Ropivacaine for modified tangential excision of nail matrix

Abstract

We read with great interest the recent article by Zaiac and OcampoGarza (2018) on the advantages of injecting lidocaine into matrix around pigmented lesion prior to performing the tangential excision. They made an effort to lower the destruction of the matrix by tangential excision eventually simplifying through an ingenious method. Tangential excision enables the removal of the matrix epithelium and a thin layer of the underlying dermis with limited postoperative dystrophy, along with wide excisions (Richert, Theunis, Norrenberg, & André, 2013). However, postoperative recurrent pigmentation is the main drawback of the procedure. It is significant that its structure is unaffected on the removal of excessive tissues. The authors performed a shallow incision through the matrix epithelium and the papillary dermis until the specimen was completely removed using a scalpel with extreme difficulty. Zaiac and Ocampo-Garza (2018) injected 1 cc lidocaine directly into the matrix by making an incision easier on the cushioned tissue and thus preserving the remaining matrix. As proposed by Zaiac and Ocampo-Garza (2018), we performed a similar procedure using ropivacaine contrary to lidocaine because ropivacaine has an onset similar to that of lidocaine providing better postoperative pain relief (up to 9 hr; Peng et al., 2002). The use of ropivacaine injection into matrix area along the tangential excision may help reduce excessive postoperative pain making patients comfortable as the pain is remarkable after nail surgery. The procedure was carried out by a 27-gauge or 30-gauge needle carefully inserted through the epithelium of the matrix, and the depth of the needle was observed shining through the tissue (Figure 1). We stopped injecting ropivacaine (5 mg/mL) until the nail matrix turned pale rather than injecting up to 1 cc. The comparison with pigmented lesion developed more obvious as the injected matrix turned white. This allowed the surgeon to define and identify the edge of longitudinal melanonychia more easily. Moreover, the swelling of matrix followed by injection separates the upper dense tissue from lower soft tissue making it easier than described by Zaiac and OcampoGarza (2018). Thus, we performed the procedure on a much thinner sample using ropivacaine injection prior to tangential excision confirmed by histopathological examination (Figure 2). In brief, the application of ropivacaine in modified tangential excision of the nail matrix indicated that a very shallow injection with the F IGURE 1 Injecting ropivacaine into matrix around the pigmented lesion, the depth of the needle was observed shining through the tissue