There are two fundamentally different approaches. Elevation of the lateral nail margin and excision and cautery of the granulation tissue of the nail fold were already described by Paul Aegineta — and Abu al-Qasim, also known as Abulcasis — Fabrizius ab Aquapendente — excised and avulsed the ingrowing nail margin. Michaelis gave a detailed description of various treatment methods as early as , [ 26 ] on which Emmert later based his surgical treatment [ 27 ]. Gosselin in had already counted 75 different varieties of local treatment and described a method, by which an elliptical wedge-shaped piece of nail matrix and skin including the whole nail groove along the edge was removed [ 28 , 29 ].
The Bernese surgeon Emmert in and proposed a wedge excision of the lateral nail wall, groove, adjacent nail, and matrix [ 30 ], which is in fact the method proposed by Baudens in [ 31 ]. It was also Emmert who had first described the three stages of ingrown toenails [ 27 ]. In the late s, there were more similarly radical surgical operations such as those of Hildebrandt [ 32 ].
He also noted that there are three ways to remove the cause, whether the nail grows down into the flesh or the flesh grows up against the nail; something may be interposed between the nail and the flesh—what is now known as packing—; the nail may be removed from the flesh; the flesh may be removed from the nail. He proposed an incision to be carried out through the nail beginning at its free end and running parallel to the ingrowing edge, through the skin and matrix to allow skin flaps overlying the matrix to be reflected.
The matrix attached to the nail strip was dissected [ 29 ]. This is in fact the first description of a selective matrix horn resection. The terminal Syme operation is even more radical and is in fact an amputation of the tip of the toe [ 36 , 37 ]. This short historical overview demonstrates what ingrown toenail sufferers had to face in the past. It is a shame that many of these obsolete methods are still performed by surgeons and other physicians treating ingrown nails although the most reasonable technique had already been described [ 29 ].
In the following, some methods will be briefly discussed; it is not possible to deal with all of those ever described. Nail avulsion causes significant postoperative morbidity. When the nail regrows, the plate is still as wide as it was before and will therefore grow in again. Further, during the period where there was no plate, the nail bed usually shrinks both longitudinally as well as transversely. Absence of the big toenail leads to dorsal dislocation of the most distal portion of the pulp of the toe with a resultant false distal nail wall because of lack of counterpressure of the nail plate during gait.
For a fraction of a second, the entire body weight is on the tip of the big toe plus the kinetic energy of the forward thrust resulting in two to two-and-a-half-fold the body weight.
This is even more during sports activities. Once there is a distal nail wall, the nail plate cannot overgrow it. The matrix continues to produce nail substance which turns into a thickened, yellowish, and opaque nail with considerable onycholysis.
Unfortunately, there are still practitioners and surgeons that avulse ingrown nails. This is almost invariably followed by a recurrence. Nevertheless, some patients had to go through this inadequate and torturing procedure six times [ 36 ].
In our experience, nail avulsion for treatment of ingrown nail is not only useless, but it is almost always also harmful. Even for the treatment of infected granulation tissue, nail avulsion is not indicated. This takes the outward pressure of the nail plate away and—according to the authors—allows the nail to grow out without piercing into the lateral grooves. It permits normal activities after about 3 days [ 38 ].
However, this should be accomplished with gauze or cotton packing in order to free the nail spicule from the nail groove. Wedge excisions in their many minor variations do not consider the true shape of the matrix of the great toe, as is shown in most schematic illustrations of their authors [ 27 , 39 ]. Most authors do not draw the correct shape of the matrix horns Figure 8. Wedge excisions have a very high morbidity rate as healing of the wound takes 3 to 6 weeks in many patients.
It is also mutilating as the lateral nail folds are removed and the nail is no more ensheathed by them. Often, the nail becomes dystrophic, particularly when the operation was carried out together with a nail avulsion. The nail will grow markedly narrow, distorted, onycholytic, thickened, discolored, and deviated Figure 9.
