INVITED ARTICLE

Surgical management of ingrowntoenails – an update overdue

Bertrand RichertDermatology Department, Université Libre de Bruxelles, University HospitalBrugmann – Saint Pierre – Children Hospital Queen Fabiola, Brussels, Belgium

ABSTRACT: For decades, every year sees a wide number of articles about treatment of ingrown toe-nails. There is still a debate about the cause of this painful condition. Surgical treatments rely on twomain approaches: either narrowing the nail plate or debulking the soft tissues. It is up to the surgeon toselect the most appropriate approach in each case. All procedures cited in this article have high curerates as long as they are properly performed. As with all surgical procedures, they are operator depen-dent. Chemical cautery is the easiest and most versatile technique that may help in almost all instancesfor lateral ingrowing. For distal embedding and very hypertrophic and exuberant lateral folds, debulk-ing with secondary intention healing is the most effective and easy to perform, with great results.

KEYWORDS: ingrown nail, nail surgery

Introduction

For decades, every year sees a wide number ofarticles in the podiatry, dermatology, general, andorthopedic literature about treatment of ingrowntoenails. There is still a debate about the cause ofingrowing toenails. Some are convinced that thenail is responsible for the condition and thus willintervene on the plate itself; others are prone tothe idea that the periungual soft tissues are atfault and favor a surgical procedure on them. Baranclassified ingrowing toenails in different categorieslong ago, suggesting that each type may benefitfrom a specific treatment (1). Surgical treatment ofingrown toenails is indicated either when conser-vative treatments have failed or when the condi-tion is extremely painful or recurrent and that thepatient asks for a radical issue.

The literature offers numerous studies showingthe superiority of one technique over another, butnone of them showed that the procedure is per-formed on the same type of ingrowing toenails.Many studies are open, nonrandomized with shortfollow-up. Despite various trials, there is disagree-ment on which procedures give the most consis-tent results. Some do not hesitate to compare aconservative technique with an aggressive radicalsurgical procedure (2). And of course, comparing asurgical procedure you are used to, to another onewith which you are not familiar, will skew the finalresults (3). One should also remember that mostlyall surgical procedures are operator dependent,and that very easy ones to perform will certainlyget higher success rates. There is indeed a no “cure-all” technique for ingrowing toenails, but mainlytwo different approaches (narrowing the plate ordebulking of soft tissues) are both excellent, as longas they are performed in appropriate cases. Oneshould carefully examine each patient’s toe anddecide which technique would suit best accordingto his/her skills. Sometimes, several types of proce-dures may be performed on the same ingrowingtoenail to obtain best results.

Address correspondence and reprint requests to: BertrandRichert, MD, PhD, Dermatology Department, CHU Brugmann,Place Van Gehuchten 4, 1020 Brussels, Belgium, or email:Bertrand.Richert@chu-brugmann.be.

498

Dermatologic Therapy, Vol. 25, 2012, 498–509Printed in the United States · All rights reserved

© 2012 Wiley Periodicals, Inc.

DERMATOLOGIC THERAPYISSN 1396-0296

Development of ingrowing toenails

A recent study failed to demonstrate any abnor-mality in the forefoot alignment in patients withsymptomatic ingrowing toenails (4). The painfulconflict between the plate and the periungual softtissues may result from the following.

An epidermal breakage in the lateral nail sulcus

Constant pressure from the nail plate against thesoft tissues in a narrow shoe, especially if the nail iscut short, may push up the distal pulp, resultingin a painful distal corner. To alleviate discomfort,the patient starts to dig with nail clippers in thelateral nail fold and is unable to clip the mostlateral and deep part of the plate, thus leaving aspur (FIG. 1). The latter will grow distally and runthrough the epidermis of the lateral sulcus leadingto pain, inflammation, pyogenic granuloma, andeven infection. The same etiology is responsible foringrowing toenails observed in teenagers who tearoff their nails, softened by the humidity fromsneakers: the nail is torn in a lateral motion verydeep in the lateral sulcus. This phenomenon maybe worse in some patients as transverse curvatureand nail plate width vary inter- and intraindividu-ally, particularly in the toes. It is not rare to observepatients where the lateral border of the nail platecurves to reach to or even beyond the midline ofthe lateral aspect of the big toe (5). Those individu-als with more pronounced transverse curvature oftheir toenails tend to be more prone to developingingrowing nails.

