Podiatry - Attending for Nail Surgery

What is nail surgery?

Partial nail removal and total nail removal are minor surgical procedures performed by a Podiatrist to cure painful ingrown toenails.

Partial nail removal - This is the treatment of choice when one or both sides of the nail are ingrown. This method leaves most of the nail in place, only removing the “offending” portion of the nail.

Total nail removal - This is the complete removal of the toenail where the nail is extremely curved thickened or damaged. This method results in permanent loss of the whole nail.

Both procedures are performed under local anaesthetic, which is injected into the toe.

What are the benefits?

The benefit of the procedure must outweigh any risks. The benefits of having the procedure include:

• Permanent Cure
• Relief from the painful condition
• Allowing the tissues to fully heal
• Preventing infection from coming back
• Preventing the need for a general anaesthetic and risks associated with this
• Treatment in a community clinic
• Minimal time off school/work
• Partial removal of the nail will be cosmetically acceptable

Are there any risks involved?

As with all surgical procedures there are some risks involved. These are rare, but may include:

• Re-growth of the nail that has been removed
• Nerve/Blood vessel damage
• Deep Vein Thrombosis
• Delayed or Non-Healing of the wound
• Phenol chemical burn to healthy tissues
• Temporary loss or deformity of the remaining nail plate
• Bruising
• Chronic Regional Pain Syndrome (CRPS)
• Deep Vein Thrombosis
• Infection
• Pain
• Bleeding
• Allergic reaction including anaphylaxis
• Need for repeat procedure

At your assessment appointment it is important to tell your Podiatrist if you have epilepsy. If you suffer from epilepsy please let your Podiatrist know when your last seizure was and what are your identified triggers so that we can provide the most suitable clinical setting to perform your nail surgery.
 
If you take an anti-coagulant medication that requires regular blood tests by the anti-coagulation team ( for example Warfarin) it is important that you inform the Podiatrist of this and they will provide you of instructions to follow on the day of the procedure.

Preparing for your appointment

On the day of your appointment:

• Please ensure that any nails that are having the minor surgical procedure are completely clear of any nail varnish or synthetic material, including acrylic, gel or shellac nails
• Avoid alcohol consumption 24 hours before the procedure
• Bring a loose slipper or open toe sandal
• Bring any inhalers, sprays or medication that you may need with you
• If you are under 16, a parent or guardian must attend with you
• If you are over 16 you may attend with a relative/friend for support if required
• Please feel free to bring anything that may be a welcome distraction for example any personal music, books, magazines, electronic tablet devices etc
• There is no need to fast before your appointment, please eat and drink as normal
• Arrange for a car or taxi to take you home, as due to the local anaesthetic your insurance to drive will not be valid until your toe returns to normal sensation
• Make sure you plan for a few hours of rest after the treatment
• You must inform the Podiatrist upon arrival if you have been given any anaesthetic in the last 24 hours
• It is unlikely that you will need to alter your medication prior to surgery, therefore do not stop your tablets etc. unless you have been advised to do so

What happens when you attend for Nail Surgery?

• The appointment itself will take around an hour
• At the start, the procedure will be discussed with you and we will check you are happy to go ahead. There will be opportunity to ask any questions
• We will always discuss the procedure and make sure this is still appropriate based on the presentation of the nail on the day. In some cases we may discuss having the whole nail removed rather than just part of it and vice versa. We may decide that the procedure is not required for example if the problem has resolved since the assessment
• We will ask if there has been any change to your medication and health
• We will confirm your written and verbal consent to proceed
• We will lie you back in the treatment chair (unless you wish not to) and provide a pillow for comfort
• Local anaesthetic will be injected into either side of your toe to make it go numb. (As with any injection this part of the treatment can be uncomfortable, but it does not take long. Once the anaesthetic is working the procedure is pain free. We will not start the treatment until you are happy that the area is numb).
• We will perform some checks to make sure the toe is completely numb before starting the procedure
• When the toe is completely numb a rubber band called a tourniquet is applied to the toe to stop it from bleeding while the procedure is performed
• The agreed section of the nail will be removed
• A chemical called phenol will be applied to the nail bed and root to prevent the nail from growing back
• The chemical is removed after a total for 4 minutes
• The rubber band will then be removed
• Finally, a dressing will be applied to your toe
• Your dressing will be checked for any excessive bleeding before you leave. If there are any signs of excessive bleeding we may apply a dressing over the current dressing
• You will be provided with an aftercare sheet and some advice on how to look after the wound while it is healing
• In some cases we may book you a follow up appointment however this isn’t always needed.

Podiatry Students

Please be aware that student podiatrists may be undertaking training for nail surgery, under the supervision of a senior member of staff. This is an important part of the training programme for students, to be able to become Podiatrists in the future.

