Surgical toenail removal procedure is simple for villains in fact or fiction, whether it’s older men or younger victims being tortured for information or simply for the fun of it. A good pair of pliers, pleasure at hearing screams, and the deed is done.
In the podiatrist’s office, it’s a little more civilized than that. As they age, many men (and some women) find their great toes in pain from ingrown nails that get way too aggressive, the wide base corners getting wider and more curved, slicing down into and around the toes. Doctors specializing in foot care see a lot of these cases and have developed detailed procedures for dealing with the problem efficiently.
Please note that I did not say painlessly. Not quite. But they’ve become very good at what they do.
WARNING: If you can’t stand the sight of blood, even dried blood, you might want to stop reading this article here and now.
A TALE OF TWO TOES
July 1992, Custer, South Dakota. At forty-eight years of age, my big toes are developing classic toenail overgrowth problems. When those ingrown curved-knife corners start taking over more flesh territory that they deserve, the result is an unpleasant ache in the affected regions. If left unattended, the situation can get a lot worse than that. Inflammation, pain, infection, all the good stuff.
My then-wife (#6) says, “Why not go see Dr. C., the podiatrist in Rapid City?” And so I do. In the waiting area at his office, a sign hangs on the wall:
A PODIATRIST IS
A FOOT DOCTOR
WHO FAILED KNEES
This doctor has a sense of humor.
Which is a good thing; it takes a sense of humor for a medical practitioner to survive unscathed when dealing with me. Overall, I’m not terribly trusting when it comes to the AMA, though I do appreciate a good cutter when I need one.
Dr. C. is both personable and professional. He numbs my big toes a bit, then slices the sides of the nails away, removing the aggressive corner roots. For now. “I’ll see you in a year or two,” he tells me.
“No, you won’t,” I reply. “You don’t know me.”
For the next twenty-six years, I entirely remove my own toenails whenever they become too achy. And I learn a lot. For example:
1. When a podiatrist removes a nail entirely and doesn’t want it to grow back, a chemical (phenol) is applied to destroy the nail bed matrix. I have no phenol, so the nails keep growing back.
2. However, they grow back a little smaller each time. Over the decades, they get the idea I don’t like them very much. It affects their attitude.
3. I develop my own procedure, or set of procedures:
A. If the nail isn’t really ready to leave, lifting the corner (or both corners) sometimes gives relief to the toe for another day, week, or even a month at a time.
B. If it’s time for the nail to get outa Dodge, I use a pointy but dull folding knife to lift one corner, then grab the corner of the nail with a small pair of needle nose pliers and roll the pliers, slowly r-r-ripping the nail out from side to side, removing the entire nail in one clean sweep.
C. A paper towel is placed under the area to catch blood until I can hit the bloody toe with spray antibiotic and apply a giant Band Aid.
4. By the time a nail is ready to be removed, a second nail is already growing up under the older nail. Spooky.
5. Removing a nail this way usually has to be done only once every 6 months to 1 year.
Eventually, however, we arrive at a turning point.
Early June 2018, Deer Lodge, Montana. I’d removed the left big toenail weeks earlier…but not entirely. Offended at all the abuse I’d dished out over the years, this time the nail was not a complete nail. There was a rounded, pearly look to a corner piece on the left side. That came out into the standard needle nosed plier roll just fine, but across the center of the toe there was no hardened nail at all. Just a thin, fabric-like skein of flexible keratin, like a blanket of tough gauze. And it was separated entirely from the right side corner piece, which did not have enough surface showing to allow the pliers a decent grip.
Well, foo. Time to go see a podiatrist for the second time in my life. I’m only seventy-four years of age now; this is ridiculous.
Dr. Brian Komm in Butte, Montana, looked like a good bet. After a bit of Internet research, my gut said, “This is the guy.” And he was. Personable, professional, in practice for the past nineteen years. Soft spoken, too; the next time I go see him, I’ll wear my hearing aid so he doesn’t occasionally have to repeat himself.