This type of ingrowing is mostly an acute andpainful phenomenon. When conservative treat-ments have failed or are inadequate with regardto an acute painful condition, the first-choice

treatment is the definitive narrowing of the nailplate with curettage of the pyogenic granuloma ifany. This will allow a radical cure, as the distallateral corner of the nail will be in a physiologicalposition, at the level of the distal groove. More-over, the permanent narrowing will limit thetransverse curvature of the plate, thus avoidingrecurrences. Avulsion of a lateral strip of nailwithout destroying/removing the lateral horn ofthe matrix will lead to an identical regrowth inthe former nail. The larger regrown nail will have a“step effect” (FIG. 2), inducing again an epidermalbreakage in the lateral sulcus with recurrent pyo-genic granuloma.

A pinching of the subungual soft tissues(pincer nail)

This occurs subsequently to bony alterations of theunderlying phalanx. The matrix is firmly attachedto the bone. Widening of the distal interphalang-eal joint (either from osteoarthritis, or trauma orsurgery) will lead to a narrowing and elevation ofthe distal part of the plate to which the bed remainsattached. This can be demonstrated easily with apaper model. The result is a distorted distal nailbed that is pinched between the two lateral edgesof the plate (FIG. 3A). With time, the constantpulling of the distal part of the bed may result in atraction osteophyte visible on X-rays (6) (FIG. 3B).Pain will develop progressively over time, imped-ing footwear, and sometimes bedsheet contactbecomes unbearable. Conservative techniqueshave shown some results but recurrence is the rule(7). Two surgical techniques are available: eithernarrowing of the nail plate – which immediately

FIG. 1. Clipping the nail too short may leave a spur.

FIG. 2. “Step effect” after avulsion of two lateral strips of nailplate without matricectomy. Conservative treatment withtaping.

Ingrowing toenails

499

alleviates pain, but often leaves a very narrow nail –or a functional and cosmetic surgical treatmentthat may be offered to patients with pincer nailassociated with dorsal hyperostosis of the distaltuft, known as Haneke’s surgery (6).

A swelling of the periungual tissue

Swelling of the periungual tissue may be observedphysiologically in infants (FIG. 4), where surgery iscontraindicated, and abstention, or sometimesconservative treatments, will always lead to com-plete resolution within a few months (8). In adult-

hood, swelling of the periungual soft tissues issecondary to chronic ingrowing, enhanced bycutting the nails very short in the distal corners,without inducing any acute reaction. This chronicinflammation generates a fibrosis, giving rise toperipheral fibrous sausages in which the nail sinksand disappears (FIG. 5A). Here, the best approachis the debulking of the soft tissue to have the nailreappear. Narrowing the nail surgically will work,but will leave a very narrow unsightly nail. Distalembedding results from the loss of counter-pressure exerted by the plate on the distal pulp.It occurs after a nail loss either from trauma orsurgery. It is an acute painful condition presentingwith a distal inflammatory extremity into whichthe distal edge of the newly regrown nail impacts.Here again, surgery is directed toward a reductionof the volume of the periungual tissues: freeingthe nail to let it grow without encountering anyhindrance.

Surgical techniques

Definitive narrowing of the plate

Chemical cauterization. Partial chemical matri-cectomy with 88% phenol has been performed formore than half a century (9) and is the most com-monly used technique by dermatologists (10,11).

A B

C D

FIG. 3. (A) Pincer nail, front view; (B) X-rays on the toe, lateral view; (C) exposition of the hyperostosis after elevation of the nailbed; (D) after resection of the hyperostosis.

FIG. 4. Hypertrophic lateral folds in a toddler. Conservativetreatment is a must.

Richert

500

A B

C

E F

G

D

FIG. 5. (A) Ingrowing toenail with hypertrophic lateral nail folds, upper view; (B) front view; (C) drawing of the excision; (D) afterexcision of the excess tissue; (E) postoperative aspect; (F) 6 months postoperative upper view; (G) 6 months postoperative frontview, note the very discrete scar and the complete freeing of the nail.

