Clinical REVIEW

Toenail surgery: Indications,

options and techniques
Ian Reilly

The hard nail plate forms the majority of the nail unit apparatus. There are many disorders of the nail
unit that may require a surgical approach, with the ingrowing toenail being the most common. The
condition occurs when the nail plate punctures the sulcus, giving rise to pain and inflammation. When
the nail does this, attempts at healing lead to the formation of hypergranulation tissue and secondary
infection. The condition can be staged as 1, 2 or 3, with nail surgery often required for more advanced
and chronic presentations.

Nail surgery for permanent removal of part or all of a nail unit can be performed via incisional or
physical ablative techniques. Currently, the most regularly performed technique in the UK is chemical
ablation, with the phenol-alcohol technique by far the most popular procedure under this heading. The
author will discuss partial and total avulsion techniques using phenolic nail matrix ablation, and place
these within the overall phases of surgery. Brief mention will be made of incisional techniques, with a
case study at the end of this article to prompt further thought and discussion.

Reilly I. Toenail surgery: Indications, options and techniques. Dermatological Nursing 2021. 20(1):10-18

Introduction such as hyper-curvature (involution) of

The hard nail plate forms the majority the nail plate can be a cause of pain and
 of the nail unit apparatus. The nail plate discomfort (Figure 1). Onychauxis and
 extends from the nail matrix (also called onychogryphosis are disorders of the nail
the root), emerges at the proximal nail that involve thickening (hypertrophy) and
 irregularity of the nail plate.1 The distal
fold (PNF), and reaches to the distal free
 edge or hyponychium via the nail bed to digit is also prone to an array of benign
 which it attaches. The majority of the nail neoplasia, notably subungual exostoses
plate is produced by the germinal matrix, and periungual fibromas (Figure 2),2 but
which extends for several millimetres the most common nail pathology that
Declarations proximal to the PNF. As the nail plate might require nail surgery is the ingrowing
This article did not receive any grant emerges and grows across the nail bed, toenail (IGTN),3,4 which will be the main
from funding agencies in the public, additional material derived from the pathology considered below.
commercial, or not-for-profit sectors. nail bed is added to the nail plate, which
The author has no competing makes the plate thicker.1 The ingrowing toenail
interests to declare. Organisation The IGTN – onychocryptosis (onycho
ethical approval was not required There are many disorders of – nail; crypt – hidden) is one of the
but consent for publication was the nail unit that may benefit from most commonly seen and disabling foot
given from the patients whose a surgical approach. Some patients problems encountered in the general
pictures are presented. with onychomycosis may benefit from population (Figure 3). 5,6 The condition
removal of part or all of the whole nail occurs when the nail plate punctures
Acknowledgements plate. Various dystrophic conditions the sulcus, giving rise to pain, and
The author wishes to thank the inflammation.7 This may be predisposed
College of Podiatry who kindly by a wide nail plate or from hypertrophy
Ian Reilly is a Consultant Podiatric
allowed the author to build this of the peri-ungual tissue. Most commonly,
Surgeon at the Department of Podiatric
article from a Continuing Professional the great toe is involved, but it may also
Surgery, Northamptonshire Healthcare
Document on nail surgery they involve the lesser toes.8,9 This break in the
Foundation NHS Trust, Danetre Hospital,
commissioned from him in 2019. continuity of the skin provides a portal of
Northamptonshire.

