Nail surgery is a minor procedure performed by a specialist, such as a podiatrist, dermatologist, or general surgeon, to treat various issues affecting the nail unit. This includes correcting problems with the nail plate, the nail bed tissue underneath, or the surrounding skin folds. Procedures are typically outpatient, meaning the patient can return home the same day, and are almost always performed using local anesthesia. The purpose of the surgery is to alleviate pain, remove diseased or deformed tissue, or to obtain a biopsy for diagnosis.
Common Conditions Requiring Intervention
Surgical intervention becomes necessary when persistent nail problems do not improve with conservative treatments. One of the most frequent indications is chronic or recurrent onychocryptosis, commonly known as an ingrown toenail, where the nail edge cuts into the adjacent skin fold causing pain and inflammation. Surgery is often recommended for ingrown nails that have progressed to a moderate or severe stage, involving infection or the formation of excess granulation tissue.
Another primary reason for surgery is the need to remove painful or suspicious growths originating from the nail unit. These growths can range from benign conditions like cysts to potentially malignant tumors, such as subungual melanoma, which requires a biopsy or complete excision. The procedure allows for the full exploration of the nail bed and matrix, the tissue responsible for nail growth.
Severe, treatment-resistant fungal infections (chronic onychomycosis) may also require the surgical removal of the nail plate, known as avulsion. This allows topical antifungal medications to penetrate the nail bed more effectively. Chronic inflammation of the skin folds around the nail (chronic paronychia) or structural nail deformities like pincer nails may necessitate a surgical approach for definitive correction.
The Surgical Process
The surgical process begins with the administration of local anesthesia, typically a digital block. A numbing agent like lidocaine is injected into the base of the toe or finger, ensuring the patient feels no pain while remaining fully awake. Once the area is numb, a tourniquet may be placed around the digit to temporarily stop blood flow, creating a clear, bloodless field for the surgeon.
The specific surgical technique depends on the underlying condition. For an ingrown toenail, the procedure often involves a partial nail avulsion (PNA), where only the problematic side portion of the nail plate is removed. If the goal is to permanently stop the ingrown section from regrowing, a chemical matrixectomy is performed.
During a chemical matrixectomy, a substance like phenol is applied to the exposed nail matrix tissue to destroy the cells responsible for forming the nail plate in that specific area. This technique aims for a permanent result with a high success rate and avoids the need for stitches. Conversely, a total nail avulsion (TNA) involves the complete removal of the entire nail plate. This may be done temporarily to treat severe infection or permanently if the entire matrix is destroyed.
Immediate Post-Operative Care
Immediately following the procedure, the surgical site is covered with a sterile, bulky dressing to protect the wound and manage minor bleeding. The initial dressing should remain intact for the first 24 to 48 hours unless otherwise directed by the specialist. Patients are instructed to rest and keep the foot elevated above the level of the heart during this initial period.
Elevation helps reduce swelling and throbbing pain, which are common as the local anesthesia begins to wear off. Pain management usually involves over-the-counter medications like acetaminophen or non-steroidal anti-inflammatory drugs (NSAIDs). Patients should wear loose-fitting or open-toed footwear to prevent pressure on the heavily dressed toe.
Signs of immediate complications, such as excessive bleeding that soaks through the dressing or severe pain not relieved by medication, should prompt immediate contact with the treating specialist. The first dressing change usually occurs the day after the surgery. This process involves gently removing the old dressing, cleaning the area, and applying a fresh, sterile bandage.
Expected Healing and Long-Term Results
The timeline for wound closure depends on the extent of the surgery, particularly whether the nail matrix was chemically destroyed. For a partial nail avulsion with matrixectomy, the wound site typically takes two to four weeks for drainage to stop and the skin to heal over. Full recovery, where the area is no longer sensitive and can tolerate normal footwear and activity, is generally achieved around four to six weeks post-procedure.
Patients can usually resume light, daily activities, such as an office job, within a day or two of the procedure. However, strenuous or high-impact activities should be avoided for several weeks. The long-term appearance of the nail unit varies based on the permanence of the procedure. If the nail plate was removed temporarily and the matrix was left intact, a new nail will begin to appear within six to eight weeks and will fully regrow over six to eighteen months.
If a permanent matrixectomy was performed, the goal is for the nail to no longer grow back in the area where the tissue was destroyed. The space previously occupied by the nail will heal over with normal, slightly toughened skin. The procedure aims to resolve the underlying issue, resulting in a permanent solution that prevents the painful recurrence of the problem.