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ProceduralNail unitOPCS S70 / S71

Nail surgery (avulsion + matricectomy)

Total / partial nail avulsion · matricectomy · ingrowing toenail surgery

Nail surgery encompasses nail-bed biopsy, partial / total nail avulsion, matricectomy (phenol or surgical) and tumour-related nail-unit excision. Common indications are ingrowing toenail (onychocryptosis), subungual / nail-bed tumours including subungual SCC and melanoma, chronic paronychia and onychomatricoma. UK BSDS / BOFAS guidance and access to a podiatry-surgery interface underpin practice. Critical considerations are accurate diagnosis before destructive procedures, awareness of nail-unit anatomy and post-operative care to avoid spicule formation and infection.

CurrentLast reviewed 16 May 2026

Anatomy

  • Nail plate — keratinised; produced by germinal matrix (proximal nail-fold roof + lunula floor).
  • Sterile matrix (nail bed) — distal to lunula; supports nail plate.
  • Hyponychium — distal nail-bed seal.
  • Lateral / proximal nail folds.
  • Vascular supply: digital arteries via dorsal and palmar arches.
  • Nerve supply: digital nerves; sensory only in nail-bed.

Digital anaesthesia

  • Digital block: lidocaine 1-2% plain (or with adrenaline using established adrenaline-safe protocols).
  • Wing block: dorsal proximal nail fold + lateral nail folds — fast onset, often more comfortable.
  • Distal infiltration for small wedge resections.
  • Onset 5-10 minutes; duration up to 90 minutes plain, longer with adrenaline.
  • Tourniquet: rolled-glove finger tourniquet for haemostatic field; remove at end (max 30 minutes).
  • Avoid adrenaline in patients with peripheral vascular disease, Raynaud, severe smoking, end-organ ischaemia.

Common procedures

  • Partial nail avulsion + lateral wedge matricectomy for ingrowing toenail:
    1. Digital block, tourniquet.
    2. Cut nail plate longitudinally with English nail splitter.
    3. Elevate medial / lateral spike with Freer elevator.
    4. Remove embedded nail spike.
    5. Matricectomy: phenol 80-88% applied for 30 seconds with cotton bud × 3 cycles (chemical matricectomy) — preferred for cure rate.
    6. Or surgical matricectomy (excision of lateral horn + curettage).
    7. Saline irrigation; non-adherent dressing.
  • Total nail avulsion for chronic paronychia, onychomycosis evaluation, biopsy access, exfoliative onycholysis.
  • Nail-bed biopsy: longitudinal nail biopsy with avulsion of proximal nail-fold; preserves architecture.
  • Nail-unit excision for subungual SCC, glomus tumour, onychomatricoma — refer to specialist.
  • Wide excision for subungual melanoma: traditionally amputation; digit-preserving nail-unit excision can be considered for melanoma in situ in specialist hands. Invasive subungual melanoma should be planned through the melanoma MDT; when amputation is required, use the most distal level that clears margins (e.g. through the distal phalanx / DIP joint).

Nail-unit tumours — critical considerations

  • Subungual melanoma:
    • Hutchinson sign — periungual pigment extending to nail fold.
    • Refer 2-week-wait suspected skin cancer.
    • Excisional biopsy or longitudinal nail biopsy preferred over partial / shave.
    • Multidisciplinary discussion before definitive resection.
  • Subungual SCC:
    • Chronic nail dystrophy, ulceration, pain, periungual erythema.
    • HPV association in fingertip lesions.
    • Punch / wedge biopsy; if confirmed → Mohs / wide local excision.
  • Glomus tumour: classic triad — paroxysmal pain, cold sensitivity, point tenderness; MRI; excision with nail-bed reconstruction.
  • Onychomatricoma: characteristic histological architecture; complete excision.
  • Subungual exostosis: bone overgrowth distal phalanx; radiograph.

Aftercare and complications

  • Non-adherent dressing; daily saline / chlorhexidine soak.
  • Elevation; reduce ambulation 48-72 hours.
  • Re-dress weekly until healed.
  • Complications:
    • Infection.
    • Spicule regrowth (incomplete matricectomy).
    • Nail dystrophy.
    • Hyperpigmentation.
    • Phenol burn / surrounding skin irritation.
    • Distal-tip ischaemia (excess tourniquet time / adrenaline misuse).
  • Counsel about months for full nail regrowth (~6 months hand, ~12 months toe).

References

  1. Mozena JD. The Mozena modification of the Winograd procedure for ingrown toenails. J Foot Ankle Surg. 2002;41:282-290.
  2. Eekhof JAH et al. Interventions for ingrowing toenails. Cochrane Database Syst Rev. 2012;4:CD001541.
  3. Rich P, Scher RK. An Atlas of Diseases of the Nail. 2nd ed. CRC Press; 2017.
  4. British Orthopaedic Foot and Ankle Society (BOFAS). Guidelines for the management of onychocryptosis. London: BOFAS; 2021.
  5. NICE NG14. Melanoma: assessment and management. London: NICE; 2015 (last updated 27 July 2022).

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