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Nail Matrix Biopsy

Last updated June 2, 2021

Written by: Lester Fahrner, MD

Reviewed by: Lester Fahrner, MD

Approved by: Krish Tangella MD, MBA, FCAP

Nail Matrix Biopsy is a procedure in which a surgical specimen(s) is taken from the region of the fingernail or toenail.

Background Information:

What are the other Names for the Procedure?

  • Excision of Nail Tumors (Growths)
  • Nail Bed Biopsy
  • Nail Bed Surgery

What is Nail Matrix Biopsy surgical procedure?

  • Nail Matrix Biopsy is a procedure in which a surgical specimen(s) is taken from the region of the fingernail or toenail. This is sometimes to determine if an abnormality is malignant or benign
  • Sometimes, the Nail Matrix Biopsy is done when the chance of a given growth is low, but the removal is for relief of symptoms such as pain
  • Most of the time, at least a partial removal of the nail plate is required as part of the procedure
  • The procedures performed are identical whether the surgical site is a fingernail or toenail

What part of the Body does the Procedure involve?

The Nail Matrix Biopsy procedure involves the tissues around or under the toenail or fingernail.

The nail plate, what is commonly referred to as “the nail”, is not a living tissue. Thus, there is no pain when it is clipped off at the end, just like hair

  • The nail plate itself cannot have a malignant growth, as it is a passive nail region partner
  • The major nail plate pathology is a slow, low-grade infection with fungus or molds

The nail region terminology is complex. The most important region is the nail matrix.

  • Part of it is visualized as the ‘lunula’, or ‘moon’, the crescent seen through the plate
  • The other portion of the matrix lies on top of the plate over the lunula
  • The matrix forms new nail, and slowly pushes it out towards the fingertip

The matrix can be the site of melanoma, among other abnormalities.

Why is the Nail Matrix Biopsy surgical procedure Performed?

There could be a variety of reasons for performing Nail Matrix Biopsy procedure. Some of these include:

  • Determining if a pigment stripe extending down the nail plate is caused by a benign mole, or a malignant melanoma
  • Removal for biopsy of growths under the nail plate, for symptomatic relief
  • Removal of the nail matrix at the edge of (usually) a toenail that is causing the pain of ingrown nails

What are some Alternative Choices for the Procedure?

Presently, there are no alternatives for a Nail Matrix Biopsy procedure.

What are the Recent Advances in the Procedure?

Some of the recent advances include the awareness that lidocaine can, with certain guidelines, be safely used in nail surgery. Also, clever advances have been made in surgical preparation and instrumentation.

What is the Cost of performing the Nail Matrix Biopsy surgical procedure?

The cost of the Nail Matrix Biopsy procedure depends on a variety of factors, such as the type of your health insurance, annual deductibles, co-pay requirements, out-of-network and in-network of your healthcare providers and healthcare facilities.

In many cases, an estimate may be provided before the procedure. The final amount depends upon the findings during the surgery/procedure and post-operative care that is necessary.

When do you need a Second Opinion, prior to the Procedure?

  • It is normal for a patient to feel uncomfortable and confused with a sudden inflow of information regarding the Nail Matrix Biopsy procedure and what needs to be done
  • If the patient needs further reassurance or a second opinion, a physician will almost always assist in recommending another physician
  • Also, if the procedure involves multiple steps or has many alternatives, the patient may take a second opinion to understand and choose the best one. They can also choose to approach another physician independently

What are some Helpful Resources?

https://www.aad.org/ (accessed on 05/16/2021)

Prior to Nail Matrix Biopsy procedure:

How is the Nail Matrix Biopsy surgical procedure Performed?

The Nail Matrix Biopsy procedure is performed in the following manner:

  • The non-living nail plate is removed from above and below the nail matrix
  • This is done carefully with specially-designed nail nippers and elevators, to separate the nail plate from the nail bed
  • Using a small scalpel, or a punch biopsy instrument, the living tissue to be sampled is removed
  • Sutures are used to cover the space previously taken up by the specimen or lesion
  • Any small amount of bleeding is controlled
  • Sometimes the removed nail plate section is put back in place as protection for and compression of the repaired surgical defect
  • This nail plate will never adhere again, but it is a perfect ‘custom fit’ support
  • A dressing is applied to prevent trauma, bleeding, and infection

Where is the Procedure Performed?

The Nail Matrix Biopsy procedure is usually performed in a clinic surgical suite, or an outpatient procedure suite.

Who Performs the Procedure?

The Nail Matrix Biopsy procedure is usually performed by a dermatologist, a hand surgeon, or a podiatrist.

