procedure is very painful, due to trauma to the periosteum and traction from the stitches.

  • Removal of the dressing is done after 1 day, as bleeding may occur. The wound is soaked into an antiseptic footbath until removal of all clotted blood, pad dry and covered with a greasy ointment. This procedure should be repeated twice per day at home until removal of the stitches, 2–3 weeks post op.

Evolution

  • Healing is fast. However, pain from surgery may remain for up to 3 weeks and may impair footwear. The patient should be checked after 2–3 months to verify that there is no recurrence (Fig. 4.3d).

Complications

  • Infection is the most common complication, especially in patients not doing proper home cares (Fig.  5.3). This may be also observed when surgery is performed on a non-clinically visible infected area. Systemic antibiotics are indicated. Infection may lead to suture’s dehiscence.

  • Incomplete removal of nail matrix tissue will result in recurrence, spicules or nail inclusion. Epidermal cyst may occur from the inclusion of epidermal cells during incision or suturing.

Author’s Point of View

  • This technique is the choice of all orthopedic surgeons and some rare dermatologists. Post operative period is very painful and daily activities are compromised by at least 2 weeks. Walking with crutches is necessary for the first days.

  • There is no evidence that the recurrence rate of the wedge technique is lower than the nail matrix phenolization [10, 11].

Curettage of the Matrix

It is very rarely used as the sole treatment for ingrowing toenail. After avulsion of a lateral strip of nail, the proximal cavity containing the lateral horn of the matrix is curetted. There is no post operative oozing as observed with chemical cautery.

One paper only compares curettage to electrocauterization. Recurrence rates were considered low in both groups, showing that curettage is as effective as electrocauterization [12]. Some surgeons advocate to curette the matrix before phenolization. A study comparing phenolization with or without prior curettage demonstrated that there was no statistically significant difference between the two techniques [13]. On another hand, it has been clearly demonstrated that removal of all modified tissue immediately after phenolization, either with a gentle curettage or using a blade, dramatically shortens the oozing time from chemical matricectomy [14].

Indications

  • Mild cases of ingrowing nails without hypertrophic tissue (Fig. 4.4a).
    Fig. 4.4

    (a) Mild case of ingrowing nail (grade I – Heifetz). Bleaching results from the distal digital block (b) detaching the lateral nail plate from the lateral nail fold (c) detaching the lateral nail plate from the nail bed (d) a nail plate strip is cut from the free edge to the matrix (e) the nail plate strip is easily avulsed (f) nail matrix and bed are vigorously curetted

Expectations

  • Narrowing of the nail plate permanently.

Material

  • Basic ingrowing nail surgery tray.

Procedure

  • A lateral strip of the nail plate is detached from proximal nail fold, lateral nail fold and nail bed, using a nail elevator (Fig. 4.4b, c). Particular attention should be given to fully free the proximal lateral horn from the plate.

  • The nail plate is split using scissors or nail nippers up to it most proximal edge under the proximal nail fold (Fig. 4.4d). The strip of plate is removed with a sturdy hemostat or with an elevator (Fig. 4.4e). Be sure to remove the strip of nail up to its most proximal attachments.

  • The nail bed, nail matrix, and lateral nail fold are vigorously curetted until complete removal (Fig. 4.4f).

Key Point

  • The most proximal attachments of the lateral strip of nail should be completely removed.

  • Curettage should be aggressive enough to remove the nail matrix, but should not hurt the underlying periosteum or bone.

Post Op Care

  • Antiseptic ointment is applied on the surgical wound and covered with non-adherent gauze and a bulky dressing.

  • Potent pain-killers should be prescribed.

  • Removal of the dressing is done after 1 day. The wound is soaked into an antiseptic footbath until removal of all clotted blood, pad dry and covered with a greasy ointment. This procedure should be repeated twice per day at home until complete healing.

Evolution

  • Healing is fast – about 2 weeks.

  • Pain is the rule from the injury to the periosteum.

Complications

  • Complications are uncommon.

  • Recurrence may occur if nail matrix removal is incomplete.

Author’s Point of View

  • Curettage of nail matrix is extremely difficult because the matrix has an elastic consistence and smooth surface. The procedure almost invariably induces periostitis (as well as electrocautery).

  • There are no sufficient studies with long-term follow up to prove any efficacy of this technique. The authors highly recommend against this procedure.

Physical Destruction of the Matrix Horns

Electrosurgery

Electrosurgery uses the electricity to cause thermal tissue destruction, most commonly in the form of tissue dehydration, coagulation, or vaporization. It can be divided into four types based on their mechanism of tissue damage: electrolysis, coblation, high-frequency electrosurgery and electrocautery. Electrocautery uses low-voltage, high-amperage, direct or alternating current to heat a surgical tip causing tissue desiccation, coagulation or necrosis by direct heat transference to tissue. It is compatible with patients who may not tolerate current flow, for example those with an implantable cardiac pacemaker or defibrillator. Most destruction with electrocautery occurs close to the heating element, and is thus more readily seen and controlled compared to electrosurgery. Histologically, this results in amorphous tissue with charred foci and formation of steam spaces [15, 16, 17].

Instead of surgical dissection of the matrix horn, electrocauterization may be used. After local anesthesia, a lateral strip of nail is removed and the lateral matrix horn is exposed. Electrocauterization of the matrix is performed in a bloodless field. The power setting depends on personal experience. No matrix horn should remains. As a lot of heat is delivered, a thermal periostitis with long-term post operative pain, long healing time and nail dystrophy is potentially likely [1, 18]. Electrocautery is a safe procedure, when performed by a trained surgeon and has high success rate, but does not offer any advantages compared to other matrix ablation techniques [12, 19, 20, 21].

Indications, expectations, material, post op cares and complications are the ones described below for laser matricectomy.

Radiocautery

Radiocautery is a term used to describe a high-frequency electrosurgery. It uses tissue resistance to the passage of high-frequency alternating current to convert electric energy to heat, resulting in thermal tissue damage. Heat generation occurs within the tissue, while the treatment electrode remains ‘cold’. This makes radiofrequency more selective and reduces heat generation thus producing only a very narrow margin of thermal tissue destruction, accelerating wound healing and improving scarring [22]. Radiosurgery should not be performed in patients with cardiac pacemakers.

The surgical procedure is identical to the one for electrocautery. The spade-like electrode is rubbed onto the lateral horn of the matrix after avulsion of a lateral strip of nail. Special insulated electrodes are designed for the treatment of ingrowing toenail with radiosurgery. The electrode is flexible and coated for protection of the upper tissue (ventral part of the proximal nail fold) while it destroys the underlying matrix layers (Fig. 4.5). This makes the radiofrequency machine virtually as versatile as the CO2 laser at a much lower cost [23].
Fig. 4.5

Spade-like coated and insulated bending electrode used in radiosurgery for the destruction of the lateral horn of the matrix

Indications, expectations, material, post op cares and complications are the ones described below for laser matricectomy.

Laser

Laser treatment has been widely described for the treatment of ingrowing nails since 1983 [24], using ablative lasers, CO2 in the vast majority of cases [25, 26, 27], exceptionally Er:YAG [28].

Indications

  • Mild cases of ingrowing nails without or with little hypertrophic tissues.

Expectations

  • Narrowing of the nail plate permanently.

Material

  • Basic ingrowing nail surgery tray.

Procedure

  • The area of matrix to be vaporized needs to be exposed. For this, most authors advocate either to retract the proximal nail fold with a hook or perform a lateral oblique incision allowing full exposure of the lateral horn of the matrix (Fig. 4.6a).
    Fig 4.6

    (a) Two lateral strips of nail are avulsed using the cutting mode (b) after avulsion and partial retraction of the proximal nail fold, the matrix is vaporized (Courtesy E. Duhard, Tours, France)

  • The exposed lateral matrix is dried from any blood.

