What I do on 99% of nail matrix proc, esp recur ones... my main assist and I bust these out in about 15min usually (maybe 25min if bilat bi-border)
- double or triple skin prep, cryo spray and 4-5cc lico most adults (don't try to be a hero and do 2-3cc block... wastes time, causes pain very often), inform them they may get a bruise at inject site and no problem
- digit band (arm IV tourniquet 15cents cut in half, twist hemostat... so phenol's not diluted, aids visualization) on 90% of ppl with good bloodflow (don't do matrix at all if any question of PAD, do avulsion +/- abx on PAD pts)
- After edge avulsion, use the 6200 sterile blade tip to cut the matrix tissue in a square pattern, pull it out with hemostat (basically do a surgical matrix AND then chemical)
- Phenol single use vials (fresher chemical, doesn't vapor up the room, no chance of big problem if bottle dropped)
- MICRO tip cotton applicators (this is a must, regular cotton tips a hospital or MSG office are terrible)
- Approx 3x30sec for most matrix, maybe 4 or 5 for a revision that regrew ... alc rinse 4-6 times over (rinse is quantity of them, not volume... chem class), rinse with the 1cc lido left in the syringe, very light small compress dsg2" kling stretch around ankle 4x4 soft at proc site and 1" coban over that fits into their shoe.
- Post procedure care bag with alc pads and fabric band aids and print instructions (costs me well less then $1, save them trip to drug store)
I tell them to just supply the OTC acet or nsaid, use it when they get home (before lido wears off) and then as needed (usually 2-5d).
Instruction is to leave my small roll bandage for about 2 days, then alc and band aid
at least daily, showers but
NO soaking or swimming. Alc and air it out whenever sitting with no pets around. Abx oint only if looking very dry.
The soaking is for imbeciles. There is absolutely no evidence for it. It makes no sense. It is something PCPs and midlevels and dumb pods advise it, and I have
no idea why. It's taught that way in our schools and residencies, it's on the internet, and it shouldn't be. Tap water's not sterile. Wounds do better neutral/dry than macerated... and matrix is inherently a draining wound. We all know that 95% of the nail procedures that get infected got macerated.
These do
much better drying out sooner and making escar... I encourage airing out whenever possible after the first couple days. It's better to do no soaking (showers ok, then alc cleanse and band aid if they are going to wear shoes). At the 2-3wk follow up (defintely 10+ days
🙂 ), i usually just do a look, sometimes a curette debridement, betadine it if they're not allergic to really dry it, allow return to soaks/swim then or soon after, another alc + band aid bag if they need it, rare PO abx and very rare I&D small abscess (they'd 90% call office sooner).
....so yeah, I basically do matrix normally, with 3 things most pods do not:
- Add the surgical matrix part... whatever we can do to lower recurrence (we are the specialist... PCP/Peds who referred wants results, people pay money, time off work to get these done - assuming typical PP patients).
- Single use phenol vials... expensive, sure, but many advantages, better results (again... we're specialist, $3 is nothing for $200+ proc, ppl spend time and money and want best outcomes). I'm not saying that PP pts are better than govt VA or MCA or etc patients getting "free" visits with little choice of doc/facility. They all deserve good care and results, but there is 100% an expectations difference. Private pts have choices. PCPs sending their private pts have choices. Give the best outcomes (if you have any control of your supplies).
- No soaking... common sense to me, but to each their own. Bags with alc and band aids (again, make it easy, encourage compliance, and good doc/pt relation move). Even if you can't control supplies, you can definitely control the post procedure instructions.
I tell people the success is 85-90% for each nail edge treated if not infected at the time - maybe 50/50 if highly cellulitic or abscessed. I am
amaaaaaazed how many recurs there are from other docs... no just spicules, total regrowth despite patient saying the used phenol. I don't know if it's old phenol, bad technique, it was highly cellulitic to begin with? There is even gangrene occasionally from doing these on PVD patients; I've seen it and it's very sad convo with patients. I have rare recurs of my own, and I might re-do those without charging if the pt clearly followed direction (will just charge e/m, not proc).
This is fairly easy procedure is not easy... hence tons of PCPs and UCare and midlevels and even pods messing them up. Still, we do these basically every day (sometimes many times in a day!), and
we should be awesome and fast at them. That's what works for me.
