Nail surgery made simple

WASHINGTON – There’s a lot of anxiety about nail surgery, particularly nail biopsies, for both physicians and patients, according to Dr. Maral K. Skelsey.

The goals of successful nail surgery are threefold: avoid complications, reduce patient pain and anxiety, and optimize pathologic diagnosis, said Dr. Skelsey of Georgetown University Medical Center in Washington.

Because nail surgery is often performed to obtain a clinical diagnosis, a good specimen is needed to allow the dermatopathologist to make a diagnosis, she noted at the Atlantic Dermatological Conference.

Approach preoperative assessment for nail surgery as any other surgery, said Dr. Skelsey. Take a full history, including information about vascular impairment, arterial disease, latex allergies, and a history of anticoagulant use. "We don’t stop anticoagulants, usually," Dr. Skelsey noted, but she does assess the prothrombin time (PT/INR) within 1 week.

Also, don’t underestimate the value of an x-ray. "One thing I have found physicians don’t do often" is to x-ray to check for bony changes and any anatomic abnormalities, she said.

To help optimize nail surgery outcomes, Dr. Skelsey recommended the following preoperative instructions for patients: Remove nail polish, scrub the area with povidone-iodine twice daily for 3 days prior to surgery, bring open-toed shoes (for toenail surgeries), arrange for a ride home, and plan to elevate the hand or foot as much as possible for the first 48 hours following the procedure.

Also, it "will help reduce morbidity if you tell your patients ahead of time to reduce their exercise and activity" immediately after the procedure, she said.

The right tools "will make your nail surgery much more successful," Dr. Skelsey said. Her essential tools: a nail splitter, nail nipper, and nail elevator.

Allow the patient to recline with goggles and ear phones to reduce anxiety during the procedure, she said.

For anesthesia, "I always use a 30-gauge needle, injecting very slowly," she said. She prefers a wing block, injecting slowly at a 45-degree angle towards the bone. This injection also acts as a volumetric tourniquet.

When obtaining the specimen during nail surgery, "visualize the location of the pathology by reflecting the proximal nail fold with a suture of skin hook and full or partial nail avulsion," said Dr. Skelsey.

"You can use a punch biopsy for longitudinal melanonychia less than 3 mm," she noted, but for anything more than 3 mm, a transverse excision or shave biopsy with a tangential excision is needed.

After the biopsy, Dr. Skelsey said that she applies an absorbable gelatin sponge saturated in aluminum chloride.

"What’s very important is giving your dermatopathologist a good specimen," she said. Don’t forget to ink the margins and orient the specimen. "You don’t want to go through all this trouble and have someone tell you there is nothing there," she added. She also recommended using separate, labelled formalin jars for the nail plate, bed, and matrix.

Dr. Skelsey said that she had no financial conflicts to disclose.

[email protected]

WASHINGTON – There’s a lot of anxiety about nail surgery, particularly nail biopsies, for both physicians and patients, according to Dr. Maral K. Skelsey.

The goals of successful nail surgery are threefold: avoid complications, reduce patient pain and anxiety, and optimize pathologic diagnosis, said Dr. Skelsey of Georgetown University Medical Center in Washington.

Because nail surgery is often performed to obtain a clinical diagnosis, a good specimen is needed to allow the dermatopathologist to make a diagnosis, she noted at the Atlantic Dermatological Conference.

Approach preoperative assessment for nail surgery as any other surgery, said Dr. Skelsey. Take a full history, including information about vascular impairment, arterial disease, latex allergies, and a history of anticoagulant use. "We don’t stop anticoagulants, usually," Dr. Skelsey noted, but she does assess the prothrombin time (PT/INR) within 1 week.

Also, don’t underestimate the value of an x-ray. "One thing I have found physicians don’t do often" is to x-ray to check for bony changes and any anatomic abnormalities, she said.

To help optimize nail surgery outcomes, Dr. Skelsey recommended the following preoperative instructions for patients: Remove nail polish, scrub the area with povidone-iodine twice daily for 3 days prior to surgery, bring open-toed shoes (for toenail surgeries), arrange for a ride home, and plan to elevate the hand or foot as much as possible for the first 48 hours following the procedure.