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 Clinical REVIEW

entry for micro-organisms and therefore adolescents and young adults with a 2:1 Presentation
secondary infection is often seen male:female ratio, but the condition is The clinical presentation of an ingrowing
accompanying IGTN. seen in all age groups.6 In adolescence, toenail was divided into three stages by
the feet are more prone to sweating Heifetz in 193713 as:
When the nail punctures the skin, causing the skin and nails to become soft
attempts at healing lead to the formation and more liable to splitting.4,8 In older  Stage one: some inflammation,
of hypergranulation tissue. This continues people, the problem is usually chronic swelling, and pain (Figure 6)
to be produced until the splinter of nail and may arise as a result of a reduced  Stage two: more inflammation, pain
is removed.10 This hypergranulation ability to self-care and/or impaired vision and granulation tissue (Figure 7)
tissue now complicates the painful IGTN, in combination with age-related nail  Stage three: abscess formation and
typically accompanied by a chronic thickening, all leading to nail ingrowth.3 chronic induration of the nail fold
paronychia and nail fold hypertrophy.11 Sensory neuropathy – failing to sense (Figure 8).
In neglected cases the sharp edge of early problems, and ischaemia –
nail can exit the apex of the toe, further leading to frailty of the tissues, put the Treatment options
increasing the ingress of micro-organisms elderly and/or individual with diabetes More current staging systems now
(Figures 4 and 5). at increased risk of developing nail exist,12,14 which may be useful to help
penetration and infection.4,9 guide treatment (see Table 1 for a
Cause summary). Haneke provides a succinct
The condition is caused by a combination overview of the controversies in the
of extrinsic and intrinsic factors, such Various dystrophic treatment of ingrown nails.15
as improperly trimmed nails, poorly conditions such as hyper-
fitting shoes, tight socks, excessive curvature (involution) of For stage 1 cases, conservative
sweating, soft tissue abnormalities of the nail plate can be a cause treatment in the form of basic nail
the toe, and underlying nail deformity.8,12 care and footwear advice may be
of pain and discomfort
IGTNs are most frequently seen in adequate to relieve the symptoms.12
Nail avulsion without phenolisation has a
70% recurrence rate16 and is therefore
generally discouraged, but may be
indicated for:

 A singular IGTN event with no

underlying nail pathology
 Removal of fungal nail in preparation
for antifungal treatment
 Patients with poor healing capacity
where use of phenol is contra-
indicated.

Eekhof et al7 suggest that surgical

Figure 1. Figure 2.
interventions are more effective than
Involuted nail Periungual fibroma

Figure 3.
Ingrown toenail Figures 4-5.
(from IReilly and Associates, with permission) A spike of nail that pierced the skin and exited the skin

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Clinical REVIEW

Figure 6. Figure 7. Figure 8.

Stage 1 Stage 2 Stage 3

non-surgical interventions in preventing individual to take personal responsibility

the recurrence of an ingrowing toenail. Table 1. for this.
Therefore, if conservative care fails – Treatment options by stage – summary
or is not appropriate – definitive nail The phases of surgery
surgery may be considered. Chapeskie Stage I: Erythema and swelling of the lateral nail fold. The process of surgery can be broken
and Kovac16 suggest that any surgery These usually respond to non-operative treatments: down into three distinct phases:
should be technically simple, cost  Reshaping of the nail profile with patient advice the pre-, intra- and post-operative
effective and yield good cosmetic for self-care phases. These phases are collectively
results with low recurrence rates and  Packing of nail edge with cotton wool known as the peri-operative period
low complication rates. The procedure  Taping back of the surrounding tissue and may overlap and vary in relative
should ideally be carried out on an  Use of an interdigital spacer to reduce pressure importance, depending on the
outpatient basis with a quick return to from tight digits. individual patient and the nature of the
normal activities. planned surgical procedure.19 Whilst
Stage II: Infection with accompanying oedema and nail surgery would be considered
Nail surgery drainage. minor in nature, the overall results of
Nail surgery techniques for permanent Some authors postulate that stage I treatments surgery still depend upon the effective
removal of part or all of a nail can be combined with antibiotic therapy may resolve the assessment and management of each
considered under two categories17: problem. If not, surgery is often required. phase. Remember the mantra: there is
 Excision of the pathological nail nothing so trivial that cannot be made
Stage III: Chronic infection characterised by
and/or soft tissue using sharp worse with surgery. The steps in the
hypertrophy of granulation tissue.
instrumentation (cold steel peri-operative assessment process are
This mass of tissue overlies the nail and bleeds easily
procedures) detailed in Table 2.
if traumatised. Surgery is the treatment of choice at
 Destruction of the pathological tissue
this stage.
by physical means such as topical Pre-surgical assessment
chemotherapy (phenol, etc), freezing, The purpose of the preoperative pre-
electro-galvanism or lasering. the UK is chemical ablation, with the surgical assessment is to:20
phenol-alcohol technique by far the  Review the history of the presenting
Nail surgery procedures are most popular procedure.4,7,9 The clinician illness or complaint
carried out by podiatrists, podiatric undertaking nail surgery must develop  Review the major systems of the
surgeons, general practitioners (GPs), and maintain competence in these body and ascertain whether these
extended scope nurse practitioners, procedures and be fully cognisant of nail systems are functioning within
dermatologists, general surgeons anatomy, nail surgery instrumentation, normal limits and, if not, to facilitate
and orthopaedic surgeons, though the appropriate peri-operative the management of this
techniques – and outcomes – vary.15,18 evaluation and care. They should have  Arrive at an informed
Anecdotally, GPs favour simple avulsion received the necessary training and position regarding the medical
without nail matrix destruction, while supervision to be able to reflect on and appropriateness of the planned
UK medical-surgical colleagues more evaluate their competency. They must surgical procedure
often utilise incisional procedures such be able to demonstrate this competency  Identify any factors that may
as the Zadik procedure. Currently, the and have the necessary skills to perform contraindicate surgery or place the
most regularly performed technique in nail avulsions.14 The onus is on the patient ‘at risk’.

