Nail & Skin Disorders

A Doctor's Notes on Ingrown Toenail Surgery

Ingrown toenails often become severe enough to require surgery. Dr. Mix shows you step by step what happens in the ingrown toenail surgery procedure.

The ingrown toenail has a mystique of its own. How many times have we heard that we must cut our toenails straight across or risk causing an ingrown toenail? We have been told by many knowledgeable individuals to cut a V in the free edge of the toenail to prevent the formation of an ingrown nail. I hear this reasoning expounded by my patients almost every day. There are many old wives’ tales related to this. The following discussion will make it easier to understand what is actually happening when a nail “ingrows.” For the purposes of this discussion, we’ll define an ingrown nail as one that is painful or becomes chronically infected. This disorder occurs along the nail margin as a result of nail pressure on the soft tissues.

The nail plate is formed by the matrix bed. Once the plate is formed and passes beyond the matrix bed onto the nail bed, it is essentially a dead, pre-formed horny layer of protein. The size, thickness, and side-to-side curvature of the nail plate is determined by the matrix bed. If this is true, then how can trimming the nail straight across or cutting a V in the free edge of a dead nail plate going to change anything? As anyone who has ever had an ingrown toenail can tell you, these trimming methods do not work. What does work is the proper trimming and rounding off of the corners of the plate so that they do not cut into the skin fold along the nail grooves.

The matrix bed has a natural side to side arch to it. The ingrown nail disorder in most instances occurs because the natural arch of the matrix bed is too curved. The margins of the plate are formed in a deep nail groove on one or both sides. 

We generally inherit this shape, or arch, from our parents. If you ask your clients who have ingrown nails, you will find that the majority of them have one or both parents with ingrown nails. As the nail plate grows toward the free edge, that portion of plate in the groove will generally encounter a soft tissue wall at the end of the groove. If something is not done, the nail will continue to grow and cause pressure on the tissue, finally cutting into it. This produces a portal of entry for infection, and a classic ingrown nail disorder is produced. The nail wasn’t actually “grown in,” but is trying to “grow out” beyond the end of the toe.

Warning: Ingrown Toenail Ahead

Injuries, tight shoes, and some disease's processes can affect the shape of the matrix bed or soft tissues around the nail and set up conditions that may cause a malformed nail plate, which can then produce an ingrown nail. As we walk, the upward pressure exerted on the soft tissues at the end of the toes can force these tissues up against the nail edge, which can also produce an ingrown nail. Hammertoes and the deformed big toes associated with bunion afflictions can also cause ingrown nails because they put abnormal pressure on the soft tissues along the edges of the nail.

Improper trimming of the nail margin may aggravate the ingrown nail disorder, but in my opinion, it doesn’t actually cause the nail to ingrow. In the true ingrown nail condition, the disorder is going to occur whether it is trimmed or not. If the patient or the nail technician, in trying to relieve the painful pressure, cuts soft tissue, an infection can develop. Is this an ingrown nail? No, it’s an infection caused by the cut in the soft tissue. If the nail is cut improperly and a “hook” is produced on the edge of the nail, the point of this hook will easily penetrate the soft tissue and the result is the classic infection of an ingrown nail. This hook is produced when the tip of the nail cutting instrument does not extend past the edge of the nail when the nail is cut.

Getting Clients Back on Their Toes

What can the nail professional do for those clients with ingrown nails?  In many cases, proper nail trimming will prevent ingrown nails and keep the client comfortable and happy. How do you know a client needs only careful trimming? First, look closely at the nail and nail groove. There should be no infection present. The edge of the nail should not be so deep in the nail groove that it cannot be easily observed. You must be able to see what you are trimming, and you must have the proper instruments to work with. 

These so-called toenail clippers that are large versions of the fingernail clipper should never be used to cut toenails. They are not even shaped like toenails and in most instances, will cause cuts in the soft tissues around the nail or in the toe next to the nail that is being trimmed. They most certainly cannot be used to trim out the edge of a nail that has the potential to ingrow. Also, I have seen a nail cutting instrument at nail tradeshows that is advertised as a “podiatry toenail cutter” or nipper. I personally have never seen a podiatrist use this instrument. The cutting jaw basically has the same shape and design as the toenail clipper I advised you not to use. It cannot be used to properly trim out the edge of an ingrown nail. For toenail clipping, I recommend a nail clipper with slender pointing cutting jaws that can be easily placed under the edge of the nail. 

There is also a small spoon-shaped instrument called a curette that can be used to remove the buildup of dead skin and other debris along the nail groove. A small metal file, about a 1/8-inch wide and ½-inch long, attached to a metal handle should be used to lightly file the edge of the nail after it has been trimmed. This guarantees that you do not leave a rough edge or hook. Only trim the nail back enough to reduce pressure. It is extremely easy to cut the client by trying to remove too much nail along the nail groove.

When It’s Too Much for You

Those clients whose ingrown nails are already infected and clients whose toenails you have questions about should be sent to your podiatrist. She will decide whether routine nail care is indicated or whether the patient would be better serviced by a permanent removal of the nail margin. Ingrown toenail surgery is one of the most common procedures that podiatrists do to correct an ingrown nail problem. If the shape of the nail causes it to be deeply incurvated along the nail margin and the patient has chronic pain and infections, permanent correction (surgery) is the treatment of choice. No amount of trimming will give any lasting comfort in these cases. The following pictures illustrate a permanent removal of an ingrown nail using the “phenol technique.”

Toenail Surgery, Step by Step

1. The big toe has been anesthetized and prepared for the correction of an ingrown nail. The toe is bluish in color because a rubber band tourniquet has been applied to the base of the toe.

 

2. A chisel-like surgical blade called a nail splitter is used to cut the nail from the free edge to the back of the matrix bed. The blade is then used to loosen the part of the nail to be removed from the nail bed and matrix bed. The nail splitter doesn’t cut into the nail bed, only the nail plate.

 

3. Hemostat forceps are then used to grasp the nail to be removed. With a twisting motion, the nail border is avulsed (separated from the body by cutting) from the nail margin.

 

4. This shows the nail margin after it was avulsed from the nail groove. Compare its size to what you can actually see of the nail margin in the second photograph. Also, notice the small hook on the bottom of the nail. The sharp part of the hook is what was growing into the soft tissue and causing the pain.

 

5. Phenol- (89% carbolic acid) soaked cotton applicators are then inserted into the matrix bed area to sterilize the exposed matrix cells. Fresh soaked applications are gently manipulated in the area for approximately three minutes to complete this process.

 

6.  A tube gauze bandage is applied over the toe. It looks large but easily fits into the shoe. This bandage is removed in two days and the patient is instructed to wash the surgical area daily with warm soapy water. Use a triple antibiotic ointment on the site and keep it covered with a small adhesive bandage.

This is a tried and true procedure, and my recurrence rate is less than 1%. While the patient is recovering there is also minimal discomfort. Most people can wear shoes and the patient only has to wear an adhesive bandage just two or three days after the procedure. The nail margin will drain slightly for two to three weeks while it’s healing. I have used other techniques, including the laser, but have always gone back to the phenol procedure.

-- Godfrey F. Mix, D.P.M. has been a podiatrist for 25 years. He is a member of the American Podiatric Medical Association, has served on the California Board of Podiatric Medicine, and is board-certified by the American Board of Podiatric Surgery. He is a regular contributor to NAILS Magazine.

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