Definition & Overview

Toenail removal is a procedure performed to remove ingrown nails in cases where fungal infection is present. Depending on the extent of the condition and severity of infection, the procedure may involve removing either a part of the nail in a procedure called debridement, or the whole nail, in a process called avulsion. Having ingrown nails is a typical problem for a lot of people, and toenail removal is one of the ways to ease the pain and other complications that the condition may cause.

There is no clear indication as to when a surgical procedure needs to be performed and preferred over non-surgical treatment options. The decision usually lies on the patient himself and the doctor’s recommendation, which is based on the result of the physical assessment, tests and diagnosis. However, it is better to treat the problem with surgical means as early as possible because ingrown nails only become worse as time passes. Using non-surgical treatments when the condition has already progressed will only make treatment more difficult and time-consuming. This is because in the advanced stages of the disease, there will be heavy granulation tissue formation, which may cause pain even when the patient is simply walking. Once this occurs, no non-surgical treatment will be effective anymore. Moreover, when epithelium forms over the granulation tissue, a problem may occur with the drainage of the abscess, allowing it to form continuously. The excess tissue that becomes inflamed in the latter stages usually makes it harder to lift off the nail edge, rendering all nonsurgical methods useless.

Who Should Undergo & Expected Results

The people who should undergo toenail removal are those who have ingrown nails and fungal infection on their toenails that typically lead to abscess, pain, and inflammation. An ingrown is a common toenail problem that a lot of people experience. Although an ingrown does not seem to be a major health problem for it to require surgical intervention, the condition can cause a lot of pain, which is why many people opt to have the ingrown surgically removed.

To understand how an ingrown develops, it is important to know the structure of the nail. The nail consists of the nail plate, which is the part that is exposed, and the root, which is covered by a fold of skin known as the eponychium. The edge of the eponychium is called the cuticle. The nail plate rests on a portion of the skin known as the nail bed, and the surrounding skin on the edges of the nail plate is called the nail walls. When the nail grows into periungual soft tissue, it starts to grow inwardly, and this causes an ingrown to develop.

Any toenail can develop an ingrown, although it most typically occurs on the big toe. This is usually because this toe tends to get compressed by footwear, so there is not enough space for the nail to grow freely. The risk is heightened when the nail is not cut properly. When the nail is improperly cut along the lateral portion, the nail fold can become irritated or penetrated. This makes it possible for bacteria and fungi to grow in the area. Abscess can then follow suit, and symptoms, such as inflammation, edema, erythema, and pain, may also be felt. Hypertrophic granulation tissue may also form, further irritating the nails and making the situation a lot worse.

How Does The Procedure Work

The doctor will start by typically giving the patient immunization against tetanus as the open wound can develop a bacterial disease that results in spasm of the voluntary muscles. However, the tetanus shot is only given if the patient has not received one in the last five years. An x-ray may also be performed to find out if the infection has spread to the bone and has developed into osteomyelitis.

Once all preliminary procedures have been performed, the doctor will inject anesthetic into the area where the toe connects to the foot, numbing the whole foot in the process.

Once the surgery is under way, the doctor will treat the infection before removing the extra tissue and a small part of the nail so the skin will heal without irritating it. Chemicals, such as silver nitrate sticks, sodium hydroxide, or phenol, may be used to destroy some cells, preventing the development of new ingrown nail. However, while phenol may lessen the chance of recurrence, there is a tendency for it to increase the infection. Thus, the other options are more often used. If chemicals do not work or are not suitable for some reason, other alternative methods of destroying the cells may be used, such as surgical laser, curettage, electrocautery, or using extreme cold.

When the condition is very severe, chronic and recurrent despite undergoing traditional surgery, the doctor may recommend the complete destruction of the nail matrix. A procedure called lateral matricectomy, which is the surgical removal of a portion of the nail bed, is then performed. However, there are alternative types of surgery that do not involve removing the nail bed completely. In this type of surgery, the doctor removes a small part of the soft tissue beside or underneath the nail so that there would be space for the nail to grow out. There are also times when a flexible tube is inserted into the side of the nail to help the nail heal better. Although these types of surgical interventions are promising, they are not yet considered standard procedures in ingrown treatment.

However, take note that the total removal of the nail plate is rarely necessary. The typical method that is still preferred is partial nail removal unless there is inflammation involved. The toenail needs to be removed because without the toenail, it becomes easier to directly apply antifungal cream on the affected area, thus making it easier to cure the infection.

At the end of a toenail removal procedure, an ointment will be applied on the toe and it will be covered with gauze. Antibiotics are not normally used for this because the draining of the abscess is done to make sure that the infection dies. After the surgery, patients need to keep the dressing for two more days. On the second day, the dressing needs to be removed and the affected area needs to be washed with soap and water. Patients will also be taught how to apply a triple antibiotic ointment before covering the area with new gauze. This procedure must be repeated until the wound has fully healed.

Possible Complications & Risks

Having ingrown nails usually results in uncomfortable symptoms such as pain, bleeding, and inflammation. Toenail removal can help get rid of these discomforts. However, the procedure itself may cause patients some discomfort. Infection may also occur if the wound is not properly cleaned and disinfected after the procedure and during the healing period.

The risk of acquiring infection can be lessened by making sure that the area is clean and dry during the procedure and by applying an antibiotic treatment.

References:

  • Heidelbaugh JJ, Lee H. Management of the ingrown toenail. Am Fam Physician. 2009;79(4):303-8.

  • Ishikawa SN. Disorders of nails and skin. In: Canale ST, Beaty JH, eds. Campbell’s Operative Orthopaedics. Philadelphia, Pa.: Elsevier Mosby; 2012:chap 87.

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