What is the procedure for an onychectomy (nail removal)?

Onychectomy (Nail Removal) Procedure

Indications and Pre-Procedure Assessment

Onychectomy should be performed for specific medical indications including severe recurrent ingrown nails unresponsive to conservative management, nail unit malignancies (particularly squamous cell carcinoma in situ), or severe dystrophic nails causing significant pain and functional impairment. 1, 2

Key Pre-Procedure Considerations:

• Confirm diagnosis with biopsy before proceeding if malignancy is suspected, as squamous cell carcinoma in situ can present with hyperkeratotic proliferations, erosions, or nail dystrophy 1
• Ensure adequate anesthesia (local digital block or general anesthesia depending on extent) 3
• Obtain informed consent discussing risks including infection, pain, regrowth, and functional limitations 1

Surgical Technique

Patient Positioning and Preparation:

• Position patient comfortably with affected digit accessible 3
• Perform standard aseptic preparation and draping 3
• Apply tourniquet to digit if hemostasis needed 1

Nail Removal Steps:

For complete nail apparatus removal (indicated for malignancy or severe dystrophy):

1. Incise around the nail fold to expose the entire nail apparatus including the matrix 1

2. Elevate the nail plate using a sterile dissector or elevator, separating it from the underlying nail bed 1

3. Excise the nail matrix completely - this is critical to prevent regrowth. The matrix extends proximally under the proximal nail fold and must be completely removed 1

4. Remove any dermatophytomas or infected tissue if present, as these dense lesions can harbor persistent infection 1

5. Achieve hemostasis through electrocautery or chemical cautery 1, 4

Closure Options:

The wound can be managed by:

• Secondary intention healing (most common for nail unit procedures) 1
• Primary closure with sutures if adequate tissue approximation possible 1
• Skin grafting or flap repair for larger defects requiring reconstruction 1

Chemical Matricectomy Alternative

For partial nail removal (lateral nail avulsion for ingrown nails), chemical matricectomy with silver nitrate or phenol is highly effective and may be superior to electrocautery. 4

• After partial nail plate removal, apply silver nitrate to exposed matrix for 30-60 seconds 4
• This achieves lower recurrence rates (4.7%) compared to electrocautery (11.2%) 4
• Results in fewer postoperative infections (1.7% vs 4.0%) 4

Post-Operative Management

Immediate Care:

• Irrigate wound copiously with saline and apply sterile dressing 3
• Initiate prophylactic antibiotics with coverage for Staphylococcus aureus if infection risk is high 2
• Prescribe adequate analgesia - NSAIDs combined with opioids for first 48-72 hours 5

Wound Care Protocol:

• Continue antiseptic soaks twice daily with dilute vinegar (50:50 dilution) or 2% povidone-iodine for 10-15 minutes 2
• Apply mid to high-potency topical steroid ointment to surrounding tissue twice daily to reduce inflammation 2
• Monitor for signs of infection including increased pain, redness, swelling, or purulent drainage 2

Follow-Up Schedule:

• Reassess at 2 weeks to evaluate wound healing and identify complications 2
• Monitor for persistent pain or drainage beyond 2-4 weeks which may indicate incomplete matrix removal or infection 2
• Watch for nail regrowth which occurs in 7.4% of cases and indicates incomplete matrix excision 1

Common Pitfalls and How to Avoid Them

Critical technical errors to avoid:

• Incomplete matrix removal - The matrix extends further proximally than visible; ensure complete excision under the proximal nail fold to prevent regrowth (7.4% incidence if incomplete) 1

• Inadequate hemostasis - Hemorrhage occurs in 31.9% of cases; use electrocautery or chemical cautery methodically 6

• Insufficient analgesia - Pain is reported in 38.1% of cases; provide multimodal analgesia including local blocks, NSAIDs, and opioids 6, 5

• Failure to address dermatophytomas - These dense fungal lesions resist treatment and must be mechanically removed during surgery 1

Special Considerations for Malignancy

When onychectomy is performed for squamous cell carcinoma in situ:

• Mohs micrographic surgery is preferred to ensure complete excision while preserving maximum normal tissue 1
• Consider distal phalanx amputation if invasive carcinoma is present or margins cannot be cleared 1
• Multidisciplinary approach with dermatology, surgery, and pathology is essential for optimal outcomes 1
• Obtain adequate tissue for histopathology - the three-dimensional nature of the nail bed makes diagnosis challenging 1