FLORENCE, ITALY An alternative to the classic, 150-year-old surgical technique for repairing ingrown toenails may be associated with fewer recurrences and a much-improved aesthetic result, two Swiss dermatologists reported at the 13th Congress of the European Academy of Dermatology and Venereology.
Bernard Noël, M.D., and his coauthor Renatto G. Panizzon, M.D., maintain that their new technique is superior to Emmert plasty, a procedure that consists of a rather superficial wedge excision of granulation tissue, as well as both the adjacent nail bed and the corresponding matrix.
To refine Emmert plasty, however, they first had to scrutinize its steps to understand why it has a recurrence rate as high as 10%30%.
Dr. Noël and Dr. Panizzon, professor of dermatology at the University of Lausanne (Switzerland), theorized that recurrences may be related to the surgical target of Emmert plasty: the nail, which is narrowed by the radical surgery and sometimes left in a dystrophic state that may be vulnerable to the same pressure that led to the development of the ingrown nail initially.
Moreover, when a significant portion of the nail bed is sacrificed and the nail width is permanently reduced, aesthetic results are often "unsatisfactory," according to Dr. Noël, chief of dermatologic surgery and the wound healing clinic at Centre Hospitalier Universitaire Vaudois of the University of Lausanne.
By contrast, their approach preserves the nail apparatus while deeply targeting the granulation tissue and reducing the size of the toe itself.
"The breadth of the toe extremity is clearly reduced in a way that radically reduces the lateral pressure exerted by the shoes," Dr. Noël said.
"The great toe looks thinner, with a nail plate covering almost completely the distal phalange, reducing, therefore, the risk of recurrence," he noted.
The procedure is performed using a digital block and tourniquet at the toe base. Large, deep excisions remove granulation tissue before the wounds are closed in standard fashion.
Among 10 patients followed for a year or more, there has been a 100% success rate and no incidence of recurrence, Dr. Noël and Dr. Panizzon reported in their detailed poster presentation.
The authors believe their findings bode well for patients who are prone to develop ingrown toenails, which are the most common of all toenail disorders, believed to account for as many as 20% of foot-related physician visits.
Excessive pressures on the lateral toenail because of body weight, the wearing of ill-fitting shoes, or the practice of improperly cutting toenails all have been cited as contributors to the inflammation and the formation of granulation tissue that causes nails, usually of the great toe, to become ingrown.
When patient education and conservative therapy fail, repeated recurrences can lead to infections and extreme discomfort.
Granulation tissue is removed with large and deep excisions.
The toe extremity is narrowed but the nail appartatus is entirely preserved. Photos courtesy Dr. Bernard Noël