Nail surgery requires careful patient selection to prevent unnecessary complications.
The technique used for anesthesia depends on the type of surgery. Distal digital block with ropivacaine 2 mg/mL is usually the best option.
Partial nail avulsion allows the exploration and/or the treatment of a subungual lesion or the removal of a pathologic nail plate. Total nail plate avulsion should be discouraged to prevent nail bed shrinking and distal embedding.
Nail biopsies are performed to determine the histopathologic features of a lesion or to clarify an uncertain clinical diagnosis.
Lateral longitudinal biopsy is the best technique for inflammatory disorders or lateral longitudinal melanonychia.
Punch biopsy less than 3 mm in the distal matrix does not produce serious dystrophy.
Tangential shave excision is the best option for superficial matrix tumors such as wide longitudinal melanonychia or superficial epithelial benign tumors.
The main objectives of nail surgery are to aid diagnosis by biopsy, to treat infection, to alleviate pain, to remove local tumors, and to ensure the best cosmetic results in acquired and congenital abnormalities.
Providing the patient with an exact illustration of the operation is helpful to give the patient insight into the procedure and its expected outcome. A thorough discussion regarding postoperative morbidity is essential.
Preoperative photographs as well as any taken during surgery may be useful medicolegally. Careful history taking may reveal systemic disease such as diabetes mellitus, blood dyscrasia, vascular disease, vascular collagen disease (scleroderma), allergy, chronic pulmonary disease, or immune impairment. Any of these may at times be relative contraindications to surgery, may be associated with severe complications (infection, necrosis), or may call for alteration of the technique to be used. Surgery of the nail is not recommended in patients with high-risk conditions. A history of concurrent use of drugs may be relevant, because these drugs may affect anesthesia (eg, monoamine oxidase inhibitors or phenothiazines), prolong bleeding (eg, aspirin and anticoagulants), delay healing (eg, glucocorticoids), or have toxic effects on the nail apparatus (eg, retinoids). There may be a history of allergy to lidocaine or mepivacaine or to parabens contained in both as a preservative. A magnifying lens and dermoscopy are useful to observe the color, surface, and structure of the periungual tissue and to compare the unaffected contralateral digit. It may be necessary to probe to localize pain, to obtain a radiograph to rule out underlying bone involvement, or to ask for ultrasonography and MRI when a tumor is suspected. The basic requirements for nail surgery include a detailed knowledge of the anatomy and physiology of the nail apparatus on the part of the surgeon. Full aseptic conditions, regional block anesthesia, and local hemostasis are indispensable.
The nail plate is the ...