Ingrown Nail Surgery

 Ingrown Nail Surgery

Ingrown nail surgery is the removal of a nail, or a portion of a nail, that is covered by skin and causing pain and/or infection. It may also involve the destruction of the nail bed itself. This may be done on fingernails or toenails and is considered if conservative measures have proven ineffective. This surgery may also be done if you have recurring ingrown nails and/or are at increased risk for complications (e.g., if you have diabetes).
What Is Ingrown Nail Surgery?

During ingrown nail surgery, part or all of the affected nail is surgically removed. The procedure may require cutting the skin and/or drainage of pus.1

 If a portion of the nail remains, it is shaped so that the edge is straight and no longer pressing into the skin beside it.

The bed that the ingrown nail sits on is also sometimes treated. Cells are destroyed so that, if and when the nail does grow/grow back, it is thinner than it was before (and, therefore, less likely to cause problems). Any tissue that may have accumulated on the sides of the nail may also be surgically removed during this procedure.

This procedure can be done with a surgical blade, chemical solution, and/or carbon dioxide (CO2) laser.2

Most of the time, the procedure is done with local anesthesia for pain control. If the surgery is being done to treat a severe infection involving the bones, you may have regional anesthesia.

Your surgery may be done by a podiatrist (foot doctor) or family physician, typically in an in-office setting. Procedures that need to be done in the operating room due to infected bone are done by a surgeon.

You must be prepared to keep your surgical nail and the surrounding skin clean for several weeks after your surgery. If you can't do so for some reason, you would have to postpone your surgery until you can.

If you have a bacterial infection near your ingrown nail, you might need that infection treated with antibiotics before having ingrown nail surgery. But your doctors may proceed with your ingrown nail surgery along with surgical management of the bacterial infection if it isn't responding to medication and requires such intervention.
Common Foot Infections
Potential Risks

Generally, ingrown nail surgery is safe. But there are risks and potential complications of the procedure.

Possible adverse outcomes include:3

A wound that doesn't heal
Damage to the surrounding bone or nerve
Permanent deformity of the hand or foot

Purpose of Ingrown Nail Surgery

Surgery is not a common approach to managing ingrown nails, which form when the skin on one or both sides of a nail grows over the edges of the nail, or when a nail grows into the skin.

But it may be the best option when an ingrown nail continues to grow into the skin despite conservative measures. These can include soaking the nail in Epsom salt mixed with room-temperature water or your doctor lifting the nail's edge and placing sterile cotton or a splint underneath.

While an ingrown nail may not be more than an annoyance at first, persistent or worsening effects can occur even after these treatments are tried, including:

Hardening of the skin around the nail
Skin irritation or a sense that the skin feels raw
Pain and tenderness, especially with pressure
Bacterial infection: Signs include warmth, redness, pus drainage, and/or a foul odor. While rare, the infection can spread beyond the nail and the skin, and may involve the bone, joints, or spread throughout the blood.
Inhibited ability to walk or use your hands
Necrosis (tissue death)

Surgery is intended to head off these issues or help improve them if they have already occurred. It can also help prevent the nail from becoming ingrown again.

There are several factors that can lead to or increase your risk of an ingrown nail, including trauma to the nail, ill-fitting footwear, fungal nail infections, advancing age, a hereditary predisposition, and certain medical conditions such as lung disease, circulation issues, and diabetes.4

Some of these factors may lead your doctor to suggest ingrown nail surgery sooner than later.

You need to be able to rest the hand or foot that was operated on as you are recovering. As such, if you need ingrown nail surgery on both feet or hands, two separate procedures need to be scheduled.
An Overview of Infected Nails (Paronychia)
How to Prepare

Your doctor will diagnose an ingrown nail by its appearance. Testing may be necessary to determine if you have an infection and clarify the details of your case before going into surgery.

If you have a fever and there is concern that an infection has spread in your body, your doctor may order a complete blood count (CBC), which can show an elevated number of white blood cells (WBCs)—a sign of infection.

If there is pus present, you might have a sample taken for a laboratory culture test to identify the infectious microorganism.

An X-ray may be performed if there is a concern that an infection has spread to the bone or joints.

