Grasp the edge of the nail plate with a straight hemostat. Using the same instrument in step 3, gently lift the lateral edge of the nail plate. A Freer septum elevator or hemostat can be used to push the cuticle off the nail plate. Prepare the toe with povidone-iodine, chlorhexidine (Peridex), or alcohol. After adequate time has elapsed (five to 10 minutes), test the patient's ability to sense pain in the digit. Wear nonsterile gloves and perform a digital nerve block using 1% or 2% lidocaine. Provide informed surgical consent and place the patient in the supine position, with the knees flexed and the foot flat on the table or the leg extended and the foot hanging off the end of the table. 2 Prevention of recurrence between wedge resection and radical excision of the nail fold showed no significant difference after 12 months. 2 Less recurrence after 12 months with wedge resection (risk ratio = 0.19 95% CI, 0.05 to 0.80) and radical excision of the nail fold (risk ratio = 0.17 95% CI, 0.04 to 0.72) than with the rotational flap technique was also noted. In the Cochrane review, one study showed no significant difference in recurrence with nail-edge excision and total avulsion of the nail. Surgical procedures are supported by minimal comparative data. Surgical procedures for ingrown nails include the following: partial nail avulsion (Ross procedure) with or without partial matrixectomy wedge excision, wedge segmental excision, or wedge resection with nail matrix destruction (Winograd procedure) total nail avulsion with or without excision of any granuloma with or without total (chemical or surgical) excision of the matrix (Zadik procedure) rotational flap technique of the nail fold or radical nail-fold excision (Vandenbos procedure). Matrixectomy further prevents recurrence and can be performed through surgical, chemical, or electrosurgical means. The most common surgical approach is partial avulsion of the lateral edge of the nail plate. These approaches are superior to nonsurgical ones for preventing recurrence. Surgical approaches seek to remove the interaction between the nail plate and the nail fold to eliminate local trauma and inflammatory reaction. A cotton nail cast made from cotton and cyanoacrylate adhesive, taping the lateral nail fold, or orthonyxia may also alleviate mild to moderate ingrown toenail. Application of a gutter splint to the ingrown nail edge to separate it from the lateral fold provides immediate pain relief. Simple nonsurgical palliative measures include correcting inappropriate footwear, managing hyperhidrosis and onychomycosis, soaking the affected toe followed by applying a mid- to high-potency topical steroid, and placing wisps of cotton or dental floss under the ingrown lateral nail edge. Nonsurgical treatments are typically used for mild to moderate ingrown nails, whereas surgical approaches are used in moderate and severe cases. No consensus has been reached for the best treatment approach, but ingrown nails may be nonsurgically or surgically treated. Ingrown toenails occur most commonly in young men, and nail care habits and footwear are most often contributory factors. Ingrown toenails account for approximately 20% of foot problems in primary care.
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