Nail surgery involves procedures on the anatomical structures that produce or support the nail, such as the nail plate, nail bed, or nail matrix. Procedures range from simple nail removal to complex tumor excision and reconstruction. Determining the appropriate medical professional depends on the location of the affected nail (hand or foot) and the nature of the underlying condition. The required specialization shifts based on whether the issue is a common ailment or a complex pathology.
Podiatrists and Lower Extremity Nail Surgery
Podiatrists, or Doctors of Podiatric Medicine (DPMs), are the primary surgical specialists for conditions affecting the feet, ankles, and associated structures, including the toenails. Their training provides a deep understanding of the unique biomechanical forces acting upon the lower extremities. These specialists manage the vast majority of common surgical problems that affect the toenails.
The most frequent surgical procedure performed by a podiatrist is the treatment of onychocryptosis, commonly known as an ingrown toenail. This condition occurs when the nail plate pierces the surrounding soft tissue, causing pain and potential infection. Initial treatment often involves a partial nail plate avulsion, which is the surgical removal of the offending nail border under local anesthesia.
For chronic or recurrent ingrown toenails, a permanent solution known as a partial matrixectomy is often employed. This procedure involves chemically or surgically destroying the portion of the nail matrix responsible for growing the problematic nail edge. Phenol, an alkaline chemical agent, is frequently used to achieve this destruction, preventing recurrence with a high success rate.
Beyond ingrown nails, podiatrists address other lower extremity nail issues requiring surgical intervention. This includes the debridement or surgical removal of thickened, deformed nails caused by severe onychomycosis (fungal infection) when topical or oral treatments fail. They also manage traumatic injuries to the toenail unit, ensuring proper healing and alignment of the nail bed.
The specialized training of a DPM incorporates the complex weight-bearing dynamics of the foot, which is distinct from the hand. This focus allows them to address how foot structure or gait abnormalities may contribute to chronic nail problems. Their expertise is rooted in both surgical technique and the functional context of the lower limb.
Dermatologists and General Nail Pathology
Dermatologists specialize in the skin, hair, and nails across the entire body, making them experts in general nail pathology for both hands and feet. Their primary strength lies in diagnosing nail diseases that present as changes in color, shape, or texture of the nail unit. They routinely perform diagnostic procedures to understand complex nail conditions.
When the cause of a nail abnormality is unclear, a dermatologist often performs a nail biopsy to obtain a tissue sample for microscopic examination. Biopsies of the nail bed or matrix are necessary to differentiate between inflammatory conditions, infections, and potentially malignant growths. The precise technique chosen (punch, shave, or excisional biopsy) depends on the suspected diagnosis and the location within the nail unit.
The management of nail unit tumors, both benign and malignant, is a significant area of dermatological surgical focus. Subungual melanoma, a rare but aggressive form of skin cancer, requires specialized excision techniques for complete removal while preserving underlying structure. Non-melanoma skin cancers affecting the nail unit may be treated using Mohs micrographic surgery. This technique allows for precise, layer-by-layer removal with immediate microscopic margin control.
Dermatologists frequently perform surgical procedures on fingernails, particularly those requiring fine, precise work on the nail matrix. They may surgically treat chronic paronychia (inflammation around the nail fold) or perform corrective surgery for nail dystrophies caused by systemic disease. This delicate work requires understanding the growth dynamics of the nail matrix to prevent permanent disfigurement.
While podiatrists focus on the mechanical issues of the foot, dermatologists specialize in the cellular and molecular processes affecting the nail unit’s health. Their surgical role is intrinsically linked to their diagnostic capabilities, ensuring intervention addresses the underlying disease process. This dual expertise in pathology and procedural skill defines their specialized contribution to nail surgery.
Specialized Surgeons for Complex Reconstruction
For highly complex cases involving severe trauma or extensive tissue loss, the expertise of specialized surgeons becomes necessary. These situations require sophisticated reconstructive techniques that go beyond the scope of routine dermatological or podiatric practice. Injuries often include crush injuries, degloving accidents, or major lacerations that severely damage the nail bed and surrounding soft tissue.
Hand surgeons, typically orthopedic or plastic surgeons with specialized fellowship training, manage the most severe injuries to the fingers and fingernails. Their procedures involve microsurgery for the replantation of severed fingertips or complex skin grafting to repair a damaged nail bed. Plastic surgeons may also be involved in complex aesthetic reconstruction following tumor removal or significant trauma.
When a nail unit tumor, such as a large subungual exostosis or an aggressive malignancy, requires removal that impacts bone or joint structure, an orthopedic surgeon may take the lead. These specialists coordinate the tumor excision with the preservation of digit function and stability. The need for this high level of surgical training is dictated by the depth and spread of the pathology.