  • The latter is vaporized with carbon dioxide laser [29, 30, 31]. Power depends on the machine used and personal experience (Fig. 4.6b).

  • Ozawa et al. used methylene blue staining to better estimate the degree of lateral matrix ablation [32]. Another technique consisted in a wide vaporization to an area equivalent of a wedge excision, down to the bone, leaving a defect that was finally sutured [33].

Key Point

  • Vaporization should be aggressive enough to remove the nail matrix, but should not hurt the underlying periosteum or bone.

Post Op Care

  • Antiseptic ointment is applied on the surgical wound and covered with non-adherent gauze and a bulky dressing.

  • Potent pain killers should be prescribed.

  • Removal of the dressing is done after 1 day. The wound is soaked into an antiseptic footbath until removal of all clotted blood, pad dry and covered with a greasy ointment. This procedure should be repeated twice per day at home until complete healing.

Evolution

  • Most authors emphasized the haemostatic effect and reported minimal pain, quick healing time and good cosmetic outcome [33, 34, 35, 36].

Complications

  • Complications are uncommon.

  • Recurrence may occur if nail matrix removal is incomplete. Recurrence rates were inconstant, varying from 1.45 [37] to 50 % [38]. Orenstein et al. showed that additional vaporization of the lateral nail fold dropped the recurrence rate from 37.5 to 6.2 % compared to the sole partial matricectomy with carbon-dioxide laser [39]. Spicules rates, when reported, reached 5 % [33].

Author’s Point of View

  • For the authors, carbon dioxide laser for ingrowing nails is poorly evidenced based and has never shown any superiority to the “gold standard treatment” that is chemical cautery.

  • The procedure is highly operator-dependant. Best results are obtained with skilled laser surgeons who definitely know the precise anatomic location of the matrix and have an excellent knowledge of their laser device.

  • Its main advantage is that it is a “clean” procedure, almost bloodless. A local block is required, as in any surgical procedure.

  • Complications are rare, unless a too powerful and deep vaporization was done leading to a painful periostitis.

Chemical Destruction of the Matrix Horns

Phenol 88 %

Nail matrix phenolization is a half a century old technique [40] and it has become more and more popular these last decades among dermatologists and podiatrists. Three consecutive Cochrane studies [41, 42, 43] demonstrated that phenolization was the most effective technique for definitive treatment in terms of morbidity and success rate, compared with other excisional surgical procedures, in preventing recurrence at 6 months or more. The preference from nails doctors for this procedure is due to its low morbidity, high success rate when compared with other excisional surgical techniques, besides being very easy, fast and cheap (Table 4.2) [31, 48, 49, 52].
Table 4.2

Largest series published on phenolization with duration of follow-up and success rates

Year

Authors

No of cases

Follow-up in months

Recurrence rate (%)

1995

Kimata et al. [44]

537

6

1.1

2001

Bostanci et al. [45]

350

25

0.57

2004

Andreasi et al. [46]

948

18

4.3

2005

Lau et al. [47]

106

12

5.7

2010

Di Chiacchio et al. [48]

267

33

1.9

2013

Karaca et al. [49]

348

24

2.3

2013

Zaraa et al. [50]

171

2.1

2.7

2014

AlGhamdi et al. [51]

30

6

3.3

Indications

  • Treatment of all grades of ingrowing nail.

Expectations

  • Narrowing of the nail plate to cancel the nail plate – lateral fold conflict.

Material

  • Basic ingrowing nail surgery tray plus Sturdy hemostat.

  • 88 % phenol solution.

Procedure

  • After a distal digital block, a tourniquet is placed to ensure a completely bloodless field. If blood is present, the cauterant will turn into a brown jelly, meaning that it has coagulated the blood proteins instead of those of the matrix epithelium.

  • When granulation tissue is present, it should be curetted for a better view of the nail plate avoiding an excessive nail plate removal (Fig. 4.7a, b).
    Fig. 4.7

    (a) Ingrowing nail (grade II – Heifetz) (b) after curettage of granulation tissue (c) detachment of a lateral strip of nail using the elevator (d, e) the nail is split using nail nippers up to its hilt, under the proximal nail fold (f) after avulsion of the lateral strip of plate (g) phenolization using the elevator. The cauterant adheres by capillarity to the elevator (h) nail matrix phenolization with a cotton swab (not dripping) (i) whitening of the tissue after phenolization (j) incomplete resection of the plate up to its hilt interfering with phenolization of the lateral horn of the matrix; the nail is regrowing as it was before (k) overphenolization from sliding of phenol under the lateral sides of the plate

  • The procedure starts with a lateral (or bilateral if the condition affects both sides) avulsion of a strip of nail about 3–5 mm of lateral nail plate: it is detached from the nail bed, and the lateral and PNF using a nail elevator (Fig. 4.7c). The width of the strip to remove may easily be appreciated; while pressing the lateral fold onto the edge of the plate, a line is drawn with a pencil at the medial limit of the lateral fold. Relaxing the fold will exactly show the amount of nail to be removed to suppress the nail/soft tissue conflict. Doing like will also ensure a nice cosmetic result in avoiding to excessively narrow the nail plate.

  • Particular attention should be given to fully free the proximal lateral horn from the plate.

  • The nail plate is split using scissors or nail nippers up to it most proximal edge under the PNF (Fig. 4.7d, e). The strip of plate is removed with sturdy hemostat or with an elevator (Fig. 4.7f). Be sure to cut and remove the strip of nail up to its most proximal part.

  • Remnants of granulation tissue on the bed and in the lateral sulcus are gently curetted away. The matrix should not be curetted. It has been shown that this procedure does not increase the efficacy [13]. Moreover, it may injure the periosteum and the bone.

  • The exposed nail bed and matrix are carefully dried with gauze or a cotton swab pushed along the lateral sulcus and under the PNF. No blood should remain.

  • Check that the nail overlying the matrix is fully removed because any remnant nail will protect the matrix from the chemical cauterant and prevent its destruction.

  • A cotton swab is soaked in the 88 % phenol solution and then cautiously padded on gauze to have it just moistened and not dripping. If there is excess of liquid on the cotton-tipped applicator, it will spill onto the nail folds causing unnecessary burn. This is why the first description of the technique recommended protecting the surrounding skin with some greasy ointment. Any overflow should be mopped away immediately with a gauze.

  • Other applicators may be used for applying the cauterant: orange sticks, urethral swabs or the elevator itself (Fig. 4.7g) [53].

  • The applicator is pushed into the lateral sulcus, under the proximal fold and rubbed vigorously onto the matrix (Fig. 4.7h). Work it carefully in the lateral and proximal pocket of the matrix.

  • Cauterized tissues appear white from coagulation of proteins (Fig. 4.7i).

  • One minute seems to be a sufficient time of application of the phenol. This duration has been shown to be clinically effective with high success rate [54]. However, an interesting histologic study on cadavers shown that 4 min is necessary for complete destruction of nail matrix, down to its basal layer [55].

  • There is no need to neutralize the phenol as it will be inactivated immediately with the blood flow returning after release of the tourniquet.

  • The wound is cleaned with saline solution and dried with sterile gauze. Alcohol lavage does not neutralize the phenol as thought in the past, reason why it was named the “phenol-alcohol procedure”. Studies demonstrated that alcohol only dilute the phenol and drags it partially away [56].

