Nail surgery 101

New Orleans - Many dermatologists do not feel comfortable doing nail surgery. Sometimes, lack of exposure to nail surgery during residency training is to blame. Even those who have adequate training might eventually avoid nail surgery if they have not gained enough experience doing the procedures in practice.

Those who know the ins and outs of basic nail surgery, however, often find that the procedures are easily done in the office and result in high patient satisfaction, according to Elizabeth M. Billingsley, M.D., dermatologist, associate professor in the department of dermatology, Penn State Hershey Medical Center, Hershey, Pa.

"There is a knowledge base and host of tips that no dermatologist doing nail surgery should go without," said Dr Billingsley at the 63rd Annual Meeting of the American Academy of Dermatology (AAD), here.

The basics Different nail disorders tend to be related to a nail disease affecting a specific part of the nail unit.

"For example, you can get a lot of different changes in the nail with psoriasis," Dr. Billingsley says. "If the psoriasis is involving the nailbed, you will often get what is clinically seen as oil spots and subungual hyperkeratosis; whereas, if it involves the proximal matrix, you get more pitting and onychorrhexis. If the psoriasis is more on the distal matrix or hyponychium, you will get the classic onycholysis."

Among the many nail diseases and conditions are: onychorrhexis, which are often superficial longitudinal striations of the nail plate; onychocryptosis, or ingrown nails; and onychauxis, hypertrophied nail plate.

Benign growths of the nail include mucus cysts, glomus tumor, warts and pyogenic granuloma. Malignant growths include squamous carcinoma and melanoma.

"Melanoma that occurs in the nail unit is most commonly seen in the thumb and great toe," Dr. Billingsley says.

"And dermatologists should be aware that up to 20 percent of melanomas found in the nail may be amelanotic, or without pigment."

Overcoming anesthesia apprehension Patients are, generally, most apprehensive about getting anesthesia before nail surgery.

"If you can get the patient through the actual anesthetizing of the digit, the rest of the procedure should go fairly well," Dr. Billingsley says.

According to Dr. Billingsley, some tips for anesthetizing these patients are to: position and relax the patient as best you can; proceed slowly with the anesthetic administration; and give adequate time for the anesthesia to take effect before starting on the procedure.

Dr. Billingsley usually begins with a digital block, supplementing that with a wing block.

"I use plain lidocaine and often add Marcaine (AstraZeneca) at the end for some prolonged anesthetic," she says. "Whenever you do anything on the nail unit, you want to numb the whole digit - the toe or finger. The digital block numbs the base of the digit. It hurts patients a lot less to numb back there, first, give it a good 10 minutes or so for the anesthesia to take effect; then, go up and add some more of the wing block, which is adding supplemental anesthesia at the junction of the lateral and proximal nail fold."

Minimizing nail dystrophy There are ways to avoid or at least lessen the potential for permanent postoperative nail dystrophy.

"I think that a lot of physicians are hesitant to do nail surgery because they are worried about permanent nail dystrophy," she says. "Often - especially in the case of a possibly malignancy in the nail - it is important to proceed with the biopsy."

According to Dr. Billingsley, matrix biopsies should be taken from the distal matrix when possible and be 3 mm or less. Biopsy sites should be sutured, if possible. Yet another important tip: Orient biopsies that are in the nail matrix in a transverse fashion, but orient biopsies in the nailbed, longitudinally.