NAIL EXTRACTION

Nadia Puspita-c111 11 141

Fitri Mutiah Sappewali-c111 11 129

INTRODUCTION
Nail surgery is special branch of hand and
dermatologic surgery. It is not widely performed,
and many phycians do not feel at ease to perform
it. Nail Surgery is a precise technique that require
careful administration and attention to details.
If performed correctly with adequate skills, nail
surgery will lead to functionally and aesthetically
satisfying results in the majority of instances.

ANATOMY OF THE NAIL APPARATUS

PHYSIOLOGY OF THE NAIL

Fingernail is an important structure made of
keratin. Generally serve two purposes. It serves
as a protective plate and sensation
function.

Finger nails grow at an average rate of

1mm/week, slower in the toe nails.

PATHOLOGIC NAIL
CONGENITAL
NAIL
ANOMALIES

ACQUIRED
NAIL
CHANGES

NAIL
APPARATUS
INFECTION

CONGENITAL NAIL ANOMALIES

Pachyonychia Congenita
Isolated Congenital Nail Dystrophy
Nail Patella Syndrome
Other

NAIL APPARATUS INFECTION

Acute Paronychia
Blistering Dactylitis
Chronic Paronychia
Onychomycosis

ACQUIRED NAIL CHANGES

Onychodystrophy
Leukonychia
Trachyonichia
Median Nail Dystrophy

Onychogryposis
Ingrown Nail

INDICATION OF NAIL EXT.

DIAGNOSTIC

THERAPEUTIC

INDICATION FOR DIAGNOSTIC

Unclear disturbances
Atypical inflammation
Suspicious pigmentations
Neoplasias

INDICATION FOR THERAPEUTIC

ABSOLUTE
Unclear disturbances
Atypical inflammation
Suspicious
pigmentations
Neoplasias

RELATIVE
Onychogryposis
Nail Mycosis
Discoloration due to
chromogenic bacteria
Subungual warts,
hematoma
Longitudinal Split Nails
Recalcitrant Chronic
Paronychias

CONTRAINDICATION OF NAIL EXT.

Malformed nails due to matrix disease
Large scars of the nail bed/ ingrowing nail
An extraction of nail plate doesnt have healing
effect

NAIL EXTRACTION PROCEDURE

1. Use a digital block or local anasthesia
2. Place the digital tourniquet once the finger is
anesthetized. Alternatively, you can wait to place
the tourniquet until the nail has been removed.
3. Place a small hemostat clamp just beneath the
nail (between the nail and nail bed).
4. Gradually spread the clamp (open its jaws) to
free the nail completely from the underlying
nailbed.

 5. Gradually advance the clamp proximally, until

it is under the proximal portion of the nail
(where it emerges from under the skin).
6. Grab the nail with the clamp, and pull. It may
take some effort.
7. Clean the nail, and save it in saline-moistened
gauze or a cleansing solution ( Betadine). The
nail may be useful for splinting the nail bed
repair.

AFTER CARE
1. Place a small amount of antibiotic ointment
around the nail, and cover the fingertip with light
gauze.
2. After 1 or 2 days the fingertip can be left open
without a dressing.
3. The hand should be kept elevated at all times. The
finger will start to throb if the hand is dependent.
4. Encourage the patient to move all the joints of the
finger to prevent stiffness.

5. Remember pain medication. Because fingertip

and nail bed injuries are quite painful.
6. Strongly encourage the patient to refrain from
using tobacco products, which significantly
delay healing.

TREATMENT
Conservative approach
1. Taping. Taping is the least aggressive method.
It uses tape to pull the lateral nail fold away
from the offending lateral nail edge.
2. Packing. Packing is simple method. A wisp of
cotton is inserted between the corner of the
nail and the nail fold.
3. Dental Floss. Instead of cotton, dental floss
was inserted under the nail corner in order to
separate it from the nail groove.

Figure1.Schematic illustration of taping.

Figure 2. Schematic illustration of packing.

4. Gutter Treatment. Gutter treatment is the

insertion of a small guard between the lateral
nail margin and the nail fold. The gutter is
fixed with one or two stitches, tape or acrylic
glue. The gutter not only protects the lateral
nail groove, but also exerts some pressure on it
making the granulation tissue disappear even
faster

Figure 3: Schematic illustration of gutter treatment.

5. Nail Braces and Similar Devices. Nail braces

are designed to open the curvature of the nail.
Their main field of indication is nail
overcurvature leading to pincer nail.
6. Hygienic Measures. Foot baths and consistent
foot hygiene are important factors during
conservative treatment, to maintain its effect
and as a preparation for surgery.

 Surgical treatment
1. Nail avulsion, causes significant postoperative
morbidity. This takes the outward pressure of
the nail plate away and according to allows the
nail to grow out without piercing into the
lateral grooves.
2. Wedge excision, by mutilating as the lateral
nail folds are removed and the nail is no more
ensheathed by them. The nail will grow
markedly narrow, distorted, onycholytic,
thickened, discolored, and deviated

Figure 4: Schematic illustration wedge excisions, the

wedge is very wide in the middle of the lateral nail fold,
but the lateral matrix horn not completely excised.
(a) Transverse section at the level of the midnail bed,
(b) transverse section at the level of the matrix horns.

Figure 5: Toenails of a 38-year-old

female patient 16 years after
bilateral wedge excisions for ingrown
nails showing onychogryphosis
and malalignment.

Figure 6: 16-year-old boy, 4 years after a

wedge excision, which had been complicated
by infection and necrosis of the lateral
nailfold.

3. Reduction and Removal of the Lateral Nail

Fold. Over a long period, the nail fold becomes
fibrotic and has no tendency to return to a
normal size. Excision of a fusiform piece of
skin from the lateral aspect of the distal
phalanx and suture pulls the exuberant nail
fold laterally and away from the nail.

Figure 7: Schematic illustration of the reduction of a

hypertrophic lateral nail fold by a fusiform excision.

4. Excision of the Nail Bed. This is an inadequate

and far too radical method and in no case
indicated.
5. Amputation of the Tip of the Toe. It involves
resection of the nail bed and matrix,
amputation of the distal half of the terminal
phalangeal bone, and defect closure with a flap
formed by the ridged skin of the tip of the toe.

6. Surgical Segmental Matrix Excision. A nail

elevator is inserted under the ingrown lateral
strip of the nail to free it from the nail bed and
then from the overlying proximal nail fold. The
plate is cut straigh back to the cuticle and
under the nail fold to the proximal end of the
matrix.

When the nail strip is taken out, the nail edge

very often shows a sharp spike resulting from the
improper nail cutting of the patient. The matrix
horn with about 2mm of the adjacent nail bed is
meticulously dissected from the bone.

Figure. Schematic illustration of the selective lateral matrix horn

resection.

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