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Table of Contents
Year : 2018  |  Volume : 22  |  Issue : 2  |  Page : 87-89

Exuberant ingrown nail: Satisfactory esthetics results combining surgery techniques

Department of Dermatology, Professor Rubem David Azulay Institute of Dermatology, Santa Casa de Misericórdia do Rio de Janeiro, Rio de Janeiro, RJ, Brazil

Date of Web Publication21-Sep-2018

Correspondence Address:
Kleber Ollague Cordova
Department of Dermatology, Instituto De Dermatologia Professor Rubem David Azulay, Santa Casa Da Misericórdia Do Rio De Janeiro io De Janeiro
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jdds.jdds_15_18

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Subcutaneous onychocryptosis is one of the most common diseases of the nail unit. It causes significant morbidity and disability in daily life and may become chronic if not treated. It is classified in three stages as defined by Heifetz and Frost. Conservative treatment is favored in mild cases, while surgery is necessary for stages 2 and 3 ingrown toenails. We describe a case of subcutaneous onychocryptosis Grade III, in which alpha stitch and Howard–Dubois techniques improved final esthetic result. The aim of this article is to present an exuberant case of onychocryptosis and how a combination of surgical techniques can produce a better outcome.

Keywords: Alpha stitch technique, Howard–Dubois technique, ingrown toenails, onychocryptosis

How to cite this article:
Cordova EO, Cordova KO, Studart AC, Leverone A, Regazzi P, Quintella D. Exuberant ingrown nail: Satisfactory esthetics results combining surgery techniques. J Dermatol Dermatol Surg 2018;22:87-9

How to cite this URL:
Cordova EO, Cordova KO, Studart AC, Leverone A, Regazzi P, Quintella D. Exuberant ingrown nail: Satisfactory esthetics results combining surgery techniques. J Dermatol Dermatol Surg [serial online] 2018 [cited 2023 Feb 9];22:87-9. Available from: https://www.jddsjournal.org/text.asp?2018/22/2/87/241905

  Introduction Top

Subcutaneous onychocryptosis is one of the most common diseases of the nail unit.[1] It is more prevalent in adolescents, young adults, and obese people.[2] It principally occurs in the hallux.[2] It causes significant morbidity and disability in daily life and may become chronic if not treated.[3],[4] The most common causes of ingrown toenails are incorrect clipping of nails, wearing tight shoes, obesity, trauma to toes and/or nails, and hyperhidrosis.[2],[4] Several precipitating factors include heredity, disproportionate nail plate and nail bed widths, and increased transverse curvature of the nail plate.[1] Hypertrophy of the skin folds is a common finding with ingrown toenails.[5] Subcutaneous onychocryptosis is classified into three stages as defined by Heifetz and Frost.[2] Grade I onychocryptosis is characterized by the presence of inflammatory signs such as erythema, mild edema, and pain. When there is emergence of exudate, secondary infection and local drainage are considered Grade II. Finally, the Grade III onychocryptosis means formation of granulation tissue and hypertrophy of the lateral nail fold.[1] Conservative treatment is preferred in mild cases, while surgery is necessary for stages 2 and 3.[2] This case report describes an exuberant soft-tissue hypertrophy secondary to subcutaneous onychocryptosis and how combining surgery techniques can contribute to the final result.

