Permanent Toenail Removal Procedure: Pre and Post-Operative Care
For a 68-year-old male patient requiring permanent removal of the 2nd and 3rd toenails of the left foot, nail avulsion with chemical matricectomy is the recommended procedure, as it offers the highest cure rate with minimal morbidity when performed properly.
Pre-Procedure Assessment and Planning
Medical Evaluation
- Assess for underlying conditions that may affect healing:
- Diabetes status and glycemic control
- Peripheral vascular disease (consider ABI measurement if indicated) 1
- Immunosuppression
- History of previous nail procedures
Nail Assessment
- Confirm indication for permanent nail removal:
- Onychomycosis unresponsive to medical therapy
- Recurrent ingrown toenails
- Nail dystrophy
- Chronic pain
Mycological Considerations
- Obtain mycological confirmation before proceeding if onychomycosis is suspected 1
- Consider culture to identify specific pathogen (dermatophyte vs. yeast)
Procedure Protocol
Preparation
- Cleanse the foot thoroughly with antiseptic solution
- Apply digital nerve block with appropriate anesthetic (1% lidocaine without epinephrine)
- Apply tourniquet to minimize bleeding during the procedure
Nail Avulsion Technique
- Separate nail plate from nail bed using nail elevator
- Remove entire nail plate with forceps
- Thoroughly clean the nail bed and obtain cultures if infection is suspected 1
- Perform chemical matricectomy with phenol (88%) application for 2-3 minutes to destroy the nail matrix
- Neutralize with alcohol or saline irrigation
- Alternative: surgical matricectomy for complete destruction of the nail matrix
Post-Procedure Care
Immediate Care
- Apply antiseptic ointment to the nail bed
- Apply non-adherent dressing
- Elevate foot for 24-48 hours to reduce pain and swelling
- Prescribe appropriate analgesics (acetaminophen or NSAIDs)
Follow-up Care
- First follow-up visit within 48-72 hours to assess for infection or complications
- Regular wound checks until complete healing (typically 2-4 weeks)
- Instruct patient on proper wound care:
- Daily cleansing with mild soap and water
- Application of antiseptic solution
- Regular dressing changes with non-adherent material 1
Monitoring for Complications
- Infection: redness, increased pain, purulent discharge, fever
- Spicule formation: incomplete destruction of nail matrix
- Persistent pain or discomfort
- Abnormal granulation tissue
Special Considerations for Elderly Patients
Healing Concerns
- Healing may be prolonged in older patients
- Monitor more closely for signs of infection
- Consider prophylactic antibiotics if high-risk patient
Mobility Considerations
- Provide appropriate ambulatory aids if needed
- Recommend wide, comfortable footwear during healing phase
- Advise on limited weight-bearing for first few days
Patient Education
- Explain that complete healing may take 4-6 weeks
- Emphasize importance of keeping the area clean and dry
- Instruct on proper dressing change technique
- Advise to avoid tight footwear until complete healing
- Explain that mild drainage is normal for first few days
Common Pitfalls and How to Avoid Them
Incomplete matrix destruction
- Ensure adequate phenol application time (2-3 minutes)
- Consider double application for thick nails
Post-operative infection
- Meticulous sterile technique during procedure
- Regular wound checks and appropriate dressing changes
- Consider cultures if infection is suspected 1
Recurrence
- Complete removal of all nail matrix tissue
- Adequate chemical or surgical matricectomy
- Follow-up to ensure complete destruction of nail matrix
Prolonged healing
- Appropriate wound care instructions
- Consider underlying conditions affecting healing
- Regular follow-up to monitor progress
By following this protocol, permanent removal of the 2nd and 3rd toenails can be achieved with minimal complications and optimal outcomes for the patient's quality of life and mobility.