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Ingrown toe-nail
INGROWN J.
J.
Associate
TOEyNAIL* M.D.
KIRSCHENMANN, Surgeon,
Norwegian
BROOKLYN,
I
NGROWN toe-naiI is a common condition where dirt, sweat and irritation meet and it is doubtfu1 that the trimming of a toe-naiI in any particuIar fashion is the causative agent. However, when tight shoes, perspiration, uncIeanIiness or friction unite and set up a IocaI irritation of the skin aIIowing invasion of bacteria, a socalled ingrown toe-nai1 may result. In the first stage there is simpIe inflammation of the naiI-waI1 with sweIIing and redness causing what appears to be an embedding of the IateraI naiI-edge. In the second stage this inff ammatory condition continues to suppuration. In the third stage the suppuration of the naiI-waI1 progresses and burrows under the naiI-body and root. It is with this second and third stage that I wiI1 specificaIIy dea1. In the second stage excision of a smaI1 wedge will probably cure the condition but recurrence is common. In the third stage excision of a wedge is rareIy satisfactory unIess part of the nai1 and growth matrix are aIso removed. This operation is unsatisfactory in the hands of many men; it Ieaves a deformed toe and nai1 which is unsightIy, and frequentIy a smaI1 piece of growth matrix is Ieft from which spicuIes of nai1 grow and cause constant irritation. In 1932 a gir1 presented herseIf with an ingrown toe-nai1 that required radica1 surgery. Due to the fashion of going stockingIess she refused excision of part of her nail-bed as she feIt it wouId interfere with her appearance when she exposed her poIished naiIs. In overcoming her objections I performed a sIightIy different type of operation which has been satisfactory in over IOO cases without recurrence. * From the Out Patient
N.
Hospital
Y.
Operation is done under IocaI novocain and a rubber band at the base of the toe. The extent of the inffammatory condition
FIG. I. LateraI
view showing incision in nail-waI1.
across the naiI-root is taken into consideration and an incision s/4 inch Iong is made in the skin down to the naiI-root at a point where the maximum sweIIing just ceases (Fig. I). The incision is then carried IateraIIy and downward to the IeveI of the Iower third of the side of the toe. It is then carried forward at this IeveI to the end of the toe. The depth of this incision is about s/4 inch. A pointed scissors is then inserted under the free end of the nai1 at such a point as to meet the incision in the naiI-bed and the nai1 cut. The cut portion of the nail is then grasped with a hemostat and Iifted out of its bed. The naiI-waI1 is then heId back with a thumb forceps whiIe the scaIpe1 cuts down aIong the nai1 suIcus to the IeveI of the incision in the Iower third of the side of the toe (Fig. 2). If the incisions are properIy pIaced a bIock of tissue is freed which Iifts out except at the nai1 root where it must be freed being carefuI not to injure the growth matrix. BIeeding is rare. Before packing with iodoform gauze the rubber band is cut and a11 bIeeding controIIed. The packing is Ieft
Service of the Norwegian 349
Hospital.
350
AmericanJournal of Surgery
Kirschenmann-Ingrown
in pIace for forty-eight hours and repeated for one week. When the sIight sIoughing has discontinued the wound is stimuIated
FIG. 2. DorsaI view showing incision and naiLwaIl.
in nail-bed
with balsam of Peru. GranuIations form very rapidIy and must be fought down constantIy so that when the wound is compIeteIy heaIed this side of the toe is Aat with no visibIe naiI-waI1 (Fig. 3). I fee1 that the fighting down of the granuIations is a very essentia1 part of the operation. If not properIy done the side waI1 wiI1 not
Toe-NaiI
APRIL,1937
be fiat and there might be a possibiIity of recurrence in the new formed naiIwaI1. The nai1 grows back in four to six
FIG. 3. End resuk showing flattening of naiI-waII.
months and the aesthetic appreciative.
patient is most
SUMMARY
A satisfactory operation for the cure of an ingrown toe-nai1 that can be performed by the average man with uniformIy good resuIt had been presented.
