Bernard Raskin, MD

Nail Surgery

Bernard Raskin, MD

Valencia CaliforniaBRaskin@CreatingBeauty.com

GENERAL INFORMATION:Surgery is delicate, but rarely

difficult.Becomes a challenge when poor or

dull instruments are used.Bloodless field is important.

Aseptic sterile technique required.

Information

Tissue oozing, consider discontinuing aspirin beforehand, maybe Plavix.Traumatic or contaminated wounds warrant tetanus toxoid injection, if not done within the last five to ten years.X-ray recommended prior to excising distal digit tumors.

CLINICAL TERMINOLOGY:

Onychoschizia - distal horizontal splittingOnychauxis - surface irregularity and thickening with hypertrophyOnychogryphosis - curvature and horn-like hypertrophy of the nailOnychocryptosis - ingrown nail

Terminology

Onychomadesis - separation of nail plate proximallyOnychomycosis - fungal nailOnychorrhexis - superficial longitudinal striationMacronychia - widened nailTrachyonychia - roughened nail

ANATOMY:

See nail unit anatomy illustrations.Note that deep to the nail bed is periosteum. No fat under the bed or matrix.Extensor tendon insertion is at the base of the nail matrix near the mid line. Insertion is usually 2 to 3 mm distal to the distal interphalangeal joint or 12 mm proximal to the cuticle and is usually not a problem.Nerves parallel the arterial supply.

BLOOD SUPPLY

Blood supply directly from the digital artery arises from the mid point of the middle phalanx and anastomosis with the lateral digital artery arcade, therefore, dual blood supply exists.Clinically important is presence of a visually apparent branch of the digital artery immediately under the matrix. Minimal risk of local surgery impairing circulation.Arterial venus anastomoses throughout the circulation.

BLOOD SUPPLY

Dual blood supply occurs from superficial arcades that derive from lateral digital arteries and form anastomoses.Vessels enter distal phalanx adjacent to the volar bony surface, then from extensive branches within the digital pulp.Both a proximal and distal arcade supplies matrix and nail bed.

ANESTHESIA:

Digital blocks most effective approach.Great toe usually use ring block.Typically non-epinephrine agents are utilized, although recent reports indicate epinephrine is safe.Generally 10 to 20 minutes required for digital blocks to be effective.

ANESTHESIA

When doing ring block on great toe, dorsiflex the toe so that ring block on dorsum of aspect goes under the tendon.Usually about 1.5 cc on each side of a finger or toe. Larger amounts may be necessary in the great toe.

Anesthesia

Consider injection Bupivacaine into the surgical site directly, after the procedure.Bulky dressings are needed so that people are aware of the digit and do not inadvertently close their finger in a car door.

PREPARING THE FIELD

Exsanguination technique may be helpful prior to surgery.Draping method, glove roll down method, tourniquet method.

INSTRUMENTATION:

Dual action nippers are particularly helpful due to hinge, allows for molding of the nail bed shape.English nail splitters useful due to Anvil like jaw on the bottom and cutting blade on the top.

INSTRUMENTATION

Blunt elevators are very helpful for lifting the nail. Periosteal elevators may also be used. Dental spatula may be purchased. Freer septum elevators also popular.

Dissector

Square sharp edged dissector useful for cutting distal nail plate that nail nippers cannot reach. Used much like a chisel to punch through the last connections.

POSTOPERATIVE STATUS

Gel foam effective on the nails. Bulky dressings helpful to prevent catching a finger in a door or other problem while anesthetized.

Source: 2007. Elsevier Inc. Dermatologic Surgery Tips and Techniques

Post Op

Postoperative pain may be a problem, typically narcotics given.Sutures removed in seven days on the nail.

NAIL AVULSION:

Dissect both under and on the superior portion of the nail plate to free it from the tissue.When underneath the nail and on top of the nail, make sure that the nail undermining is performed past the last point of resistance. There is considerable resistance when dissecting and then suddenly there is minimal resistance, that is the stopping point.

AVULSION

Grasp corner of nail with a large hemostat and doing twisting or rolling motion to remove the nail.Apply gel foam.On partial nail avulsion, nail splitter is used to split the nail and only the affected area is removed in the fashion described above.