Ingrowing toenails

501

A recent review in the Cochrane Library demon-strated that phenolization was the most effectivetechnique for definitive treatment in terms ofmorbidity and success rate, compared with otherexcisional surgical procedures, in preventing re-currence at 6 months or more (12). In most largestudies, the success rate is 95% or above (13–15).Phenol has three main properties that are interest-ing both for the surgeon and the patient: it is necro-tizing, disinfecting, and anesthetic. This allows, atthe same time, a destruction of the tissues where ithas been applied, a disinfection of the surgical field(allowing one to operate even moderately infectedtoenails), and a very comfortable postoperativefor the patient as phenol induces demyelination ofthe terminal nerve endings for several weeks (16).After a local block, granulation tissue, if present,is curetted for a better view of the lateral part ofthe nail plate (FIG. 6A,B), avoiding excessive nailplate removal. A lateral (or bilateral if the condition

affects both sides) strip of nail about 3 to 5 mm issplit under the proximal nail fold up to the mostproximal part of the nail and avulsed (FIG. 6C). Thesize of the strip should place the new distal lateralcorner of the plate at the level of the distal groove.This may, in some rare instances, lead to severenarrowing. A tourniquet is placed to ensure a com-pletely bloodless field. Phenol is applied onto theexposed lateral horn of the matrix and bed witha wisp of cotton wool (FIG. 6D–F), urethral swab,gauze (17), or with the elevator itself (18). Oneshould be cautious not to use oversoaked cottonswabs in order to avoid the cauterant to slide underthe plate (and overphenolize) and to be spilledonto the periungual tissue. Phenol acts by coagu-lating tissue proteins. A bloodless field is manda-tory at this point, otherwise phenol will coagulateblood proteins instead of those of the matrix epi-thelium. This is the most common cause for recur-rences. Ideal time of application varies from 2 to

A B

C

E F

D

FIG. 6. (A) Ingrowing toenail with pyogenic granuloma; (B) curettage of the pyogenic graniloma reveals the offending spur; (C)after avulsion of a lateral strip of nail; (D) chemical cautery of the lateral horn of the matrix; (E) postoperative aspect (note thatthe distal lateral corner of the nail is at the level of the distal groove); (F) pressure on the lateral fold shows how healing will occur.

Richert

502

3 minutes (19). Histological studies on matrixcadavers demonstrated that application for lessthan 2 minutes will not be able to coagulate thematrix basal cell layer whereas more than 3minutes will not be more effective (16) but mayonly induce longer oozing (19). There is no need tocurette the matrix before applying the cauterantas it does not increase the success rate (20) andexposes the toe to periostitis with potentiallycatastrophic consequences (21). It has been dem-onstrated that phenolization is safe both forthe patient and the surgeon (22). A recent studyshowed in vitro that phenol does not diffusethrough the skin and alcohol lavage, does not neu-tralize, but may only dilute and remove any excessof residual phenol (23). Anyway, the cauterant willbe immediately inactivated with the blood flowreturning after release of the tourniquet. The pro-cedure may be performed in diabetics – with thesame success rate as in nondiabetics (24) – in chil-dren (25) and in recalcitrant ingrowing from epi-dermal growth factor receptor inhibitors (26). Themain drawback of the technique is oozing forseveral weeks (3 to 6). This may promote infectionespecially in patients with poor hygiene (27).However, with regard to the very large numberof phenolizations performed, infection remainsvery unlikely. An application of 20% ferric chlorideafter phenolization reduces duration of oozing(28). More recently, it has been shown that usinglidocaine with epinephrine for the anesthesia sig-nificantly shortens the oozing period (29).

Sodium hydroxide (10%) has also been used ascauterant for selective matricectomies. Successrates are similar to phenol (30) and postoperativedrainage is shorter (average: 9 days for sodiumhydroxyde versus 17 days for phenol). Applicationtime is 1 minute (11). This cauterant is also suitablefor diabetics (31) and children (32).

Trichloracetic acid (100%) was used for matrixcauterization in only one series. Success rate wasalso similar to the one with phenol and sodiumhydroxide (95%), with very quick healing in only 2weeks (33).

