Nail Surgery
Nail surgery covers a group of specialist dermatology procedures for benign and malignant conditions and structural problems of the nail unit. A thorough knowledge of surgical anatomy and of techniques that protect the nail matrix is what prevents permanent nail deformity and keeps the risk of recurrence as low as possible.
Surgical Anatomy of the Nail Unit
The nail unit has five main anatomical structures that must be protected or handled precisely during any procedure:
- Nail plate: the hard keratin layer on top that shields the soft tissue beneath.
- Nail bed: the connective tissue under the nail plate, running from the lunula to the free edge, which anchors and supports the plate.
- Nail matrix: located at the base of the nail under the proximal nail fold, it contains the germinative cells that produce 80% of the nail plate's thickness. Injury to the matrix causes permanent scarring (pterygium) or grooves in the nail.
- Nail folds: the proximal fold and two lateral folds, which form a physical barrier against bacteria.
- Hyponychium: the area of skin linking the nail bed to the tip of the finger or toe.
Regional Anesthesia for Nail Surgery
Because the fingertip has a very high density of sensory nerve endings, nail surgery calls for precise regional anesthesia.
- Digital nerve block: the standard technique for all nail procedures. The doctor injects 2% lidocaine without epinephrine (or with epinephrine 1:200,000 if there is no peripheral vascular disease) on both sides of the base of the finger or toe to block each digital nerve.
- Wing block: used for minor procedures involving only one side of the nail fold.
- Bleeding control: a digital tourniquet placed at the base of the digit for less than 30 minutes keeps the field dry so the matrix can be seen clearly.
Common Nail Surgery Techniques
Partial Nail Avulsion and Matrixectomy
The main treatment for stage 2 and stage 3 ingrown toenails.
- Step 1: straight nail scissors are used to split off the 2–3 mm strip of nail plate that is digging into the lateral fold.
- Step 2: the strip is pulled free from the matrix without tearing the nail bed.
- Step 3: the matrix is destroyed chemically with 88% phenol, applied in 3 rounds of 30 seconds each, then neutralized with 70% alcohol. This brings the recurrence rate below 3%.
Nail Biopsy
Recommended for suspected pigmented lesions of the matrix, squamous cell tumors or atypical nail psoriasis.
- Matrix punch biopsy: a 3 mm punch is passed through the proximal nail fold to sample the matrix. Defects under 3 mm usually heal on their own without stitches.
- Longitudinal excision biopsy: a full-length strip is removed from the proximal nail fold through the matrix and nail bed to the free edge when melanoma in situ is suspected.
Subungual Glomus Tumor Excision
Recommended for glomus tumors under the nail that cause sharp pain with cold or light pressure.
- The nail plate is opened as a trap-door (book) flap or temporarily removed in full.
- The pinkish-purple tumor is exposed in the nail bed or matrix.
- The tumor is removed intact with its capsule and the nail bed is repaired with 6-0 absorbable sutures so the new nail does not grow back wavy.
Aftercare and Managing Complications at Haute-Derma
- Dressings: the digit is dressed with non-stick gauze and 2% mupirocin ointment. Patients keep the foot or hand raised for the first 24–48 hours.
- Preventing complications: we take care to avoid secondary infection, hook-shaped regrowth of the nail, nail bed scarring and adhesion of the nail fold.
