Nail Surgery Among Mohs Surgeons: Prevalence, Safety, and Practice Patterns Alyssa Findley, MD,* Kachiu Lee, MD,† and Nathaniel J. Jellinek, MD*†‡

BACKGROUND Among US dermatologists, Mohs surgeons perform most of the nail surgeries. The specific practice patterns and safety precautions have not been formally studied. OBJECTIVE To study the practice patterns, safety precautions, and complications of this group when performing nail surgery. METHODS A survey was sent electronically to all members of the American College of Mohs Surgery Listserv. The survey evaluated the demographics of the surgeons, the types of surgery performed, the techniques for obtaining a bloodless field, and complications. RESULTS Those surgeons who performed more procedures in training tended to continue that practice and performed more surgeries when in practice, as did surgeons with greater time since completing fellowship. Complications were rare. CONCLUSION The data herein support that nail surgeries performed by Mohs surgeons are safe, with minimal complications, despite a broad range of approaches to obtaining a bloodless field and with a variety of procedures performed. The authors have indicated no significant interest with commercial supporters.

ail surgery comprises a field of dermatologic surgery that is relatively deficient of data-driven guidelines. In addition, most dermatology residents and fellows receive scant teaching and exposure to nail pathology and the specific techniques required to perform nail surgery.1 As is the case with any surgical approach or procedure, one is more likely to practice the skills that are acquired during training. Among dermatologists in the United States, Mohs surgeons perform most of the nail surgeries.


Methods This study investigated the particular nail procedures Mohs surgeons are performing and how they are doing it. We sought to determine the safety of current practice, evaluating complications and risk factors for complications. The data were stratified in the context of years

of experience and time since the completion of fellowship training. A questionnaire was sent through SurveyMonkey to all members of the American College of Mohs Surgery. The survey was conducted in an anonymous fashion. Our response rate for the survey was approximately 17% (N = 164), accounting for 298,161 physicianyears of experience. The questionnaire inquired about the performance of specific nail surgery techniques, surgeon’s practice of obtaining a bloodless field, and use of a tourniquet and/or epinephrine-containing anesthesia. Surgeons were polled on their perception of safe tourniquet time, the concentration of epinephrine used in local anesthesia, and maximum volume of local anesthesia used. Surgeons were additionally queried on perceived contraindications

*Dermatology Professionals, Inc., East Greenwich, Rhodes Island; †Department of Dermatology, The Warren Alpert Medical School at Brown University, Providence, Rhodes Island; ‡Division of Dermatology, University of Massachusetts Medical School, Worcester, Massachusetts


© 2014 by the American Society for Dermatologic Surgery, Inc. Published by Lippincott Williams & Wilkins ISSN: 1076-0512 Dermatol Surg 2014;40:691–695 DOI: 10.1111/dsu.0000000000000018



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to the use of epinephrine on digits and were asked about their experience with complications when performing nail surgery. Results Our data demonstrate that surgeons who performed up to 10 nail surgeries during fellowship are currently performing on average twice as many as those who performed fewer than 10 nail procedures during their fellowship (p < .001) (Table 1). Furthermore, more experienced surgeons, with greater than 5 years of experience, are performing an increased number of nail procedures compared with those who have more recently completed their fellowship training (17 vs 9 surgeries per year, respectively, p < .01). Most of the responders perform Mohs surgery for nail tumors (93.1%). Punch biopsies are performed by 86% of respondents, and 66% perform shave (tangential) biopsies (p < .01). Years in practice (#5 vs >5 years) did not influence the type of biopsy most commonly performed. Those who performed 10 or more nail biopsies during fellowship were more likely to perform shave biopsies than those with less experience during fellowship (76% vs 57%, respectively, p < .01). To achieve a bloodless field, over half of Mohs surgeons use a tourniquet or a modified glove tourniquet and 71.4% use epinephrine-containing anesthesia. Fewer surgeons, however, combine the use of these 2 measures (17.6%). Just over 25% of the survey respondents did not attempt to obtain a bloodless field. Our survey showed that physicians in practice for less than 5 years were more likely to use epinephrine when performing nail surgery. There was no relationship between the number of nail surgeries completed during fellowship and the use of epinephrine. Of those responders using epinephrine-containing anesthesia, the most common concentrations are 1:100,000 or 1:200,000. The maximum concentration of epinephrine-containing local anesthesia varied greatly between responders, from 0.5 to 8 mL per surgery (mean, 2.5 mL; median, 2.5 mL) or base of the amount used solely in visualizing impaired blood flow in the digit. The maximum volume of epinephrine-containing anesthesia was not related to the years in practice (p = .4).


