Exploring a Minimally Invasive Technique for Surgical Nail Matrixectomy

Ingrown toenails are a common condition that every podiatrist encounters, with multiple associated procedures. In our experience, in-office chemical matrixectomies are very common and successful in permanently addressing this issue. The most common chemicals used in-office for matrixectomy include phenol or sodium hydroxide. There are extensive descriptions of both techniques, and in our observation, they are taught as standard to podiatry students. However, in anywhere from 2.8% to 30.4% of patients,^1-6 there are recurrences that require further treatment, especially in the adolescent population. Recurrence of ingrown nails is a frustrating experience for both the physician and the patient. Further treatment may include repeat chemical matrixectomy or consideration for surgical nail matrixectomy.
 
Surgical matrixectomy has proven to be successful in removal of ingrown nails, for which many techniques have been published in the medical literature. Some of the more popular surgical techniques that have been previously described include Winograd, Frost, Modified Frost, Zadik, and Kaplin.⁸ These techniques typically incorporate some type of skin wedge resection or complete avulsion of the nail. Some of these techniques require significant removal of skin, potentially leading to increased chance of pain and/or infection. Presented here is author Dr. Morgan Jerabek’s (MJ) preferred surgical matrixectomy technique, which she finds successful and reproducible with minimal skin incision and soft tissue trauma.

Steps in the Surgical Technique

1.    One makes an approximately 0.5 cm linear incision, extending from the proximal aspect of the medial/lateral nail fold distally in line with the anticipated partial nail avulsion (Figure 1).
 
2.    Next, one executes the partial nail avulsion with freer elevator, English anvil, and hemostat to remove the offending nail border. Surgeon pearls: for patient’s with pincer nail deformity, remove the portion of the nail plate where it begins to incurvate into the nail border. This will help reduce the risk of a narrower nail border from potentially causing a repeat ingrown nail. Some pincer nail deformities may benefit from a total nail matrixectomy (Figure 2).

3.    Utilizing visibility gained by the incision, the DPM identifies the “pearly” nail matrix and removes it in total, ensuring that the most proximal corner is completely visualized and the matrix is completely removed (Figure 3).
 
4.    If removed in a single piece, the matrix will resemble a “clam” shape (Figure 4).

5.    After flushing the incision site, one then performs a final inspection for further nail spicules, nail matrix, or granulomatous tissue, removing them prior to skin closure.

6.    For closure, 4-0 Monocryl is utilized to span the corners, avoiding the nail matrix to prevent any further trauma to the remaining nail matrix. Additional trauma may lead to nail deformation (Figure 5).

The authors reviewed of all of MJ’s surgical matrixectomies performed from April 2019 to April 2022. A total of 12 patients were brought to the operating room for surgical matrixectomy. A total of 32 partial nail removals were performed using this technique on this same patient group with one recurrence in the postoperative period. That patient successfully underwent a repeat surgical matrixectomy. No postoperative infections occurred in any of the patients. All patients had minimal pain in the postoperative period and returned to all normal activities within one month.

In Conclusion

Presented above is a highly successful minimally invasive approach to surgical matrixectomies. It is the belief of these authors that chemical matrixectomy remains the best first-line treatment for ingrown nails due to a high success rate. However, in the rare instances that chemical matrixectomy should fail, surgical matrixectomy is required. It is our belief that a minimal approach should be performed for less pain and better cosmesis after healing. Despite the small sample size of MJ’s patient group, this procedure still had a 97% success rate in preventing recurrence. Procedures involving wedge resection are at higher risk for postoperative pain and infection. These studies found an increased bleeding and infection rate of 13.4% in their sample.⁷ Most importantly, surgical matrixectomy needs to be successful in nail removal. However, minimizing pain, minimizing infection, and a quicker recovery are beneficial to the patient. The technique presented above is successful in accomplishing those goals.
 
Dr. Gorski, Dr. Jerabek, and Dr. Hoffman are attending physicians for the Denver Health Podiatric Residency.
 
Dr. Kerns and Dr. Fischer are second year residents at the Denver Health Podiatric Residency.

References
1.     Byrne DS, Caldwell D. Phenol cauterization for ingrowing toenails: a review of five years' experience. Br J Surg. 1989;76(6):598-599.
2.     Travers GR, Ammon RG. The sodium hydroxide chemical matrixectomy procedure. J Am Podiatry Assoc. 1980;70(9):476-478.
3.     Bostanci S, Ekmekçi P, Gürgey E. Chemical matrixectomy with phenol for the treatment of ingrowing toenail. Acta Derm Venereol. 2001;81(3):181-183.
4.     Andreassi A, Grimaldi L, D'Aniello C, et al. Segmental phenolization for the treatment of ingrowing toenails. J Dermatolog Treat. 2004;15(3):179-181.
5.     Muriel-Sánchez JM, Becerro-de-Bengoa-Vallejo R, Montaño-Jiménez P, Coheña-Jiménez M. The treatment of ingrown nail: chemical matrixectomy with phenol versus aesthetic reconstruction. A single blinded randomized clinical trial. J Clin Med. 2020 Mar 20;9(3):845. doi: 10.3390/jcm9030845. PMID: 32244966; PMCID: PMC7141528.
6.    Hassel JC, Hassel AJ, Löser C. Phenol chemical matrixectomy is less painful, with shorter recovery times but higher recurrence rates, than surgical matrixectomy: a patient's view. Dermatol Surg. 2010 Aug;36(8):1294-9. doi: 10.1111/j.1524-4725.2010.01625.x. Epub 2010 Jun 22. PMID: 20573174.
7.     Oliveira F, Izquierdo-Cases JO, Martínez-Nova A, Contreras-Barragán E, Munuera-Martínez PV. The modified versus the conventional Winograd technique for the treatment of onychocryptosis: A retrospective study. Int J Environ Res Public Health. 2022; 19(13):7818.
8.     Watkins J. Pocket Podiatry. Churchill-Livingstone, 2009.