Source: 2007. Elsevier Inc. Dermatologic Surgery Tips and Techniques

BIOPSIES AND SMALL EXCISIONS:

See illustrations.Consider using a larger punch to punch through the nail and then a smaller punch to remove the tissue underneath.Needle often required to help elevate the tissue off of the periosteum.

Source: 2007. Elsevier Inc. Dermatologic Surgery Tips and Techniques

BIOPSIES AND EXCISIONS

Primary closure is possible with 3 mm punch. Nail Bed and/or Periosteum may be elevated a few mm in each directions. Sometimes lateral incisions, relaxing incisions at the lateral edges of the nail bed help reduce tension.

Biopsies and Excisions

Closure generally with fine absorbable suture. Sutures may be passed through the nail plate. As long as nail matrix not violated, no permanent nail defect results.

NAIL MATRIX:

With nail matrix biopsy there may be residual nail defect abnormality, such as ridging, thinning, or splitting.If punch does not violate lunular edge and the biopsy is of the distal matrix, potential defect occurs on undersurface of nail plate only.

NAIL MATRIX

Must maintain the integrity of distal lunar curve, otherwise distal onycholysis may result,Can retract the overlying nail fold. Accomplish by bilateral longitudinal incisions and folding the nail fold upward.See illustrations.

POINTS TO REMEMBER

Avoid transection of the matrix when possible.Suture defect when possible.Length of matrix responsible for thickness of nail, so suture defect within matrix results in local thinning.

Points to Remember

Distal rather than proximal biopsy is recommended because proximal part generates more of nail surface.Try to avoid distal curvature of the nail matrix.

PARTIAL NAIL UNIT EXCISION

A standard fusiform is performed on the lateral aspect of the nail fold.Removal of part of the nail plate is performed by the nail nipper.Excision carried to the periosteum.Wound may granulate or be sutured.Very effective treatment in lateral nail fold hypertrophy.

Ingrown

Oral antibiotics for infections.Partial nail avulsion may be useful, with or without excision of elevated ridge of tissue on lateral nail fold.Cryosurgery effective for freezing hypertrophic tissue, approximate freeze time 30 seconds.

MATRICECTOMY:

Can be performed with scalpel, C02 laser, electrosurgery, or chemical. Generally podiatrists use chemical method or laser.Harder problem is matrix horns extend proximal and outward from the nail plate (medially and laterally). Unless the horns of the matrix are removed, recurrence or spicules are common.If using electrosurgery, recommend a Teflon-coated probe.

Chemical Matricectomy for Derms

1 minute application 10% NaOHNot 30 seconds, not 2 minutes92% success rate at 14 monthsMay have drainage for 3 weeks

NaOH Matricectomy

Treat infection first till complete healingRemove nail plate—all or partExcise or Curette hypertrophic tissue10% NaOH with cotton applicator

10% NaOH Method

Remove excess from cotton applicatorMust have bloodless fieldChemical vigorously rubbed into matrix area

Matricectomy

Must treat lateral hornsOnly one application to the area with applicatorAfter 1 minute, lavage extensively with 10% Acetic AcidDress with antibiotic and gauze

Few Additional Points

Consider 30-50% urea BID to nail plate firstUse urethral swab to reach along nail groove area

SUBUNGUAL HEMATOMA:

Severe pain. Generally only one or two drops of blood.Methods are heated needle, paper clip heated red hot, #11 blade, electrocautery, small punch.Clot may seal the hole and cause additional pain subsequently. Therefore, larger hole than paper clip recommended.

CHRONIC PARONYCHIA:

Red chronic process with disappearance of the cuticle, separation of the proximal paronychia from the nail plate.Surgically can treat with full thickness excision of the proximal fold. Keep a spatula or similar instrument under the proximal nail fold as shown in illustration to prevent damage to matrix.

CHRONIC PARONYCHIA

Allow to granulate.Transection of distal tendon insertion avoided if proximal nail fold is sandwiched between septum elevator and scalpel.In general, the nail fold heals with a normal appearance; however, more nail is clinically visible compared to the other nails.

PROXIMAL NAIL FOLD LESIONS:

Small lesion can be excised with a wedge-shaped excision. Often relaxing incisions are needed laterally for closure. Keep a nail elevator underneath the scalpel to prevent excess damage to underlying tissue.Lateral relaxing incision only need be 5 mm.

