Ingrown toenail Surgery and its Treatment
Ingrown toenail is a foot disease that creates toe injury and results in a serious painful condition if not cured in time. There are various methods for ingrown toenail removal where one of them is Ingrown toenail surgery, which is a perfect method to get rid of ingrown toenail permanently and is used majorly nowadays. Its useful and successful.
The ingrown toenail is a relatively common condition that affects the big toe preferably young adults. The surgery is often necessary, but the recurrence rate is high risk with functional and aesthetic sequelae irreversible. Among the many surgical techniques described, none is universally considered the best. As with any dermatologic surgery, the procedure must not only curative but also aesthetically acceptable. The surgeon’s skill and experience are crucial. A review of the main techniques is presented.
i) All about Ingrown Toenail:
The ingrown toenail is a relatively common condition often affecting the big toe a young population. This is the result of a conflict between the nail plate and tissues. Several factors may be involved: poorly-fitting shoes, poor nail cutting, hyperhidrosis, bone changes secondary to osteoarthritis, static disorders of the foot, or malformation of the nail tissue and etc.. The surgery is necessary when medical care fail.
Surgery for ingrown toenail looks fairly simple. Unfortunately, the functional and aesthetic sequelae are not uncommon after this type of intervention (Figure 1) . There are many surgical techniques described in recent literature we are focusing. The nail clip, which is a very particular form, will not be discussed in this article.
ii) Anatomy of the nail unit:
A good knowledge of anatomy is essential in the surgical treatment of ingrown toenail. The nail unit includes fabric paronychium, the tablet bed and the matrix (Figure 2) .The fabric is formed by the paronychium nail proximal and bead seat side. The tablet is securely attached to the bed. Subungual dermis lies directly on the periosteum without subcutaneous tissue which makes it very adherent to the bone. The root of the nail deep into the dermis. It affects almost interphalangeal joint and the tendon of the extensor toe. The tablet is produced by the matrix. The lunula is the distal portion of the matrix as seen by transparency. Feet, the replacement of a fingernail takes ten to eighteen months. A lesion of the matrix can cause permanent nail dystrophy.
iii) anesthesia of the nail unit
-Before any surgery on the ends, it is recommended to palpate peripheral pulses to exclude any underlying arteriopathy that could compromise healing. Doppler examination is recommended in cases of doubt. Patients with pressure index ankle / lower leg 0.5 or with a blood pressure of the big toe lower than 40 mm Hg are at risk of harm heal.
-Most interventions are performed with anesthesia ring. Generally used 5-10 ml of 1% lidocaine without epinephrine. At small interventions granulation tissue, it may be sufficient local anesthesia limited to the operated area.
-The placement of a tourniquet at the base of the toe should not exceed fifteen minutes. It should therefore be used only during the most critical phase of the intervention.
iv) Medical Treatment
-Antiseptics and antibiotics are necessary.
-Footbaths with Dakin’s solution and an antiseptic dressing (povidone iodine, sulfadiazine) or antibiotic (fusidic acid) are usually sufficient in the acute phase. Oral antibiotics are rarely necessary except in cases of infection of the surrounding tissue.
v) Foot care
-Podiatry care are essential in the initial stage if you want to avoid surgery. Must consider not only the feet but also the shoes of each patient. The shoes are too tight with raised heels should be avoided. The back foot should be maintained so that the forefoot is relieved and is not only to keep the shoe in place, which may cause trauma to the toes. The mules are prohibited.
-Improper cutting of the nail can promote the appearance of ingrown toenail. If the nail is cut too short, the groove will close périunguéal incentive to cut the nail more short causing a vicious cycle that will gradually worsen the problem. Milling of the nail can soften and reduce the pressure on the fabric paronychium.
-Ingrown nails may result from a conflict between the first and second toe. It may therefore be useful in these cases to insert a separator toes (silicone orthosis). The establishment of an orthosis nail (orthonyxie) can also be very useful in raising the lateral edges of the nail (Figure 3). This type of brace is particularly effective when the nail tends to bend too transversely.
All these methods are most effective if taken early. The surgery is usually inevitable in advanced cases.
vi) Surgical Procedures
-Excision and cauterization of granulation tissue pain
-The excision of granulation tissue with a scalpel or painful electrocautery can quickly relieve the patient. It can also destroy chemically with silver nitrate. Recurrence after such interventions are very common if the factors involved are not corrected by appropriate foot care.
##Simple nail avulsion
The avulsion of the nail quickly relieves the patient. However, in the absence of nail, the distal hallux pulp is pushed dorsally during walking that will promote recidivism and exacerbate the problem. This technique is generally discouraged except in onychodystrophy important or infection.