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The implied question is always: will vascular status and the findings of any important to discuss with the patient
the toe heal after nail surgery? The tests carried out, e.g., blood pressure, all common complications and risks
typical adolescent IGTN is unlikely to palpation of pulses, capillary refill, etc. associated with the procedure. The
be a medical challenge but a systematic patient should be provided with written
approach to history taking will ensure Consideration over the range of details of the risks and evidence for
that the practitioner covers all relevant medical pathology that might impact on treatments offered. Special attention
areas in the enquiry process.21 Findings decision making is outside the scope of should be given to consenting children
recorded with this system (Table 3) will this document, but for example, planning and those with reduced capacity. The
determine the need for further clinical for the diabetic patient undergoing process of nail avulsion should be
or laboratory investigation and indicate nail surgery should begin with a fully explained to the patient, in order
the patient’s suitability for a range of discussion about glycaemic control, to obtain Montgomery-complaint
treatments. The clinician will decide anti-diabetic medication and a history informed consent.23 This information
which headings/factors are relevant to a of neuropathy/ischaemia.22 Poor pre- should be recorded in the patient’s
particular patient (see case study). operative glycaemic control is strongly notes. Information about the procedure
associated with impaired healing, and must be explained clearly in terms that
The functional systems enquiry may most guidelines advise that patients the patient can understand. It is good
then be completed, again using the with diabetes undergoing surgical practice that the patient relays this back
CRAGCEL format, but with emphasis procedures should have an HbA1C to you, so that you are sure they have
on the peripheral circulation. With the value of below 9%/75mmol/mol.3 High- understood the information you have
threat of clinical negligence ever present risk diabetic patients, however, should provided. This should all be documented
it important to note the peripheral be appropriately classified and suitably in the patient record, backed up
managed in conjunction with a specialist by a (document-managed) patient
foot protection team as appropriate. information leaflet (PIL).
Table 2.
The peri-operative assessment process For the patient to consent to the At the end of the assessment, the
procedure, they must be informed practitioner will have an opinion in their
Pre-operative of all eventualities associated with mind as to whether the patient is fit for
Information from the primary patient assessment the procedure and the reasons surgery, with patient suitability for nail
 What is the diagnosis? that this treatment option has been avulsion demonstrated in the patient
 What are the important facets of the history? recommended by the practitioner. It is record. This will allow the practitioner
 What further investigations are required? to proceed knowing that the risk of
 Health status and fitness for surgery encountering an intra- or post-operative
 Is the patient fit for the planned surgery? Table 3. complication has been reduced to a
 Are there any concomitant diseases that minimum, and that any future complaint
Pre-surgical history could be defended.
increase the perioperative risk?
 Is the patient taking any medication that could Part 1. The medical history
influence the surgical outcome? Intra-operative considerations
 Current health status Correct site surgery
 What medical management is required?  Past and current medication The concept of ‘Never Events’ was
Intra-operative  Past medical history introduced into the UK in 2009 with
The anaesthetic a list of eight adverse patient safety
Part 2. Family history
 Local, regional or general anaesthetic? events, and a definition of “serious,
 If local - which technique will be used – field, Part 3. Personal social history largely preventable patient safety incidents
digital, ankle, other?  Home circumstances that should not occur if the available
 The operation  Occupation preventative measures have been
 What is the aim of surgery?  Sports and hobbies implemented”. Amongst the original eight
 What is the surgical plan?  Foreign travel Never Events is ‘wrong site surgery’. The
 Does the surgery itself pose any special National Safety Standards for Invasive
Part 4. The systems enquiry – CRAGCEL(D)
problems? Procedures (NatSSIPs) were published
 Cardiovascular system
 Has signed informed consent been obtained? in September 2015 to support NHS
 Respiratory system
 Alimentary system organisations in providing safer care
Post-operative
 Genitourinary system and to reduce the number of patient
After the operation
 Central nervous system safety incidents related to invasive
 Can any problems be anticipated?
 Endocrine system procedures in which surgical ‘Never
 What home support is required/available?
 Locomotor system Events’ can occur.24 All information
 Have redressing appointments been arranged?
 (some authors also include ‘D’ for must be documented in the patient’s
 What other factors will affect the
dermatology) notes regarding correct identification
postoperative recovery?
of the site for surgical intervention; it

