Corrective Toe Nail Surgery

Toe nails require surgical treatment for a number of reasons. When conservative measures fail to give relief from discomfort, infection, or disfigurement a surgical correction may be the avenue of choice
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Toe nails can become distorted either through trauma, disease, or congenital reasons. Diseases such as psoriasis and fungi (athletes foot) can lead to thickening and distortion of the nail plate. Trauma from dropping something on the toe nail may cause the matrix (root) to become distorted and make the nail thick and disfigured. Minimal trauma due to the toe nail hitting either a short or shallow shoe during skiing, skating or running may also distort the toe nail. Some general diseases such as chronic obstructive lung disease can cause "spoon nails". However, incurvated and ingrown toe nails consist of the majority of nail problems which require surgical correction. An incurvated nail is one in which the matrix (root) is distorted at the nail plate so that the sides curl downwardly into the toe itself. If the nail plate is thin and brittle it may even cut through the tissue. A so called "ingrown" toe nail usually occurs from improper nail cutting which leaves a sharp hook along the side of the nail (Often done to attempt to get relief from an incurvated nail.) or due to splitting of the nail from trauma. If a sharp or rough piece of nail breaks the skin bacteria will enter and cause an infection. If this break in the skin is not dealt with in a reasonable period of time granulation tissue (proud flesh) develops. This tissue is red, inflamed, raw and enlarged. The enlargement of this tissue causes it to wrap around the sharp piece of nail to a greater degree and makes treating the ingrown nail more difficult.

Modern surgical procedures date back to 1933. "Ingrown" toe nails which result strictly from improper nail cutting can frequently be dealt with by simply cutting away the sharp portion of the nail which is breaking the skin under local anaesthetic and filing the border of the nail adjacent to the tissue. A small cotton packing is placed between the tissues and the remaining nail plate to prevent further irritation of the skin. The packing is allowed to stay in place as long as the nail is shorter than the toe itself. Once the nail plate has grown beyond the nail lip the packing is usually no longer necessary. The "ingrown" toe nail which results from either a curved matrix (root) or an enlargement of the lip surrounding the edge of the nail can become chronic and necessitates either surgically narrowing of the nail plate or reducing the lip.

Frost, in 1950, described a procedure where the curved side of the nail plate was excised, the skin opened and the portion of the nail bed and matrix was excised. Earlier, Winograd had described a surgical procedure which simply cut away a wedge of tissue on the side of the nail including the nail plate, bed and lip. Modern podiatrists now use procedures which do not require cutting of the skin or tissue around the nail. There are presently three common podiatric procedures for nail correction. One uses chemical cautery or burning of the bed and matrix (either by Phenol or Sodium Hydroxide). Another is radiosurgical ablation (cautery and vaporization of the bed and matrix); and lastly laser vaporization of the bed and matrix. Since there is no suturing and incisions are not made deeply into the toe generally much less discomfort is experienced by the patient. There is less likelihood of infection of the underlying bone since tissues close to the bone are not being invaded. Since there are no sutures involved the cosmetic result seems preferable. In all three of these procedures only the upper layers of the matrix and bed are being destroyed. The possibility of a "spicule" reoccurrence is small due to the cautery or burning effect of the exposed bed and matrix. Either of these three procedures can yield a good cosmetic and comfortable result in the hands of an experienced practitioner.

When a toe nail becomes distorted due to trauma or disease and one wishes to remove it permanently due to cosmetic requirements or pain, specific procedures for removal of an entire toe nail have also been developed. Earlier procedures (Symes) necessitated the surgical excision of the entire toe nail and matrix. In order to close this defect half of the end bone of the toe was excised and remaining toe was then folded over and sutured down to close the defect. In light of modern technology this now seems to be a great deal of surgery and discomfort which is no longer necessary. Unfortunately the Symes procedure yields a short disfigured toe which is cosmetically compromised. A surgical procedure to cut away the nail matrix and bed for the entire nail in a similar fashion to that of the Frost procedure for partial nail was developed by Zadik. As in partial nail resection tissues are cut and sutures are placed into the toe. This leaves scarring and significant more discomfort due to greater tissue damage than modern procedures.

Again, chemical, radiosurgical, and laser procedures can be utilized for destruction of an entire toe nail. There are still no sutures or no cutting of the tissues. Following local anaesthetic the nail plate is gently eased off the toe and the exposed nail bed and matrix are cauterized (burnt) to destroy those tissues which generate the nail plate.

Post-operative care is simple dressings and soaks to care for the burn as it heals. A vast majority of patients require only Tylenol or Aspirin for any post-operative discomfort. Many persons cease taking analgesic medication the day after the procedure. Patients are immediately ambulatory. After having the foot elevated for twelve hours unrestricted walking is permitted in a large or cut out shoe.

Ingrown and disfigured toe nails need not be a chronic and painful condition. Modern podiatric procedures can permanently correct these conditions with minimal discomfort and disability.

Robert Goldbert, DPM

March 17, 1997 by Robert Goldbert, DPM