What is nail surgery?
Nail surgery is a treatment used for fingernails or toenails that cause pain, are infected or are unsightly. It involves injecting a local anaesthetic into the less sensitive part of the affected finger or toe to numb the entire area.
A section of the nail, or sometimes even the whole nail, is removed, and then a chemical might be used on the nail bed so that the removed nail section does not grow back. (I'll talk about this in more detail shortly).
When is nail surgery a good idea?
Nail surgery is a good idea if:
You have recurrent ingrowing nails.
You have very curved (also known as 'involuted') nails that dig into you, causing pain.
You have a one-off issue with an ingrowing nail, but treating it without anaesthetic would be too painful.
You are an athlete who may be forced to miss competitions due to your nails becoming painful.
You have a bacterial infection, which is bad enough to require antibiotics.
You have injured the nail or the nail bed, and the nail is now mostly detached.
You have a large blood blister under the nail or behind the cuticle (this often happens to runners)
You have a fungal infection in the nail that has been difficult to shift.
You have health conditions, meaning that lengthy courses of oral antifungals would be a bad idea, so removing the nail means a shorter course of treatment.
You have a health condition that means caring for your nails is difficult or will become difficult as you get older.
You have a health condition that means that you are immunocompromised, and infections from ingrown nails would put your health at risk.
When is nail surgery a bad idea?
Nail surgery is rarely a bad idea; however, these are some reasons when I think it is worth considering your options:
You don't want to have nail surgery and would prefer to have conservative (non-surgical) treatment every 3-12 weeks)
You don't have any problems with your nails.
You are taking a medication that is causing your ingrowing nails.
Isotretinoin (Roaccutane) has been known to cause ingrowing nails, so if you are on a course of acne treatment, then you might not need nail surgery for the long term.
Young children and young adults who develop an ingrowing nail because they did not know how to cut their nails
Foot and hand models should choose their podiatrist carefully to ensure that only the minimum amount of nail will be removed as the aesthetic of their foot or hand may change.
Professional athletes and sportspeople should consider the timing of their procedure relative to any games or competitions that may be upcoming.
However, sometimes it may be better to have the procedure and have some time out from the sport than to continue playing and risk longer-term issues.
If you are due to go on holiday or take part in an activity where you will not be able to keep the affected digit appropriately clean
If the patient cannot look after the wound after the procedure and does not have the correct support in place.
If you have a history of a condition known as Complex Regional Pain Syndrome (CRPS)
Can you have nail surgery while taking 'biologic' drugs or undergoing chemotherapy, such as for cancer or autoimmune conditions?
Yes, you can. Sometimes.
The timing of the procedure is essential with some drugs as the drugs will increase the risk of the patient developing an infection or other complications. However, especially with ingrown toenails, it may sometimes still be more beneficial to have the surgery despite the timing of the procedure not being ideal.
This is because when the toenail (or fingernail!) is ingrowing, it causes a bacterial infection and allows more infections to get into the skin. Whereas having the surgery, it means that
The puncture wound caused by the nail can close up.
The body can start to fight the infection more effectively.
The person operating can also:
Clean out the wound.
Apply a strong anti-bacterial to the area.
Get a deep swab to identify any of the infecting organisms as well.
The other benefit of having the procedure now is that if the infection has happened once, it will likely happen again. So, rather than having to heal from one infection and then have time without the biological or chemotherapy drugs for the second procedure, it can be dealt with properly in one go.
Can you have nail surgery if you are pregnant?
Yes, you can. It is considered controversial because the 'wisdom' passed down through generations of podiatrists states that the chemicals used could harm the growing baby. However, this is not correct.
Whilst the chemical (phenol), which is used to prevent the nail from regrowing, may cause damage to your developing baby if used in substantial quantities, the amount of the chemical used is tiny. Likewise, it is present everywhere. So, if you ever eat food from plastic containers, enjoy smoked salmon regularly, clean with TCP or walk past smokers, you also absorb some of that chemical.
I wrote a paper about this and have given lectures on the topic, too, so feel free to ask me more about it.
What are the advantages of nail surgery?
Nail surgery is pretty painless once the injection is out of the way.
The aftercare is simple:
Bathe your foot 1-2 times daily in warm salt water for 5 minutes.
Put a plaster on over your toe.
Repeat until a dry scab has formed or the toe is completely healed (ask your podiatrist which is more appropriate)
It is effective 95% of the time.
There is an approximate 'failure' rate of 5% for those who have nail surgery as a permanent solution. This means that in 5% of people who have the nail bed killed off:
A part of the removed section might grow back.
The whole removed section might grow back.
But even when it is ineffective, many patients still report improving their pain or reducing the infection rate.
You don't have to worry about the nail ingrowing in the future if the chemical is applied to prevent regrowth.
Why should the nail bed be killed off?
It is not always appropriate to kill the nail bed during surgery. After all, many people will only struggle with the nail ingrowing as a one-off, so throwing the baby out with the bathwater is a little extreme.
I often say to patients, where this is the case, that they shouldn't make the decision in anger. After all, when something is painful, you might be tempted to say, "Chop it off", or "I don't care what happens". This, although understandable, is not the way to move forward, and although anaesthetic may be used, having the nail bed killed off at this point may be premature.
Likewise, if a nail has been traumatised, then there is a possibility it will grow entirely normally afterwards. However, the opposite can also be true.
Finally, nails with a fungal infection may benefit from having the nail removed and 'starting afresh', and to boost the chance of success, it can be worthwhile having your doctor prescribe you an antifungal for while the nail is initially growing until a topical antifungal can be applied.
Summary
Nail surgery is an excellent treatment choice for the frequently problematic nail or a nail that would be too painful to treat without anaesthesia. It is a quick procedure (often, the paperwork takes longer than the procedure!), and the satisfaction rates are high. If how the nail will look after the surgery is a concern, then you should discuss this with the person operating and ensure that they can give you the outcome you want or get you close to it.
There are many procedures available for nail surgery. Although this blog post mainly covers the 'phenolisation method', other methods exist and can often be discussed if your podiatrist knows them.
If you are interested in nail surgery, you might also like to take a look at this link which goes into more detail about nail surgery and what your next steps might be.