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Non Surgical ingrown toenail removal

Discussion in 'General Issues and Discussion Forum' started by hill, Oct 12, 2018.

  1. hill

    hill Active Member

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    Hi. I would like to present a video that I made on the topic of non surgical ingrown toenail removal. Being one of very few podiatrists in Israel, and one of the few of us that deal with ingrown toenails to such a large degree, I have a unfortunately seen a lot of mismanaged ingrown toenails. Even a lot of my patients who have been to other podiatrists internationally, it seems that there is a lack of willingness or perhaps ability to deal with ingrown toenails more moderately than nail surgery and more thoroughly than mere removal of a small nail spike. Very often I feel that the practitioner goes straight for nail surgery with phenolisation, when a more moderate approach is available. For example, when dealing with someone who is suffering for the first time with an ingrown toenail, there is not necessarily a need to jump into nail surgery ( unless of course there is clearly a nail structure deformity that would make it clear that it’s going to recur). But on the other hand one wants to remove enough of a section to ensure as much as possible that the patient has piece and quite for as long as possible. Also, we all know the patient that comes into us and their first words are “ I hate needles “. Very often patients tell me that the treatment that I did on them hurt even less than the local anesthetic injection that they had previously at another podiatrist.
    I also think that this video can be good for junior podiatrists starting out, who still need to develop their technique.

    There is an introduction of about 7 minutes and then my demonstration starts at minute 7:15 about.
  2. Dieter Fellner

    Dieter Fellner Well-Known Member

    Nicely done my friend, but really this is Podiatry 101. In my 30 experience, once a patient develops the clinical features of IGTN, the problem almost always recurs. The nonoperative form of management still has a role and when there is a first occurrence it is a reasonable approach, for some patients. I will always advise a patient there is a risk of recurrence and when it does, the next step is a procedure. For as many 'poor' results as you claim to have seen, I can assure you, there are very many excellent results and satisfied patients.

    As an aside, partial nail ablation with phenolisation is not the only option. There are several choices.
  3. hill

    hill Active Member

    I totally agree that when it’s not the first time then totally think about surgical removal, and believe me I do plenty of nail surgery, with excellent results. However, I have seen many many many patients who for whatever reason have it for the first time (without a clearly obvious structural nail problem that would indicate that it would return) and all they have needed is a more thorough first time treatment and it does not return. I have also seen many patients who have undergone full nail surgery for something that most probably could have been treated more conservatively. I.e, more thoroughly than just a small nail spike removal but not as drastic as full nail surgery.
  4. hill

    hill Active Member

    I posted a video only of my performance of the above treatment because I think it has something to add and that people can perhaps think about what I was saying. I have nothing to add however by posting a video of me performing full nail surgery because I don’t really have anything to add over what every podiatrist hopefully knows very well how to perform. However, I feel that there is a need for podiatrists to consider sometimes a more conservative approach than full nail surgery but more thorough than just a simple nail spike removal. I had a patient come to me here and told me that she went to another podiatrist who told her to go to a pedicurist for the nail spike removal because he will only do full nail surgery and if it’s not called for then he sends to a pedicurist. I think that’s wrong and that’s why I think podiatrists should also consider other options when surgery is not called for right away.
  5. hill

    hill Active Member

    And yes, I am well aware of the fact that there are other procedures for nail surgery, however I think it’s safe to say that chemical ablation, usually with phenol, is the most common, so that’s why I mentioned it.
  6. Anthony Caruso

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  7. Dieter Fellner

    Dieter Fellner Well-Known Member

    ok, I want to know - what is it, you think you have (that hasn't been done before)
  8. Dieter Fellner

    Dieter Fellner Well-Known Member

    Don't panic now,lol. I commented only because your 'technique' is the very most basic of how to manage the IGTN. I am pretty sure any well trained Podiatrist is aware.
  9. hill

    hill Active Member

    The question is how many podiatrists do that basic treatment shown above without the use of local anaesthetic and without pain whatsoever. Many patients come to me after being at other podiatrists who some version of the above but with a painful ( subjective to the patient) local anaesthetic injection or without local anaesthetic but with a lot of pain inflicted. The question is patient comfort and pain threshold of the patient. In my video the patient has not had any local anaesthetic and does not have any pain. That is the question. And also, we all know patient who need nail surgery but refuse.
  10. hill

    hill Active Member

    I think that what is important and often lacking is the need to put ourselves in the patient’s situation. Very often the patient is scared ,is afraid of needles and pain, and no matter how hard we try to convince them, refuse nail surgery. If we are able to do a thorough removal of the ingrown toenail section, without the use of local anesthetic and without any pain inflicted, then the patient feels much better. And unfortunately I have seen plenty of patients who come to me after being at other podiatrists where that is not the case. So yes, the above treatment is “ podiatry 101” as you say, but the trick is doing it without analgesia of any kind and without pain inflicted at all. As a patient once said to me after my performance of the above treatment, a sensitive patient who had been to many other podiatrists in the past, and who was reluctant to do nail surgery, he said “that is the first time that I have been to someone who did the treatment on me as if he was doing it to himself “. That is the challenge that we as podiatrists face.
  11. FootDaddy

    FootDaddy Welcome New Poster

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  12. Dieter Fellner

    Dieter Fellner Well-Known Member

    I agree, with some of your points. The technique you demonstrate in your video is well performed. It is also the technique I was taught as a student in 1987. I would assume the technique is still taught now - perhaps not. I will add, also, that an IGTN will often come back when this slant back type of resection is performed. Once a nail takes the trajectory to produce IGTN, it will frequently continue to do so. The PNA/chemical cauterization is the definitive solution in 94% of cases.

    I cannot agree that 'very often' a patient refuses a nail procedure. Sure, they don't love the LA (who loves needles!) but with a little TLC, reassurance and a DermaJet, the anesthetizing process is never as traumatic as they imagine it to be. There will always be a place for the conservative alternative option, but in my patient population this will be a minority of patients. In fact many come to the office requesting the definitive treatment. And, for sure, there is place for both procedures.

    Do you offer LA/PNA?
  13. Dieter Fellner

    Dieter Fellner Well-Known Member

    Can you please take your perverted ideas and practices elsewhere! This is a professional forum.
  14. hill

    hill Active Member

  15. hill

    hill Active Member

    I average about 120 patients a week and a large majority of those are ingrown toenails.
  16. david meilak

    david meilak Member

    The procedure you carry out is exactly what I do. My suggestion, although you may have already tried it out is to use a straight pointed (11cm) nipper instead of a curved bulky type ( my opinion as this is due to how you feel with different instruments)which I find so easy to get under the side of the nails in cases such as yours.
    I find it very easy to also clean out the sulcus from the offending nail using a round nail drill bit ( medium size), where I manage to clear out from the distal point to the proximal sulcus. I have patients who prefer to come monthly for this instead of nail surgery. The drill I use is a wet drill. cheers.

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