  • It has been clearly demonstrated that removal of all modified tissue immediately of phenolization, either with a gentle curettage or using a blade, dramatically shortens the oozing time from chemical matricectomy [14].

  • Always check that the tourniquet has been removed.

Key Point

  • A tourniquet is mandatory as any blood will impair chemical cautery. This is the main cause of recurrence.

  • The removal of granulation tissue with curette avoids to avulse an excessive lateral strip of nail plate.

  • Remove the lateral strip of nail plate up to its most proximal limits.

  • The cotton swab should just be moistened and not dripping.

  • Patients must be informed that oozing is not infection.

  • Phenol has been demonstrated to be safe for both the patient and the surgeon [57].

Post Op Care

  • Antiseptic ointment is applied into the surgical wound and covered with a nonadherent gauze (Fig.  1.30) and a bulky dressing. Sandals are a must post operatively (Fig.  1.29).

  • The limb should be kept elevated for 2 days. The dressing is removed after 2 days and the wound cleaned with 3 % hydrogen peroxide to remove all blood clots. Back to normal comfy footwear is possible at that time.

  • The lateral sulcus is filled with a thin layer of antiseptic ointment, lotion or antibiotic pellet and covered with a simple plaster.

  • The patient is asked to soak his foot twice daily in an antiseptic footbath until oozing disappears.

Evolution

  • Oozing appears on the third day and may continue to up to 6 weeks. It can be reduced by applying ferric chloride 20 % at the end of phenolization [58].

  • A slight edema on the proximal and the lateral nail folds may remain for 1 week from the irritation from the cautery [59].

  • Preoperative and post operative antibiotics are not necessary [60, 61]. Most doctors mix up inflammation and infection.

  • Follow-up is mandatory at 3 months to check that there is no recurrence.

Complications

  • Complications are uncommon.

  • Intense inflammatory process is unusual, but it may appear due to a prolonged time of application of phenol. In these cases non steroidal anti-inflammatory should be used.

  • Infection is the most common complication as drainage promotes bacterial contamination. It is mostly observed in patients with poor hygiene and lack of proper home care (Fig.  5.3) [62].

  • Perfect healing with a brutal intense inflammation at the junction of the lateral and PNF 6 weeks post operatively, suggests that the nail plate was not severed up to its hilt: the new growing nail pushes the remnant of the former wider nail out, irritating the lateral pocket (Fig. 4.7j). This spur is clipped away with sharp nail nippers allowing complete cure. No new matrix cauterization is necessary.

  • When the avulsion induces a medial onycholysis, the cauterant may slide under the detached nail and induce in a definitive nail dystrophy (Fig. 4.7k). To avoid this, pressure on the detached nail with the surgeons thumb during the phenolization, along with very delicate rubbing of a moisturized cotton swab onto the matrix may help.

Author’s Point of View

  • Nail matrix phenolization is a very easy, fast and cheap procedure to treat all grades of ingrowing nails that every dermatologist should be able to perform. It relieves the patient immediately and offers a very comfortable post op.

  • Patients can return to their normal activities in 2 days.

  • Recurrence rate is very low (<3 %) (See Table 4.1)

Sodium Hydroxyde (NaOH) 10 %

In 1980, chemical matricectomy with 10 % sodium hydroxyde was tempted and showed excellent results [63, 64]. It was put back on stage by a Turkish team a decade ago [65]. Sodium hydroxide is a strong basic salt and in contrast to phenol (carbolic acid) it causes a basic tissue destruction associated with liquefaction necrosis that is known to heal faster than coagulation necrosis (as induced by phenol). Acid burns on the skin produce a dry crust as a result of coagulation of tissue colloids. The coagulation necrosis is characterized by the loss of the nucleus with preservation of the cellular outline. Protein denaturation occurs following cellular death. The proteins are rendered insoluble thus blocking proteolysis and preserving the dense acidophilic coagulated cells for a period of hours or days. Monocytes and macrophages eventually phagocyte the coagulated cells. Alkaline burns produce a liquefaction necrosis, which results from enzymatic destruction of the cells with a proteinaceous by product that is readily reabsorbed or phagocytized by macrophages. The result is that alkaline burns heal quickly and resolve faster [63]. For this reason, chemical cautery using a base (NaOH 10 %) was attempted for chemical matricectomy.

Indications

  • Chemical cautery of the matrix epithelium for permanent destruction. The indications are identical to that of phenol.

Expectations

  • NaOH is expected to reduce the oozing period and shorten healing compared to phenol.

Material

  • The one used for any chemical matricectomy.

  • NaOH 10 %

Procedure

  • The surgical procedure is the one for any chemical matricectomy.

  • Three application times were evaluated: 30 s, 1 min and 2 min. Thirty seconds application is associated with frank lower success rates and 2 min increases post operative pain and lengthens oozing. One minute is the most adequate application time [66].

  • After 1 min, NaOH should be neutralized with 5 % acetic acid solution.

Key Point

  • Application time should be one minute, not less, no more.

  • With acetic acid solution, a true neutralization occurs with a 1:1 stoichiometric reaction, on the contrary of phenol that is only diluted with alcohol.

  • As with any cauterant, NaOH has to be applied with caution in order to prevent overdestruction of the matrix or injury to adjacent tissues.

Post-op Care

  • Identical to the one for other types of chemical matricectomy.

Evolution

  • NaOH and phenol cauteries were compared in a large study. Phenol was applied for 3 min and NaOH for 1 min. It appeared that they both give high success rate (>95 %) without any significant statistical difference [67].

  • Mean duration of post operative drainage is reduced to 10 days with NaOH compared to the 15 days in the phenol group. There was no difference in the severity of the drainage [67].

  • Pain is twofold more important in the NaOH group compared to the phenol group during the two first days post op [67].

  • NaOH has shown to be safe for chemical matricectomies in diabetics [62]

Complications

  • As with phenol, complications seem to be exceptional but nail dystrophy, allodynia and hyperalgesia after sodium hydroxide matricectomy have been recently reported [68].

  • Recurrence rates varied from 15/1000 [63] to 5 % [67].

  • Amazingly no study mentioned any post op infection with sodium hydroxide cauterization.

Author’s Point of View

  • NaOH is a good option for chemical matricectomy if phenol is not available. It is very easily found all over the world.

  • Even if the oozing time is a bit shortened, the authors found that the post op pain, even for only 2 days, are not worth it, as phenol makes the post op more comfortable and that the overall success rates are identical for both cauterants.

  • In their personal experience, they also found that the liquefaction necrosis from NaOH gave an oozing more prone to infection. None of the studies mentioned if they had infection or not post operatively.

TCA 100 %

The latest chemical matricectomy used by a few authors is trichloracetic acid (TCA) with a concentration ranging from 80 to 100 % [69, 70, 71].

Indications

  • As phenol, TCA is a protein denaturant and induces coagulation necrosis of the cells [70]. The indications are identical to that of phenol.

Expectations

  • TCA is expected to reduce the oozing period and shorten healing [69], compared to phenol, but no prospective comparative study has yet been conducted.

Material

  • The one used for chemical matricectomy.

  • TCA 80–100 % (saturated).

Procedure

  • The surgical procedure is the one for chemical matricectomy.

  • Application time varied from 10 s to 4 min [69, 70, 71].

Key Point

  • As with any cauterant, TCA has to be applied with caution in order to prevent overdestruction of the matrix or injury to adjacent tissues.

Post-op Care

  • Identical to the one for other types of chemical matricectomy.

Evolution

  • Post operative pain was reported to be minimal in most of the patients [69, 70, 71].

  • Complete healing or major improvement of post operative drainage was achieved within 8–15 days in more than 80 % of the cases in the three studies [69, 70, 71].