After giving the toe–in fact, both feet entirely–a thorough inspection, Dr. Komm recommended removal of the entire new toenail (such as it was) so that I’d never again have to deal with the problem, at least on that foot. I’d been hoping for that, so that’s what he did.
NOTE: Before writing this post, I took a look at some of the other toenail discussions online and was deeply impressed with how well I’d done by removing my own nails for twenty-six years before a podiatrist did the permanent removal. Some people end up with multiple stitches, which were not needed today because the practitioner didn’t have to make any incisions whatsoever. The nail was ready to say, “Okay, you got me; I quit.” But I’m not suggesting you do what I did. It just worked out for me.
Here’s the way today’s procedure went:
1. The doctor produced an extremely slender syringe with a needle that was Nightmare on Elm Street scary: Almost as thin as an acupuncture needle–if the acupuncture needle was on steroids–and several inches long. Flexible, too, as I could see when he started sticking it into my toe (no, not all the way), shifting it to different angles and pumping anesthetic into different parts of the toe. He pierced the inboard side first (sting-sting-but-not-bad), then the outboard side (sting-YOWCH! HIT A GREAT LITTLE NERVE THERE!). But I was ready. Had my fists gripping my belt as I sat in the exam room operating chair with legs extended. I jerked at that worst one, but only my upper body; no way was I going to wiggle a toe while a skinny spear was stuck in it.
2. The toe numbed up at warp speed. Dr. Komm next wrapped a rubbery length of material around and around the toe, starting at the tip and working back to the base. Then he rolled it down over itself, away from the tip, producing a tourniquet at the base of the toe that shut off the blood supply entirely. White toe! He clamped that off and was ready to get down to the nitty gritty.
3. I’d thought he’d need to make a small incision to remove the offending corner nail piece, but no. This guy is good; using nothing but what looked like a top of the line toenail grabber, he had the chunk out of there in less than a minute, with no tearing.
4. Next, he removed the new nail that was trying to grow in.
5. Now the phenol, the nail matrix killing chemical agent, applied thoroughly yet carefully with a tiny brush.
6. Taking his time, he did quite a bit of probing down in under the surrounding nail flap (surface flesh and skin) with some sort of slender pick-looking instrument, presumably to make sure he’d done everything possible to assure the nail would not grow back.
7. Gauze pad applied–probably with antibiotic, though I didn’t ask.
8. Stretchy self-stick wrap around the entire toe, and…done!
Um…not completely. I have to return in a couple of weeks so he can “debride the nail bed.” In other words, scrape/cut loose the dead stuff so the healing can continue in the preferred fashion. And there will be more such sessions. “It’ll take a long time to heal completely,” he pointed out. As in months, possibly. Plus, there are aftercare instructions I need to follow. Wait 24 hours, then remove the bandage and soak the toe (twice a day) in warm, soapy water. Followed by applying polysporin and re-wrapping with a Band Aid.
Okay. That’s doable. After returning home and making a couple of necessary phone calls, I decided to celebrate with a nap. Didn’t undress, though, just flopped flat and snoozed for a couple of hours, clothes on. When I got back up, it was time to shuck the shoes and don flip-flops for the rest of the evening.
Oops. With the shoe off, it was obvious the toe had bled through the wrapping and quite thoroughly soaked a portion of the sock. Sock off, cold water rinse to remove the blood, hang the sock to dry. Pain, you ask? Not bad, just a mild ache. Nothing I haven’t known from my own DYI procedures. Certainly not enough to take the extra strength Tylenol (acetaminophen) recommended on the aftercare instruction sheet.
This post won’t be published until the toe is completely healed, but writing stuff down before I forget it seems like a good idea. So far, nearly 1,500 words of good idea.
June 22, 2018, one day post surgery. Twenty-four hours have passed since I left the doctor’s office. Time to remove the toe bandage, soak the toe in warm soapy water for fifteen minutes, apply some polysporin, and finish off with a Band Aid.