J.
Associate
TOEyNAIL* M.D.
KIRSCHENMANN, Surgeon,
Norwegian
BROOKLYN,
I
NGROWN toe-naiI is a common condition where dirt, sweat and irritation meet and it is doubtfu1 that the trimming of a toe-naiI in any particuIar fashion is the causative agent. However, when tight shoes, perspiration, uncIeanIiness or friction unite and set up a IocaI irritation of the skin aIIowing invasion of bacteria, a socalled ingrown toe-nai1 may result. In the first stage there is simpIe inflammation of the naiI-waI1 with sweIIing and redness causing what appears to be an embedding of the IateraI naiI-edge. In the second stage this inff ammatory condition continues to suppuration. In the third stage the suppuration of the naiI-waI1 progresses and burrows under the naiI-body and root. It is with this second and third stage that I wiI1 specificaIIy dea1. In the second stage excision of a smaI1 wedge will probably cure the condition but recurrence is common. In the third stage excision of a wedge is rareIy satisfactory unIess part of the nai1 and growth matrix are aIso removed. This operation is unsatisfactory in the hands of many men; it Ieaves a deformed toe and nai1 which is unsightIy, and frequentIy a smaI1 piece of growth matrix is Ieft from which spicuIes of nai1 grow and cause constant irritation. In 1932 a gir1 presented herseIf with an ingrown toe-nai1 that required radica1 surgery. Due to the fashion of going stockingIess she refused excision of part of her nail-bed as she feIt it wouId interfere with her appearance when she exposed her poIished naiIs. In overcoming her objections I performed a sIightIy different type of operation which has been satisfactory in over IOO cases without recurrence. * From the Out Patient
N.
Hospital
Y.
Operation is done under IocaI novocain and a rubber band at the base of the toe. The extent of the inffammatory condition
FIG. I. LateraI
view showing incision in nail-waI1.
across the naiI-root is taken into consideration and an incision s/4 inch Iong is made in the skin down to the naiI-root at a point where the maximum sweIIing just ceases (Fig. I). The incision is then carried IateraIIy and downward to the IeveI of the Iower third of the side of the toe. It is then carried forward at this IeveI to the end of the toe. The depth of this incision is about s/4 inch. A pointed scissors is then inserted under the free end of the nai1 at such a point as to meet the incision in the naiI-bed and the nai1 cut. The cut portion of the nail is then grasped with a hemostat and Iifted out of its bed. The naiI-waI1 is then heId back with a thumb forceps whiIe the scaIpe1 cuts down aIong the nai1 suIcus to the IeveI of the incision in the Iower third of the side of the toe (Fig. 2). If the incisions are properIy pIaced a bIock of tissue is freed which Iifts out except at the nai1 root where it must be freed being carefuI not to injure the growth matrix. BIeeding is rare. Before packing with iodoform gauze the rubber band is cut and a11 bIeeding controIIed. The packing is Ieft
Service of the Norwegian 349
Hospital.
350
AmericanJournal of Surgery
Kirschenmann-Ingrown
in pIace for forty-eight hours and repeated for one week. When the sIight sIoughing has discontinued the wound is stimuIated
FIG. 2. DorsaI view showing incision and naiLwaIl.
in nail-bed
with balsam of Peru. GranuIations form very rapidIy and must be fought down constantIy so that when the wound is compIeteIy heaIed this side of the toe is Aat with no visibIe naiI-waI1 (Fig. 3). I fee1 that the fighting down of the granuIations is a very essentia1 part of the operation. If not properIy done the side waI1 wiI1 not
Toe-NaiI
APRIL,1937
be fiat and there might be a possibiIity of recurrence in the new formed naiIwaI1. The nai1 grows back in four to six
FIG. 3. End resuk showing flattening of naiI-waII.
months and the aesthetic appreciative.
patient is most
SUMMARY
A satisfactory operation for the cure of an ingrown toe-nai1 that can be performed by the average man with uniformIy good resuIt had been presented.