  • Cosmetic results were always considered as satisfactory [70, 71].

Complications

  • Barreiros et al. reported moderate complications in only a few cases, 30 days after surgery: mild oozing, erosion or persistent granulation tissue [69].

  • Secondary infection occurred in four out of 133 patients [70] and in one out of 25 patients [71].

  • Recurrence rates varied between 2 and 5 % [69, 70, 71].

  • Spicule rate reached 4 % in one study [69].

Author’s Point of View

  • Up to now, the superiority of TCA over phenol, considered as the “Gold Standard technique”, has not been proven, due to the lack of prospective comparative studies.

  • The three published studies [69, 70, 71], show that TCA matricectomy is safe, simple and an effective procedure. TCA should be considered as a serious alternative, especially when phenol is not available (Table 4.3).
    Table 4.3

    Comparison of the differents chemical cauteries for ingrowing nails

     

    Concentration

    Application time

    Post op oozing time (days)

    Postop pain

    Overall success rate (%)

    Degree of evidence

    Phenol

    88 % (liquefied)

    1–4 min

    15–28

    Minimal

    95–99

    1

    Sodium Hydroxyde

    10 %

    Strictly 1 min

    10–18

    Severe the first 2 days then minimal

    95–99

    2

    Trichloracetic acid

    100 % (liquefied)

    10 s to 4 min

    8–15

    Minimal

    95–99

    2

    1 Double-blind studies, 2 clinical series, 3 anedoctal

  • An average time of 1 min of application seems reasonable, as experimented by the authors.

Resection of the Soft Tissues

With time, chronic ingrown nail will induce hypertrophy of the lateral and distal nail fold, covering progressively the lateral aspects of the plate, the latter appearing then very narrow (Fig. 4.8a). Narrowing the nail plate in these instances will not solve the problem in all instances and will end in a very narrow nail on a bulky extremity. Here, the surgical procedure should be directed towards the excess of soft tissues that covers the plate or towards the distal pulp against which the nail plate abuts in distal embedding.
Fig. 4.8

(a) Long standing chronic ingrowing toenail with hypertrophic lateral walls (b) drawing of the incision (c) after removal of the strip of skin down to the bone (d) running lock suture for hemostatic purposes (e) 8 months post operatively. The nail has returned to a normal shape and has not been narrowed. (f) Note the very discrete scar

Howard Dubois’ Procedure

At the end of the nineteenth century, Howard proposed removing a crescent of soft tissue parallel to the distal groove around the tip of the toe to treat ingrowing toenail [72]. Once again, as always in History, this technique was forgotten and reintroduced more than half a century later by Dubois who made it quite popular in France [73, 74].

Indications

  • This procedure is a must in the treatment of distal embedding.

  • It is also a good approach when dealing with moderate hypertrophic lateral folds.

Expectations

  • Removal of enough soft tissues and suturing the defect should induce a pulling down of the distal soft tissues with decompression of the nail.

  • The nail plate recovers its original width.

Material

  • Tourniquet

  • Full ingrowing nail surgery tray

  • Non absorbable suture 3/0

Procedure

  • As this is a bleeding procedure, placing a tourniquet is mandatory.

  • A fish-mouth incision is carried out parallel to the distal groove around the tip of the toe or the digit, about 5 mm distally from the distal groove and 5 mm laterally from the lateral grooves. The incision starts and ends 5 mm proximal to the end of the lateral nail fold.

  • A second incision is then made to yield a wedge of maximum 5 mm at its greatest width in the middle of the distal wall (Fig. 4.8b).

  • One extremity of the crescent is held with sturdy Adson forceps and pull strongly on it to help the dissection of the area to remove at bone contact with sharp pointed scissors (Fig. 4.8c).

  • A #15 blade should be then inserted under the upper part of the incision, skimming the bone from one side to the other, in order to free the attachment of the distal bed.

  • Then, check that enough tissue has been freed and removed by pulling on the two edges of the wound with forceps. If not, re-excise a new strip of 3 mm maximum from the lower edge of the wound. Check again and repeat the procedure until accurate removal of tissue.

  • Do not hesitate to remove fat generously.

  • Suturing the defect immediately frees the distal edge of the nail. Sutures may be simple sutures or a running lock suture for hemostatic purposes (Fig. 4.8d). They should re-approximate the defect and not pull too much on the distal wall.

Key Points

  • Freeing the distal bed from the bony phalanx is mandatory. There is often some fibrocartilaginous tissues from the chronic ingrowing. Sectioning those facilitate the pulling down of the distal bed.

  • Do not get too close to the distal and lateral grooves. Keep a minimum of 5 mm between the incision and the grooves.

  • Remove excess tissue progressively, sparingly at each time, until the correct amount is removed.

  • Do not over-tighten stitches.

Post Op Care

  • Expected pain from this procedure is severe and results from the pulling of tissues. Plan potent pain killers (mild opioids narcotic analgesics).

  • Very greasy non-adherent dressing. Use Tulle gras and Teflon coated gauze (Telfa®, Melolin®).

  • Very bulky dressing as the wound may bleed.

  • The dressing should be replaced after 24 h, not later, as bleeding may render the dressing hard and uncomfortable.

  • Antiseptics soakings twice per day with removal of any crust is highly recommended.

  • The limb should be elevated for 48 h.

  • A first set of stitches is removed after 15 days. The remaining ones are removed 1 week later.

Evolution

  • The new nail seems then to grow faster immediately as it is freed.

  • Pain and discomfort may remain for several weeks.

  • Anesthesia and dysesthesia of the distal wall may persist for up to 1 year and result from section of numerous tiny nerves endings on the distal wall.

  • If possible this procedure should be performed when sandals may be worn for several weeks. The patient will be only able to wear regular footwear after 1 month or more.

Complications

  • Main complication is necrosis from over-tightened sutures after excess removal of soft tissues (see Fig  5.6 p. 130).

  • Removal of not enough tissue will not be curative and will result in recurrence.

Author’s Point of View

  • This is a very rewarding technique when performed adequately (Fig. 4.8e, f).

  • A modification of this procedure has been proposed where it is coupled with a partial nail avulsion [75]. For the authors this variant does not offer any advantage to the original technique.

Noel’s Procedure

This procedure was described in 2008 by a Swiss dermatologist [76]. He reported his technique on 23 patients. It is aimed to reduce the amount of hypertrophic soft tissue. It may be considered as a vertical variant of a Howard-Dubois.

Indications

  • This procedure is indicated when one or both lateral folds are hypertrophic (Fig. 4.9a, b).
    Fig. 4.9

    (a) Ingrowing toenail with hypertrophy of the lateral walls, upper view (b) front view (c) scheme illustrating the Noel’s procedure (d) two vertical wedge of soft tissue are removed, skimming the lateral aspect of the bony phalanx. Neither the plate or the matrix are touched at any time, upper view (e) front view showing the extension of the excision down to the pulp (f) suturing with eversing suture in order to re-create lateral folds, upper view (g) simple stitches are placed at the front

Expectations

  • Removal of enough soft tissues and suturing the defect results in an immediate cancellation of the plate-fold conflict.

  • The nail plate keeps its original width.

  • No dystrophy is expected, as the matrix is not touched at any time.

Material

  • Tourniquet is mandatory

  • Full ingrowing nail surgery tray

Procedure (Fig. 4.9c)

  • The first incision runs all along the lateral nail groove up to 1 cm into the proximal nail fold. The blade should be skimming the lateral aspect of the bony phalanx, until it has reached the pulp. The second incision starts from the end of the previous one and extends laterally to remove a vertical wedge-shaped ellipse of soft tissues (Fig. 4.9d).