The moment it is free from the binding wrap, the toe becomes absolutely comfortable. I follow the doctor’s instructions. There’s a bit of sting when the toe is first submerged in the warm water, but it settles down after a bit.Wrap off, 1 day post surgery.
July 1, 2018, ten days post surgery. The toe is much less sensitive now. I no longer have to do my military pushups “one footed.” The recommended twice daily toe soak has become treasured time, providing me a great excuse to do nothing but relax. I now start the soapy water out on the hot side of warm; the toe doesn’t react much to the heat any more and I get to soak longer before the water gets cold. In truth, the soaking has become a bit of an addiction. I never soak the toe for “just” fifteen minutes and in one instance fell asleep in my chair for an hour and a half before realizing I needed to dry the foot off and dump the water.
There is still a fair bit of inflammation. It’s unpredictable, flaring or receding but never entirely disappearing. When it’s the worst, the benefit of the soak is most noticeable; soaking reduces the inflammation every time. One curious development: The nail bed “opening” seems to be changing shape and size, not shrinking but growing back a bit toward “normal original” size and shape. It’ll be interesting to see how far that goes. Also interesting is the fact that the long left-forward crease has disappeared; I did not see that one coming.
July 10, 2018. It’s now 19 days post surgery. Quite a bit has happened since the last update. Nothing bad, but at day 14, I decided the Band Aid had to go. The seam under my toe was just too irritating for words; walking on that for another five days before seeing Dr. Komm again could (IMO) cause long term damage. The soaking continued, however; that helps a lot. Other than that, I’ve just been spraying the toe “at need” with Dermoplast first aid spray, which is both pain relieving and antibacterial. Polysporin was out at this point since it required a Band Aid cover to keep from doing more to the sock than to the toe. When it has gone too long between soaks–which are done “whenever,” though still twice a day–the skin around the nail bed “pinches in,” gets tight, and starts to wrinkle from the effort. Soaking relaxes that wrinkle-pinching completely.
In order not to unnecessarily irritate the good doctor, I did soak the toe this morning, applying Polysporin and a Band Aid before driving to Butte for my first post surgery appointment. If he’d asked whether or not I’d followed his orders, I would have told him honestly what had (and had not) been done, but he gave no sign of doubt. That told me the toe was still healing at an expected rate, or at least close enough for company work.
Dr. Brian Komm deserves a few extra kudos here: He has an extremely talented, sensitive touch when dealing with a human body. He used a little pair of curved, sharp surgical pliers (cutters) to remove (debride) the unnecessary material from the toe bed, yet hardly caused me to flinch at all. I was impressed and told him so. He seemed to appreciate that.
His new instructions were to start using a tiny gauze pad, soaking it with saline solution (which he prescribed) and covering it with a Band Aid. Again with the Band Aid, right? This procedure “will speed healing,” he informed me. “The good news is,” he added with a smile, “you no longer need to soak.”
It all made sense…and I knew I was going to avoid following his instructions yet again. By the time I’d reached the Walmart parking lot, about half an hour after leaving his office, the toe was aching again. So, off came the Band Aid and gauze pad–which would be ideal, but (IMO) better to heal more slowly in comfort than to heal more quickly in pain. A quick spray of the toe with Dermoplast, and off I went to do my shopping, the toe so comfortable that I mostly forgot all about it for the next couple of hours.
Unfortunately, I didn’t think to take a photo of the toe as it looked right after the doctor had done his part. It looked really good, at least to my layman’s eye. By midnight, things were getting a little hinky again; the nail bed was aching some (mildly, not debilitating), inflammation was up, and the pinch-wrinkling of the surrounding skin was once again making itself known.
Side note: There’s still a slight “numbness” feeling when the big toe brushes against its neighbor. Nothing worth mentioning to the podiatrist. There isn’t anything he can do about it. But it does motivate me to postpone surgery on the right foot for a while yet. At minimum, I’d like to have the left foot completely healed before tackling the right foot. Dr. Komm tells me the healing usually takes “from six to eight weeks.” We’re now two weeks and five days into the process.
