What are the partial nail avulsion surgical techniques used in the treatment of ingrown nails?

Updated: Nov 06, 2020
  • Author: Amira M Elbendary, MBBCh, MSc; Chief Editor: William D James, MD  more...
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Answer

Partial nail avulsion surgical techniques are as follows:

  • Phenol matricectomy: It is the most commonly used chemical agent for matricectomy, with good results and a low recurrence rate; however, because of the extensive tissue damage it causes, drainage and delayed wound healing may occur. [37] Dizziness, abdominal pain, hemoglobinuria, cyanosis, and cardiac arrhythmias are adverse effects that have been reported following phenol application. [38] Application of phenol for 1 minute duration has a better safety profile than prolonged application and is sufficient for destruction of the germinal matrix. [38]  Use of an antimicrobial hydrogel containing oakin, an oak extract, may help reduce phenol caustic activity and healing time. [39]

  • Chemical matricectomy with 10% sodium hydroxide: This is as effective as phenol. It acts through liquefactive necrosis by alkali burning, resulting in less postoperative drainage and a shorter healing time. However, care should be taken to not apply strong alkali for prolonged periods, as this may cause excessive tissue damage by from slowly progressive liquefactive necrosis. [40]  Additional adverse effects described following sodium hydroxide matricectomy include allodynia, nail dystrophy, and hyperalgesia. [41]

  • Trichloroacetic acid matricectomy: Chemical matricectomy using 90% trichloroacetic acid was tested following partial nail avulsion and was found to be helpful, with low rates of postoperative morbidity. [42] Trichloroacetic acid had shown high success rates with a healing time of less than two weeks. [43, 44]

  • Matricectomy using carbon dioxide laser: Performing selective matricectomy using a carbon dioxide laser is associated with a low recurrence rate, but technical difficulty, prolonged healing time, and poor cosmetic results are drawbacks for such a procedure. [45]

  • The Winograd procedure (wedge resection): This involves local anesthesia and digital tourniquet application followed by a longitudinal incision along the eponychium followed by removal of the lateral nail border, hypertrophied tissue, and germinal matrix. [46]

  • Wedge excision and phenol matricectomy

  • Cryotherapy

  • Electrocautery or curettage: Both methods are safe with high success rates. Curettage was found to be superior to electrocautery regarding postoperative inflammation and pain. Electrocauterization may cause heat osteonecrosis that may result in prolonged postoperative pain from the heat generated from the periosteum. [47]

In a study aiming to compare the wedge resection method and chemical matricectomy using sodium hydroxide, postoperative pain severity, drainage rate, and recovery time were reduced with chemical matricectomy. [48] However, there was no difference regarding recurrence rate.

Trichloroacetic acid was found to be as effective as phenol. It remains an option when phenol is not available. [49]

The use of local anesthetics that contain vasoconstrictors has shown to be effective, eliminating the adverse effects of using a digital tourniquet (lower anesthetic effect and postoperative bleeding). Reduction of postoperative bleeding and perioperative pain can be achieved with the addition of epinephrine to the local anesthetic, but use caution so as not to inject it into an artery. [50]


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