  • Incisions are deep enough to remove a large volume of soft tissues, with preservation of some skin of the lateral aspect of the nail to ensure direct closure (Fig. 4.9c).

  • Neither the plate nor the matrix are incised at any time.

  • The defect is closed with simple interrupted 4/0 sutures (Fig. 4.9f, g).

  • The procedure may be performed if needed only on one side of the toe.

Key Point

  • The procedure should remove enough soft tissues in order to avoid recurrences and not too much to impair suturing.

  • Back stitches may re-create the lateral fold.

Post Op Care

  • Expected pain from this procedure is severe and results from the pulling of tissues. Plan potent pain killers (mild opioids narcotic analgesics).

  • Very greasy non-adherent dressing. Use Tulle gras and Teflon coated gauze (Telfa®, Melolin®).

  • Very bulky dressing as the wound may bleed.

  • The dressing should be replaced after 24 h, not later, as bleeding may render the dressing hard and uncomfortable.

  • Antiseptics soakings twice per day, until complete healing and removal of stitches around 2–3 weeks post op.

  • The limb should be elevated for 48 h.

Evolution

  • Overall cosmetic results for all procedures are excellent.

  • Healing is quick as there is no oozing and primary closure.

  • There is no risk of nail dystrophy as the procedure does not involve the matrix or the bed.

Complications

  • The ones that may occur from any skin surgery: bleeding, infection, necrosis.

Author’s Point of View

  • This technique is very nice under several conditions: the surgeon should evaluate the adequate amount of soft tissue to excise. Too much removal leads to excessive pulling down of the lateral edge of the plate causing pain and unsightly post operative aspect (narrowing of the toe with vertical lateral aspects). If not enough tissue is removed, recurrence is likely.

  • To ensure a nice cosmetic aspect, it is important to re-create the lateral fold using back stitches: the needle is run into the lateral aspect about 2–3 mm volar to the plane of the nail bed-bone interface, through the nail bed and plate, and back again through the lateral thumb skin, which upon knotting will be elevated, thus forming a lateral nail fold (Fig. 4.9f).

  • In the author’s experience, in some instances this technique may not be sufficient: the removal of the excess tissue may reveal the cause of the ingrowing nail that may be either a too wide or transversally overcurved nail plate. This is obvious per operatively. A treatment of the cause is necessary (narrowing of the nail plate) and should complete the procedure several weeks after complete healing (see Clinical Case 15 (Marie), page 200).

  • The authors find that this procedure requires some more experience than Dubois’. The toughest part of the procedure is the skimming curve incision around the bony phalanx.

Debulking of Soft Tissue with Secondary Intention Healing (Vandenbos’ and Super “U”)

This technique was first described in 1959 by Vandenbos and Bowers [77] who proposed a theory whereby the excess skin surrounding the nail was burdened with daily weight-bearing, resulting in the bulging of nail-fold soft-tissues and subsequent pressure necrosis. Recently, Chapeskie brought back this procedure in vogue but with some slight modifications [78]. Dr Ival Peres Rosa from Brazil developed in 1989 another variant that he called the “Super U” [79, 80]. All these procedures share a wide debulking of the soft tissues, with some very slight differences. In both techniques, neither the matrix nor nail bed are involved. The name “super U” comes from the U-shape of the debulking all around the tip of the toe. In these techniques, healing occurs by second intention. They are easy to perform but long healing procedures. These original techniques were created to remove only the soft tissues, but nail matrix phenolization can be performed in the same session if the physician thinks that narrowing the nail is necessary. Indeed, debulking may reveal the original cause of the chronic ingrowing, like transverse overcurvature.

Indications

  • Chronic ingrowing with prominent hypertrophy of lateral and distal nail folds (Fig. 4.10a)
    Fig. 4.10

    (a) Chronic lateral and distal ingrowing (Heifetz grade III) (b) after removal of a “U” strip of skin all around the nail unit, removing a part of the lateral and distal nail folds, thus freeing the nail (c) a running lock absorbable suture is performed for haemostatic purposes. (d) Haemostatic foam is applied onto the wound left for secondary intention (e) outcome after 4 months

  • Congenital hypertrophic lip in infants.

Expectations

  • Removal of enough hypertrophic tissues to free the nail with second intention healing of the wound without resulting hypertrophic walls.

Material

  • Tourniquet

  • Full ingrowing nail surgery tray

  • Absorbable suture 4/0

Procedure

The first incision starts at the junction of the lateral – proximal nail fold and runs laterally up to the lateral half of the lateral aspect of the toe. It curves then distally to reach the tip of the toe. A same incision is performed on the other side and joins the previous one, giving the U shape. The third incision starts from the same place as the first one and skims the contour of the plate down to the bone. Using sharp scissors, the tissues in between these two U shaped incisions is removed down to the bone (Fig. 4.10b). Be careful not to remove the onychodermal band. The hypertrophic tissue between the two inverted “U” incision lines is removed all around the nail unit. The fat tissue at the distal fold is preserved to serve as a “bumper” post operatively, otherwise the distal phalanx abuts directly on the shoe which is painful.
  • In the Vandenbos’ procedure, a portion of the proximal nail fold is excised (V notch) and the very tip of the pulp remains in place (it is not a U shaped excision) (Fig. 4.11a–f).
    Fig. 4.11

    (a) Terrible chronic ingrowing toenail with exophytic lateral walls (b) Vandenbos’ procedure with wide lateral debulking and leaving the distal pulp, limiting the risk of injuring the onychodermal band (ce) progressive healing by secondary intention (f) final outcome (Courtesy H. Chapeskie, Canada)

  • Hemostasis is achieved with a running locked suture with absorbable suture (4-0) all around the U shaped wound (Fig. 4.10c). In the Vandenbos’ procedure, delicate electrocautery is used to stop the bleeding.

Key Point

  • Tourniquet is mandatory to avoid bleeding during the procedure.

  • Be generous, remove all the hypertrophic tissue down to the bone.

Post-op Care

  • Bleeding might be an issue at the removal of the dressing. An injection of a large amount of anesthetic or saline on the lateral aspect of the distal joint will stop the bleeding in a few seconds. Do not apply a tight dressing to stop the bleeding as this may cause pain in the following hours.

  • Hemostatic foam may be applied on the wound to limit bleeding (Fig. 4.10d)

  • Pain is moderate and light painkillers are usually enough.

  • The affected limb should be elevated for 2 days.

  • The wound is covered with a greasy non-adherent dressing and covered with several layers of gauze as a bulky dressing. It is replaced after 48 h.

  • Antiseptics soakings twice per day and greasy ointment are mandatory till complete healing

  • Sandals are recommended until almost complete healing.

Evolution

  • Healing takes about 40 days and is the main drawback of these techniques.

Complications

  • Infection is possible in case of a poor home care.

  • Removal of onychodermal band may give rise to parrot beak nail (which will never occur in the Vandenbos’ procedure).

  • Excess removal of the distal fat tissue results in loss of padding inducing persistent pain at the tip of the toe when wearing shoes.

  • The two last complications are less prone to develop with the Vandenbos’ procedure that leaves a piece of the distal wall.

Author’s Point of View

  • These two procedures are excellent for severe cases of hypertrophic lateral and distal nail folds. They are very easy to perform, generate very moderate pain and have almost no risk of dystrophy.

  • Despite it is considered as an aggressive procedure with a long healing time, the outcome is fantastic (Fig. 4.10e).

Tangential Excision (“Shaving”)

This technique is known for a long time and probably from the antic times!

