Temporary Nail Procedures
At first glance, it may seem nonsensical to
attempt a temporary nail procedure. After all, why would anyone wish to
temporarily fix a nail condition when you could do it permanently?
Well, there are a couple reasons it may make
sense to try this sort of procedure. First, if there is nothing really
wrong with the nail, but the ingrown nail was caused by a one-time trauma, by
cutting the nail improperly or by some other one-time event, it may be quite
reasonable to address the acute problem temporarily in such a way that once the
tissues heal, the problem may not be likely to return.
A couple examples of procedures that fall into
this category are listed below:
This procedure simply aims to remove the offending portion of the ingrown nail
without touching the remainder non-problematic nail. Depending upon the
severity of the problem, this procedure may be performed with or without
procedure aims at removing the portion of skin that often grows up and over the
nail plate when ingrown nails are present. This abnormal growth of skin is
known as a Granuloma or Proudflesh,
and usually appears red, angry-looking (though they may be painless) and very
bloody. While a granuloma excision may performed as an isolated
procedure, it is frequently performed along with a permanent nail
plasties are techniques that primarily address an abnormal component of skin
that may be the cause of the problem. For example, a portion of skin may
be excessively large and the nail may continually grow into the skin.
Again, this may be performed as an isolated procedure or in conjunction with a
permanent nail procedure.
Permanent Nail Procedures
When we aim to
permanently remove a portion of a nail (or
an entire nail), there are numerous
techniques available to the podiatric
technique is the one we use most in our
Radiosurgical techniques can also be used to permanently resolve nail problems.
Radiosurgery creates less peripheral damage
to surrounding tissues than any other
technique, including laser. And nail
procedures typically heal faster than any
other technique as well, usually within
about a week or two.
Ingrown toenails of both sides
of the left great toe.
machine by Ellman
Further, there is substantially less
discharge than with other techniques, and
there is no scarring.
Unfortunately, this technique is not widely
known or used for nail conditions in the
podiatric medical or general medical field. This is too bad because this technique has
all the advantages and none of the
disadvantages of other procedures, and we
feel it is the best procedure currently available to treat this condition.
are similar to radiosurgery; they just use a different part of the
electromagntic spectrum. Laser procedures tend to heal quicker than
chemical or "sharp" procedures (discussed below), but not quite as fast as with
The main downside to laser is the cost. It is typically the most expensive
Simply put, chemical procedures attempt to
permanently resolve an ingrown nail by chauterizing the nail root through the
application of a strong chemical.
In theory, any chemical strong enough to
chauterize the root of the nail without adversely affecting the patient could be
used, but the most common chemical techniques are listed below.
The advantage of chemical procedures are that
they are known for being
relatively painless; there is typically no scalpel used in these
procedures, so there is little scarring, and so they also tend to look very nice
after they are completely healed; and chemical procedures don't denude the
covering from the underlying bone, which diminishes the odds of a post-operative
The downside to these procedures is that
they create a minor chemical burn in the area, so they tend to drain, often for
four weeks or longer.
Soaking and bandage changes are usually prescribed.
The most common names of
chemical agents you might hear are:
The phenol procedure involves applying an acidic chemical
known as phenol to the root of the nail. (See diagram to the right
for an image of phenol's chemical structure.) This is probably the
most common chemical procedure by podiatrists to treat ingrown toenails,
and it has the benefits of providing no scarring and minimal pain.
The main downside to the phenol procedure is that it drains for several
P&A procedure is short for "Phenol and Alcohol", because alcohol
is commonly used at the end of the phenol procedure to wash away any remaining
phenol. So a P& A is the same as a phenol procedure.
second most common chemical method involves using the base known as Sodium
Hydroxide. Some practitioners believe it creates less drainage than
of you who have studied chemistry may recall that NaOH is the chemical
abbreviation for sodium hydroxide, so the NaOH procedure is the same as
the Sodium Hydroxide procedure.
"Sharp" procedures are known by that
name because they all have in common the use of a scalpel
to excise a portion of the nail root. Because the nail root is being cut
out, or "excised", this family of procedures is properly known as
known as matrixectomy procedures, with the suffix
"-ectomy" meaning "excision". A matrixectomy may
either be a partial matrixectomy, when only a
portion of the nail root is removed, or a total or complete
matrixectomy, when the entire nail root is removed.
Compared to chemical procedures, sharp
procedures have the advantage of looking better immediately after the procedure,
and they typically have less drainage.
While sharp procedures are still performed
frequently by other medical professionals, particularly in an emergency room or
in the family physician's office, it's probably safe to say that In the
podiatric profession they are performed much more infrequently today than in
years past because of the down side to these procedures:
First, there is cutting
involved, so they may create more scar tissue than other types of procedures, so
they may have a more noticeable post-operative appearance. Further,
recurrence rates are usually higher, and they may hurt more
post-operatively. And because these procedures physically remove the nail root from the bone,
they potentially increase
the odds of a bone infection.
Here are some of the more common "sharp" nail
procedure involves freeing the skin behind the nail and removing the nail, then
peeling away the root of the nail.
procedure involves an incision that is angled at about 45 degrees from the nail
border, and excising just the nail root.
of the older "sharp" procedures, the Frost involves making an
"L"-shaped incision behind the nail plate, peeling back the soft
tissues to expose and excise the nail root and any abnormal soft tissue
associated with it.
Winograd procedure involves a "D"-shaped excision of the nail root and
overlying soft tissues. Not so aggressive as the Kaplan procedure, the
Winograd may be a good choice when sharp procedures are considered.
Kaplan procedure may be the most well documented nail procedure in the
literature. It involves an "H"-shaped incision and requires the
excision of both the nail root and the nail bed (the soft tissue upon which then
nail rests). This procedure may still be indicated in cases where
the bone underlying the nail is involved, but this procedure is more aggressive
then necessary for the vast majority of ingrown nails.
Terminal Syme procedure is basically an amputation of the tip of the
toe. I'd like to say this procedure is rarely done any longer for
routine ingrown nails, but from time to time, I still see people who have had
this done. There are very few indications for this procedure to be