Case Series: Soft-tissue nail-fold excision: a definitive treatment for ingrown toenails

Abstract

Background: Ingrown toenail, or onychocryptosis, is a common source of morbidity worldwide. The current standard of care focuses on the nail as the causative agent, and, in cases that are resistant to medical management, surgical correction via nail avulsion and phenol matrix ablation is used. Unfortunately, this treatment leads to poor cosmetic results, high rates of recurrence and low patient satisfaction.

Methods: We retrospectively reviewed a case series of 124 consecutive patients who underwent surgical correction of ingrown toenails from 1988 to 2004. We recorded the operative technique and postoperative wound healing via photographs. We assessed outcomes and patient satisfaction using self-reports and 7-point Likert scale questionnaires.

Results: Our surgical approach involved the excision of excessive nail-fold granulation tissue with preservation of the nail and its matrix. In total, 72.5% of patients were under the age of 29 (69.4% men). Before surgical intervention, 78.8% of patients scored their pain as severe, 69.9% had difficulty wearing normal footwear and 64.3% had difficulty with normal activities because of their ingrown toenails. A total of 212 surgical sites were analyzed, with a median follow-up of 8 years. No recurrences were identified in any patients (100%, n = 124). Overall, 94.3% (n = 116) stated that they were highly satisfied with the procedure. Only 1.6% (n = 2) reported a loss of sensation at the surgical site.

Conclusion: Surgical correction of ingrown toenails via soft-tissue excision of the nail folds, coupled with preservation of the nail and its matrix, had excellent cosmetic results, no recurrences and high rates of patient satisfaction.

Fig. 1

Examples of the severity of ingrown toenails surgically corrected by soft-tissue nail-fold excision. The preoperative appearance (left) highlights the extensive medial and lateral nail-fold granulation tissue. The images obtained in the postoperative period (centre, right) show the surgical site following nail-fold excision. The excision of soft tissue was typically generous and adequate, with all portions of the granulation tissue removed.

Fig. 2

The soft-tissue nail-fold excision procedure for ingrown toenails. In step 1, the toe is cleansed with an iodine solution, and ring block anesthesia is applied with 2% xylocaine without epinephrine. A tight elastic tourniquet is placed at the base of the toe to maintain a clear surgical field. An initial incision of 5–10 mm is made proximally from the base of the nail and about 3–5 mm from the lateral border of the nail to encompass the proximal nail fold. Care is taken to leave the nail matrix intact. In steps 2 to 4, the lateral nail fold is excised using a lateral elliptical sweep that proceeds distally to encompass all involved granulation tissue and adjacent soft tissues. In steps 5 and 6, all skin and subcutaneous tissues at the edge of the nail is removed. Occasionally, a portion of the distal phalanx is exposed. The operative site following complete excision of soft-tissue nail folds is shown in step 7. Note the intact nail and preservation of the nail matrix. The applied tourniquet successfully minimizes bleeding in the surgical field. In step 8, electrocautery is used to obtain hemostasis, and the wound is left open to close by secondary intention following the application of gauze dressings.

Fig. 3

Images showing healing by secondary intention following surgical nail-fold excision. Post-op = postoperative.

Fig. 4

Postoperative recurrence (A) and patient satisfaction (B) in 124 patients (212 sites) following surgical correction of ingrown toenails using soft-tissue nail-fold excision.