  • Not all general dermatologists perform this procedure. Dermatologists trained in procedural dermatology fellowships, or Mohs micrographic surgery will be qualified
  • Hand Surgeons may have completed training either in plastic surgery or orthopedic surgery. Then, an additional fellowship in hand surgery is added
  • All podiatrists who perform surgery would perform a Nail Matrix Biopsy, but only on the toes

How long will the Procedure take?

The Nail Matrix Biopsy procedure usually takes about 30 minutes to perform.

What do you need to tell your Physician before the Procedure?

It is very important to provide the following information to your healthcare provider. This enables your healthcare provider in assessing the risks for the procedure and helps avoid complications.

  • Provide medical history such as diabetes, hypertension, heart disease, etc. (if any)
  • Provide a complete list of medications you are currently taking to your physician. This information is useful for a variety of reasons. For example, it can help your healthcare provider prevent complications due to a drug interaction
  • If you are allergic to any specific medication or food items
  • If you are taking blood thinners, such as aspirin, warfarin, herbal supplements, or any other such medications
  • Any medical or family history of bleeding disorders or blood clots
  • If you have ever been diagnosed with blood clots in your leg (deep vein thrombosis) or lung (embolism of lung)
  • Any unusual effects of anesthesia from prior surgery
  • A list of all previous surgical procedures you have undergone, like for example - removal of appendix, gallbladder, or any other part, of your body; surgical repair of any body part, such as hernia repair, perforation of bowel wall, etc.

What Preparations are needed, prior to the Procedure?

The physician performing the procedure will evaluate the patient prior to the procedure and discuss the details with risks for complications and obtain his/her permission (termed informed consent).

  • Some medications increase a person’s chances of bleeding and it may be recommended to discontinue them for a period of time, before the procedure is performed
  • Blood tests may be performed to determine if there is a bleeding tendency or any other medical conditions that prevents the person from undergoing the procedure
  • Blood work, glucose, and pregnancy tests (if applicable) will be undertaken per physician recommendations
  • Avoid application of any deodorant or topical medicines on the area, prior to the procedure
  • It is advisable to quit smoking and the use of any nicotine based products, for a while, before the procedure
  • Consumption of alcoholic drinks must also be avoided for a period of time, as instructed
  • Generally, the patient is told to eat, as anesthesia is local only, and the patient is awake.
  • Individuals with diabetes, hypertension, or other cardiac conditions, are required to discuss these (including medications taken) with their attending physician well in advance
  • For individuals with diabetes, it is important that the blood sugar stays within the normal range; if not, their diabetologist may have to control blood sugar by recommending insulin and/or a combination of oral medicines

Pregnant women and individuals with severe underlying sicknesses are advised to disclose their health status prior to the procedure.

What is the Consent Process before the Procedure?

The physician will obtain permission for the Nail Matrix Biopsy procedure using an Informed Consent Form.

Consent for the Procedure: A “consent” is the approval to undergo a procedure. A consent form is signed after the risks and benefits of the procedure, and alternative treatment options, are discussed. This process is called informed consent.

In case of minors and individuals unable to give informed consent, the parent or legal guardian or next of kin can sign the consent for the procedure.

What Tests are needed, before the Nail Matrix Biopsy surgical procedure?

In many cases, no tests are typically necessary prior to the Nail Matrix Biopsy procedure. However, if required, the healthcare provider may recommend the following tests such as:

  • Blood and urine tests if indicated
  • Imaging studies if a bony abnormality of the finger or toe is possible

What are some Questions for your Physician?

Some of the questions that you might ask your healthcare provider are as follows:

  • What is a Nail Matrix Biopsy procedure?
  • Why is this procedure necessary? How will it help?
  • How soon should I get it done? Is it an emergency?
  • Who are the medical personnel involved in this procedure?
  • Where is the procedure performed? 
  • What are the risks while performing the procedure?
  • What are the complications that might take place during recovery?
  • How long will it take to recover? When can I resume normal work?
  • How many such procedures have you (the physician) performed?
  • Are there any follow-up tests, periodic visits to the healthcare facility required, after the procedure?
  • What are the costs involved?

During the Nail Matrix Biopsy surgical procedure:

What kind of Anesthesia is given, during the Procedure?

Local anesthesia by injection is administered for the procedure.

How much Blood will you lose, during the Procedure?

There is not much blood loss during an uncomplicated Nail Matrix Biopsy procedure.

What are the possible Risks and Complications during the Nail Matrix Biopsy surgical procedure?

