What to Expect When You Have Nail Surgery

So, your podiatrist has told you that you need to have nail surgery and you may be a little apprehensive.

Well, in this article we will look at why you may need a nail surgery, what’s involved and what you can expect so you can put your mind at ease!

First up, let’s have a quick look at the anatomy of the toe nail.

Nail Anatomy

Nails are made of keratin, which is a type of protein that also makes hair and skin cells.

In order to grow, nails require a healthy blood supply. At the beginning of each nail is a web of capillaries that branch off an artery, which supply the nail matrix with healthy blood.

In the image to the right, you can see all of the different elements that make up the nail. They are as follows:

The nail plate

This is the nail itself.

The nail bed

This is the skin that sits underneath the nail plate and is what it is adhered to.

Lunula

This is the half moon white area of the nail.

If this part of the nail is injured, the nail is unlikely to grow back normally. The absence of a lunula can sometimes indicate underlying health issues including anaemia.

Nail folds

These are situated on either side of the nail and are also referred to as the sulci.

In the instance of an ingrown toenail, this is the site where people may experience pain.

Cuticle

This is the junction between the nail and the skin.

The cuticle acts as a barrier to protect the nail matrix from infection.

Nail matrix

This is where the nail originates from.

It begins approximately 5mm below the cuticle and is not visible.

Why would I need to have nail surgery?

A nail surgery is referred to as either a partial nail avulsion (PNA), where we take a section of nail, or a total nail avulsion (TNA), where we take the entire nail plate.

It is most commonly performed on the big toenails.

There are a few reasons why your podiatrist may suggest a nail surgery. These can include:

Ingrown toenails

This is by far and away the main reason that we perform a nail surgery.

Ingrown toenails can range in severity and can be incredibly painful and debilitating.

This involves the nail growing into the sulcus of the nails (the nail fold).

It is a very common condition and can be caused by genetics, trauma, incorrect footwear, fungal infections and poor nail cutting techniques.

Trauma to the nail

Significant trauma to the nails, such as stubbing the nail or dropping something onto it may require part of the nail or the whole nail to be removed.

Fungal infection

Severe fungal infections may require the nail to be partially or completely removed, particularly if they are very thick or causing significant pain.

Recurring infections

The signs of this can include redness, heat, swelling and pus at the nail.

If these infections are recurring, it generally means that the skin may be breaking down due to the nail and it is more prone to infection.

What does a nail surgery involve?

If your podiatrist has recommended surgery for your nail, it is usually due to the fact that other conservative options have failed, such as applying foam to the sides of the nails or taping the skin away from the nail.

It is the best long term solution to help reduce the risk of recurrence and can decrease your pain quite quickly.

The surgery procedure is largely the same, regardless of whether you are having a partial nail avulsion or a total nail avulsion.

Step One:

Firstly, we will inject local anaesthetic into your toe. We use a local anaesthetic called xylocaine and numb the nerves surrounding the nail.

Before we do this, we work out what your maximum safe dosage (MSD) is. This tells us the maximum amount of local anaesthetic that we administer in one day that is safe for you and it is calculated by your body weight.

This local anaesthetic can take 5-10 minutes to come into effect so in the meantime, we prep the room and the surgery kit.

We then test the site to see how effective the local anaesthetic has been. It is completely normal that you may still feel pressure during the procedure, however we want to make sure that you cannot feel pain at all. It is very important that you make this distinction to help guide us.

There are a few things that can interfere with the action of the local anaesthetic including infection and a high amount of adrenaline in the bloodstream.

This is why we will often ask you to consult your GP to address the infection first with antibiotics, and ask you to bring in a book, headphones or a tablet to distract you if you tend to get quite nervous with procedures.

Step Two:

Once we are confident and comfortable that you cannot feel pain, we apply betadine to the foot. This antiseptic helps to reduce the risk of infection.

Step Three:

We will then test the sites again for pain and if you still can’t feel pain, we apply a tourniquet.

This helps to manage the blood flow to the toe whilst we are performing the procedure. It makes our job a lot easier!

The tourniquet can safely stay on for roughly up to 2 hours, however it is extremely rare for it to be on for more than approximately 20 minutes.

We make note of the time that the tourniquet is applied.

Step Four:

The next step is to lift the nail plate from the nail bed to make it a lot easier to remove.

This is done very carefully so as not to damage the nail bed as much as possible as this can delay healing.

Step Five:

The next step will differ depending on whether you are having a partial or a total nail avulsion.

If you are having a partial nail avulsion procedure, we will then make a longitudinal cut in the nail. The location of the cut will depend on how much of the nail needs to be removed.

In some total nail avulsion procedures, we can simply remove the whole toenail in one go once it has been lifted from the nail bed. However, in some cases such as fungal infections or severe ingrown toenails on both sides of the nail, we may need to do this in stages which requires cutting the nail out in a few pieces.

Step Six:

Once the cuts have been made, the nail is then removed.

Some people can feel a pulling force when this happens as we often have to use a little bit of force as the matrix is quite strong.

The good news is that the vast majority of people don’t even feel a thing and are very surprised when we say that the nail is out!

Step Seven:

Now that the entire toenail/part of the nail has been removed, we check the nail bed to make sure that there is nothing left over.

This is important as sometimes there is thickened skin at the site and this needs to be removed too so as not to impede healing.

Step Eight:

Then we apply a chemical called phenol. This stops the nail matrix from reproducing a nail plate at that site.

Research suggests that there is approximately an 8% chance that the phenol doesn’t take and the nail grows back, which is very rare.

Step Nine:

Next, we apply an antibacterial dressing called batigras that will help to reduce your risk of infection in the first 24 hours or so.

Once this is applied, we remove the tourniquet and note the time.

We also show another member of staff that we have removed the tourniquet as part of our safety procedures.

Step Ten:

The final step is applying the bandage.

This may differ between clinics, but the aim is to manage bleeding and protect the site as much as possible.

At Watsonia Podiatry, we apply a dressing called melolin and secure it with tape called hypafix. Then we apply either a tubigrip or coband over the top which helps with bleeding.

What Can I Do After My Nail Surgery?

For the first 24 hours after surgery, it is important to rest.

You will have quite a large bandage on the toe so it is nice and protected, however it is important to keep the foot elevated and keep the dressing dry to prevent infection.

This is a great excuse to have your partner or kids cook dinner and do the housework!

We typically advise against any high intensity physical activity or strenuous exercise for 2 weeks after a nail surgery.

With a large dressing on, it may be uncomfortable to wear an enclosed shoe for 24 hours after the surgery. However, your dressings at home will be slightly smaller, so you are able to go into enclosed shoes when you feel comfortable.

Avoiding tight shoes, heels or pointed shoes is very important for the weeks following your nail surgery.

What Happens After My Nail Surgery?

You will come back to the clinic the following day to have the toe cleaned and redressed.

At this appointment, we check to make sure that everything has gone to plan.

We cleanse the site with saline and teach you how to dress your toe yourself.

We then see you weekly until the site is healed.

The number of times you come back will depend on a few factors including how well you are redressing the toe at home, how much nail was taken, how quickly you are healing and if you have picked up an infection.

In the images below, you can see a nice before and after of an ingrown toenail surgery performed at our clinic! The photo on the left shows quite a subtle ingrown toenail that was causing this patient significant pain. The photo on the right is what it looked like after surgery and the patient had very little pain and was very happy with the result!

If you’re experiencing any pain or discomfort with your feet, lower limbs or toenails, you should book in to see us here at Watsonia Podiatry today. Call us 03 9432 2689 or book online here.

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