Complications are frequent. There appears to be a risk of postoperative infection Figure 10 , and many surgeons give peri- or postoperative antibiotics. Even fungal septicaemia has been observed postoperatively [ 40 ]. However, most toe necroses after ingrown nail surgery were due to a neglected tourniquet [ 42 , 43 ]. It is not clear whether the authors really mean the nail bed or rather the matrix, which is responsible for the nail plate formation.
They had to reoperate 9. As a consequence of the foreign body irritation by the ingrown nail, the lateral nail fold often becomes swollen, overlaps the lateral aspect of the nail plate, and develops granulation tissue. Over a long period, the nail fold becomes fibrotic and has no tendency to return to a normal size.
Excision of a fusiform piece of skin from the lateral aspect of the distal phalanx and suture pulls the exuberant nail fold laterally and away from the nail Figure 11 [ 45 ]. This has been slightly modified in that the ellipse has been turned into a crescent [ 46 ]. The Vandenbos technique takes out a big chunk of the soft tissue of the lateral nail fold down to the bone.
After cauterization for haemostasis, the defect of approximately 1. Neither the nail plate nor the matrix or nailbed are touched [ 27 , 47 ].
The cosmetic results are very good; however, healing takes several weeks [ 48 ]. The first incision is carried out from the middle of the distal lateral nail wall through the lateral nail groove up to one centimeter into the proximal nail fold.
From there a second incision runs laterally to remove an elliptic wedge of soft tissue. DuVries recommended to widely excise the lateral nail wall and subcutaneous fat and to suture the skin of the lateral aspect of the distal phalanx directly to the nail bed so that the nail lies on top of the skin and cannot dig into the hypertrophic nail fold because there is no sulcus left [ 50 ]. In contrast to the aforementioned technique, the super U does not reach into the lateral aspect of the proximal nail fold.
Haemostasis is achieved by a locked suture. Healing is by second intention and may take up to ten weeks. Improvement is excellent. Howard proposed to remove a crescent of soft tissue from the tip of the toe parallel to the hyponychium [ 53 ].
A fishmouth-like incision is performed from one side of the tip to the other and another incision starting and ending at the same points like the first is made to yield a half-moon-shaped piece of tissue, which is excised down to the bone.
By suturing the resulting wound, the hyponychium is pulled down abolishing the false distal nail wall and also pulling down the junction of the lateral nail groove with the distal nail groove, which is the most frequent site of ingrowing.
This technique was redescribed about 80 years later [ 54 ] and appears to have been widely practiced in France. A modification is the so-called lateral foldplasty [ 55 ]. A rectangular flap is formed from the most distal part of the lateral nail fold, and a triangular piece of skin is excised from the lateral part of the hyponychium. Skin is excised in addition below the flaps so as to pull down the junction of the distal groove with the hyponychium.
This is in fact a modification of a hemilateral Howard operation. A comparative study showed In our opinion, this is an inadequate and far too radical method and in no case indicated. The terminal Syme operation is in fact an amputation of the tip of the toe [ 36 ]. It involves resection of the nail bed and matrix, amputation of the distal half of the terminal phalangeal bone, and defect closure with a flap formed by the ridged skin of the tip of the toe. It results in a shortened, bulbous toe.
As even this method is not free from recurrences, it is a mutilating and obsolete technique. Selective excision of the lateral matrix horn is a much less-invasive approach and respects the aetiopathogenesis of ingrown nails. It leads to a narrowing of the nail with a very high cure rate in ingrown nails.
A nail elevator is inserted under the ingrown lateral strip of the nail to free it from the nail bed and then from the overlying proximal nail fold. The plate is cut straight back to the cuticle and under the nail fold to the proximal end of the matrix. An oblique incision is made at the junction of the proximal and distal nail folds, and the folds are reflected allowing the deep part of the lateral matrix to be seen.
When the nail strip is taken out, the nail edge very often shows a sharp spike resulting from the improper nail cutting of the patient. The little wound is left open, but the nail walls are brought together either by simple stitches or suture strips steristrips. We insert small tapered antibiotic tablets into the wound cavity that also contain lidocaine Leukase Kegel both for local antibiotic treatment, to reduce postoperative pain and above all to keep the space open to allow the wound secretion to escape.
