Nail surgery
Introduction
Apart from nail avulsions, nail surgery is performed relatively infrequently in clinical practice. This is surprising, as general practitioners, surgeons, hand and plastic surgeons, and orthopedic surgeons, as well as dermatologists, take care of nail disorders, although with variable degrees of basic knowledge and skills. Nail surgery is generally thought to be difficult and demanding, but this is not true if one has understood the anatomy, biology, and pathology of the nail and has acquired some skills in dermatologic surgery. The results of skilled nail surgery are generally very rewarding.1., 2.
Section snippets
Patient preparation
As with any surgical treatment, the keys to success include patient selection, a working diagnosis, and patient preparation. A thorough patient history helps to avoid unnecessary complications and will identify potential contraindications. Acute infections and serious impairment of the peripheral arterial blood supply should be treated prior to a surgical intervention. Drugs may interfere with anesthetics or antibiotics deemed necessary before, during, or after surgery. Preoperative
Disinfection and anesthesia
Disinfection is extremely important in order to avoid contamination of the wound with consecutive infection. Isopropyl alcohol scrub and chlorhexidine have proven to be superior to povidone iodine washing.3
Good anesthesia is of paramount importance. Although any local anesthetic can be used, ropivacaine 1% is the author’s preferred drug, as it has a rapid onset of action and a long duration, usually between 8 to 12 hours, sometimes even longer. This is highly appreciated by “experienced”
Diagnostic biopsies
Histopathology is the gold standard for the diagnosis of nail disorders,8., 9. but surprisingly, diagnostic nail biopsies are performed only rarely. Even nail clippings give valuable information for the diagnosis of onychomycosis and ungual psoriasis. A punch biopsy is good for nail bed and matrix diseases, but in the matrix, the punch should not be bigger than 3 mm in diameter.10
Fusiform biopsies of the nail bed have to be oriented longitudinally, whereas those of the matrix must be oriented
Nail avulsion
Nail avulsion is rarely indicated, although often performed when the consulted physician has no idea what to do. It is almost never a treatment per se. Many different techniques have been described that are often seriously traumatizing to the entire nail organ. The use of a sturdy hemostat clamp that is run under the nail, closed, and then rotated to tear the nail from the matrix and nail bed is obsolete. Using a nail elevator is less traumatizing: It is gently inserted under the proximal nail
Paronychia
Acute paronychia is usually a painful bacterial infection resulting from a break in the skin, a prick of a thorn, or a splinter. When neglected, it may lead to severe finger deformity.16 Often, a superficial abscess can be identified. It can be drained with a #23 or #21 gauge needle by lifting the nail fold with the tip of the needle. Copious disinfection with chlorhexidine solution and/or methylated spirit is added. A short course of oral antibiotics may be given, although there is no report
Trauma
Injury of the distal digit frequently presents with typically different patterns between fingers and toes. A common mechanism is the crush injury of the fingertip in a door (Figure 2). This is not only exceedingly painful but may also cause a fracture of the distal phalanx, with more or less pronounced posttraumatic nail dystrophy. A general rule is that when the hematoma occupies more than 50% of the nail field, a fracture is likely. In case there is no dislocation of the bone fragments, the
Onychogryposis
The ram’s-horn–like thickening of the nail is called onychogryposis. It is mainly seen in debilitated and elderly individuals. The nail grows up instead of out and may even cause a pressure sore on the nail bed or perionychium. The patient can no longer cut his nail, which has become a nuisance. Nail avulsion is difficult from the distal aspect but very easy with the proximal approach.
Ingrowing nails
This is one of the most frequent ailments and often considerably decreases the quality of life. There are hundreds of different treatment approaches, some of which work, while others do not.22 Table 1 gives an overview of the various forms of ingrown nails, ranging from neonatal to old age.
Ingrowing toenail in infancy
There are three kinds of ingrowing toenails presenting in infancy before the age of 2 years.
- 1.
Distal toenail embedding with normally directed nail. This is sometimes seen in neonates. Conservative management by gently massaging the distal nail wall in distal-plantar direction is the treatment of choice. In those rare cases where permanent improvement has not been obtained by 1 year of age, a circular soft-tissue resection may be performed in an identical manner as in adults.23
- 2.
Congenital
Juvenile ingrown toenail
There is virtually always an imbalance between the width of the nail plate and that of the distal portion of the nail bed.27 Overcurvature of the nail plate is an aggravating factor.28 Additional factors are medial rotation of the toe, thinner nails and thicker nail folds, sweating, convex cutting of the nail, and pointed-toe and high-heeled shoes.29
Clinically, three stages are differentiated:
- 1.
Erythema, edema, and pain on pressure
- 2.
Purulent drainage and infection
- 3.
