Nail Surgeries and Procedures

What are nail surgeries and procedures?

Nail surgeries are performed to address various nail conditions, such as ingrown toenails, fungal infections, nail deformities, or even to remove a nail lesion or exclude a malignancy arising from the nail apparatus.

How do nail surgeries and procedures work?

A dermatologist often performs procedures such as surgical nail avulsion to alleviate discomfort, improve nail health, and restore normal nail function for patients who experience an array of nail-related concerns or injuries.

Some common nail surgeries and procedures include:

Surgical nail avulsion (with or without matricectomy)

Surgical nail avulsion involves the partial or complete removal of the nail from the nailbed, and it involves the following steps:

• Preparation: the affected area and surrounding skin are disinfected with an antiseptic to reduce the risk of infection.
• Numbing the area: the finger or toe is numbed with two injections, one on each side of the digit, to effect a digital block. This ensures that you feel no pain throughout the procedure.
• Removing the nail: once the finger or toe is numb, the edge of the toenail or fingernail is carefully lifted using specific tools. It is then cut and removed. The size of the cut depends on the condition or the scale of the injury or infection.
• Phenol Matricectomy (optional): Phenol Matricectomy is a chemical that destroys the nail matrix, which is where the nail grows from. If this is part of the treatment plan, it is applied after removing the nail. This step prevents the nail from regrowing and causing the recurrence of the same problem, e.g. ingrown nails.
• Dressing the toe: after removing the nail, the toe or finger is dressed with a light compression dressing to protect it while it heals.

Nail bed or nail matrix biopsies

A nail biopsy is conducted to determine the underlying cause of a nail condition, and it includes the following steps:

• Preparation: the biopsy area is disinfected with an antiseptic solution to prevent infections.
• Numbing the area: the finger or toe is numbed with two injections, one on each side of the digit, to effect a digital block. This ensures that the patient feels no pain throughout the procedure.
• Taking the sample: once the area is numb, a small tissue sample from either the nail bed or the nail matrix is removed. This will depend on the suspected diagnosis and its location.
  • A nail bed biopsy involves removing part of the nail and performing a direct shave biopsy from the nail bed.
  • In a nail matrix biopsy, part of the nail is removed, and two incisions are made along the nail fold to access the nail matrix before a shave biopsy of the affected area is performed.
• Replacing the avulsed nail: the avulsed nail is often just partially avulsed, and we will place it back in its original location so that it can act as a biological dressing and minimise discomfort.
• Closing the wound: pressure is applied to stop any bleeding, and a small bandage or adhesive strip is placed over the wound to protect it from infection or inflammation.
• Testing the sample: the collected tissue sample is sent to a laboratory for analysis. The results will be returned in approximately two weeks.

Chemical nail avulsion

A chemical nail avulsion, also known as medical nail avulsion, involves softening the nail and gently removing it by chemical means. It is typically used to treat fungal nail infections. It can also treat thickened nails in children, such as those with twenty-nail dystrophy.

Chemical nail avulsion includes the following steps:

• Preparation: the affected area is cleaned with an antiseptic to sterilise the skin and the nail and remove dirt or oil.
• Applying the chemical solution: a chemical solution containing urea is applied to the affected nail. The solution softens and breaks down the nail's proteins, making it easier to remove.
• Covering the nail: after applying the solution, the nail is covered with a dressing or an occlusive bandage. This helps keep the chemical in contact with the nail and enhances its potency.
• Waiting period: the patient must keep the dressing intact and return in a few days when the nail has considerably softened.
• Removing the nail: once it has softened, it can be gently scraped away from the nail bed.

Benefits of nail surgeries and procedures

• Improved nail function and appearance
• Relief from pain and discomfort
• Treats chronic conditions such as chronic ingrown nails or recurrent fungal nail infections

What conditions can nail surgeries or procedures treat?

Nail surgeries and procedures can address several nail-related conditions, such as:

• Chronic paronychia: chronic paronychia is a recurrent inflammation of the nail folds.
• Fungal nail infections: fungal nail infections are relatively common and are occasionally linked to fungal skin infections of the foot.
• Ingrown toenails: ingrown toenails occur when the side of the nail grows into the skin or flesh.
• Nail deformities: nail deformities or abnormalities may require a nail matrix biopsy to determine the cause of the deformities so that targeted treatment can be instituted.
• Longitudinal melanonychia: longitudinal melanonychia are pigmented streaks on the nail that may require a nail matrix biopsy if there is any suspicion of malignancy.
• Nail bed tumours or growths: nail tumours or growths resulting in pain or changes in the nail's appearance may require a biopsy to exclude malignancy.

What can I expect from nail surgeries and procedures?

While recovery time varies, most nail procedures are minimally invasive. As such, they require minimal downtime, allowing you to resume normal activities quickly.

However, the recovery period will depend on individual factors such as your adherence to post-operative care. This may include keeping the area clean, changing the dressings regularly, and avoiding activities that put pressure on the finger or toe. You may also be prescribed antibiotics to prevent infection and oral painkillers to manage discomfort during recovery.

Throughout the recovery time and for every nail procedure, it is essential to attend every follow-up so your dermatologist can closely monitor your healing process.

Frequently asked questions

Are nail surgeries or procedures painful?

At Lumine Dermatology & Laser Clinic, we perform nail surgeries by performing a digital block (which involves one injection at each side of the digit) to anaesthetise the nail completely. Once the digital block is effective, the procedure is often painless. Occasionally, soreness or a light throbbing pain may occur a few hours post-procedure. However, this is easily managed with oral painkillers and dressings. Oral antibiotics may also be prescribed after the procedure to minimise the risk of infection.

Will my nail grow back after the procedure?

Nails are remarkably resilient and typically grow back after a procedure. However, it may take 6-12 months for full regrowth to occur. The nail may not grow back completely normal for nail matrix and bed biopsies. If you have undergone a surgical nail avulsion with Phenol Matricectomy, your nail will not grow back at the sites where phenol was applied, which is the intended consequence of the surgery.

What are the chances of recurrence after I’ve undergone the procedures?

The chance of an ingrown toenail recurring after avulsion largely depends on the underlying cause of the ingrown toenail, the method of avulsion performed, and post-procedure care. If the ingrown toenail was due to external factors such as improper footwear, injury, or improper nail trimming habits, addressing these factors can significantly reduce the risk of recurrence.

The recurrence rate for patients who undergo a simple avulsion without matricectomy can vary. However, in procedures where a portion of the nail matrix is also treated (a process known as matricectomy), the chance of recurrence is significantly reduced.