A properly treated nail bed has a white appearance after electrocautery. The electrode is placed beneath the nail fold, just above the nail bed, and cautery is applied to a bloodless field using 20 to 40 W of coagulation current (setting, 2 to 4), with sparking, for two to 10 seconds, treating the entire exposed nail bed and matrix twice. The flat matricectomy electrode is coated on one side to avoid damage to the overlying proximal nail fold. No fragment of nail plate should remain under the proximal nail fold.Įlectrocautery ablation is used to destroy the nail-forming matrix beneath the area where the nail plate has been removed. If the lateral nail plate breaks, the remaining nail is regrasped and pulled out. The lateral nail plate is removed, in one piece if possible, by rotating the fragment outward toward the lateral nail fold, while pulling straight out toward the end of the toe. The physician grasps the lateral piece of nail with a hemostat, getting as much nail plate as possible into the teeth of the instrument. (C) The lateral nail bed and matrix are now exposed for ablation.
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(B) The free lateral nail now is grasped with a hemostat or clamp and removed. Some physicians prefer to slide a flat nail elevator beneath the nail before making this cut in an effort to reduce trauma to the nail bed. After administering digital or local anesthesia, scissors, a scalpel blade, or a nail splitter can be used to cut proximally and create a smooth, straight edge. (A) An ingrown nail is seen with lateral nail fold hypertrophy on the left side of the nail. The nail bed extends distally to the hyponychium (I).ILLUSTRATIONS BY CHARLES H. The nail matrix extends to the lateral horns (H). The nail matrix can be seen at the junction with the nail bed, called the lunula (G).
The lateral nail fold lies outside of the lateral nail groove (F) and is the area where ingrown nails develop. The nail plate is visible from the proximal nail fold (cuticle) (D) to the distal or free edge (E). The nail plate is created by the nail matrix (C). The nail plate (A) receives nutrition from the underlying nail bed (B). When the scissors cut through the most proximal edge of the nail beneath the cuticle, a “give” can be felt. A straight, smooth, new lateral edge to the nail plate is created. The physician uses a nail splitter or bandage scissors, cutting from the distal (free) end of the nail straight back (proximally) beneath the proximal nail fold ( Figures 1 and 2).
This area is usually where the nail curves down into the toe. The lateral one fourth or one fifth of the nail plate is identified as the site for the partial lateral nail removal. A nail elevator or the closed tips of iris scissors are slid under the cuticle to separate the nail plate from the overlying proximal nail fold. The toe is rewashed with surgical solution, and a fenestrated drape is placed over the foot, with the involved toe protruding through the drape. A tourniquet should be used for the shortest possible time only. Alternatively, pressure to the sides of the toes during the procedure can reduce bleeding. A clean, unused rubber band can be placed in a sterilization pouch and put through an autoclave. Some physicians use a sterile rubber band around the base of the toe for a dry operative field. A wait of five to 10 minutes allows the block to become effective. About 2 to 3 mL of lidocaine on each side of the toe is usually sufficient for adequate anesthesia. A standard digital block is performed with 1 percent lidocaine (without epinephrine), using a 10-mL syringe and a 30-gauge needle. The toe is prepped with povidone-iodine solution. The patient is placed in the supine position, with the knees flexed (foot flat on the table) or extended (foot hanging off the end of the table).
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