Would the recommended saline/gauze pad with Band Aid cover have prevented this film from forming, and is that part of how it would speed healing? I suspect the answer is yes and that the toe really would heal faster if I did what I was told. Sadly, I’ve never been very good at that….
Side note: At the inception of my first visit to Dr. Komm, the front desk lady (also a nurse?)–Carolyn–took my vitals. My blood pressure measured 139 / 79, which I stated was, “…about right in a new situation.” (Meaning, I was mildly anxious about asking a total stranger to carve up my foot with a sharp steel blade.) Today, on my second visit and with no surgery anticipated, the BP measurement was downright astounding: 117 / 52. “Sixty-two?” I asked. I’d heard her right but simply couldn’t believe it as low as fifty-two, having never before seen my blood pressure numbers look that good. Must be doing something right.
July 11, 2018. The toe started aching enough to convince me to try following the doctor recommended protocol after all. Will wonders never cease. It (the toe) doesn’t much care for open air, at least not long term. There is immediate relief when the saline-soaked gauze pad is applied. I’m not as skilled as Dr. Komm when it comes to trimming a pad to precisely fit the nail bed, though, so my pads tend to cover a bit of the surrounding tissue as well. Which is not a bad thing; there’s no more wrinkling. The left-forward crease is again visible, but not nearly as dramatic as it was in the beginning.
July 13, 2018. Continuing the saline/gauze protocol. Tip portion of the nail bed is now covered with a whitish substance that makes me think of condensed spider webbing. Which makes no sense, since spider webs are not white, but there it is.
July 18, 2018. Four weeks post surgery, the toe still sting-burns at times, but the (mild) pain is more localized as the nail bed continues to heal. The open wound area continues to diminish. Dr. Komm’s statement that it would take six to eight weeks to heal is looking pretty accurate. The “white cover” of the forward portion of the nail bed is no longer evident. Since surgery, the toe’s appearance has varied as much as the weather.
Bonus observation: The feeling of numbness when one toe rubbed against another is gone. It took nearly a month after surgery for that to work out. Strangely, as the healing progresses, discomfort has become entirely unpredictable. Yesterday, for example, the stinging sensation was so strong that I found myself limping as I moved back and forth between house and garage while working on a window frame remodeling project. Yet today, continuing the same project, comfort was so complete that I forgot all about the toe for hours on end. If there have been too many hours between saline-soaked gauze changes, the stinging is more likely–but nothing is guaranteed.
July 23, 2018. I see Dr. Komm tomorrow. He’ll check the healing toe. I’ve decided that if he has the time, I’ll also ask him to go ahead and remove the other (right) big toenail. Which means, lucky reader, that you get to see a Before picture after all.
Huh. The two toenail areas look a lot alike at this point, don’t they? Despite the fact that one still has a toenail in it and one does not. (Cue audio track: “Doo-doo-doo-doo, doo-doo-doo-doo….) [Theme from The Twilight Zone.] Maybe I’d better take a side-by-side photo. Wouldn’t want y’all think it was all one toe and a trick mirror or something….
July 24, 2018. I am free! I am free! I am free! Free of the pair of great toenails that required my occasional, ripping attention for the past twenty-six years. At my request, Dr. Komm removed the right side big toenail this afternoon. Braced for possibly greater wound damage and pain, I was pleasantly surprised. All that was left for him to remove was a nice, solid, side-to-side nail that looked to be no more than one eighth of an inch long. Three sixteenths at the most.
“Is that all there was?” I couldn’t contain my surprise.
“Yes,” he replied, smiling.
Amazing. Nine hours later, there doesn’t even seem to be any blood seeping through the wrap he put on it after surgery. Nothing like the utterly soaked bandage on the left side a month ago. Just as amazing, the newly ripped right toe remains more comfortable than the still-healing left toe.
