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- Presentation
Pearls for Nail Surgery: Preparation, Biopsy Techniques, and Hemostasis
Description
The speaker shares practical pearls for nail surgery, emphasizing thorough preparation, understanding lesion location, and anticipating complications such as anticoagulant use or other underlying conditions. Key points include gathering the right instruments, especially nail elevators and clippers, and using radiographs when needed. For biopsy planning, the speaker explains how lesion position helps determine whether it is in the distal matrix, proximal matrix, or nail bed, and stresses marking subtle pigment lesions like melanonychia before nail plate removal. Surgical exposure is improved by soaking the nail unit to soften the plate, using vertical pressure with a nail elevator to avoid damaging the nail bed, and employing a “submarine hatch” technique to lift part of the nail plate for biopsy and then reattach it with liquid glue or Dermabond for better cosmetic and functional recovery. Hemostasis is highlighted throughout, with practical options such as glove tourniquets and careful control before closure. Additional tips include using an 18- or 16-gauge needle to decompress subungual hematomas, draining or excising mucous cysts when appropriate, using intraoperative dermoscopy to better localize melanonychia, and the “pillow technique” of injecting saline or anesthetic into the matrix to facilitate tangential shave biopsy. The overall take-home message is to be prepared, locate and mark lesions carefully, maintain hemostasis, and use thoughtful techniques to minimize morbidity.
View moreConclusions
- Successful nail surgery depends mainly on careful preoperative planning, proper equipment, and anticipating anatomic and patient-specific challenges before starting the procedure.
- The exact lesion location within the nail unit must be identified and marked before any nail plate removal because pigmentation or the target can be lost once the nail is altered.
- Soaking the nail unit and using appropriate anesthesia, antisepsis, and hemostasis can make nail procedures easier and less traumatic.
- Different biopsy approaches should be matched to lesion location, with nail bed biopsy generally causing the least morbidity and matrix biopsies requiring more precision.
- Using vertical pressure with nail elevators and working deliberately under the nail plate helps reduce trauma to the nail bed and improves visualization.
- Simple bedside techniques such as needle decompression can effectively relieve subungual hematomas and drainage can also be used for myxoid cysts.
- The submarine hatch method and careful replacement of the nail plate with liquid glue can preserve the nail appearance while still allowing tissue diagnosis.
- Intraoperative dermoscopy and tissue injection techniques such as the pillow method can improve lesion localization and make tangential shave biopsies more accurate.
- The overall message is that nail surgery is safest and most effective when the surgeon is prepared, localizes the lesion precisely, controls bleeding well, and uses technique-specific tools and methods.
- Zaiac, Martin N., M.D., FAAD. "My Nail Surgical Pearls." American Academy of Dermatology Association / AAD Annual Meeting, March 27–31, 2026, Denver, Colorado.
- "Up to Date Treatment of Scalp, Hair and Nail Disorders," S-047, AAD Annual Meeting, March 27–31, 2026, Denver, Colorado.