Also, it "will help reduce morbidity if you tell your patients ahead of time to reduce their exercise and activity" immediately after the procedure, she said.

The right tools "will make your nail surgery much more successful," Dr. Skelsey said. Her essential tools: a nail splitter, nail nipper, and nail elevator.

Allow the patient to recline with goggles and ear phones to reduce anxiety during the procedure, she said.

For anesthesia, "I always use a 30-gauge needle, injecting very slowly," she said. She prefers a wing block, injecting slowly at a 45-degree angle towards the bone. This injection also acts as a volumetric tourniquet.

When obtaining the specimen during nail surgery, "visualize the location of the pathology by reflecting the proximal nail fold with a suture of skin hook and full or partial nail avulsion," said Dr. Skelsey.

"You can use a punch biopsy for longitudinal melanonychia less than 3 mm," she noted, but for anything more than 3 mm, a transverse excision or shave biopsy with a tangential excision is needed.

After the biopsy, Dr. Skelsey said that she applies an absorbable gelatin sponge saturated in aluminum chloride.

"What’s very important is giving your dermatopathologist a good specimen," she said. Don’t forget to ink the margins and orient the specimen. "You don’t want to go through all this trouble and have someone tell you there is nothing there," she added. She also recommended using separate, labelled formalin jars for the nail plate, bed, and matrix.

Dr. Skelsey said that she had no financial conflicts to disclose.

[email protected]

WASHINGTON – There’s a lot of anxiety about nail surgery, particularly nail biopsies, for both physicians and patients, according to Dr. Maral K. Skelsey.

The goals of successful nail surgery are threefold: avoid complications, reduce patient pain and anxiety, and optimize pathologic diagnosis, said Dr. Skelsey of Georgetown University Medical Center in Washington.

Because nail surgery is often performed to obtain a clinical diagnosis, a good specimen is needed to allow the dermatopathologist to make a diagnosis, she noted at the Atlantic Dermatological Conference.

Approach preoperative assessment for nail surgery as any other surgery, said Dr. Skelsey. Take a full history, including information about vascular impairment, arterial disease, latex allergies, and a history of anticoagulant use. "We don’t stop anticoagulants, usually," Dr. Skelsey noted, but she does assess the prothrombin time (PT/INR) within 1 week.

Also, don’t underestimate the value of an x-ray. "One thing I have found physicians don’t do often" is to x-ray to check for bony changes and any anatomic abnormalities, she said.

To help optimize nail surgery outcomes, Dr. Skelsey recommended the following preoperative instructions for patients: Remove nail polish, scrub the area with povidone-iodine twice daily for 3 days prior to surgery, bring open-toed shoes (for toenail surgeries), arrange for a ride home, and plan to elevate the hand or foot as much as possible for the first 48 hours following the procedure.

Also, it "will help reduce morbidity if you tell your patients ahead of time to reduce their exercise and activity" immediately after the procedure, she said.

The right tools "will make your nail surgery much more successful," Dr. Skelsey said. Her essential tools: a nail splitter, nail nipper, and nail elevator.

Allow the patient to recline with goggles and ear phones to reduce anxiety during the procedure, she said.

For anesthesia, "I always use a 30-gauge needle, injecting very slowly," she said. She prefers a wing block, injecting slowly at a 45-degree angle towards the bone. This injection also acts as a volumetric tourniquet.

When obtaining the specimen during nail surgery, "visualize the location of the pathology by reflecting the proximal nail fold with a suture of skin hook and full or partial nail avulsion," said Dr. Skelsey.

"You can use a punch biopsy for longitudinal melanonychia less than 3 mm," she noted, but for anything more than 3 mm, a transverse excision or shave biopsy with a tangential excision is needed.

After the biopsy, Dr. Skelsey said that she applies an absorbable gelatin sponge saturated in aluminum chloride.

"What’s very important is giving your dermatopathologist a good specimen," she said. Don’t forget to ink the margins and orient the specimen. "You don’t want to go through all this trouble and have someone tell you there is nothing there," she added. She also recommended using separate, labelled formalin jars for the nail plate, bed, and matrix.

Dr. Skelsey said that she had no financial conflicts to disclose.

[email protected]