Be sure you are clear about the technique your doctor plans to use. Often, health insurance payers do not cover laser-based ingrown nail procedures.

You will have your procedure in your doctor's clinic office. If your ingrown nail has caused an infection that has spread beyond your nail bed, you will have your procedure in a surgical operating room.
What to Wear

If you are having a procedure on your foot, you may want to wear footwear to your appointment that is appropriate to go home in after surgery (otherwise, bring it with you).

Shoes should have an open toe, but not be thong-style flip-flops; the strap in between the toes can get in the way of the bandages that will be placed and may make the surgical dressing uncomfortable.
Food and Drink

You do not need to abstain from food or drink before your surgery.

You shouldn't have to adjust your regular medications (including blood thinners) before having ingrown nail surgery.

You may be given a prescription for oral antibiotics if you have an infection. Be sure to take it according to your doctor's specific pre-surgery and post-surgery instructions.
What to Bring

You should bring a form of personal identification, your health insurance information, and a form of payment for any portion of the procedure that you would be responsible for.

Also, bring along someone who can drive you home after your surgery. If your foot was operated on, you will not be able to put pressure on it. If you had surgery on your hand, you might not be able to grip the wheel to drive safely.
Pre-Op Lifestyle Changes

You will need to make sure you keep your ingrown nail clean and avoid placing excessive pressure on it.

Tight shoes or activities like kicking a ball or jumping can further injure the skin around an ingrown toenail, and actions like heavy lifting can cause your ingrown fingernail to dig further into your skin.

You should be able to walk and maintain routine activities, but use sound judgment and avoid activities that could cause injury or contamination.
What to Expect on the Day of Surgery

When you go to your surgery appointment, you will register and sign a consent form.

If you are having your procedure in your doctor's office, you will be escorted to a procedure room. If you are having the surgery in an operating room, you will go to a pre-surgical area first.
Before the Surgery

You will have your temperature taken and be asked to remove your shoes and socks, if the nail being operated on is on your foot. You will then lie down and your doctor will examine your ingrown nail.

Your arm or leg (in-office surgery) or whole body (operating room procedure) will be covered with a surgical drape. Just your ingrown nail and a portion of the toe/finger will be exposed.

It will be cleaned with a surgical cleansing solution to prevent infection. Then, an anesthetic medication will be injected near the nail for pain control.

If you have a severe infection or necrosis, you might have regional anesthesia, which may be injected into the groin. The medication is used to decrease nerve sensation. It might be given as a one-time injection with a syringe near the targeted nerve or continuously adjusted through a catheter that would be left in place near the nerve during your surgery.
During the Surgery

If you receive local anesthesia, you will be awake during your surgery. Before your doctor begins, they may ask you whether you feel any pain or pressure. If you have any sensation, you might receive more anesthetic medication, and your doctor will wait until you can't feel anything in the surgical area to ensure that the anesthetic has taken effect.

Your doctor will take several of the following steps, depending on the condition of your nail and nail bed:

Remove a portion of your nail or the whole nail with a surgical blade5
Make an incision to cut and remove the nail bed3
Drain pus
Apply topical antibiotic to a deep layer of tissue
Debridement (removal of dead tissue)4
Pack the wound with gauze and leave it open, without suture1
Stitch the wound or part of the wound
Control bleeding with a surgical cautery device
CO2 laser directed to the whole nail and nail bed6
Place phenol (a mild acid) on the nail bed to prevent the regrowth of the nail into the skin7

Your doctor will place topical antibiotics to the outer surface of the wound after the surgery is complete. Your wound will be covered with a surgical dressing and covered with bandages.
After the Surgery

If you had surgery on your foot, you will need to raise it for about an hour in the office, waiting room, or a postoperative recovery area. Your medical team will ensure that you are wearing shoes that don't place pressure on your toe if you've had surgery on your toenail. You will be told to continue elevating your foot at home for the rest of the day.

Your doctor may advise you to use crutches for several days. If this is the case, they will request crutches for you that you can use as you leave.

If you had surgery on your hand, you will need to keep it from dangling during your time in recovery and for the remainder of the day as well. You can set your hand on your lap if you are sitting, or at your sides if you are lying down.