Chemical cautery is very easy to perform andshould be known by all dermatologists. It is indi-cated in ingrowing toenail stage 2 with or withoutpyogenic granuloma and in any pincer nails. In thelatter, it will immediately relieve the patient fromthe pinching effect on the underlying tissue. Withinthe postoperative year, the nail will flatten. Dueto the long-standing pressure in the lateral nailfold, fibrosis may not allow retraction of the foldclose to the plate, leaving a lateral fibrotic gutteron the side of the plate (FIG. 7). All patients with

pincer nails should undergo X-rays searching fora hyperostosis of the distal tuft. If present, oneshould carefully examine the nail and determine ifpain occurs from lateral or upper pressure. If painoccurs only from lateral pressure, chemical cauterywill suffice to alleviate pain. In case upper pressureinduces pain, then more aggressive surgery may beneeded, known under the name of Haneke’s pro-cedure. It associates bilateral avulsion of strips ofplate with chemical cautery of the lateral horns ofthe matrix coupled with partial avulsion of thedistal 2/3 of the plate and longitudinal incision ofthe bed allowing resection of the distal bony hyper-ostosis (6) (FIG. 3A–D). This procedure should beperformed in full aseptic conditions with surgicalfacilities meeting orthopedic surgery standards.

Wedge excision. Wedge excisions remain verypopular in the orthopedic literature. Several vari-ants have been described under the name ofWinograd’s, Zadik’s, or Emmert’s procedures. All ofthem involve en bloc resection of the lateral partof the nail plate, its corresponding bed and matrix.Contrary to what one might think, this is a verydelicate surgery as complete dissection of thelateral horn from the underlying periosteum is noteasy. With skilled nail surgeons, this type of surgerymay give high results (34) as they perfectly knowthe anatomical bounds of the lateral horns of thematrix and for this reason curve proximally theirincision, as they would do for a lateral longitudinalbiopsy (5,35) (FIG. 8A,B). This is the main reasonfor the various recurrence rate observed in the dif-ferent studies. Pain is the major drawback of thetechnique, due to the trauma to the periosteuminduced by the dissection of the adherent matrix.Complications are frequent: (i) high postoperative

FIG. 7. Fibrosis of the lateral part of the nail due to long-standing pincer nail.

Ingrowing toenails

503

infection rate (20%) due to the unique concentra-tion of resident microbes in the nail folds, thereason for warranting routine antibiotic prophy-laxis (36) with even a fungal septicemia reported(37); (ii) lateral deviation when more than 3 mm ofplate is resected (38); (iii) spicule formation is verycommon (39) (FIG. 9); and (iv) inclusion nail (40).For all these reasons, wedge excisions should notbe recommended anymore for ingrowing toenails.

Lasers. A lot of publications on laser treatment ofingrowing toenails have been published. Mostcommonly, an ablative CO2 laser is used. A lateralstrip of nail plate is avulsed either surgically, as forother techniques, or removed with the laser beamin a cutting mode. Most authors incise the proxi-mal nail fold laterally and recline it to allow fullexposure of the lateral horn of the matrix. Hereagain, no blood is tolerated and a tourniquet ismandatory. The lateral matrix horn is vaporized(power and spot size may vary according to per-

sonal experience and machine used) and some-times the corresponding nail bed (41). Staining thelateral matrix with sterile methylene blue may aidin estimating the degree of matrix ablation (42).Experienced and skilled laser surgeons may reachhigh success rate almost similar to that of chemicalcautery (43,44). The main advantage of CO2 laser isits hemostatic effect.

Radiosurgery. In this technique, the heat is gener-ated in the tissue itself and the main differencewith electrocautery is that the electrode remainscold during the procedure. This allows selectivematrix destruction with only a very narrow marginof thermal tissue damage. After removal of a lateralstrip of nail to expose the lateral horn of the matrix,under bloodless conditions, the spade-like elec-trode is inserted under the proximal nail fold. It isbendable and coated on its upper part, thus avoid-ing any injury to the ventral aspect of the proximalnail fold. The power and time used will depend onthe manufacturer’s instructions. Results are said tobe as good as phenol but no large studies are avail-able (45). Overzealous cauterization may lead topainful periostitis.

Debulking of the periungual soft tissues

Howard–Dubois’ procedure. At the end of the 19thcentury, Howard proposed removing a crescent ofsoft tissue with a fish-mouth incision carried outparallel to the distal groove around the tip of thetoe, about 5 mm below the level of the distal lateralgrooves, reaching about 3 to 5 mm at its maximumwidth at the distal tip of the phalanx. All incisions

A

B

FIG. 8. (A) Wedge excision with a curved proximal lazy “S”incision allowing complete removal of the lateral horn of thematrix; (B) after closure.

