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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/or hereditary and congenital abnormalities.
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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.
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Factors to be considered include the following:
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- History of systemic disease
- History of allergies
- Concomitant drug use
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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 contraindications to surgery 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 (e.g., monoamine oxidase inhibitors or phenothiazines), prolong bleeding (e.g., aspirin and anticoagulants), delay healing (e.g., glucocorticoids), or have toxic effects on the nail apparatus (e.g., retinoids). There may be a history of allergy to lidocaine or mepivacaine or to parabens contained in both as a preservative. A knowledge of previous antitetanus immunization is important, because administration of tetanus toxoid may be advisable in association with surgery involving the toenail or traumatic lesions that come into contact with soil.
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A magnifying lens may be 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 in order to localize pain, to obtain a radiograph to rule out underlying bone involvement, or to ask for ultrasonography and magnetic resonance imaging when a tumor is suspected.
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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.
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(See reference 1 and Chapter 89).
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The nail plate is the permanent product of the nail matrix. Its normal appearance and growth depend on the integrity of the perionychium and the bony phalanx (Fig. 245-1). The nail is a semihard horny plate covering the dorsal aspect of the tip of the digit. The nail is inserted proximally in an invagination that is practically parallel to the upper surface of the skin and laterally in the lateral nail grooves. This pocket-like invagination has a roof, the proximal nail fold, and a floor, the matrix from which the nail is derived. The matrix extends approximately 6 mm under the proximal nail fold, and its distal portion is only visible as the white semicircular lunula. The general shape ...