What is the difference between avulsion and excision

The physician grasps the lateral piece of nail with a hemostat, getting as much nail plate as possible into the teeth of the instrument. 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. If the lateral nail plate breaks, the remaining nail is regrasped and pulled out.

No fragment of nail plate should remain under the proximal nail fold. Electrocautery ablation is used to destroy the nail-forming matrix beneath the area where the nail plate has been removed. The flat matricectomy electrode is coated on one side to avoid damage to the overlying proximal nail fold.

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.

A properly treated nail bed has a white appearance after electrocautery. If excessive lateral granulation tissue is noted, the physician may consider removal with electrocautery ablation. A 5-mm ball electrode is moved back and forth over the lateral granulation tissue, coagulating with 40 to 50 W of current setting, 4 to 5. The destroyed tissue can usually be wiped away with gauze, and the process repeated until a concavity reveals normal tissue at the base.

This site will fill in as healing takes place over the next few weeks. Antibiotic ointment is applied, a bulky gauze dressing is placed, and the patient's foot is put in a disposable surgical slipper. The patient should apply antibiotic ointment daily until healing is complete. The patient should be given the instruction sheet and told to take ibuprofen Motrin and acetaminophen Tylenol for postoperative pain. Daily cleansing with warm water is encouraged, and strenuous exercise is discouraged for at least one week.

A pathology evaluation performed on tissue removed during ingrown toenail surgery is rarely needed; only when an abnormal growth or suspected malignancy is encountered would a specimen be sent for pathologic evaluation. If increasing pain, swelling, redness, or drainage develop, the toe should be evaluated for infection. Infection is common after ingrown toenail removal. Early intervention with oral antibiotic therapy can be highly effective in preventing infectious complications.

Incomplete matricectomy can allow a spicule of new nail to grow laterally, interfering with the newly created lateral nail groove.

A second procedure may be required to obliterate the lateral spicule if inadequate matricectomy is performed during the first procedure. Patients with distal toe ischemia usually present with duskiness, poor healing, occasional ulceration, and even necrosis of the affected digit. Ingrown toenail removal can be performed without a tourniquet, but it is easier with a bloodless surgical field. If a tourniquet is used, it should be removed as soon as possible. Prolonged or high-current cautery has the potential to damage the fascia or periosteum underlying the nail matrix.

If the toe is healing poorly several weeks after the procedure, the physician may consider debridement, antibiotics, and possible radiographic evaluation. Infection is not unusual after the procedure, and oral antibiotics can be liberally administered. Some physicians routinely prescribe antibiotics for a few days after the procedure. Management of aggressive infection can reduce the chance of patients developing the rare complication of osteomyelitis.

If inadequate matricectomy is performed, a spike of nail can regrow along the new lateral nail fold. This laterally growing piece of nail creates another inflammatory reaction in the lateral toe, necessitating a second procedure.

The physician must make sure that the lateral horn matrix cells under the proximal nail fold are adequately ablated the first time. The physician must cut with the smallest blade of the scissors beneath the nail.

The tips of the scissors should be slightly angled upward to avoid lacerating the fragile nail bed beneath the nail plate. Usually, bleeding from superficial lacerations is controlled by electrocautery. Deep lacerations may require suture repair and removal of additional nail.

Patients should be reminded that the procedure will permanently narrow the nail. In addition, the concavity left when the lateral granulation tissue is removed can be a shock, but patients can be reassured that the tissue will gradually fill in.

The technique of nail avulsion and matricectomy is easily learned by physicians with soft tissue surgery and electrosurgery experience. Physicians should have precepted patient procedures. Novice physicians may need 20 procedures before they are comfortable performing the procedure unsupervised.

Experienced physicians may be comfortable after performing three to five procedures. Already a member or subscriber? Log in. Interested in AAFP membership? Learn more. Adapted with permission from Zuber TJ. Office procedures. Benjamin RB.

Excision of ingrown toenail. In: Benjamin RB, ed. Atlas of outpatient and office surgery. J Dermatol Surg Oncol. Fishman HC. Practical therapy for ingrown toenails. Frumkin A. Ingrown toenail procedures are by nature painless, because the toe is completely made numb by a local anesthetic before the procedure is performed.

Most people have just a little tenderness with direct pressure on the nail area for a week or two after the procedure , although some people feel no discomfort at all. It is important to know that the nail will not appear the same as other nails if this ingrown toenail surgery technique is performed. The recovery process can take up to six to eight weeks. The presence of infection prior to surgery will prolong the recovery period. Share on Pinterest A toenail should grow back within 18 months.

When the toenail begins to fall off, a person may be advised to seek medical attention. However, in the first instance, they may start treatment on the toenail by: using a file to remove rough edges. This is a minor procedure that involves removing the part of the nail that is ingrown.

Before surgery , the doctor will numb your toe by injecting it with medicine. First, they cut your toenail along the edge that is growing into your skin.

Then, they pull out the piece of nail. Electrocautery ablation is used to destroy the nail -forming matrix beneath the area where the nail plate has been removed. The flat matricectomy electrode is coated on one side to avoid damage to the overlying proximal nail fold. Ingrown toenail surgery aftercare For the first day or two after surgery , you should rest your foot and limit activity.

Wear open-toed or loose-fitting shoes for about two weeks after surgery. This gives your toe room to heal. The nail may be completely or partially torn off after a trauma to the area. Your doctor may have removed the nail , put part of it back into place, or repaired the nail bed. If completely removed , fingernails may take 6 months to grow back. Toenails may take 12 to 18 months to grow back.

Keep your foot elevated and rest on the day of surgery. Your toe will have a large bandage on it. This dressing is usually left on for 24 hours. On average it will take six to twelve weeks for your nail to heal. You should wear loose-fitting shoes or sneakers for the first 2 weeks after the procedure. Please avoid wearing high-heeled or tight-fitting shoes in the future. You should avoid running, jumping, or strenuous activity for 2 weeks after the surgery. The procedure involves removal of either all of, or part of the painful toenail.

In a healthy young adult, regrowth of a fingernail is expected to take around 9 months. It takes about 18 months to fully grow a great toenail. Nail growth may be slower in older individuals or in people with poor circulation. See smartphone apps to check your skin. DermNet NZ does not provide an online consultation service. If you have any concerns with your skin or its treatment, see a dermatologist for advice. Medical nail avulsion — codes and concepts open. Treatment or procedure.

Urea paste, Onychomycosis, Onychogryphosis, Onychocryptosis, Ingrown nail. NC50, ND Sign up to the newsletter.