AQ : 1

Of those responders who use a tourniquet or a tourniquet-like device, most use a modified glove technique with a finger rolled back (71.4%).2 A Penrose or a similar drain was followed in frequency (44.5%), followed by a range of other techniques (14.8%). Very few respondents used a T-ring (0.8%),3 and there were no claims of using a zip tie.4 Several of those who chose “other techniques” listed manual compression of the digital arteries by an assistant. Of those who use a tourniquet or similar device, the median amount of time it is left in place is 12.8 minutes (mean, 14 minutes, range 3-60 minutes). Several respondents commented that the tourniquet was kept in place only as long as required for the procedure. Raynaud disease/phenomenon and peripheral vascular disease were considered the most significant contraindications to the use of epinephrine on the digits. Of the respondents, 19.1% felt that there were no absolute contraindications to the use of epinephrine in digital surgery. There was no relationship between the number of nail surgeries completed during fellowship and the number of years out in practice to perceived absolute contraindications to nail surgery (p = .7 and p = .07, respectively). Regarding experience of surgeons with complications, there was only 1 reported case of digital infarction in 298,161 physician-years of experience and 2.5% reported cases of prolonged ischemia without resultant digital necrosis. The most common complications were persistent paresthesias, followed by nail dystrophy, prolonged ischemia, and infection. The number of years since completing fellowship was not related to having complications (p = .7). Discussion A bloodless or near-bloodless field is of the utmost importance when performing nail surgeries. It has been quoted in the hand surgical literature that “operating on a hand without a tourniquet is like trying to fix a watch in a bottle of ink.”5 A bloodless field is generally achieved through the use of a tourniquet or epinephrine-containing anesthesia. Mohs surgeons are split between these two, with nearly three quarters using epinephrine and over half using a tourniquet or tourniquet-like technique.


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TABLE 1. Nail Survey Questions With the Number of Surgeons Responding to Each Question


No. of Surgeons Responding (% Responding of 950 Invited)

How many years have you been in practice?

162 (17), range: 1.5–35 years

How many nail surgeries did you perform or assist in during your fellowship training?

161 (17), range: 0–150

What is the estimated number of nail surgeries you perform annually?

161 (17), range: 2–150

Which type(s) of nail procedures do you perform?

160 (17)

Shave/tangential biopsy


Punch biopsy


Longitudinal biopsy Mohs surgery

121 149

Chemical/surgical matricectomy




En bloc excision


Do you use a tourniquet or modified glove tourniquet?

159 (17)





Both If yes, what is the maximum time that the tourniquet is left in place? Which type of tourniquet device do you routinely use?

28 122 (13); range: 2–60 minutes 128 (13)

Modified glove tourniquet (glove with finger rolled back)


Penrose or similar drain


Zip tie




Other device (please specify)


If no, how do you obtain a bloodless field? Wing block with plain anesthesia

79 (8) 16

Assistant holding digital artery pressure


Epinephrine in local anesthesia


Did not attempt bloodless field


Do you use epinephrine? Yes No

161 (17) 115 46

If yes, what concentration? If yes, what is the maximum volume of local anesthesia used?

114 (12) 118 (12); range: 0.5–6 mL

Do you routinely combine the use of a tourniquet and epinephrine-containing anesthesia?

