How To Attain The Best Results With The Phenol And Alcohol Onychoplasty

Patrick DeHeer DPM FACFAS

While the phenol and alcohol onychoplasty is the most commonly performed procedure by podiatric physicians, it is also the one that is least written about. This is possibly because it is a relatively simple procedure that even the least surgically inclined podiatrist is comfortable performing.

I have discovered three important tips for the partial phenol and alcohol procedure that have made a good procedure even better. For a video of my approach with this procedure, check out the following link ( http://bit.ly/aOpe47 ) at the PodiatryLIVE™ website.

Using the Tourni-Cot™ digital tourniquet (Mar-Med) is my first recommendation. This digital tourniquet is certainly more expensive than a Penrose drain digital tourniquet but the benefits surely justify the expense. There are multiple sizes to fit various sized toes. When applying the tourniquet, one exsanguinates the toe. This tourniquet also provides a complete bloodless field. I am of the opinion that blood in the field neutralizes the phenol and makes this procedure less effective. The Tourni-Cot completely eliminates this problem.

The second tip I would like to recommend is to use a hemostat to roll out the nail border and then cut it with an English anvil. I think this is much better than using a Beaver blade, which tends to lacerate the nail bed no matter how careful you are in your approach. I also think an English anvil can make it difficult to cut the nail plate all the way to the proximal aspect and/or damage the proximal nail fold. By rolling the nail plate out, it is very easy to make sure you have cut the nail plate all the way back to the proximal aspect and made a straight cut. This also does not elevate the nail plate as much off the nail bed.

The third tip I would like to recommend is the use of AmeriGel® Wound Dressing (Amerx Health Care) postoperatively. AmeriGel is a hydrogel that has substantially improved the postoperative course for my patients. I have the patient remove the original dressing the next day and then apply AmeriGel and a Band Aid with a piece of gauze. Patients change the dressing twice a day. After a week, I have the patient use AmeriGel and a Band-Aid during the day, then clean the area with warm soapy water in the evening and leave the toe open with no AmeriGel or Band-Aid. This continues for two more weeks. After this, I have the patient discontinue all home care. I see less erythema and drainage with this approach, and usually quicker healing.

I have come to the conclusion that some people are more sensitive to phenol than others. This is why some patients blister and have more tissue destruction in comparison to other patients undergoing the same application process.

Furthermore, I do not like to do both borders at the same time. Often this leads to the central nail plate coming off during the postoperative period. Most of the time, it grows back without complication. However, sometimes it grows back incurvated into the distal tip of the toe or does not grow back at all.

The partial phenol and alcohol procedure is a very good procedure. These tips I have provided have given me more consistent results for my patients and I hope they are of benefit to you and your patients.

Comments

I don't understand why you need a beaver blade and/or an English anvil. I agree you need to cut all the back to the proximal aspect of the toe nail. You can do this with a five-inch bone cutter. Loosen up the nail around the skin. Cut all the back to the bone and then use an elevator to remove the piece. The key is to use a bone currette to make sure you scrap the area to the periosteal area. Just my opinion. Everyone has a different way to skin the cat.

I read with interest the second suggestion, namely to use a hemostat to roll out the nail border. At first, I thought this would be an improvement but I started to think that the pressure on the nail plate by the 'stat would be transmitted proximally and possibly disrupt that portion of the nail at its interface w/ the matrix cells. The result could be a thickened, dystrophic nail due to this added trauma.

Have you noticed this effect in practice?

Also, how do you introduce the 'stat underneath the nail plate ... by blunt pressure? If so, wouldn't this practice also traumatize the nail bed? I agree there is no atraumatic way to separate the nail from the nail bed and your method seems preferable to using a Beaver blade.

I read with interest your tips and thank you for sharing them. I do not feel it necessary to roll out the nail border. I too feel the 6100 beaver causes too much injury. However, I was having a problem with the English anvil causing the remaining nail plate to separate or lift from the bed, especially proximally at the matrix. This was resulting in phenol contacting unintended nailbed and matrix.

Now I use the anvil to cut the distal portion of nail plate, stopping just before the matrix. Here the nail plate in much softer and I carefully use the Beaver blade to incise the remainder with little or no matrix injury.

Rather than use an English anvil, I sometimes use a straight narrow diamond burr to cut the nail plate and then cut back to the matrix with a beaver blade. If you are careful with the beaver blade and keep the nail plate cool, there is minimal trauma to the nail bed.

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