MYXOID CYSTS:

Methods include cryosurgery, injection TMC 3 to 5 mg per cc, repeated drainage. Electrosurgery may be effective. Small cyst may be excised with crescenteric excision of the entire nail fold. Large cysts usually require excision.

CYSTS

Large cysts beyond purview of lecture Sterile methylene blue injected into the cyst and all blue stained tissue must be excised, including the stalk, which may communicate with the distal interphalangeal joint. Care must be taken not to traumatize the extensor tendon.

LATERAL NAIL FOLD EXCISIONS:

See illustrations.Excisions can be left to granulate or close primarily. With some chronic nail fold inflammatory conditions, exophytic lateral nail fold tissue occurs, and may be shaved down and left to granulate.Skin on the lateral aspect of the excision is sutured directly to the nail plate. (Needs PC3 type needle or better. Result is slightly narrowed nail.)

LATERAL NAIL FOLD

If intent is to excise the underlying matrix in the proximal nail fold area, the incision must extend deeply to the periosteum. Excision encompasses lateral nail fold, adjacent nail lateral bed, and proximal nail fold. By making sure excision extends 8 to 10 mm proximal of the cuticle and includes periosteum, the underlying matrix is excised.

DISTAL NAIL TIP EXCISION:

Deformities and hypertrophic tissue result from atrophic or abnormal nails. Without counter pressure from nail plate, pulp gradually distorts from walking. Conservatively, repeated massage from the distal nail wall that develops may allow the nail to overgrow, resulting in return to normality. Alternatively, crescent shape incision can be accomplished. This may be very narrow allowing primary closure, or may granulate.

LONGITUDINAL MELONYCHIA

Must biopsy the most proximal portion of the pigment.

SPLIT NAIL DEFORMITIES:

See illustrations.Nail plate is removed first proximally Relaxing incisions laterally placed in the nail folds if needed Scar or other abnormality at base of nail removed and sutured.

NAIL PLATE DEBRIDEMENT:

40% urea compounded at 40% urea, 5% bees wax, 20% lanolin,, 25% petrolatum, and 10% silica gel type H, has four month shelf life. Can be applied to the nail and left in place overnight and repeatedly applied. Typically removes dystrophic portions leaving normal nail intact.

DEBRIDEMENT

Occlusion of nail important, must apply adhesive felt around the nail plate and build this up, so that normal skin is not be damaged by the urea. Urea may be left in place for three to seven days at a time.

Nail Unit Excision

Extend across lateral nail bedDistally along lateral nail fold past hyponychiumExcise across tip of digitSharply dissect from underlying boneFTSG from volar forarm, antecubital fossa or upper armTie over dressing

Nail Unit Excision

Persistent pain or inflamation over weeks must consider osteomyelitis

Fibrokeratoma

May present as smooth exostosisHidden within nail fold presenting as thinned nail or grooved nailExpose base of processIdentify plane within the dermisBluntly dissect

Glomus Tumors

Remove Nail plate—can lift like hood of carPunch excision possible since tumor encapsulatedFor enlarged tumor, excise and reconstruct with split thickness graft from great toe nail bed

Split Thickness Graft

From great nail bedOnly small piece possibleUse sawing motion to removeHarvest from distal of the lunula

Minor Lacerations

Delayed Repair after 2 weeks can be doneEval for tetnus and fractureGranulation worksCar Hood lifting of nailSuture defectReplace nail and suture plate in place laterally and medially

Pterygium

Secondary to TraumaPainfulFree prox fold from plateInsert silicone sheet or xeroform gauzeSuture fold back in placeUndersurface of fold epithelializes releasing adherence

Distal Pterygium

Remove distal 5 mm of nail from bed3 mm strip of hyponychium and bed resectedReplace with STSGCauses non adherence of hyponychium

Racquet Thumbnail

Short Wide Nail lacks lateral foldsNarrow nail and create lateral foldsExcise nail and matrixUndermine at level of periostiumCreate Lateral Nail Fold by 3 mm bite of tissue folded up and sutured through nail plateExtra thick bite of tissue forms lateral ridgeSulcus epithelializes secondarily

Pincer Nail Deformity

Transverse CurvatureWide Proximal NailNarrow Distal NailTechnically Challanging Reconstruction

Mohs