Ingrown Nail Surgical Procedures

 

When an ingrown nail does not respond to conservative care, an attempt may be made at a permanent correction of the problem through surgical means.  Surgical nail procedures have improved greatly over the years, and they may be designed to temporarily or permanently correct ingrown nail conditions.   Listed below are just some of those procedures.   


 


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:

Wedge Resection   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 anesthesia.  

Granuloma Excision  This 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 procedure.  

Skin Plasties  Skin 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

There are three families of procedures that permanently address nail conditions--"sharp" procedures, chemical procedures, and miscellaneous procedures.   

"Sharp" procedures

"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, it's probably safe to say that In the podiatric profession they are performed much more infrequently today than in years past because of their down side.   First, there is cutting involved, so they may create more scar tissue than other types of procedures, they may have a more noticeable post-operative appearance, they may hurt more and they physically remove the nail root from the bone, potentially increasing the odds of a bone infection.  

Suppan  This procedure involves freeing the skin behind the nail and removing the nail, then peeling away the root of the nail.  

Zadik Procedure  This procedure involves an incision that is angled at about 45 degrees from the nail border, and excising just the nail root.    

Frost Procedure  One 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  The 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  The 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  The 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 performed.  

Chemical Procedures

Simply put, chemical procedures attempt to permanently resolve an ingrown nail by chauterizing the nail root through the application of a strong chemical.  Because the root of the nail is not actually removed, chemical procedures are not really matrixectomies, though they are often referred to as being so. 

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 bone infection.  

The downside to these procedures is that they create a minor chemical burn in the area, so they tend to drain.  Soaking and bandage changes are usually prescribed.   

The most common names you might hear?  

Phenol  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 used today.   

P&A  The 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.  

Sodium Hydroxide  The second most common chemical method involves using the base known as Sodium Hydroxide.   Some practitioners believe it creates less drainage than phenol procedures.   

NaOH  Those 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.   

Miscellaneous Procedures

In addition to sharp procedures and chemical procedures, other techniques exist to address ingrown nails.  The two most common are listed below: 

Laser  Lasers can also permanently resolve nail problems.  Proponents suggest there is less post-operative discharge and less pain involved when lasers are used, but it has been my experience that when performed correctly, there is very little pain involved with most other procedures anyway.  In Canada, lasers are used relatively infrequently for this indication because of their high cost.  

Radiosurgery  Radiosurgical techniques can also be used to permanently resolve nail problems.  Much less expensive than lasers, radiosurgery offers the same benefit, namely less discharge postoperatively.    

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