FIG. 9. Spicule from an improper resection of the lateralhorn of the matrix in an Emmert procedure. Note the shape ofthe proximal incision and compare with Fig 8.

Richert

504

were carried down to the bone. Removal of enoughsoft tissues and suturing the defect resulted in apulling down of the soft tissues with decompres-sion of the nail (46) (FIG. 5A–F). Once again, asalways in history, this technique was forgottenand reintroduced more than half a century laterby Dubois who made it quite popular in France(47,48). This procedure is indeed a must in thetreatment of distal embedding. It is also a goodapproach when dealing with moderate hyper-trophic lateral folds, but one should be aware thatpulling down too much on the distal and lateralwalls may induce wound margin necrosis. Thisprocedure is painful and good pain control is man-datory. Some authors proposed variants of theoriginal technique: removal of a crescent of flesh inthe lateral nail fold associated with partial nailavulsion (49) or excision of a triangular piece of thelateral aspect of the toe named “lateral foldplasty”(50).

VandenBos’ procedure. In 1959, Vandenbos andBowers (51) proposed a theory whereby the excessskin surrounding the nail was burdened with dailyweight bearing, resulting in the bulging of nail-foldsoft tissues and subsequent pressure necrosis.Recently, Chapeskie and Kovac brought back thisprocedure in vogue but with some slight modifica-tions from the original Vandenbos procedure. Itinvolved wide excision of excessive nail-fold granu-lation tissue with preservation of the nail plate andits matrix. The debulking was generous, oftenleaving a skin and soft-tissue defect measuring 1.5to 3 mm and occasionally exposing a portion of thedistal phalanx (FIG. 10A–C). An application ofsilver nitrate or electrocautery was used to reducepostoperative bleeding. Care was taken at all timesnot to damage the nail matrix. The wound was thenallowed to close via secondary intention within 4 to6 weeks. A total of 124 patients (164 toes) weretreated with the technique for a total of 212 surgicalsites with a median follow-up time of 8 years. Norecurrences were identified in any patients (100%cure rate), and all cases had excellent cosmetic out-comes (52). This procedure is very easy to perform,generates very little pain, and has almost no risk ofdystrophy. It should be indicated in very severehypertrophy of the lateral nail folds covering a largesurface of the nail plate. The main drawback is thelong healing time.

Super U. This procedure developed by the Braziliandermatologist Peres Rosa (53) is very similar to theone by VandenBos. It removes all the excess tissue

A

B

C

FIG. 10. (A) Exophytic lateral nail folds; (B) wide debulkingof the lateral folds exposing the lateral aspect of the bonyphalanx; (C) after healing by secondary intention (courtesy ofChapeskie, Canada).

Ingrowing toenails

505

very generously in a U-shaped manner. The onlydifference is that it does not include the proximalnail fold and that hemostatis is obtained not byelectrocautery but by a running lock suture aroundthe wound. Healing occurs also by secondary inten-tion without any plate dystrophy (FIG. 11A–C).

Noël’s procedure. This procedure may be consid-ered as a vertical variant of Dubois’. A wedge-shaped ellipse of soft tissue, including the fibroticand granulation tissue, is removed on both sidesof the nail. The incision lines are adjacent to thelateral borders of the nail plate and deep enough,

A

B

C

FIG. 11. (A) Inflammatory and moderately hypertrophicnail folds; (B) after large debulking; (C) postoperative aspectafter secondary intention healing (courtesy of I. Peres Rosa,Brazil).

A

B

C

FIG. 12. (A) Hypertrophic inflammatory nail folds; (B) exci-sion of two vertical wedge of soft tissue preserving plate andmatrix (Noël’s procedure); (C) immediate postoperative view.

Richert

506

down to the lower third of the lateral aspect ofthe toe, to remove a large amount of soft tissues.At no time is either the plate or matrix touched(FIG. 12A,B). The defect is closed by simple inter-rupted sutures (FIG. 12C). Moderate pain shouldbe foreseen. On a series of 23 patients, completecure was achieved in all patients with no recur-rence after 1 year. Cosmetic outcome was excellentin all cases (54). This procedure requires somemore experience than Dubois’ and may be per-formed if needed only on one side of the toe. Thetoughest part of the procedure is the skimmingcurve incision around the bony phalanx. It givesgreat quick results for hypertrophic lateral walls.

