Surgical Pearl: Hemostat-assisted nail avulsion revisited

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From the Department of Dermatology, University of Alabama at Birmingham. Reprints not available from authors. J Am Acad Dermatol 2001;45:943-4. Copyright © 2001 by the American Academy of Dermatology, Inc. 0190-9622/2001/$35.00 + 0 16/74/118544 doi:10.1067/mjd.2001.118544 N ail plate avulsion is performed to facilitate nail bed or matrix biopsy (or both), to treat onychocryptosis and pincer nail deformity, or to debulk onychomycotic nails. Through the years, nail surgeons have proposed several different techniques and instruments for use in this endeavor. In the 1970s, textbooks described nail avulsion with the straight hemostat.1,2 Later, other instruments were introduced, such as the Freer elevator and several combination instruments that were created specifically for nail avulsion.3,4 These instruments have their advantages, but we propose that the hemostat is still a reliable, inexpensive instrument to be used alone for partial and complete nail avulsion. To use an elevator or spatula in nail avulsion, it is passed between the nail plate and nail bed and with repeated side-to-side strokes or by entry, removal, and reentry, the nail plate is detached. Then, the nail plate is grasped with hemostats and rolled laterally to remove. With this method, often the nail plate must be rigorously rocked back and forth to break attachments between the nail plate and the proximal and lateral nailfolds. In partial nail avulsion, longitudinal strips of the nail plate are removed in a similar fashion after the selected section has been detached and split from the remaining nail plate. Although elevator/spatula type instruments have been used successfully, these instruments have some drawbacks. Because of its thickness, the Freer elevator can potentially damage or traumatize the nail bed and matrix when inserted between the nail plate and nail bed, leading to postoperative pain, scarring, and onychodystrophy. In addition, the thickness and curvature of the instrument may work satisfactorily for larger nails that have a curvature similar to the instrument; however, as the nail size decreases, the thickness and curvature of the instrument may become excessive. If the sharp edge of the Freer elevator is used, unwanted laceration of nail bed tissue or matrix may occur. Finally, the hemostat is usually needed in addition to these instruments to complete the job. We propose that the hemostat, as presented by the pioneers in nail avulsion, is the one instrument needed for this procedure. The hemostat is opened and one arm is grasped in the palm. With the serrated surface against the dorsal nail plate, the tip of the hemostat is used to free the attachments of the nail plate and the proximal and lateral nailfolds (Fig 1). One jaw is then inserted, serrated side against the ventral nail plate, between the nail plate and the nail bed at the midpoint of the nail (Fig 2). The hemostat jaw is advanced proximally, removed, and reinserted until the desired amount of separation is obtained, whether partial or complete. The other jaw of the PEARLS