Indications

  • Main indication is the hypertrophic distal fold in infants neither involuting spontaneously nor with topical steroids massaging (Fig. 4.12a).
    Fig. 4.12

    (a) Very prominent distal wall in an infant. Conservative treatments have failed (b) shaving of the hypertrophic distal tissue (c) results at 6 weeks, the nail is regrowing normally and the kid accepts to wear shoes! (d) Aspect at 1 year follow-up

  • Moderate distal ingrowing in adults not responding to conservative treatments.

  • Another option might be a moderate hypertrophic lateral lip.

Expectations

  • Freeing the distal nail abutting on the hypertrophic lip and responsible for pain.

Material

  • Scalpel and # 15 blade

  • Hemostatic solution

Procedure

  • With the blade resting horizontally on the proximal plate and perpendicular to its longitudinal axis, the excessive distal tissue on which the nail abuts is tangentially excised from side to side (Fig. 4.12b).

  • Compression with aluminium chloride solution suffices to ensure hemostasis.

Key Point

  • Have a wide motion, be generous in your excision and check that the distal edge of the nail is free.

Post Op Care

  • Pain is very limited, as the pressure from the nail has been relieved.

  • Healing comes from secondary intention: greasy dressings with soakings twice daily until complete healing.

Evolution

  • The freed nail seems to grow faster as it has been freed.

  • Healing from secondary intention occurs in about 2 weeks and even much faster in infants (Fig. 4.12c).

Complications

  • Poor post op care may result in infection.

  • Poor excision will result in recurrence.

Author’s Point of View

  • It is a very quick and safe procedure with very few side effects, especially in infants where it may even be performed after occlusion with EMLA cream for 2 h.

Tweedie and Ranger Flap

Indications

  • Hypertrophic lip of the great toenails in adults (Fig. 4.13a). Can be performed on one side or both sides of the great toenails. Not for ingrowing nails with transverse overcurvature.
    Fig. 4.13

    (a) Hypertrophic lip in an adult resulting from long standing ingrowing of the lateral fold (b) flap transposed and sutured (c) scheme illustrating the procedure

Expectations

  • Preserving the width of the nail plate.

  • Reported 92 % success of the technique, after a follow-up ranging from 18 months to 3 years, but only one publication exists on the procedure.

Material

  • Full nail ingrowing surgery tray

Procedure: (Fig. 4.13b)

  • Hemi or complete distal digital block, according if one or two sides are concerned.

  • The pointed extremity of a scalpel blade #11 is inserted vertically in the proximal part of the lateral nail sulcus, in order to have it reappear about 1 cm below on the lateral aspect of the toe, transfixing the lateral nail fold. The blade is then pulled straight distally to free a flap. The flap is transposed inferiorly, with the help of a Burrow’s triangle at the proximal inferior part of the incision. The excess of tissue at the inferior part of the flap is cut away. Suturing the flap ends surgery (Fig. 4.13c). A small defect remains for secondary intention on the upper lateral part of the nail.

Key Point

  • Having an enough large peduncle (1 cm at least) at the base of the transposition flap.

Post-op Care

  • Pain: severe. Flap transposition procedures are painful. Ensure proper analgesia with potent painkillers.

  • Greasy antiseptic dressings until complete healing.

  • Remove stitches after 10–15 days according to evolution.

Evolution

  • Healing is quick, as this is primary closure. The small upper part of that is left for secondary intention healing and will close in about 8–10 days.

  • Pain may result from pressure on the wound from adjacent toe. Wearing large sandals is best!

Complications

  • If the base of the transposition flap is not wide enough, there is a risk of necrosis. This may also occur in heavy smokers and patients with vascular impairment. If this happens, healing will occur by secondary intention. Beware of too tight shoes as pressure may impair vascularization of the flap.

Authors’ Point of View

  • In the author’s experience, this flap is painful, as are all transposition flaps and especially when performed on the richly innervated extremities. Amazingly, the only publication [81] mentions that the procedure was remarkably pain-free.

  • The cosmetic result shows a lowered down hypertrophic lateral folds, giving rise to a bilateral bulbous aspect.

  • No other publication has been released since the original one 30 years ago. A Turkish team has described an almost similar technique [82], called lateral fold plasty. The princeps publication is not mentioned in their references. They coupled it with partial excisional matricectomy in some severe cases. The issue is identical: lowering the hypertrophic lip.

  • Another variant of this procedure was described by Bose [83], by cutting away the proximal end of the flap and let the defect heal by secondary intention, which ends in fact to a unilateral super U.

  • Recently, Hashish et al. suggested a new technique preserving the matrix: it consists in performing a nail fold and nail plate excision followed by the elevation of a composite flap of nail bed and underlying periosteum which is then advanced over the defect. The technique was reported as highly effective in a 105 case-series study, with good cosmetic results and high patient satisfaction. No recurrent case was noticed over a 6 months to 8 years follow-up period [84]. The authors have not yet used this surgical procedure that appears to be a variant form of the Tweedie and Ranger’s flap. More data are needed to fully appreciate this technique.

Deroofing

Deroofing is a term that has been coined to describe the surgical removal of the upper surface of a canal or a cavity (fistule, abcess…).

Indications

  • The only indication in nail surgery is harpoon nail [85]. Here, the canal runs within the lateral nail fold (Fig. 4.14a).
    Fig. 4.14

    (a) Harpoon nail (b) a flutted probe is inserted in the canal (c) deroofing of the canal (d) showing the offending spur (e) as the nail plate showed a transverse hypercurvature on that side, a chemical cautery was performed to ensure definitive cure

Expectations

  • The main goal of the procedure is to open the canal to expose the long spur that skewers the distal lateral fold.

Material

  • Full ingrowing nail surgical tray

Procedure

  • Best is to introduce a fluted probe at the distal opening of the canal (Fig. 4.14b) and to incise its whole length with a blade resting on the probe (Fig. 4.14c).

  • The lateral parts of the roof are severed with fine scissors allowing complete exposure of the spur and lateral aspect of the nail (Fig. 4.14d).

  • The spur may be clipped away and the wound left for secondary intention healing.

  • However, this procedure very often demonstrates the overcurvature of the nail plate demanding a radical cure. An avulsion of a lateral strip of nail, corresponding to the width of the offending part of the overcurvature, followed by chemical cautery completes the procedure in most instances (Fig. 4.14e).

  • Another therapeutic option would be a wide debulking of the soft tissues (VandenBos’ or Super U procedure). A labiomatricectomy (wedge resection carrying out the lateral fold with the spur in its canal and the corresponding matrix) may also be performed, but has not the favor of the author’s because of the pain induced by the traction of the stitches.

Key Point

  • Be sure to perform a complete cure. In many cases, deroofing might not be sufficient, as harpoon nail is the consequence of a wide overcurved nail and treatment of the cause is mandatory.

Post Op Care

  • The one of chemical cautery (see p. 92).

Evolution

  • The one of chemical cautery (see p. 93).

Surgical Procedures on the Bone and/or Bed for Pincer Nails

Widening pincer nails has always been the aim of nail surgeons. Of course, a simple bilateral chemical cautery will relieve pain that is the main issue for the patient [86]. But the nail may appear much narrower. However in some cases, especially in younger patients, it is worth trying to alleviate pain but also to improve the cosmetic aspect of the nail. For this, several techniques are available. They consist either in flattening the bone and spreading the bed laterally or elevating the lateral horns of the matrix.