Tweedie and Ranger’s transposition flap. The pro-cedure consists of making a transposition flapof the nail wall after preliminary curettage of thegranulation tissue in the nail groove (FIG. 13A,B).The treatment is effective (over 90% success rate)and not technically difficult (53). Pain may beobserved from the transposition. A variant of thisprocedure was described by Bose, by cutting awaythe proximal end of the flap and let the defect healby secondary intention (55).

Conclusions

Treatment of ingrowing toenails has been a chal-lenge for ages. Trying to know which, from the plateor the soft tissue, is at fault, is similar to guessingwhich came first, the chicken or the egg. Two mainapproaches are available for all types of nail sur-geons, from beginners to experienced. All proce-dures cited in this article have high cure rates aslong as they are properly performed. As with allsurgical procedures, they are operator dependent.However, chemical cautery is the easiest and mostversatile technique that may help in almost allinstances for lateral ingrowing. For distal embed-ding and very hypertrophic and exuberant lateralfolds, debulking with secondary intention healingis the most effective and easy to perform, with greatresults.

References

1. Baran R. [Ingrown nails]. Ann Dermatol Venereol 1987: 114(12): 1597–1604.

2. Peyvandi H, Robati RM, Yegane R-A, et al. Comparison oftwo surgical methods (Winograd and sleeve method) in thetreatment of ingrown toenail. Dermatol Surg 2011: 37 (3):331–335.

3. Hassel JC, Hassel AJ, Löser C. Phenol chemical matricec-tomy is less painful, with shorter recovery times but higherrecurrence rates, than surgical matricectomy: a patient’sview. Dermatol Surg 2010: 36 (8): 1294–1299.

4. Kose O, Celiktas M, Kisin B, Ozyurek S, Yigit S. Is there arelationship between forefoot alignment and ingrowntoenail? A case-control study. Foot Ankle Spec 2011: 4 (1):14–17.

5. Krull E. Exploration of nail tissue. In: Krull E, Zook E, BaranR, Haneke E, eds. Nail surgery. A text and atlas. Philadelphia,PA: Lippincott Williams & Wilkins, 2001: 49–53.

6. Baran R, Haneke E, Richert B. Pincer nails: definitionand surgical treatment. Dermatol Surg 2001: 27 (3): 261–266.

7. Di Chiacchio N, Kadunc BV, Trindade de Almeida AR,Madeira CL. Treatment of transverse overcurvature of thenail with a plastic device: measurement of response. J AmAcad Dermatol 2006: 55 (6): 1081–1084.

8. Piraccini BM, Parente GL, Varotti E, Tosti A. Congenitalhypertrophy of the lateral nail folds of the hallux: clinicalfeatures and follow-up of seven cases. Pediatr Dermatol2000: 17 (5): 348–351.

9. Boll O. Surgical correction of ingrowing toenails. J NatlAssoc Chiroprod 1945: 35: 8–9.

10. Haneke E, Baran R. Ingrown toenail – phenol cautery. In:Krull E, Zook E, Baran R, Haneke E, eds. Nail Surgery. A textand atlas. Philadelphia, PA: Lippincott Williams & Wilkins,2001: 163–164.

11. Ozdemir E, Bostanci S, Ekmekci P, Gurgey E. Chemicalmatricectomy with 10% sodium hydroxide for the treatmentof ingrowing toenails. Dermatol Surg 2004: 30 (1): 26–31.

12. Rounding C, Bloomfield S. Surgical treatments foringrowing toenails. Cochrane Database Syst Rev 2005: (2):CD001541.

A

B

FIG. 13. Tweedie and Ranger’s transposition flap. (A) Trans-fixion of the lateral fold with a #11 blade; (B) flap sutured.

Ingrowing toenails

507

13. Bostanci S, Ekmekçi P, Gürgey E. Chemical matricectomywith phenol for the treatment of ingrowing toenail: a reviewof the literature and follow-up of 172 treated patients. ActaDerm Venereol 2001: 81 (3): 181–183.

14. Di Chiacchio N, Belda W Jr, Di Chiacchio NG, KezamGabriel FV, de Farias DC. Nail matrix phenolization fortreatment of ingrowing nail: technique report and recur-rence rate of 267 surgeries. Dermatol Surg 2010: 36 (4): 534–537.

