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Ingrowing Toe Nail Surgery

DEFINITION : An ingrown toenail is a condition in which the edges of the nail grow into the surrounding skin. It is a common occurrence and is nearly always confined to the great toe in which the nail grows and digs into the adjacent skin (nailfold). It is usually due to tight, narrow or ill-fitting shoes and trainers. Also, due to the habit of pairing the nail downwards into the fleshy nail fold rather than trimming it straight or transversely. In such cases the sharp edge of the nail grows into the side of the nail fold. Sometimes, the nail fold grows abnormally fast and engulfs a part of the nail.

SYMPTOMS AND SIGNS : Ingrowing toe nails are commonly found in adolescent and young adult males and, to a much less degree, in females. Physical activity and games as well as less stringent hygiene practices in young males, may contribute to the gender differenceIngrown nails may produce no symptoms at first, but eventually may become painful, especially when pressure is applied to the ingrown areaThe skin of the adjacent nail fold becomes swollen, red, warm, tender and is prone to infectionIf infection by pus forming bacteria takes place, usually Staphylococcus Aureus bacteria, the symptoms and signs become worse and pus filled blisters (paronychia) may developIf left untreated, the whole toe becomes sore especially when walking. It throbs at nightThere will be a variable degree of swelling, discharge of pus and painThe nail fold becomes soggy, red-blue discoloration and exquisitely tender.

TREATMENT is either expectant or surgical, depending on the age of the patient, gender, profession, chronicity of the problem and severity.Antibiotics must not be given if there is no infection. If the surgical operation is performed by a surgeon who is familiar with the surgery of ingrowing nail, there will be no recurrence. I perform this operation under local anaesthesia.

1. EXPECTANT TREATMENT is indicated in the initial stages, provided there is no infection. These include proper hygiene of toes and feet e.g. washing with water and antiseptic soap like chlorhexidine gluconate liquid (like Hydrex or Cyteal) twice a day especially after physical activity.Advice is given on correct cutting of the nails. Nylon socks and old shoes and trainers must be discarded and replaced by several pairs of thick white or light coloured cotton socks and at least three pairs of new spacious shoes and trainersSocks must be changed twice a day. A pair of shoes or trainers should not be worn for more than a day, the other two are to be left open in a ventilated area to dry from the insensible sweatwhich takes twenty four to forty eight hoursA pledge of cotton wool tucked daily into the side of the nail bed or under the ingrowing nail after soaking of the foot in a warm or hot water to soften the nails, will encourage the nail to grow up and out to the nail foldIt is wise to refrain from physical activity for a week or two.


1) If surgery is needed, antibiotics are not substitutes to surgery and might be prescribed by the surgeon in conjunction with surgeryIn my private daycare surgical clinic in Dubai, I have performed nearly one hundred and thirty (130) surgical operations on ingrowing nails of the great toe in the operation theatre of my clinic under local ring anaesthesia of the proximal phalanx of the great toe using 2% plain (No Adrenaline) local anaesthetic and a very light soft tourniquet i..e. a soft finger stall of a sterile glove (all these operations are documented and many are photographed).

Almost all of these patients, who never had a previous surgical operation on the great toe for ingrowing nail, their nail were normal i.e. pink in colour, smooth and shiny, except the very ingrowing narrow strip of the side of the nail plate which is two to three millimetres wide of the affected nail plateThe surgical operation is called wedge excision. Wedge excision includes a) excision of the narrow strip of the nail plate, b) a limited excision of the adjacent inflamed and infected nailfold, c) a very careful excision of the corresponding nail root (matrix)It is of paramount importance not to disturb the remaining nail matrix and the normal nail plate which constitutes about 90% of the width of the original nail plate and nail matrix. In other words, the surgical procedure must be very careful and gentle. I leave the wound exteriorized to allow healing by granulation and epithelialization (secondary intention) which takes between four to ten days. I would like to emphasize that the very light and soft tourniquet must not be left for more than ten minutes, otherwise there will be damage to the delicate low pressure digital arteries and the digital nerves and subsequent ischemia of the great toe with severe, constant and unbearable post-operative painAvulsion of the whole nail plate, unfortunately a common practice, must be avoided, otherwise there will be inevitable recurrence of the ingrowing nail and, furthermore, the new nail plate will be abnormally thick, brittle, discoloured and with a rough surface. Post-operatively, the patient must lie flat while elevating the foot on pillows for the following forty eight hours.

We should remember why the big toe is called “GREAT”. This is because during walking, standing, climbing the stairs, crossing the road etc.,the great toe bears eighty percent (80%) of the weight of the body. The other four toes help to balance the individual. Furthermore, an individual with a healthy normal great toe while the other lateral four toes are amputated or absent can still compete in a marathon!

Also, the individual can cross the road safely, can escape in an emergency situation such as fire, earthquake, escaping from people who are following them, tsunami, etc. These activities cannot be performed in the presence of the outside four toes only and in the absence of the great toe.

2) The surgical operation on an ingrowing nail of the great toe in diabetic patients must be considered carefully and, if the operation is necessary, should be performed by a senior surgeonI have seen a few wet diabetic gangrene following surgical operation on a genuine ingrowing nail of the great toe in diabetic patients.

3) In middle-aged and elderly patients, it is of vital importance to take a full history of their cardiovascular system, including cardiac bypass, stents etc. and to examine clinically and thoroughly, by palpation, the pulses of the major arteries of the lower limbs i.e. femoral, popliteal, dorsalis paedis and posterior tibial, as well as the capillary circulation of the toes and soles of the feet on both sides for the “refill time” to exclude occlusive arteriosclerosis disease because, occasionally, the clinical presentation of ischemic rest pain in occlusive arterial diseases mimic symptoms and signs of ingrowing toe nails. Surgical operation on the great toe in these unfortunate patients, mistakenly diagnosed as ingrowing toe nail, will end up with ischemic gangrene of the leg and mid-thigh amputation!