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is the practitioner’s responsibility to absorption of water and coagulation considered. The use of a petroleum
ensure they have correctly identified the of proteins. It is this action that is jelly product (bacitracin, silver
correct nail for operation. exploited in the phenolisation of the .sulfadiazine or similar) is suggested.
nail matrix and can be used on all age While good technique should
Local anaesthetic ranges. 26,2 prevent leakage to surrounding
Sensation to the hallux is provided by tissue, the authors argue that this is
four proper digital nerves: two dorsal Principles of phenol nail ablation a simple and cheap method to avoid
and two plantar. Both plantar nerves are Espensen et al28 published a helpful skin damage.
derived from the medial plantar nerve review of the literature and suggested 6. No definitive method for applying
and provide innervation to the plantar eight overarching principles for nail the phenol is identified in their
surface and the dorsal-distal apex of the surgery: paper. Cotton-tipped applicators,
toe. The most suitable procedure for wooden applicators or even syringes
nail avulsion is a digital block, using an 1. Patient selection – along with their with needles have been used by
appropriate local anaesthetic (LA) agent. vascular and neurological status, the practitioners. The important point is
The digital block is straightforward and most important factor to establish is that the chemical is carefully applied
requires little specific training, though the ability of the patient to achieve to the nail matrix tissue. This will
good technique and an empathic nature wound healing. prevent unnecessary damage to the
will minimise the trauma to the patient 2. The removal of the nail border surrounding skin. Wiping off excess
and enhance reliability.25 Prior to the (for partial nail avulsion) or total chemical on pieces of gauze or
administration of analgesia, a maximum nail plate should be carried out as cotton is also recommended.
safe dose for the patient should be aseptically as possible. 7. The length of application of the
calculated (based on patient weight 3. Following the removal of the chemical is considered. The need
in kg) and recorded in the patients nail and all hyperkeratotic tissue, to curette between applications
notes, along with details of the batch curettage of the nail bed, nail fold is recommended to expose tissue
number and expiry date. While the and groove should be carried out to that would not have been in contact
low volume of LA used for digital block remove as much of the nail matrix with the chemical. Espensen28 et al
conveys minimal risk, it is recommended as possible. This will allow the commented on the fact that there
that adrenaline is available in case of phenol to come into contact with must be a balance between applying
anaphylaxis, and that all practitioners the remaining nail matrix. the chemical for long enough to
have the appropriate training to 4. Use of a dry, bloodless, field using permanently destroy the nail matrix
recognise and treat anaphylaxis. a tourniquet is standard clinical and prevent regrowth with that of
practice so that it allows good not causing too much tissue damage
Antibiotics visualisation of the area and so resulting in a long period of wound
In the age of antibiotic stewardship, that the chemical is not washed healing. The application of phenol
antibiotics are over utilised in the out by excessive bleeding (and that for 3 x 1 minute is the norm.
treatment of IGTN. It is lamentable bleeding does not carry the phenol 8. Aftercare regime should include
to see chronic IGTN cases that out of the operative area potentially dry sterile dressings, but it has
have received multiple courses of leading to phenol burns around the been noted that moist wounds
flucloxacillin. While their use may be nail unit). heal quicker than dry wounds and
of value in a simple paronychia, their 5. Use of a protective barrier to the use of daily soaks is therefore
routine use in Stage II and III cases the surrounding skin should be recommended. These soaks keep
should be questioned. Haneke considers
the use of antibiotics as “a useless waste
of resources as the nail that digs into
the soft tissue is the cause of both the
inflammation and granulation tissue. No
nail has ever been shown to be sensitive
even to the most powerful antibiotic”.15