Before being sent home, you will receive instructions on home care and next steps.

Be sure to see your doctor for a follow-up as instructed so that your wound can be checked.

To reduce your risk of infection, you will need to keep the surgical area clean and covered until the skin heals. You can wash it and gently dry it, but otherwise, you should keep it dry. Take showers instead of baths, and avoid swimming or soaking the nail in a foot bath.

You may need to change the dressing every few days until the nail and skin grow to cover the wound. Be sure to use your oral or topical antibiotics as prescribed. Avoid placing other creams, lotions, nail polish, nail polish remover, or other cosmetics and chemicals on the surgical nail until you are fully recovered.

You may have some pain, and you can take over-the-counter (OTC) pain medication, such as Tylenol (acetaminophen) or Motrin (ibuprofen), as directed by your doctor.

Laser treatment is generally associated with less pain and a faster recovery.6
When to Call Your Doctor

If your pain worsens or is not adequately controlled by OTC treatment, be sure to contact your doctor. Also call the office right away if you experience any of these signs of complications:

Pain or redness traveling up the arm or leg, away from the surgical area

Coping With Recovery

Depending on the extent of your surgery, you may be able to resume many of your regular activities the next day, or you may need to keep pressure off your healing nail and nail bed for up to two weeks.8 For example, if you have surgical stitching, pressure can cause sutures to break.

Regardless, certain activities that cause your nail to bang or rub on anything are not advised while you are recovering.

After ingrown fingernail surgery, you may need to use your non-surgical hand for some tasks during recovery. You should avoid:

Typing or repetitive finger pressure on the surgical nail
Sports that require you to throw or catch a ball or grasp a racket

After ingrown toenail surgery, you might be instructed to abstain from driving for up to two weeks. You should also avoid:

Sports that involve running or kicking a ball
Wearing shoes with a closed toe
Walking without your crutches, if you were instructed to use them

Keep in mind that these restrictions are focused on keeping the surgical area clean and avoiding rubbing or placing pressure on the surgical wound. You can still move the affected limb, however.
Long-Term Care

Generally, after fully healing from an ingrown nail surgery, you should not need continued medical care of the affected nail. The skin and the nail should grow back over the wound.

You may notice, however, that the nail isn't growing as you might expect. It might be asymmetric or could have some irregularities. Generally, if the nail doesn't grow back, the skin can thicken and scar. You might consider these cosmetic issues, but are not medical concerns.

If you are dissatisfied with the appearance of your nail, you can talk to a nail technician to see if there is something you can do to improve its appearance, such as filing the nail. You might even consider having a false nail placed, but be sure to check with your doctor first.

Surgical reconstruction is sometimes done by a plastic surgeon to improve the appearance of a nail.7
Possible Future Surgeries

An ingrown nail can recur even after it has been surgically repaired.1 Laser treatment is associated with a high rate of recurrence.2

This isn't a complication of the procedure itself, and whether recurrence is likely or not is usually unpredictable.

In such cases, non-surgical treatment may be tried again—and prove effective. Or, repeat ingrown nail surgery may be needed.
Lifestyle Adjustments

If you are prone to ingrown nails, you can try to prevent them. Taking these steps can actually be a critical part of the surgery being as effective as possible.

Learn to properly trim your nails by yourself or have them professionally maintained. Nails should be trimmed with a quality nail clipper and in a straight line; don’t cut them too short.
Wear shoes that fit well. This means avoiding tight shoes and those that are loose-fitting, as both can put pressure on your toes. Opt for square or rounded toe boxes, rather than pointed ones.
Protect your feet and hands from injury and keep them clean and dry. If you start to have a fungal infection of your nail, get treatment for it right away.

The 7 Best Toenail Fungus Treatments of 2020
A Word From Verywell

An ingrown toenail may be something you consider minor, but it can become a significant concern rather quickly and should not be ignored. Though it may be tempting, never cut an ingrown nail or into the surrounding skin yourself, as this can increase the risk of infection. See your primary care provider or a podiatrist for an evaluation. Remember that conservative management, as simple as it may seem, is usually effective. But if that's not enough, surgery may be right for you.

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