Flattening the Bone and Spreading the Nail Bed (Haneke’s Procedure, Suzuki’s Variant, Fanti’s Variant, Kosaka’s Variant)

These procedures stem from the pathogenesis of the pincer nails [87, 88]. The goals of each of them are twofold, even if they are achieved in different ways (Table 4.4):
Table 4.4

Comparison of the different procedures for flattening the nail bed

 

Haneke

Suzuki

Fanti

Kosaka

Complete avulsion of the plate

 

X

X

X

Chemical cautery of the matrix horns

X

 

X

 

Removal of bony dorsal distal tuft

X

X

X

X

Nail bed elevated in two flaps

X

X

X

 

Nail bed elevated in one flap

   

X

Removal of the distal and lateral fold

 

X

X

 
  1. 1.

    Suppression the distal dorsal bony tuft

     
  2. 2.

    Lateral expansion of the pinched nail bed

     

Indications

  • Pincer nails with a proven osteophyte on X-rays (Fig. 4.15a, b)
    Fig. 4.15

    (a) Painful thick pincer nail. Was thought to be onychomycosis and treated for so without any results (b) X-rays lateral view showing a prominent dorsal distal tuft (c) elevation of two lateral flaps of the bed reveals the distal tuft (d) after removal with a bone rongeur (e) after suturing the bed and expanding the bed with reverse tie over sutures

Expectations

  • Decreasing the pressure of the wide base of the terminal phalanx from the matrix horns. Taking the outward pressure of the wide base of the terminal phalanx away from the matrix horns will result in less uncurving of the proximal nail and thus less overcurving of the distal part of the nail plate. This alleviates pain immediately post operatively.

  • Flattening and enlarging the nail bed

Material

  • Tourniquet

  • Full ingrowing nail surgery tray

  • Bone rongeur

  • Absorbable suture 3/0

  • Absorbable suture 6/0

Procedures

Haneke’s Procedure

The aim of this technique is, at the same time, to narrow the nail plate with chemical cautery, remove the bony dorsal distal tuft and expand the nail laterally, by the use of special reserved tie-over sutures and plastic tubes to keep the nail bed stretched over the bone.
  • After bilateral cauterization of the matrix horns, an avulsion of the distal 2/3 of the remaining plate is performed.

  • A medial longitudinal incision of the nail bed is carried down to the bone from the margin of the remaining nail plate to the hyponychium. The osteophyte can be felt when the scalp run on the distal dorsal tuft.

  • Another transverse incision in the skin of the tip of digit, 0.5 cm beyond the hyponychium and perpendicular to the first one is performed, like an inverse “T”, allowing a full access to the underlying bone.

  • The nail bed is dissected from the bone, forming two flaps. Both are reclined laterally to expose the distal dorsal aspect of the bony phalanx (Fig. 4.15c).

  • The osteophyte is generously removed with a bone rongeur, flattening the distal phalanx (Fig. 4.15d).

  • The flaps of the nail bed are spread out using reversed tie-over sutures with 4/0 threads going from one lateral nail fold over the pulp to the other lateral nail fold and back again. These sutures are fixed at the volar aspect of the toe pulp. Thin rubber tubes may be inserted into the lateral nail sulci, over which these sutures are laid to avoid cutting of the threads through the paronychial tissue (Fig. 4.15e).

  • When the nail folds are pulled outward a triangular defect may appear, which is easily closed by an inward rotation of the inner margins of the nail bed flaps. The degree of rotation depends on the severity of nail bed pinching. When the hyperostosis is not too severe, a locked running suture may be sufficient to spread the bed.

  • The flaps are sutured to each other using 6/0 absorbable sutures.

Suzuki’s Variant

This technique is almost identical to the one of Haneke’s. The differences from Haneke’s technique are that: (1) there is no bilateral nail matrix cautery, (2) the nail plate is completely avulsed (3) the lateral nail folds and distal nail fold are cut away and (4) the two nail bed flaps are transposed and sutured laterally on the border of the wound resulting from the removal of the lateral and distal nail folds. The resultant triangular defect is covered by a free skin graft. An onycholytic area will develop at the place of the graft [89].
  • A complete nail avulsion is performed.

  • A “U” shaped excision of the lateral nail folds and distal fold is performed to create a space where the nail bed will be stretched laterally.

  • The first incision joins the medial to the lateral junction of the proximal–lateral nail folds and runs about 5 mm ahead of the boundaries of the lateral and distal nail sulcus.

  • The second incision parallels to the previous one but sticks to the borders of the nail bed.

  • Be careful to avoid removing the onychodermal band.

  • This periungueal tissue is removed in a “U”, in order to have a flat plan. Be sure to remove the depth of the lateral sulcus.

  • A medial incision on the nail bed, carried down to the bone, starting 2 mm distally from the lunula, extends to the hyponychium.

  • The nail bed is dissected from the bone elevating two lateral flaps.

  • The osteophyte is thus fully exposed and is removed with a bone rongeur.

  • Nail bed flaps are transposed laterally – one on each side – and sutured to the edge of the “U” with absorbable suture 5-0.

  • A running locked suture with absorbable suture 5-0 is performed around the distal incision of “U” to avoid bleeding.

  • This procedure creates a distal inverted “V” notch without nail bed. A free skin graft is harvested to cover the defect. This will allow coverage of the bone removal area. However, this will also impede regrowth of the nail bed with longitudinal ridges. This normal skin will be responsible for a small area of permanent onycholysis.

Fanti’s Variant

It is considered a variation of Suzuki’s technique [90]. The differences are that: (1) there is a bilateral nail matrix cautery, (2) the resultant triangular defect is left for healing by secondary intention. This is faster than a graft and resultant onycholysis is less likely.
  • After bilateral cauterization of the matrix horns, a complete avulsion is performed.

  • A complete nail avulsion is performed.

  • A “U” shaped excision of the lateral nail folds and distal fold is performed to create a space where the nail bed will be stretched laterally.

  • The first incision joins the medial to the lateral junction of the proximal–lateral nail folds and runs about 5 mm ahead of the boundaries of the lateral and distal nail sulcus.

  • The second incision parallels to the previous one but sticks to the borders of the nail bed.

  • Be careful to avoid removing the onychodermal band.

  • This periungueal tissue is removed in a “U” (Fig. 4.16a, b) in order to have a flat plan. Be sure to remove the depth of the lateral sulcus.

  • A medial incision on the nail bed, carried down to the bone, starting 2 mm distally from the lunula, extends to the hyponychium and the nail bed is elevated in two lateral nail flaps (Fig. 4.16c).

  • The osteophyte is thus fully exposed and is removed with a bone rongeur (Fig. 4.16d).

  • Nail bed flaps are transposed laterally – one on each side – and sutured to the edge of the “U” with absorbable suture 5-0.

  • A running locked suture with absorbable suture 5-0 is performed around the distal incision of “U” to avoid bleeding (Fig. 4.16e).

  • This procedure creates a distal inverted “V” notch without nail bed. Hemostatic foam is placed into the defect to limit the bleeding. It is left for healing by secondary intention (Fig. 4.16f).
    Fig. 4.16

    (a) Pincer nail with severe transverse overcurvature (b) After avulsion of the nail plate the lateral and distal wall are removed in a U shape shave exision (c) a medial incision starting 2 mm ahead of the lunula and extending up to the hyponychium is performed (d) the bed is elevated from the bony phalanx in two lateral flaps. The distal tuft of the matrix is removed, flattening the phalanx (e) nail flaps are transposed laterally and sutured to the edges of the U excision (f) outcome after 8 months

Kosaka’s Variant

This procedure is a bit more demanding and requires a skilled surgeon. The differences from the previous techniques are that the nail bed is elevated as a single flap and spread laterally [91].
  • After total nail plate avulsion, a W-shaped incision is made 5 mm ahead of the nail margins (Fig. 4.17a–d).
    Fig. 4.17

    (a) Pincer nail, upper view, note the triangular shape (b) front view, note the severe pinching (c) drawing of the W-shaped incision, front view (d) drawing of the W-shaped incision, upper view after nail avulsion (e) elevation of the nail bed as one flap, exposing the distal hyperostosis (f) after rongeuring the bony tuft (g) stretching the bed laterally over the flatten bony phalanx (h) the lateral walls are either de-epitheliazed or trimmed to fit to the new size of the bed (i) after suturing upper view, compare with a (j) after suturing front view

  • The nail bed is delicately detached from the bony phalanx, using a blade, fine sharp tipped-scissors or even the elevator. The main issue is not to pierce the nail bed during the procedure.