Phenol
Phenol, C6H5OH, is an organic
compound containing a hydroxyl group
(OH) directly attached to a benzene
ring. It is a colourless-to-white solid with
a sweet acrid odour. Phenol is toxic in Figure 9.
concentrated solutions and causes burns Suggested nail surgery equipment
to the skin and mucous membranes with Left to right: sponge holding forceps (for skin prep), Esmarch bandage, Black’s file, nail elevator, Thwaites nail nippers,
destruction of its chemical structure, forceps x 2 (for nail removal), cotton wool buds, scissors. Optional: Beaver blade and handle (not shown)

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Clinical REVIEW

the wound moist and prevent 5. After checking that anaesthesia has 11. Any remaining particles are removed
the formation of dry crusts and been achieved, an exsanguinating with Black’s file or micro-curette.
promote the drainage of fluid from tourniquet is applied (Esmarch™ 12. Sharp resection of hypergranulation
the wound. bandage or Tourniqot), for as short tissue is strongly recommended.
a period as possible, but for no 13. Phenol is applied to the sulcus and
Partial nail avulsion (PNA) with more than 20 minutes (use of a exposed nail bed using a sterile
phenolisation sterile glove as a tourniquet is no cotton wool bud/orange stick to a
Equipment requirements: longer considered appropriate). dry field maintained by tourniquet.
 80-100% phenol solution, also 6. The embedded margin of the nail 14. Apply phenol to any area of
available individually packed and (sulcus) is released using a Blacks file hypergranulation tissue resection
sealed in sterile containers of liquid or particular spatula. This allows the to reduce post-operative bleeding:
phenol, appropriately sized: for practitioner to ascertain the size of consider use of protection to the
example, Phenol EZ SwabsTM (these the nail plate. This is especially useful proximal nail fold.
are considered safer to use than where hypergranulation tissue is 15. Three one-minute applications are
phenol in multi-use bottles) abundant. recommended: sufficient to blanch
 Industrial methylated spirit (IMS) 7. The nail plate is completely split the area.
 Tourniquet(s) longitudinally from distal to proximal 16. After irrigation with industrial
 Local anaesthetic using Thwaite’s nippers. methylated spirit (IMS), the area is
 Nail surgery instrumentation 8. The cut is continued proximally dried, and the tourniquet removed
(sterile) – see Figure 9 under the proximal nail fold with a (note and record the total tourniquet
 Dressings. Chisel Beaver Blade (not shown in time and that revascularisation
Figure 8), or a second cut from the occurred). The phenol itself is not
Sequence (see Figures 10-19)26 nippers. neutralised as some authors believe
1. A sterile field should be prepared 9. The section is clamped as proximally – merely diluted – but should be
on a trolley for instruments, as possible with a pair of mosquito removed via swabbing, and then
chemicals, dressings, etc. or Spencer-Wells forceps and diluted with 5mL of IMS.
2. The operative site on the toe should rotated towards the mid-line of the 17. The wound is dressed with a non-
be marked (in line with local policy) nail plate. adherent primary dressing, gauze and
and the area prepared with the 10. The section with a fragment of nail (light) pressure bandage.
appropriate skin preparation. matrix attached will detach from
3. A sterile field may be applied. the site – check that this is the case Total nail avulsion (TNA) with phenolisation
4. Local anaesthetic is injected into and that the entire proximal nail has The technique is the same as for a PNA,
base of toe. been removed. save for the whole nail plate is removed

Figure 10-19.
PNA process

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 Clinical REVIEW

using an elevator, the nail being grasped

by forceps medially and then laterally,
rotated and removed. Again, sharp
dissection is recommended to remove
hypergranulation tissue. Some bleeding
will be seen, but the toe will return
to normal more quickly with sharp
dissection (see Figures 20-21). If the
hypergranulation tissue was especially
chronic and fibrotic it may completely
shrink post-TNA.

Post-operative management
While Eekhof 7 tells us that post-
operative interventions do not decrease
the risk of post-operative infection,
post-operative pain, or healing time, Figure 20-21.
many practitioners will have developed
their own post-procedure strategies. A Before and after hypergranulation resection on a TNA
personal approach is an early change
of dressing at day 2, advice on self-
care, dressing changes and saltwater
footbaths, and a further review at two
weeks, and then again as required.