15. Vaccari S, Dika E, Balestri R, Rech G, Piraccini BM, Fanti PA.Partial excision of matrix and phenolic ablation for thetreatment of ingrowing toenail: a 36-month follow-up of 197treated patients. Dermatol Surg 2010: 36 (8): 1288–1293.

16. Boberg JS, Frederiksen MS, Harton FM. Scientific analysis ofphenol nail surgery. J Am Podiatr Med Assoc 2002: 92 (10):575–579.

17. Becerro de Bengoa Vallejo R, Losa Iglesias ME, SanchezGomez R, Jules KT. Gauze application of phenol for matrix-ectomy. J Am Podiatr Med Assoc 2008: 98 (5): 418–421.

18. Abimelec P. Tips and tricks in nail surgery. Semin CutanMed Surg 2009: 28 (1): 55–60.

19. Tatlican S, Yamangöktürk B, Eren C, Eskioglu F, Adiyaman S.[Comparison of phenol applications of different durationsfor the cauterization of the germinal matrix: an efficacy andsafety study]. Acta Orthop Traumatol Turc 2009: 43 (4): 298–302.

20. Tassara G, Machado MA, Gouthier MAD. Treatment ofingrown nail: comparison of recurrence rates betweenthe nail matrix phenolization classical technique and phe-nolization associated with nail matrix curettage – is theassociation necessary? An Bras Dermatol 2011: 86 (5): 1046–1048.

21. Sugden P, Levy M, Rao GS. Onychocryptosis-phenol burnfiasco. Burns 2001: 27 (3): 289–292.

22. Losa Iglesias ME, Veiga de Cabo J, Tejedor Traspaderne J,Aguilar Franco J, Bernaola Alonso M, Becerro de BengoaVallejo R. Safety of phenol vapor inhalation during perfor-mance of chemical matrixectomy to treat ingrown toenails.Dermatol Surg 2008: 34 (11): 1515–1519.

23. Cordoba Diaz D, Losa Iglesias ME, Cordoba Diaz M, Becerrode Bengoa Vallejo R. Evidence of the efficacy of alcohollavage in the phenolization treatment of ingrown toenails.J Eur Acad Dermatol Venereol 2011: 25 (7): 794–798.

24. Felton PM, Weaver TD. Phenol and alcohol chemicalmatrixectomy in diabetic versus nondiabetic patients. A ret-rospective study. J Am Podiatr Med Assoc 1999: 89 (8): 410–412.

25. Islam S, Lin EM, Drongowski R, et al. The effect of phenol oningrown toenail excision in children. J Pediatr Surg 2005: 40(1): 290–292.

26. Dika E, Balestri R, Vaccari S, Alessandro Fanti P, Misciali C,Patrizi A. Successful treatment of pyogenic granulomasfollowing gefitinib therapy with partial matricectomy andphenolization. J Dermatolog Treat 2009: 20 (6): 374–375.

27. Gilles GA, Dennis KJ, Harkless LB. Periostitis associated withphenol matricectomies. J Am Podiatr Med Assoc 1986: 76(8): 469–472.

28. Aksakal AB, Atahan C, Oztas P, Oruk S. Minimizing postop-erative drainage with 20% ferric chloride after chemicalmatricectomy with phenol. Dermatol Surg 2001: 27 (2): 158–160.

29. Altinyazar HC, Demirel CB, Koca R, Hosnuter M. Digitalblock with and without epinephrine during chemical matri-cectomy with phenol. Dermatol Surg 2010: 36 (10): 1568–1571.

30. Bostanci S, Kocyigit P, Gürgey E. Comparison of phenol andsodium hydroxide chemical matricectomies for the treat-ment of ingrowing toenails. Dermatol Surg 2007: 33 (6):680–685.

31. Tatlican S, Eren C, Yamangokturk B, Eskioglu F, Bostanci S.Chemical matricectomy with 10% sodium hydroxide for thetreatment of ingrown toenails in people with diabetes. Der-matol Surg 2010: 36 (2): 219–222.

32. Yang G, Yanchar NL, Lo AYS, Jones SA. Treatment of ingrowntoenails in the pediatric population. J Pediatr Surg 2008: 43(5): 931–935.

