Nail bed excision

Avulsed nails can either be reinserted or removed.

The nail bed, if damaged, will result in abnormal toenail growth.

A matricectomy can be performed either with direct dissection/curettage or chemically.

With the patient placed supine, the foot is prepped up to the ankle. Inject a digital block bilaterally at the base of the proximal phalanx. Avoid usage of epinephrine.

Exsanguinate and apply a tourniquet.

Frequently, the nail can be removed with minimal force. If needed, use a spatula to free the nail from the nail bed using blunt dissection up under the ungual fold.

The nail can similarly also be freed from dorsal soft tissues.

Use pliers to remove the nail in one piece if needed.

If nail bed ablation is desired, the entire germinal matrix needs to be removed to prevent the nail's regrowth.

Make oblique incisions medially and laterally at the proximal corner of the ungual folds, down to the dermis layer.

The inferior surface of the ungual fold will contain matrix tissue. Insert a scalpel parallel to the ungual fold and separate the ungual fold sharply from the matrix.

Carry this sharp separation bilaterally to join the oblique incisions.

Perform a transverse cut of the nail bed, slightly distal to the lunula. This cut is carried down to the bone.

The matrix is then dissected out in one piece using sharp dissection. The resection site is checked to see whether there may be any matrix left.