##Wedge excision of the side bolsters
In this technique, the granulation tissue is not excised but relieved of his conflict zone by excision discharge in safe area. This is a fragment excised skin lozenge with the deep dermis into the adjacent soft parts (Figure 4) . The wound is closed by sutures. Technique and postoperative course is usually simple and relatively painful. Granulation tissue heals spontaneously after a few days. The advantage of this technique is to not have to resect the nail or its matrix. The functional and aesthetic results are good because the nail keeps its integrity without risk dystrophy. This technique is not applicable when excessive hypertrophy paronychium.
vii) Chemical destruction of the matrix with phenol
Is practiced first avulsion of the nail in its side portion to expose the bed and the corresponding matrix (Figure 5) . 80-90% phenol is then applied to the matrix for three minutes using a cotton swab. The effect of phenol is neutralized by blood, you must first perform a exsanguination of the toe and put a tourniquet at the base. The surrounding skin is protected by petroleum jelly to prevent necrosis. The treated area is then rinsed with 70% isopropyl alcohol. The wound is covered with an antiseptic dressing or antibiotic changed daily. Phenol with some anesthetic action, postoperative pain is minimal. The main disadvantage of this technique is the postoperative oozing which may be relatively important. Healing by second intention is and usually takes two to four weeks. The long-term results are satisfactory. Severe burns of the toe have been reported.
## Vaporization matrix laser CO 2 or Er: YAG
The technique is the same as that practiced with phenol but instead of chemically destroy the matrix on the laser vaporizes CO 2 or Er: YAG laser. 4.5 The use of a laser to destroy the matrix enables better control of the degree and the depth of treatment. Healing is also by secondary intention. Postoperative seeps are moderated and generally simple suites. The long-termesont comparable to those obtained by phenol.
viii) Emmert plasty
Described in 1850 by Jean Carl Emmert Baudens then, this is probably the most performed surgical technique. There is a wedge resection carrying both the granulation tissue, the lateral portion of the nail and bed, and the corresponding matrix (Figure 6) . The excision should extend to the underlying periosteum, being careful not to damage the extensor tendon to the distal phalanx. All the corresponding matrix including its horn, which can be very deep, must be excised. Avoid blind curettage could leave in place a piece of matrix and cause the regrowth of lateral spicule annoying. The wound is sutured with interrupted sutures and covered with a bandage antiseptic or antibiotic.
ix) Selective resection of the matrix
This technique requires a good skill. After avulsion of the proximal side of the tablet and it exposes the horn of the matrix is completely dissected and resected to the bone (Figure 7) .The wound is closed by two stitches or Steri-strips. It is covered by a bandage antiseptic or antibiotic.
x) Plasty toe with preservation of the matrix
This technique aims to restore the natural anatomy of the toe. The nail matrix and are completely preserved. The side bolsters are against excised widely and deeply to reduce their maximum thickness (Figure 8). The volume of the toe is markedly decreased and giving it a more refined (Figure 9). The pressure in the shoes and the risk of recurrence are significantly reduced. The wound is closed with sutures and covered with an antiseptic dressing. This type of intervention is particularly suitable for hypertrophic toes. The aesthetic and functional results are excellent.
DISCUSSION (All about it)
What is the best surgical technique to treat an ingrown toenail? According to the literature, the recurrence rate after isolated avulsion or partial nail plate to be 60 to 80%. It would be 10 to 30% for the modified Emmert plasty and only 5 to 10% for the phenol procedure. A recent Cochrane review also seems to confirm the superiority of phenol method compared to conventional surgical techniques. According Haneke, the Emmert plasty is obsolete not only because of its high failure rate but also the aesthetic sequelae that may result. It recommends a more selective resection of the matrix. The advantage of phenol is relatively simple to use while surgical excision of the matrix requires some skill. The effectiveness of the surgery may still be higher than that of phenol if it is performed by experienced surgeons. In addition, there are more complications with the procedure phenol. The vaporization of the matrix to laser CO2 or the Er: YAG laser is an attractive alternative. Primary outcomes reported treatment are excellent.
Any scalpel excision or destruction of the matrix, either by phenol or laser may cause nail dystrophy and cosmetic sequelae. Techniques that preserve the matrix thus the cosmetic benefit certain. A recent study has also shown that also this type of surgery provides excellent outcomes. Excision or destruction of the matrix is not necessarily required. If excision of lateral bulges is large enough, the nail has more room to grow dramatically reducing the risk of conflict between the shelf and the side bolsters.
In conclusion, the choice of surgical technique is largely a matter of experience and skill. As with any surgery, dermatology, must be the curative procedure but also aesthetically acceptable.
This is what we need to do to get rid of such problem, at home or by surgery if needed. Ingrown toenail is a serious foot disease but possible to cure.