  • The whole nail bed is elevated as a whole, in a single flap, and reclined dorsally (Fig. 4.17e)

  • The exposed dorsally protruding osteophyte is removed with a bone rongeur or with a diamond burr, in order to render the dorsal aspect of the distal phalanx flat (Fig. 4.17f).

  • The lateral nail walls are de-epithelialized or shaved, and the bed stretched laterally (Fig. 4.17g) and sutured with 5-0 absorbable sutures (Fig. 4.17h, i).

Key Point

  • The nail plate must be left on place and firmly pressed onto its bed during chemical cautery to avoid sliding of cauterant under the plate that would induce overdestruction of the matrix for procedures where cautery is associated.

  • Bone removal should be generous but not excessive. It should allow a complete flattening of distal phalanx.

  • Nail bed is very fragile and should not be torn away during its detachment form the bone. Dissection should be delicate.

Post Op Care

  • Pain is severe to very severe due to the nail bed plasty. Potent painkillers should be prescribed at least for 2 days.

  • As the surgery involves the bone, prophylactic antibiotics should be prescribed. The authors favour azithromycine 500 mg, the day prior to surgery, the day of the surgery and the day after the surgery.

  • The wound is covered with a large amount of greasy antiseptic ointment and non-adherent dressing, completed by a bulky absorbent dressing. Replacement should occur after 2 days maximum as the wound may bleed and render the dressing sticky.

  • Elevation of the limb is mandatory.

  • Antiseptics soakings twice per day, completed by a thin layer of antiseptic ointment, are performed until complete healing.

  • Reverse sutures are left in place, as they are absorbable. Remaining stitches are removed after 4 weeks.

Evolution

  • Oozing will appear from the chemical cautery, if any.

  • Complete healing takes from 20 to 30 days.

  • A complete regrowth of the nail occurs in 9–12 months (Fig. 4.16f).

Complications

  • Reverse suture may drop. To prevent that, be sure that the reverse tie-sutures are fixed properly at the volar aspect of the toe pulp.

  • Delayed healing and infection may occur. It results from poor home care and bad hygiene. Patient should be well informed about the importance of the post operative cares.

  • Removal of the onychodermal band may lead to parrot’s beak nail, making trimming of the nail difficult.

Author’s Point of View

  • These procedures have very high success rate. They are adequate as they are directed toward the etiologic factors of the nail pincer. The nail may be not completely flat but the cosmetic aspect of the nail is highly improved. According to authors, the success rate is over 80 % for the Haneke’s procedure [87]. Suzuki, Fanti and Kosaka report high success rate but without quoting a rate.

  • These procedures often frighten old patients that just want to get rid of their pain and prefer a simple chemical cautery.

Elevation of the Lateral Part of the Nail Bed in Pincer Nail (Zook’s Procedure)

This technique was first described by Brown, Zook and Williams in 1998 during the Annual Meeting of the American Association for Hand Surgery and published in 2000. The aim of the procedure is to flatten the pinched nail bed by elevating the lateral nail bed with dermal grafts, preserving thus the nail matrix and the width of nail plate [92]. After 5 years Zook, Chalekson, Brown and Neumeister compared the use of autograft and homograft dermis. They showed that there were no significant differences in the appearance of the nail or relief of symptoms. However, surgical time was much less when homograft dermis was used [93]. Both techniques are considered as a good option for the treatment of transverse overcurvature of the nail [93, 94], but homograft dermis is not allowed in some countries.

Indications

  • All types of transverse overcurvature of the nail – pincer, tile or plicated nail (Fig. 4.18a).
    Fig. 4.18

    (a) Pincer nail, upper view, note the triangular aspect of the plate (b) after nail avulsion (c) after tunnelization under the lateral nail bed, a dermal graft is placed to elevate the nail bed (d) the same procedure is performed on the other side (e) immediate post operative aspect (f) after 9 months (g) after 2 years

Expectations

  • Flattening the nail bed through elevation of the paronychial folds by placement of dermal grafts.

Material

  • Full ingrowing nail surgery tray

Procedure

  • The procedure starts with a complete nail avulsion (Fig. 4.18b).

  • Two small oblique incisions are performed on the tip of the digit, in line with the most lateral aspects of the nail bed, large enough to get into a dental spatula or a fine scissor.

  • Using the dental spatula or a fine scissor, the paronychial folds are gently freed from the bony attachments bilaterally, to elevate the deformed paronychium on both sides, creating two tunnels between the nail bed and the underlying phalanx. Be careful not to pierce the nail bed.

  • When an autogenous dermis grafts is used, the donor area is chosen according to the thickness of the dermis and secondary scar. The intergluteal sulcus may be a good option as well as the thenar area of the hand [94].

  • A small incision is performed proximal to the eponychial fold.

  • A Bunnel straight triangular point with a nylon suture (5-0) is passed distally into the tunnel and out through the tip incision. The graft is placed through the needle and the thread. The needle is pulled proximally to the eponychium bringing the suture and graft into the tunnel, elevating the paronychial fold (Fig. 4.18c, d).

  • Any excess of graft is excised distally, if needed.

  • The incisions of the tip of the digit and eponychium area are sutured using a nylon 5-0 (Fig. 4.18e).

Key Point

  • Avulsion is mandatory in order to ease the tunnelisation under the bed.

  • The detachment of the lateral bed from the bone should be very delicate in order not to pierce the nail bed.

  • A straight needle (Bunnel needle) is required.

Post Op Care

  • Antiseptic ointment is applied on the surgical wound and covered with non-adherent gauze and a bulky dressing.

  • Expect severe post operative pain and prescribe potent painkillers

  • The dressing is removed after 1 day. The wound is then washed with antiseptic soap twice daily and covered with a greasy ointment.

  • Sutures are removed after 10 days.

  • Comfy shoes are a must for at least 1 month.

Evolution

  • The new nail grows flatter in about 9–15 months (Fig. 4.18f, g).

Complications

  • Infection is rare, but may be observed after traumas. In this case, antibiotics are prescribed.

  • A graft of insufficient size may be responsible for recurrence.

Author’s Point of View

  • This procedure is a good option to treat all types of transverse overcurvature, but requires a good training, especially for the tunnelisation step.

  • Homografting decreases the surgical time and avoid a scar in the donor area, but some countries do not authorize it for safety reasons.

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Copyright information

© Springer International Publishing Switzerland 2016

Authors and Affiliations

  • Bertrand Richert
    • 1
  • Nilton Di Chiacchio
    • 2
  • Marie Caucanas
    • 3
  • Nilton Gioia Di Chiacchio
    • 4
  1. 1.CHU BrugmannUniversité Libre de BruxellesBrusselsBelgium
  2. 2.Dermatology ClinicHospital do Servidor Público MunicipalSão PauloBrazil
  3. 3.Clinique St Jean LanguedocToulouseFrance
  4. 4.Hospital do Servidor Público MunicipalSão PauloBrazil

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