Copyright (c) 2010 Bruce Lashley
Ingrown toenails can be caused by abnormal nail structure, irritation and pressure from poorly fitted shoes, and most commonly by improper nail trimming where the corners of the toenails are rounded off. Once the nail begins to grow into the skin, the body will begin to treat the nail as a foreign object, which results in pain and redness in the soft tissue on the side of the nail. If left untreated, the ingrown nail can begin to cut into the skin, which can lead to a skin tissue infection with oozing or a granuloma formation. (Granuloma is tissue around the ingrown toenail that is red, moist, and increases in size.)
Non-Surgical Treatment: If the ingrown nail is at the end of the toe, a simple procedure called a partial wedge resection (also called a slant back procedure) can be performed. This is performed by using a nail clipper in a slanted approach to clip off the offending portion of nail. Proper subsequent and routine nail trimming after a partial wedge resection can prevent the ingrown nail from recurring in most cases.
Surgical: In most cases, simply removing a wedge of nail at the tip does not completely resolve the problem, especially if the toenail is severely embedded within the skin.
Surgical procedures for treating ingrown nails are performed in the office. With the exception of the injection to deliver the local anesthetic, there should be no pain during the procedure. There are two major ways to remove the nail surgically. The first is a complete or partial nail removal. In this case the nail will grow back over the course of the next 9 to 12 months. In most cases as long as the causing factor (e.g. improper nail cutting or tight shoes) is avoided, the ingrown nail should not reoccur.
The second method is a partial or total chemical matrixectomy. With this method, a portion of the nail or the entire nail may be removed permanently. The nail matrix is a thin tissue layer under the nail fold that produces new nail; when this tissue is removed the nail no longer grows.
Nail Avulsion: In this procedure, the nail root, known as the matrix and found beneath the cuticles, is left alone. This will allow the nail to completely grow back. This procedure requires a local injection to numb the toe, a specially designed nail splitter to separate the nail from the nail bed, and a small clamp to remove the nail.
Local injection: Local anesthetic is injected into the toe to numb the area around the nail. The injection is not performed at the location of the ingrown nail but is injected at the base of the toe. Most patients describe the injection as a burning and stretching sensation.
Nail Removal: Once the toe is adequately numbed, the attachment of the nail to the soft tissue and cuticle is released. The portion of nail to be removed is then spilt from the nail plate using a blade and nail splitter. This is followed by removal of the nail with a thin clamp. Antibacterial cream is applied to the area, and the toe is dressed with bandages. It may take the toenail about 8 to 10 months to grow back to its original length.
Partial Chemical Matrixectomy/Total Chemical Matrixectomy: In this procedure, the nail root/matrix is removed chemically using either phenol or sodium hydroxide. This prevents the nail from growing back. The local anesthetic injection is performed using the same technique as in the above described nail avulsion procedure.
After the toe is adequately numbed, a tourniquet is applied around the toe to prevent blood flow into the area. Preventing blood flow prevents diluting the phenol or sodium hydroxide solution and keeps the chemicals strong enough to adequately destroy the nail root/matrix.
Nail Removal: When performing a “partial” chemical matrixectomy, a blade and nail splitter is used to cut out a portion of the nail. The blade and the nail splitter are applied to the end of the nail and gently pushed down through the nail plate to the cuticle. A fine-jawed clamp is used to remove the portion of the ingrown nail. Until this point in the procedure everything is the same as performed in the nail avulsion. Next a Q-tip with phenol or sodium hydroxide is inserted in the area deep and beneath the cuticle to kill the nail root. This procedure destroys the nail root on the side of the ingrown nail and allows the remaining nail to grow as usual.
If a “total” chemical matrixectomy is performed, the entire nail will be removed and the phenol or sodium hydroxide is applied to the entire area beneath the cuticle. In this case, the entire nail will not grow back.
Surgical Cautions and Complications: It is possible that all or part of the ingrown nail that was treated with the chemical may grow back. Since a chemical matrixectomy is a chemical burn, this procedure will cause mild draining during the healing process. This procedure creates a burn that is not suitable for patients who have poor healing or poor blood flow.
Post-Op Management: Between the time of the surgical procedure and the next appointment, Amerigel should be applied to the wound to aid in the healing process. While this wound is healing, it is expected to have mild drainage from the area with mild redness and swelling. Additionally, there may be some soreness, which can be alleviated with pain medication like Tylenol. Usually after the surgical removal of an ingrown nail, a follow-up appointment is scheduled in order to perform proper wound care to the surgical site and monitor the outcome of the ingrown nail removal.