33. Kim S-H, Ko H-C, Oh C-K, Kwon K-S, Kim M-B. Trichloro-acetic acid matricectomy in the treatment of ingrowingtoenails. Dermatol Surg 2009: 35 (6): 973–979.

34. Kayalar M, Bal E, Toros T, Ozaksar K, Gürbüz Y, Ademoglu Y.Results of partial matrixectomy for chronic ingrown toenail.Foot Ankle Int 2011: 32 (9): 888–895.

35. Haneke E, Richert B, di Chiacchio N. Surgery of thewhole nail unit. In: Richert B, di Chiacchio N, Haneke E,eds. Nail surgery. London: Informa Heathcare, 2010: 133–148.

36. Rusmir A, Salerno A. Postoperative infection after excisionaltoenail matrixectomy: a retrospective clinical audit. J AmPodiatr Med Assoc 2011: 101 (4): 316–322.

37. Vanhooteghem O, Gillard P, Dezfoulian B, de la BrassinneM. Scedosporium apiospermum septicemia following awedge excision of an ingrown toenail. Int J Dermatol 2009:48 (10): 1137–1139.

38. De Berker DA, Baran R. Acquired malalignment: acomplication of lateral longitudinal nail biopsy. Acta DermVenereol 1998: 78 (6): 468–470.

39. Richert BB, Dahdah MM. Complications of nail surgery.In: Noury K, ed. Complications in dermatologic surgery.Philadelphia, PA: Mosby, 2008: 137–158.

40. Vanhooteghem O, Henrijean A, André J, Richert B, De LaBrassinne M. [Ingrown nails: a complication of surgery foran in-growing toe-nail using the Zadik procedure]. AnnDermatol Venereol 2006: 133 (12): 1009–1010.

41. Serour F. Recurrent ingrown big toenails are efficientlytreated by CO2 laser. Dermatol Surg 2002: 28 (6): 509–512.

42. Ozawa T, Nose K, Harada T, Muraoka M, Ishii M. Partialmatricectomy with a CO2 laser for ingrown toenail after nailmatrix staining. Dermatol Surg 2005: 31 (3): 302–305.

43. Lin Y-C, Su H-Y. A surgical approach to ingrown nail: partialmatricectomy using CO2 laser. Dermatol Surg 2002: 28 (7):578–580.

44. Andre P. Ingrowing nails and carbon dioxide laser surgery.J Eur Acad Dermatol Venereol 2003: 17 (3): 288–290.

45. Hettinger DF, Valinsky MS, Nuccio G, Lim R. Nail matrixec-tomies using radio wave technique. J Am Podiatr Med Assoc1991: 81 (6): 317–321.

46. Howard WR. Ingrown toenail; its surgical treatment. N YMed J 1893: 57: 579.

47. Greco J, Kiniffo HV, Chanterelle A, Lapierre F, Gordien J.[Approach to the soft parts, the secret of the surgical cureof ingrown nails. Technical points]. Ann Chir Plast 1973:18 (4): 363–366.

48. Dubois J-P. Un traitement de l’ongle incarné. Nouv PresseMéd 1974: 31: 1938–1940.

49. Sarifakioglu E, Sarifakioglu N. Crescent excision of the nailfold with partial nail avulsion does work with ingrown toe-nails. Eur J Dermatol 2010: 20 (6): 822–823.

50. Aksoy B, Aksoy HM, Civas E, Oc B, Atakan N. Lateralfoldplasty with or without partial matricectomy for the

Richert

508

management of ingrown toenails. Dermatol Surg 2009: 35(3): 462–468.

51. Vandenbos KQ, Bowers WF. Ingrown toenail: a result ofweight bearing on soft tissue. US Armed Forces Med J 1959:10: 1168–1173.

52. Chapeskie H, Kovac JR. Case series: soft-tissue nail-foldexcision: a definitive treatment for ingrown toenails. Can JSurg 2010: 53 (4): 282–286.

53. Tweedie JH, Ranger I. A simple procedure with nail preser-vation for ingrowing toe-nails. Arch Emerg Med 1985: 2 (3):149–154.

54. Noël B. Surgical treatment of ingrown toenail withoutmatricectomy. Dermatol Surg 2008: 34 (1): 79–83.

55. Bose B. A technique for excision of nail fold foringrowing toenail. Surg Gynecol Obstet 1971: 132 (3): 511–512.

Ingrowing toenails

509