There are general factors that increase one’s risk of getting complications during the Nail Matrix Biopsy procedure, which include:

  • Obesity: Generally greater the degree of obesity, greater is the surgical risk
  • Smoking: Longer the smoking history (in pack years smoked), greater the surgical risk
  • Advancing age
  • Poorly controlled diabetes, as evidenced by a high hemoglobin A1c and a high fasting glucose
  • Poorly functioning kidney, as evidenced by increased BUN (blood urea nitrogen) and blood creatinine
  • Poorly functioning liver, as evidenced by increased blood liver function tests
  • Hypertension (increased blood pressure), especially if it is poorly controlled
  • Poor nutritional status (malnutrition with mineral and vitamin deficiencies)
  • Poor lung function, as evidenced by abnormal lung function tests
  • History of bleeding disorders
  • Poor immune system due to a variety of causes

Some of the possible risks and complications that may arise during a Nail Matrix Biopsy procedure include:

  • Infection
  • Bleeding
  • Injury to the neighboring structures
  • Pain
  • Discomfort
  • Anesthetic complications
  • Need for further procedures

What Post-Operative Care is needed at the Healthcare Facility after the Nail Matrix Biopsy procedure?

At the healthcare facility, generally there is no requirement for any post-procedure care, unless any complications arise. However, immediately following the surgery, the patient will be monitored for their capacity to return to their normal health status.

After the Nail Matrix Biopsy surgical procedure:

What are the possible Risks and Complications after the Nail Matrix Biopsy surgical procedure?

The risks and complications that may arise after Nail Matrix Biopsy include:

  • Excessive bleeding that may sometimes require an additional surgical procedure
  • Any symptom that causes uneasiness such as nausea and dehydration
  • Low-grade fever
  • Infection of the surgical wound
  • Postoperative pain

What is the Prognosis after the Surgery?

In many cases, the prognosis after the procedure is typically excellent. The recovery from a Nail Matrix Biopsy procedure is usually excellent, and the patient is usually discharged after safe ambulation and transportation is ascertained.

When do you need to call your Physician?

Do contact your physician or call 911 (or your local emergency number) based on the seriousness of any of the following symptoms:

  • Fever and chills
  • Severe pain
  • Shortness of breath
  • Bleeding or fluid discharge from the surgical wound
  • Nausea and vomiting
  • Signs of infection
  • Severe fatigue
  • Dizziness

What Post-Operative Care is needed at Home after the Nail Matrix Biopsy surgical procedure?

At home, the following post-operative care is recommended after a Nail Matrix Biopsy procedure:

  • Elevate the limb of the surgery above the heart for the remainder of the postoperative day
  • Follow the specific instructions given by the surgeon
  • Resume showering and keep the wound clean and dry. Gently wash the surgical wound with mild unscented soap
  • Replace dressing after showering
  • Take the prescribed medications following the procedure
  • Avoid any strenuous activity for a period recommended by the physician
  • Do not drive (post-procedure) for a period of 24 hours
  • Avoid smoking or drinking alcohol post-procedure
  • Continue old prescribed medications after checking with the healthcare provider
  • Avoid sex until complete healing has taken place (under advice by the physician)
  • Do not sign any legal documents post-procedure for a period of 24 hours

How long does it normally take to fully recover, from the Procedure?

The time for recovery from the Nail Matrix Biopsy procedure is typically about two weeks. A regrowth of the removed nail plate can take significantly longer.

Additional Information:

What happens to tissue/samples (if any), taken during the Procedure?

The samples/tissue are usually sent to the microbiology and pathology departments in the hospital, and subsequently disposed, as per the standard hospital protocol.

When should you expect results from the pathologist regarding tissue taken out, during the Procedure?

  • The samples/tissue is processed in the laboratory under a pathologist's supervision
  • Slide(s) are prepared once the tissue is processed and this is examined by a pathologist and a pathology report issued
  • Depending on the complexity of the case, issue of the report may take anywhere between 72 hours to a week's time

Who will you receive a Bill from, after the Nail Matrix Biopsy surgical procedure?

It is important to note that the number of bills that the patient may receive depends on the arrangement the healthcare facility has with the physician and other healthcare providers.

Sometimes, the patient may get a single bill that includes the healthcare facility and the consultant physician charges. Sometimes, the patient might get multiple bills depending on the healthcare provider involved. For instance, the patient may get a bill from:

  • The outpatient facility or hospital
  • The dermatologist or other nail area surgeon
  • An anesthesiologist (if anesthesia was administered)
  • A pathologist (if the tissue was sent for analysis)
  • The laboratory that processed the tissue, making it ready for the pathologist to examine.

The patient is advised to inquire and confirm the type of billing before the Nail Matrix Biopsy procedure is performed.

Reviewed and Approved by a member of the DoveMed Editorial Board
First uploaded: June 2, 2021
Last updated: June 2, 2021