Purulent granulation tissue and
Pincer nails
Distally increasing transverse overcurvature of the nails are called pincer, tube nails, or ungues constringentes. In most cases, the big toenails are symmetrically involved, combined with a lateral deviation of the long axis of the nails. When the lesser toenails are involved, they are deviated medially. This is a congenital and in many cases undoubtedly hereditary condition. Systemic X-ray examinations have shown that, in addition to deviation, basal lateral and medial osteophytes exist that
Verrucae
Common warts are benign infectious lesions due to human papillomavirus (HPV) strains of various types. They are very common in children but may occur at any age. In the beginning, they present as small round rough-surfaced hyperkeratotic nodules. With time, they may attain a size of up to 10 to 20 mm in diameter and become fissured. When located at the lateral nail folds, they are usually oval. Under the nail, they will elevate the nail plate. Under the proximal nail fold, they cause a
Ungual fibrokeratomas
Fibrokeratomas of the nail region are relatively frequent and may arise from periungual skin, under the proximal nail fold, in the matrix, and in the nail bed. Each of them has a particular clinical appearance, although they are histologically identical. Acquired fibrokeratomas are solitary lesions, but they occur in large numbers in about one half of the patients with tuberous sclerosis complex, sometimes as the only clinical sign. Independent of their origin, their removal requires cutting
Digital myxoid pseudocyst
This is the most frequent pseudotumor of the nail region. It appears as a dome-shaped, skin-colored to transparent lesion in the proximal nail fold, measuring between 4 to 10 mm in diameter. Characteristically, it causes a longitudinal depression in the nail plate due to pressure on the matrix. Spontaneous rupture into the nail pocket is not uncommon and leads to irregularities in the canaliform nail depression. Two theories as to its pathogenesis exist: (1) it may represent a localized
Subungual exostoses
These commonly develop at the medio-dorsal tip of the terminal phalanx of the hallux elevating the nail plate. They can be palpated as a stone-hard tumor. A radiograph is taken to determine the extent of the lesion (Figure 8). The overlying skin is incised, the exostosis dissected, and generously clipped off at its base with a nail clipper or bone rongeur. If the lesion is located more proximally under the nail plate, this is partially avulsed to permit access to it. When the skin overlying the
Subungual glomus tumor
Glomus tumors are rare but very well known hamartomas of the hand, particularly of the nail apparatus. Intense pain is characteristically elicited by probing or by inadvertent shock. Subungual glomus tumors are seen as a 5 to 8 mm large round to oval violaceous spot causing a longitudinal erythematous band. They are extirpated via the lateral aspect of the phalanx when they are located in the lateral third of the nail bed or matrix. An L-shaped incision is performed and the nail bed dissected
Bowen’s disease and squamous cell carcinoma
Both Bowen’s disease and squamous cell carcinoma of the nail region may be summarized under the term of epidermoid carcinoma. They constitute the second most frequent nail malignancy. Clinically, Bowen’s disease usually appears as a hyperkeratotic warty or macerated plaque in the lateral nail groove, on the nail folds, or under the nail. As its margins are often ill defined, it is excised according to the criteria of Mohs micrographic surgery. If the defect is no wider than half of the nail, a
Ungual melanoma
Melanoma of the nail apparatus is probably the most frequent malignant nail neoplasm. Two thirds to three quarters are pigmented, most of them causing a longitudinal melanonychia. Nail-bed melanomas are often amelanotic and do not cause a pigmented band. Brown streaks in the nail are treated according to their location in the nail: Laterally positioned streaks are treated by a lateral longitudinal nail biopsy; median ones by a punch or fusiform biopsy or horizontal excision.13
When the diagnosis
Complications of nail surgery
Proper patient examination prior to nail surgery and correct technique usually avoids the commonest complications and rules out high-risk patients. Bleeding is usually no problem, even though it occurs after releasing the tourniquet. The tourniquet must, however, not be left for more than 20-30 min; for longer operations, it is released every 20 min. The individual pain threshold varies considerably. Preoperative sedation is helpful. During operation, pain is due to poor anesthesia. The
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Ultrasound of nails: why, how, when
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2021, Actas Dermo-SifiliograficasNail Surgery: Six Essential Techniques
2021, Dermatologic ClinicsCitation Excerpt :The use of lidocaine with epinephrine has historically been frowned upon in digital surgery because of a theoretic risk of ischemia and subsequent necrosis; however, in the absence of contraindications, the literature supports its use safely in digital blocks.7,8 Nevertheless, ropivacaine appears to be the ideal choice for digital anesthesia because of its mild vasoconstrictive properties, its long duration of effect postprocedurally, and its relative lack of adverse effects.9 Buffering to physiologic pH can decrease pain with injection and is most commonly done with lidocaine.
A rare case of a subungual epidermoid cyst treated by surgical excision maintaining maximal functionality
2021, JAAD Case ReportsCitation Excerpt :Even if the origin is suspected to be benign, surgery is usually needed because of pain or functional limitations. Knowledge of the anatomy and physiology of the nail unit, combined with minimally invasive techniques, will help to avoid permanent damage, ranging from dystrophic growth to complete nail loss.2 A 54-year-old man consulted our dermatology outpatient clinic with a 1-year history of a slowly growing dystrophic nail plate of the left thumb that was sensitive to pressure.
Recommendations for the definition, evaluation, and treatment of nail psoriasis in adult patients with no or mild skin psoriasis: A dermatologist and nail expert group consensus
2019, Journal of the American Academy of DermatologyCitation Excerpt :Last, in the case of coexisting PsA, the treatment of choice for nail psoriasis should be a systemic agent indicated for the treatment of PsA, even in cases of a few-nail disease. Under the principles of these statements, the following recommendations should be taken into account (Tables II-IV).19-28 Nail psoriasis publications have become numerous over the past decade.