  Case Report Top

A 30-year-old female was referred to our service to evaluate an asymptomatic lesion that appeared on the lateral nail folds of her right hallux 2 years ago and that increased in size until covering the nail plate completely. The patient reported a trauma to the region before the development of the lesion. She applied several topical treatments without improvement. The patient had no comorbidities and denied to use medication regularly. Physical examination revealed hypertrophic granulation tissue and re-epithelized tissue covering the whole nail plate [Figure 1]. The hallux was increased in size when compared to the other. After a proper explanation of the surgical procedure and patient's consent, the procedure was conducted with digital block anesthesia and finger tourniquet. After cleaning the area with alcoholic chlorhexidine, the granulation tissue was cutoff following the nail plate anatomy partially exposing the nail plate [Figure 2]. The central part of the nail plate was normal. All epithelized tissues were removed, exhibiting marked onychogryphosis. The distal part of the nail was extracted [Figure 3]. It was performed partial matricectomy with fenolization of both lateral areas of the nail matrix. Then, the lateral nail folds were closed with alpha stitch technique [Figure 4]. Sutures were removed on the 20th day postoperative. Histological examination revealed squamous hyperplasia, granulation tissue, and dermis with a chronic inflammatory process and prominent fibrosis [Figure 5] and [Figure 6]. The patient returned 6 months after surgery, presenting hypertrophy of the distal fold [Figure 7]. The Howard–Dubois technique was performed [Figure 8]. One year after the second surgery, the patient returned presenting an excellent esthetic result [Figure 9].
Figure 1: Exuberant soft tissue and granulation tissue. Hyperchromia in the perinail region

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Figure 2: Partially exposed the nail plate

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Figure 3: Marked onychogryphosis. Distal edge of the nail plate removed

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Figure 4: Approximation of the lateral folds by alpha stitch technique. Immediate postoperative

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Figure 5: Squamous hyperplasia, adjacent to granulation tissue (H and E, ×40)

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Figure 6: Slightly hyperplastic epidermis and dermis with exuberant fibrosis (H and E, ×40)

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Figure 7: Hypertrophy of the distal fold

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Figure 8: Modified Howard–Dubois technique

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Figure 9: One year after the reconstructive surgery of the hypertrophic distal fold

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  Discussion Top

There are two scenarios responsible for ingrown toenail: hypertrophic nail folds or enlarged nail's width. If the enlarged width of the nail is the cause of the persistence of the disease, selective matrix excision is recommended which permanently narrows the nail. When the condition is triggered by hypertrophic nail folds, debulking of the periungual soft tissues is done.[3] Surgical treatment is based on the partial or total removal of ingrown nail.[6] The most frequently used technique is surgical matricectomy (surgical excision of the lateral matrix horn) in addition to chemical matricectomy (fenolization). Its purpose is to position the lateral fold at the nail plate level or below it to prevent recurrences.[1] In our case, there was a surgical challenge to repair the defect due to the difficulty of approaching the lateral folds which was solved using the alpha stitch technique. When the patient returned showing the distal hypertrophy, we decided to perform a modified Howard-Dubois technique by making the fish-mouth incision only at the distal nail fold. Combining these techniques improved our final esthetic result. It is important to remember that the synergy of surgical techniques improves the esthetic and functional results.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Lucares DO, Rodriguez JJ, Leverone A, Nakamura RC. Benefits of the alpha stitch technique in surgical closure in onychocryptosis. Surg Cosmet Dermatol 2012;4:310-4.  Back to cited text no. 1
Nakamura RC, Baran R. Nail diseases. 2nd ed. Rio de Janeiro: Elsevier editora ltda.; 2018. p. 117-26.  Back to cited text no. 2
Di Chiacchio N, Di Chiacchio NG. Best way to treat an ingrown toenail. Dermatol Clin 2015;33:277-82.  Back to cited text no. 3
Dadaci M, Ince B, Altuntas Z, Kamburoglu HO, Bitik O. Skin bridging secondary to ingrown toenail. Pak J Med Sci 2014;30:1425-7.  Back to cited text no. 4
Preston NL, Halaharvi C, Logan DB. Severe ingrown toenail with hypertrophic skin bridging: A case report and review of the literature. Proc Singapore Healthc 2018;27:214-7.  Back to cited text no. 5
Aydin N, Kocaoğlu B, Esemenli T. Partial removal of nail matrix in the treatment of ingrowing toe nail. Acta Orthop Traumatol Turc 2008;42:174-7.  Back to cited text no. 6


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]


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