It consists of excision of the affected part of the nail with a partial mechanical matrixectomy.
1. Provide informed surgical consent and position the patient in the supine position, with knees flexed and foot resting on the table or leg extended and foot hanging off the edge of the table.
2. Prepare the big toe with povidone-iodine, chlorhexidine (Peridex), or alcohol.
3. Perform a digital nerve block using 1% or 2% lidocaine.
Epinephrine 1:100,000-200,000 is safe in digital nerve block.
After an adequate amount of time has elapsed (5 to 10 minutes), test the patient’s ability to feel pain in the finger.
3. Tourniquets are not recommended but surgeons often prefer to place them.
4. Using a surgical instrument, gently lift the lateral edge of the nail plate. Grasp the edge of the nail plate with a straight klamp.
Use progressive medial-lateral swing rotation of the nail plate to disarticulate the edge of the nail plate from the nail bed.
5. Cut the lateral edge of the plate using heavy scissors.
Cut from the distal end of the nail plate directly back toward the cuticle to but not below the nail crease. Do not cut the ventral nail fold. Remove at least 30% of the lateral nail plate.
6. Grasp the cut nail fragment with an iron. Remove by pulling the nail plate caudally (toward the ankle) in a straight line allowing the uncut portion to pull away and release the plate.
7. After the piece has been removed, examine the lateral groove under the proximal nail crease to ensure that no nail pieces remain within the corner.
Also examine the part of the nail that was removed. If part of the nail plate is missing, it must be identified and removed, otherwise it will heal slowly and cause pain.
8. After surgery, apply a plain white Vaseline gauze and gauze or tape to snugly secure in place.
Have the patient soak the affected toe in warm water several times a day to gently remove the bandage and reapply a white Vaseline gauze and clean bandage. This should be repeated for one to three weeks after the procedure.