A post-surgery phenol
burn can cause
significant drainage and
will mimic an infection
to inexperienced eyes

Post-operative information Figure 22. Figure 23.

The patient should be advised and
Winograd procedure Frost procedure
supplied with the correct dressing
materials and all information should be
given regarding next appointments or Case study
dressing regime. The patient should Your patient is a sixty-two-year-old female patient (see Fig. 24) with type 2
be advised not to drive until the diabetes mellitus. The patient was born in Jamaica and presents with a painful,
anaesthetic has worn off, and advice involuted nail on the right
given regarding suitable footwear, and hallux, complicated by
time off work, etc. Patient information hypergranulation tissue. Her
leaflets should be verbally explained to diabetes is controlled with
the patient, and this recorded in the oral medication; she had
patient record. a total knee replacement
four years ago. The knee
Complications replacement was uneventful,
Nail surgery complications include but she tells you that the
delayed wound healing, regrowth, control of her diabetes has
infection, nail deformity, and persistent deteriorated since then.
pain, but overall, complications appear Think about how you
to be relatively infrequent.29 Significant might manage this case, what
infection (with phenol) is uncommon, pre-operative checks need
but a post-surgery phenol burn can to be performed, and what
cause significant drainage and will mimic procedure will be best – and Figure 24.
an infection to inexperienced eyes. performed by whom. Case study presentation