As the doctor was checking, debriding, and rewrapping the left toe (while anesthetic injected into the right toe was numbing things up before surgery), I’d asked, “Healing going according to plan?”
“Better than plan. It’s healing really fast.”
Well, hooray for that! “Maybe that’s how I was able to survive on the rodeo circuit for a while.”
Rodeo is an easy topic for us. Dr. Brian Komm’s father did some team roping, based out of Spokane, Washington. For that matter, my first job after college was in Spokane, and my last rodeo took place in a small town not far north of there.
When it comes to wrapping an open toe wound, there’s one difference in our techniques. He applies gauze (medicated at first, wetted with saline solution later) in precisely cut form, fitting it down inside the surrounding “walls” to cover only the as-yet-unhealed portion of the wound. It looks really neat when he does it and has worked with hundreds (if not thousands) of his patients over the past nineteen years. I would never presume to suggest to him that there might be a better way.
For myself, I prefer a much larger–and thicker–gauze pad. Using a 3″ x 3 1/2″ oblong snipped from an oversized sheet of gauze padding obtained at our local pharmacy, I fold the piece over and over until in the end it’s a tight pad of (get this) sixteen layers. Then saline solution is applied to the pad until it’s pretty well soaked, allowing the “puffy edges” to be pressed fairly flat. Next, the forward portion of the pad is trimmed in a more rounded shape. Pressing that lightly to the wound, it covers all of said wound plus a bit of surrounding skin on all sides. More saline solution is squirted on there until the pad is literally dripping wet. Only then is a Band Aid applied.
The benefits–in my mind, at least–of doing it this way are several:
1. It takes a lot longer for the pad to dry out completely. Since wetness soothes the wound, that seems like a good thing.
2. Surrounding skin doesn’t mind the saline solution, either. Inflammation is soothed a bit.
3. It would take me all day to accurately cut gauze to fit only the open wound area, anyway. The “bigger pad” method, on the other hand, fits my skill set.
Does this “big wet pad” protocol speed healing even more than usual? Maybe, maybe not, but I suspect it might be a factor. It’s certainly a factor when it comes to moment-to-moment comfort. That left toe was stinging noticeably by the time I got home from Butte today. After swapping out the smaller gauze pad for a larger, thicker, wetter pad, discomfort dropped noticeably.
August 21, 2018. Exactly two months after the left toenail was removed and four weeks following removal of the right toenail, things are looking good. The left nail bed has been fully healed for two weeks now. Yesterday, the right nail bed reached comfort status without any covering whatsoever. I’ll be seeing Dr. Komm tomorrow (routine follow-up) but decided to snap a picture tonight.
One thing seemed puzzling at first. The fully healed left side is covered with “something” that seems almost like a thin nail, hard and mostly smooth. Online research turned up the answer. The new skin turns hard like that. Apparently, lots of ladies paint this hardened skin and successfully keep all but the most observant foot fetish types from realizing the nails are gone. Impressive.
September 4, 2018. I have one more follow-up appointment with Dr. Komm tomorrow, though it’s certainly not needed. As far as I’m concerned, both toes are fully healed. It’s a waste, spending the money for this one final visit, but I’ll be there as a courtesy to the podiatrist.
The nail beds aren’t exactly “toe beautiful,” but they could be a lot worse. Comfort is excellent. Every once in a while, one or both toes will feel “tight” around the edges where surgery was performed, but the sensation never lasts long. Sting-stab discomfort is rare now, maybe once every few days, duration a matter of a minute or less. Overall, I couldn’t be happier with the results. It’s now common for me to forget about the toes entirely, except when it’s time to put on or take off socks.
Whether or not the bits of dried, crusty serum will disappear over time, I have no idea.
September 5, 2018. My final appointment with Dr. Komm wasn’t a waste after all. He spent some time scraping away unnecessary excess “junk” from both nail beds. The end result is more aesthetically pleasing to the naked eye, though for some reason that improved appearance doesn’t translate in a photograph. So, no photograph, just signing off and wishing y’all and your toes well.