The nail bed extends distally to the hyponychium (I).ILLUSTRATIONS BY CHARLES H. The nail matrix extends to the lateral horns (H). The nail matrix can be seen at the junction with the nail bed, called the lunula (G). The lateral nail fold lies outside of the lateral nail groove (F) and is the area where ingrown nails develop. The nail plate is visible from the proximal nail fold (cuticle) (D) to the distal or free edge (E). The nail plate is created by the nail matrix (C). The nail plate (A) receives nutrition from the underlying nail bed (B). When the scissors cut through the most proximal edge of the nail beneath the cuticle, a “give” can be felt. A straight, smooth, new lateral edge to the nail plate is created. The physician uses a nail splitter or bandage scissors, cutting from the distal (free) end of the nail straight back (proximally) beneath the proximal nail fold ( Figures 1 and 2). This area is usually where the nail curves down into the toe. The lateral one fourth or one fifth of the nail plate is identified as the site for the partial lateral nail removal. A nail elevator or the closed tips of iris scissors are slid under the cuticle to separate the nail plate from the overlying proximal nail fold. The toe is rewashed with surgical solution, and a fenestrated drape is placed over the foot, with the involved toe protruding through the drape. A tourniquet should be used for the shortest possible time only. Alternatively, pressure to the sides of the toes during the procedure can reduce bleeding. A clean, unused rubber band can be placed in a sterilization pouch and put through an autoclave. Some physicians use a sterile rubber band around the base of the toe for a dry operative field. A wait of five to 10 minutes allows the block to become effective. About 2 to 3 mL of lidocaine on each side of the toe is usually sufficient for adequate anesthesia. A standard digital block is performed with 1 percent lidocaine (without epinephrine), using a 10-mL syringe and a 30-gauge needle. The toe is prepped with povidone-iodine solution. ![]() The patient is placed in the supine position, with the knees flexed (foot flat on the table) or extended (foot hanging off the end of the table).
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