All students performing nail surgery will be in their final year of studies and will have passed an exam in administering local anaesthetic before they begin their placement.

You may be asked to consent to your treatment being given by a student under supervision. If you decline to help in the student training in this way, your care or treatment will not be affected.

After your Nail Surgery procedure

• Driving. Your vehicle insurance is invalid if you have had an anaesthetic in your toe, so please arrange accompanied transport home. Do not go home on the bus, on a bike/ motorbike, or walk home. This is so that you do not put pressure on your toe or have your foot resting down. This also helps to avoid excessive bleeding and pain after your surgery and reduces the risk of injury to the toe
• Walking. You will be able to walk after the procedure but your toe will feel numb until the anaesthetic wears off, which normally takes 1.5 - 2 hours. We recommend that you rest with your leg elevated for the rest of the day after the procedure
• Bleeding: There is generally very little bleeding afterwards, but sometimes more bleeding can occur with more severe cases of in- growing toe nails. If this does occur, the podiatrist will use a dressing to stop any more bleeding. If you do experience heavy bleeding contact your local Podiatry clinic as soon as possible within working hours, if it is after this time we would advise you to contact your out of hours GP. We recommend that you rest at home with the limb elevated for the remainder of the day following the procedure to minimise the risk of heavy bleeding.  The dressing will be checked before you leave clinic to ensure any bleeding has stopped. Dressings should be kept in place, clean and dry until the first re dressing appointment. Further instructions will be given at your follow up appointment.
• Pain/Discomfort. The anaesthetic usually wears off after 1.5 - 2 hours. It is unusual for the toe to be very uncomfortable although there have been cases of severe discomfort. If you do experience any discomfort you can take a painkiller but avoid anything with Aspirin in it, as this can make the wound bleed
• Alcohol. Alcohol increases bleeding and can make the surgery site bleed more and be more painful. We recommend avoiding alcohol for 24 hours after the procedure
• Healing time. Healing times depend on the type of surgery that is being performed, and if the chemical (phenol) is being applied.

If only a piece of the nail is removed (partial nail avulsion), healing will take place in an average of around 4-12 weeks. If the whole nail plate is removed (total nail avulsion), it usually takes longer as there is more skin to heal up - occurring in around 8-12 weeks.

Please note that not every person is the same - for some patients it may be a shorter or even longer time for the toe to heal.
Healing can be affected by many things, including the person’s health, medication, occupation and footwear.

The post operative wound might bleed and weep while it is healing which is normal.

FREQUENTLY ASKED QUESTIONS

How long does it take?

The appointment will last around one hour. This includes time for all the paperwork to be completed, for the anaesthetic to work and for you to relax. The procedure itself will only take 5 to 10 minutes.

Will I be able to see what you are doing?

We usually lie you flat while we carry out the procedure however if you prefer not to please let the Podiatrist know at the start of the appointment.

Will I be able to get my shoes on afterwards?

This is not usually a problem; however it may help to bring slippers or more accommodating footwear along with you.

Will I be able to walk afterwards?

Yes you will be able to walk normally after the procedure; although we do advise that you make arrangements to get home by car or taxi, and that you rest with your leg up for the rest of the day.

Will the nail grow back again?

The nail should not grow back if the procedure has been completed with the chemical application. In most cases there will be no re-growth however there is a small risk that some nail may grow back. If the nail grows back and causes problems it might be that the procedure will need to be repeated. 

When can I return to work/school/normal activities?

You will normally be able to return to work/school the next day. These procedures do not normally require any further time off. Some people find a 24 hour rest helpful. High impact physical activity/swimming should be avoided until the wound is healed.

What footwear can I wear while the toe is healing?

It is important to wear shoes that have enough depth and width at the front. It is fine to wear a closed toe shoe providing that there is enough room to accommodate the dressing and prevent any increased pressure on the wound that is healing. It is not advised to wear high heeled shoes or formal shoes that have a shallow or narrow toe box.

How long will it take to heal?

Partial nail avulsions take on average 4-12 weeks to heal completely. Total nail avulsions take approximately 8-12 weeks, however some will heal quicker and some take slightly longer. If you are in doubt contact your Podiatry department.

How long do I need to keep changing the dressings for?

It is important to keep dressing the area as per the dressing information we will provide until it is completely healed. You can stop applying a daily dressing when there is no longer any fluid on the dressing that you remove for 3 consecutive dressing changes.

How will I know if my toe is infected?

After nail surgery, it is normal for your toe to ooze a yellowish fluid.

If your toe shows the following symptoms it may be infected:

• Increased redness
• Swollen
• Painful
• Increase in discharge

If you are concerned that your toe is infected it is important that you contact the Podiatry Department or your GP as you may require a course of antibiotics.

Contact Information:

Please refer to your local podiatry contact information provided by your podiatrist.