Complications and Management in Nail Surgery

Conclusions

• Nail surgery complications are common in concept but largely resemble those seen in skin surgery, so the same basic surgical caution applies.
• Bleeding is a major immediate concern in nail surgery, but it can usually be controlled with bulky dressings, elevation, hemostatic materials, and proper tourniquet-related techniques without stopping coumarin therapy.
• Infection after nail surgery is rare despite heavy bacterial colonization of the nail unit, and prevention depends more on hygiene, patient home care, and selective antibiotic prophylaxis than on attempts at complete disinfection.
• Necrosis is unpredictable but is promoted by overly tight sutures, excess anesthetic volume, epinephrine use, smoking, and poor vascularity, so prevention and early specialist involvement are essential.
• Many nail-unit complications such as inclusion cysts, hypertrophic scars, and complex regional pain syndrome are uncommon or exceptional, but they should still be anticipated and explained to patients.
• Pain is amplified in the nail unit because of dense innervation and limited space for swelling, making careful dressings, limb elevation, and appropriate analgesia important.
• Postoperative dysesthesia is very frequent and usually self-limited over months, so patients should be reassured that sensory changes are often temporary.
• Lateral deviation, spicules, dystrophy, thinning, pterygium, distal embedding, and recurrence are largely consequences of incomplete or overly aggressive matrix surgery, especially when the lateral matrix horn is not fully addressed.
• The best way to reduce spicules and recurrence is complete excision of the relevant matrix tissue, with careful incision planning and avoidance of unnecessary pulling or partial removal.
• Matrix surgery carries the greatest risk of permanent nail dystrophy, whereas nail-bed surgery is generally safer for the nail plate appearance.
• Preserving or replacing the nail plate after avulsion helps prevent distal embedding and other secondary deformities.
• Patients should be counseled that most complications are manageable, but they need realistic expectations about temporary sensory changes and the possibility of lasting dystrophy after matrix procedures.