Nail surgery is a way to remove a portion of the nail or an entire nail due to a disorder, deformity, or fungus. Nail surgery isn’t typically the first line of treatment for nail problems, but ingrown nail surgery or nail surgery to remove an extremely thick fungus may be the best option after consultation.
Often, podiatrists conduct an ingrown toenail nail surgery for their patients after other nail grooming methods prove inefficient. For example, a patient may visit a podiatrist because their nail is hurting when they wear shoes. If trimming does not work, they may recommend an ingrown toenail nail surgery. They often perform ingrown nail surgery by cutting from the sides of the nail and applying phenol to kill a specific portion of a nail so it does not grow back to become an ingrown nail.
In dermatology, we perform a variety of nail surgeries depending on the skin issue we need to address. We use nail plate removals to treat fungus, nail biopsies to detect skin cancer or tumors under the nail, and nail plate excisions or Mohs surgery on the nail to remove skin cancer or tumors.
What Symptoms Are Treated with Nail Surgery?
We use nail surgeries treat nail fungus, tumors, or skin cancer underneath the nail.
Many people visit the dermatologist because of nail fungus. For some patients, we can diagnose the fungus based on clinical observation and begin treatment immediately. For other patients, we need to scrape a sample of the debris underneath the nail and send it for a culture or a KOH prep test to accurately diagnose the fungus.
Once diagnosed, we begin treating the fungus. We usually begin fungal treatment with an oral or topical anti-fungal medication. If these medications prove ineffective or if the patient no longer wants to deal with the thickness and appearance of the nail, they may opt to have the nail removed entirely. With a complete nail plate removal, we keep the patient on anti-fungal medications while the nail grows back. Toenails can take 8-18 months to grow out. Fingernails take 6-8 months to grow out.
Irregular Nail Grooves or Pigmentation
Irregularities in the nail plate may indicate a problem occurring underneath the nail. If we suspect a benign tumor or malignant area under the nail, we use nail surgery to biopsy the area.
Nails have different parts. The nail plate is the part of the nail we actually see. The nail cuticle surrounds the nail. The nail matrix is the area underneath the skin below the nail towards the joint. This is where the nail grows from. When we conduct a biopsy, we examine the nail matrix.
If there’s a tumor or cyst in the nail matrix area, the nail plate shows signs of the growth. When we see a groove or pigmentation in the nail plate, we know the problem is coming from the nail matrix. We will then biopsy the nail matrix to check for melanoma or another benign or malignant tumor.
Squamous cell carcinoma is probably the most common skin cancer we find in the nail matrix. It’s associated with the wart virus. For some patients, a long-lasting wart virus can develop into squamous cell carcinoma. This can then be treated with Mohs surgery.
If someone has a melanoma under the nail, it’s a severe situation that requires Mohs surgery, an excision, or (in extreme cases) an amputation of the toe.
Are There Different Types of Nail Surgeries?
Most patients we see with nail problems in dermatology need a nail biopsy to check for problems underneath the nail, want their nail plate removed because of discomfort, or need a nail excision to treat cancer or a tumor.
If a nail biopsy is needed, we first survey the specific area that needs to be biopsied — the cuticle, nail plate, or nail matrix. There is no need to remove the entire nail plate for a biopsy. In a biopsy, we take only a small tissue sample to send to a pathologist for further evaluation so we can reach an accurate diagnosis.
During a nail biopsy, we first numb the area with Lidocaine. I usually opt for a digital block numbing treatment. This numbs the entire toe or finger so the patient won’t feel anything during the procedure.
After numbing the finger or toe, we clean the area with a topical cleaning solution. If we need to get to the nail matrix, we make a small incision on each side of the nail plate, which allows us to fold the skin back far enough to examine the nail matrix. We take a small sample of tissue, put it in a specimen jar, and send it to the pathologist. The skin is then returned to its original place and reattached with 1-2 stitches. We take the stitches out in about two weeks. It’s a simple procedure — and once the patient is numb, they don’t feel it.
Nail Plate Removal
If the patient wants to have the nail plate removed for cosmetic reasons, or they want to try a different approach to eradicating a fungus, we perform a digital block to numb the finger or toe in the same way we would for a biopsy. After the digit is completely numb, we remove the nail entirely by lifting it off from the front. We use a few stitches to mend the area. Then we wrap it tightly so it can begin healing.
When skin cancer is detected, we usually opt for a more extensive nail surgery, often Mohs surgery. We numb the area with a digital block so the patient will not feel any pain during the procedure. The surgeon then operates accordingly to remove all traces of the cancerous cells.
What Should You Expect After Nail Surgery?
During these surgeries, particularly nail plate removals, we’ve exposed the nail bed. Consequently, post-operative oozing is normal. To help mitigate this, we apply a tight bandage to remain over the area for 2-3 days. Once the wrap is removed, the oozing subsides and you can continue with normal wound care until sutures are removed.
Also, keep in mind that when the entire nail plate is removed, the area will be tender for up to a week. We may offer pain medication and will have specific instructions for wound care of the exposed nail bed.
Will nail surgery hurt?
Once we’ve finished with the lidocaine, you won’t feel anything. The most you’ll feel is some pressure if you’re having the entire nail plate removed. Otherwise, the patient does not feel anything and will not experience pain.
Will the nail grow back normally?
Nail surgeries will hopefully lead to a better looking, healthier nail. However, the exact cosmetic results depend on the reason for the procedure and the type of nail surgery that needs to be done.
If there’s a large lesion in the nail matrix that needs to be removed, there may be a small deformity in the nail when it grows back. Likely, this deformity already existed in the nail prior to your procedure.
Our hope is that your nail will regrow with appropriate cosmetic healing. If we remove the nail plate to treat a fungus, you will have a healthier looking nail once it grows out.
How do I know if I need nail surgery?
The needs for nail surgeries vary based on the specific cause of the nail deformity or fungus. Never hesitate to ask your dermatologist about nail surgery to treat your nail condition.
More importantly, if you or your doctor suspect a tumor or form of skin cancer around the nail, see a dermatologist. You can have both benign and malignant growths underneath the nail. It’s important to see a dermatologist or dermatologic surgeon who can identify these clinically and take a biopsy if necessary.
Click here to find an Epiphany provider near you.