Obtain surgical consent after explaining to the patient the risks, benefits, and alternatives. Place the patient in a supine or seated position with the affected toe (Figure 4) and foot hanging off the end of the table.

Prepare the affected toe with standard povidone iodine solution. Use lidocaine (Xylocaine) or bupivacaine (Marcaine) without epinephrine for local anesthesia in a digital block fashion.

Use a tourniquet or rubber band around the toe to assist in hemostasis for only a short duration; use with caution in patients with known peripheral vascular disease or diabetes (Figure 5).

Identify the lateral 20 to 25 percent of the ingrown nail as the site of the partial lateral nail avulsion. Use a nail elevator under the nail to separate it from the nail bed (Figure 6).

Use a nail splitter to cut from the distal end of the toenail straight back toward the cuticle beneath the nail fold (Figure 7).

Grasp the avulsed lateral nail fragment with a hemostat down to just past the cuticle. Remove it by twisting the avulsed nail outward toward the lateral nail fold while pulling in a straight direction toward the end of the toe. Ensure that the entire nail fragment and flat edge of the nail bed is retrieved to prevent formation of a nail spicule and the potential for recurrence of an ingrown nail.

Release the tourniquet after adequate hemostasis is achieved. Options for destruction of the nail-forming matrix beneath where the nail plate was removed include phenolization or mechanical destruction of the nail matrix. For phenolization, apply an 80 to 88% phenol solution directly to the nail matrix three times for 30 seconds each round (Figure 8). Then, thoroughly cleanse with 70% isopropyl alcohol to neutralize the phenol. Apply phenol only to the matrix and not the nail bed or surrounding tissue, which may delay wound healing. Phenol should not be used if the patient, physician, or medical assistants may be pregnant. Options for destruction of the nail matrix, as well as for removal of any adjacent granulation tissue, include electrocautery, radiofrequency, and carbon dioxide laser ablation.

After surgery, apply a dressing of antibiotic ointment (e.g., bacitracin/polymyxin [Polysporin]), 4 X 4 gauze, tube gauze, and paper tape, ensuring a comfortable bandage (variations on materials are acceptable; these recommendations are expert opinion).

After 24 to 48 hours, soak the affected toe in warm, soapy water and reapply antibiotic ointment and a clean bandage. This should be done three to four times daily for one to two weeks after the procedure.