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Clinical REVIEW

There is a need to balance the amount nails. Journal of the American Podiatric Medical
Key messages Association 1992. 3:131-135
of destruction caused by phenolisation
This article aspects of nail surgery: a
and increased healing time versus the 13. Heifetz CJ. Ingrown toenail. A clinical study. The
complete distillation of the literature American Journal of Surgery 1937. 38: 298-315
risk of recurrence. Minimal destruction
is a library in itself. Getting the best 14. Siegle RJ, Steward R. Recalcitrant ingrowing nails.
and a speedy healing time, using a small
results requires a nuanced approach Surgical approaches. The Journal of Dermatologic
amount of phenol for a short period,
utilising a range of techniques for a Surgery and Oncology 1992. 18:744-752
will increase the risk of recurrence.
given presentation. 15. Haneke E. Controversies in the treatment of
ingrown nails. Dermatology Research and Practice
Incisional surgical techniques 2012 1-12.
There are numerous reported incisional Final thoughts
16. Chapeskie H, Kovac JR. Soft-tissue nail-fold
surgical techniques for ablation of  Stay up to date with the literature
excision: a definitive treatment for ingrown toenails.
the periungual tissue and/or a part or pertaining to nail surgery Canadian Journal of Surgery 2010. 53:282-286
the whole of the nail plate. The main  Ensure that you have obtained 17. Laco JE. Nail Surgery. In: Hetherington V
procedures are outlined below and in informed, Montgomery-compliant (ed) Hallux Valgus and Forefoot Surgery. Churchill
skilled hands may be the best option consent Livingstone, 1994. 481-496
for a small cohort of patients.  Do you augment consent with 18. Rounding C, Hulm S. Surgical treatments for
Patient Information Leaflets (PILs) ingrowing toenails. Foot. 2001. 11: 166-182
The Winograd procedure - with author, version number, 19. Reilly I. Pre- and post-operative assessment. In:
The intention of the modified active date range - that are Merriman L, Turner W (eds) Assessment of the Lower
Winograd procedure30 is to remove available for later retrieval in the Limb (2nd ed). Elsevier 2002. 469-483
a section of the nail, nail matrix and case of medic-legal challenge? 20. Reilly I. Assessment of the surgical patient. In:
nail sulcus (see Figure 22). The nail is  Do you audit your own results? If Yates B (ed) Assessment of the Lower Limb (3rd ed).
not, how do you really know what Elsevier, 2008. 529-544
split longitudinally, and an incision is
made down to the bone through the you long term outcomes are? 21. Reilly I. The medical and social history. In:
Yates B (ed) Assessment of the Lower Limb (3rd ed).
split, extending proximally beyond  Consider sharp resection of
Elsevier, 2008. 54-74
the eponychium and distally to the hypergranulation tissue.
22. Reilly I, Wareham C. Peri-operative management
toe apex. A second (semi-elliptical) of the diabetic patient. Podium 2003. 1: 4-7
incision is performed deep to bone References 23. Campbell M. Montgomery v Lanarkshire Health
circumscribing the nail sulcus and the 1. Reilly I. Toenail problems that may require Board. Common Law World Review 2015. 44: 222-228
associated portion of the matrix. The surgery. In: Botting J, Schofield JK (eds) Brown’s 24. NHS England. National safety standards for
wedge containing parts of the nail Skin and Minor Surgery: a text and color atlas. CRC invasive procedures (NatSSIPs). Patient Safety
plate, nail bed, nail lip and nail matrix is Press 2014. 170–177 Domain
removed. The periosteum is removed 2. Reilly I, Waller J. Tumours of the nail and distal 25. Uddin A, Reilly I. Continuing Professional
by rasping prior to closure and the digit. Podium Nail Academy 2005; Spring: 27–30 Development. Local anaesthetics: Pharmacology and
wound closed with sutures. 3. Reilly IN. Continuing Professional digital anaesthesia. Podiatry Now 2008. CPD Supp.
Development. Nail Surgery. Podiatry Now 2019; 26. Reilly I. Toenail surgery. In: Botting J, Schofield
The Zadik and Frost procedures CPD Suppl JK (eds) Brown’s Skin and Minor Surgery: a text and
The Zadik procedure is performed 4. DeLauro NM, DeLauro TM. Onychocryptosis. color atlas. CRC Press 2014. 289-295
Clinics in Podiatric Medicine and Surgery 2004. 27. Reilly I, Waller J. Nail surgery using phenol.
by creating a H-shaped skin flap at
21: 617-6305. Eekhof JA, Van Wijk B, Neven AK, Podium Nail Academy 2005. Autumn: 1-5
the proximal edge of the nail, avulsing van der Wouden JC. Interventions for ingrowing
the whole nail, and then resecting the toenails. Cochrane Database of Systematic Reviews. 28. Espensen EH, Nixon BP, Armstrong DG.
Chemical matrixectomy for ingrown toenails. Is
nail matrix proximal to the border of 2012(4). DOI: 10.1002/14651858.cd001541.pub3.
there an evidence basis to guide therapy? Journal
the lunula.31,32 The previously created 6. Haneke E. Nail surgery. Clinics in Dermatology of the American Podiatric Medical Association 2002.
flap is brought forward and sutured 2013. 31:516-525 92:287-295
to the nail bed. The lateral nail folds 7. de Berker DA, Richert B, Baran R. Acquired 29. Moossavi M, Scher RK. Complications of nail
are excised and closed with sutures. disorders of the nails and nail unit. Rook’s Textbook surgery: A review of the literature. Dermatol Surg
The Frost technique33 is the author’s of Dermatology, 9th Ed. 2016 Jul 15:1-76 2001. 27: 225-228
preferred total incisional technique (see 8. Park DH, Singh D. The management of 30. Winograd AM. A modification in the technic of
ingrowing toenails. British Medical Journal
Figure 23). operation for ingrown toe-nail. Journal of the American
(Online) 2012. 344:1-6 Medical Association 1929. 92: 229-230
9. Heidelbaugh JJ, Lee H. Management of the
The author’s email address is 31. Zadik FR. Obliteration of the nail bed of the great
Ingrown Toenail. American Family Physician 2009; toe without shortening the terminal phalanx. The
included within this article, and he 79: 303-308 Journal of Bone and Joint Surgery (Br) 1950. 32: 66-67
would be interested to hear your 10. Reilly I, Waller J. Onychocryptosis: An
thoughts on the article, or if you have 32. Kontos A, Anton A, Flanagan G, et al. The Zadik
overview. Podium Nail Academy 2005; Summer: 2-3
procedure: A case study. Podiatry Now 2018. Nov
any follow-up questions. DN 11. Haneke E. Nail surgery. In: Cosmetic Medicine 16-17.
and Surgery. CRC Press, 2017 287-302
For correspondence, 33. Reilly I. The Fowler total nail avulsion procedure:
12. Mozena JD. The Mozena classification system a case study. J British Dermatological Nursing Group
email: [email protected] and treatment algorithm for ingrown hallux 2020. 19: 33-35.

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