A padded dressing with an antibiotic ointment finishes the intervention. The patient is asked to elevate the foot for 24 to 48 hours. Healing is fast, usually in less than 10 days. The surgical matrix horn resection has a critical point.
The most proximal corner of the matrix is usually very deep Figure 13 , and dissection may be difficult. Insertion of an injection needle [ 1 , 57 ] and staining of the matrix horn with methylene blue [ 58 ] or gentian violet may aid in the dissection. Healing is usually faster than with phenol matricectomy though in one study it took longer [ 59 ]. Electrocautery Instead of surgical dissection of the matrix horn, it may be cauterized electrosurgically or with a radiosurgery device [ 60 ].
Again, it has to be secured that no matrix horn remnants remain. The potential disadvantage is that classical electrocautery delivers a lot of heat that may eventually lead to a thermal periostitis with long-term postoperative pain. Laser A great number of publications deal with laser treatment of ingrown toenails. Almost invariably, the carbon dioxide laser was used to ablate the matrix horn [ 61 — 63 ]. The authors stress that the use of the CO 2 laser is recommended because of markedly reduced pain, minimal disability, and satisfactory long-term results as well as shortened operation time due to minimal bleeding [ 64 — 66 ].
Some authors also vaporize the lateral groove and granulation tissue [ 69 ]. The recurrence rate after resection of the nail segment and its nail bed alone was The erbium-YAG laser was also used for a modified wedge excision [ 71 ]. Other authors used the CO 2 laser for haemostasis after surgical matrix horn resection [ 72 ]. Phenol Selective lateral matrix horn cauterization with liquefied phenol is now probably the most commonly used method.
Under stirring 9. When the solution cools down to room temperature, the water-in-phenol solution remains liquid—hence it is called liquefied phenol—with a consistency approximately like glycerol. Phenol has three positive properties for the treatment of ingrown nails; it is a chemical cauterant thanks to its protein coagulating power, it is a potent disinfectant, and it has local anaesthetic activity.
Log in. Interested in AAFP membership? Learn more. Louis, and completed a family practice residency at Santa Monica Calif. Address correspondence to Phillip Rodgers, M. Reprints are not available from the authors. The authors thank Barbara Apgar, M. Swisher, M. Figures 1 , 2 , 4 and 5 were supplied by James E. Rasmussen, M. Advances in the diagnosis and treatment of onychomycosis.
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Baran R, Hay RJ. Partial surgical avulsion of the nail in onychomycosis. There are multiple reasons why an ingrown toenail will de-velop, including improper nail cutting technique, tight-fitting footwear, trauma, anatomical factors such as thickening of the nail plate, pincer-shaped toenail, pressure from abutting digits caused by hallux valgus or lesser toe deformities, the presence of a subungual exostosis and, occasionally, the use of isotretinoin in the treatment of severe acne.
Management of ingrown toenail Figure 1. Typical ingrown toenail presentation The dashed line indicates the section of the nail plate to be removed for conservative treatment.
Br J Surg ;— Recalcitrant ingrowing nails: surgical approaches. J Dermatol Surg Oncol ;— Search PubMed Murtagh J. Patient education. Ingrowing toenails. Aust Fam Physician ; Risk factors in onychocryptosis. Efficacy of wedge resection with phenolization in the treatment of ingrowing toenails. J Am Podiatr Med Assoc ;— J Am Coll Surg ;— New millennium, new nail problems. Dermatol Ther ;— Ingrown toenail: A clinical study. Am J Surg ;— Ingrown toenail treated with cotton collodion insert. Foot Ankle ;— Nail Surgery.
Vol 1. An evaluation of partial matrix excision with Winograd method for the surgical treatment of ingrown toenails. JAREM ;— Abstract Background: Excisional toenail matrixectomies are performed on the area of the foot that has been reported to have the highest concentration of resident microorganisms.
Publication types Comparative Study.
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