NAIL EXTRACTIONNadia Puspita-c111 11 141Fitri 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•Clubbing•Koilonychia•Yellow Nail

Syndrome

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 doesn’t have

healing effect

NAIL EXTRACTION PROCEDURE

1. Use a digital block or local anasthesia2. 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 approach1. 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 treatment1. 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 afterbilateral wedge excisions for ingrown nails showing onychogryphosisand 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 hornresection.

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