160 (17)

Yes No What do you consider to be absolute contraindications to epinephrine use on the digits?

75 85 157 (17)

Raynaud disease/phenomenon


Connective tissue disease


Peripheral vascular disease


Tobacco use


Uncontrolled hypertension


Beta blocker use


None Other (please specify)

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Continued No. of Surgeons Responding (% Responding of 950 Invited)

Question What, if any, complications have you had performing nail or digital surgery?

158 (17)

No complications


Prolonged ischemia Digital infarction

4 1

Persistent paresthesias


Other (please specify)


If there were any complications listed in question 14, how many cases in career?

Ample evidence exists to support the safe use of epinephrine in local anesthesia when performing digital surgery. Epinephrine triggers digital artery spasm and creates a bloodless or near-bloodless field, although Doppler studies have shown that most digits still receive arterial perfusion during surgery. In the absence of contraindications, this has been shown to be reproducibly safe, as evidenced by the lack of long-term complications demonstrated in this study. Nevertheless, the epinephrine effect likely accounts for the 2.5% of respondents who described prolonged ischemia as a complication. One of the major disadvantages of using epinephrine is that the digit may remain cold and white without evidence of reperfusion for a variable amount of time. This duration may exceed that in which the patient is observed following completion of the nail surgery and discharged from care. As an alternative, tourniquets control bleeding and limit the time of ischemia to that of the surgery itself. Most surgeries performed by the surgeons take fewer than 10 minutes, with more involved procedures such as en bloc excision of all nail tissues requiring approximately 20 to 30 minutes of a bloodless field. We have recently found success using a proprietary tourniquet, the T-ring, at our institution without concomitant epinephrine use. This device has been shown to provide a bloodless field with consistent and low digital artery pressure.3 Its use is only limited by the size of the digit (difficult to fit on the great toe), and it serves as an alternative to handheld digital artery pressure or the rolled glove when working on the fingers or lesser toes.


26 (3)

The most common long-term sequelae after nail surgery are paresthesias, likely resulting from damage to small nerves during surgery.6 Our survey failed to support this as a common occurrence, with only 7% of the respondents documenting this complication. Most of the surgeons who completed the survey denied any complications, and there was only 1 report of a recurrence of squamous cell carcinoma after Mohs surgery on the digit. Although this number is less that the rates published in case series, this information supports the safety of Mohs surgeons performing nail surgery and Mohs surgery for nail tumors. The second most common complication listed was nail deformity, including nail dystrophy and loss, spicules, and dyspigmentation. Two of the respondents who had performed surgery leading to nail deformity also stated that these patients experienced persistent pain, although no further details were provided. There were only a few accounts of postoperative infection. There were several limitations of this study. We only polled fellowship-trained Mohs surgeons in the United States, excluding other physicians such as general dermatologists, hand orthopedic surgeons, podiatrists, and nonresponders. Additionally, we were limited to drawing conclusions based on the 17% response rate. However, we were able to account for a large number of physician-years of experience when performing our statistical analysis. Our sample size was adequate and allowed us to generate an acceptable 95% confidence interval.


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dermatology residents. J Am Acad Dermatol 2011;64:475–83, 483. e1–5.

The results of this survey lend support to Mohs surgeons safely performing nail surgery and performing Mohs surgery for nail tumors. Surgeons who perform a greater number of nail procedures during fellowship are more likely to continue this practice after training. Most of the Mohs surgeons use epinephrine-containing anesthesia or a tourniquet to obtain a bloodless field. There have been very few long-term complications as a result of this practice. There remains a need to generate data-driven evidence and guidelines to enhance safety and improve patient outcomes.

2. Harrington AC, Cheyney JM, Kinsley-Scott T, Willard RJ. A novel digital tourniquet using a sterile glove and hemostat. Dermatol Surg 2004;30: 1065–7.


Address correspondence and reprint requests to: Nathaniel J. Jellinek, MD, 1672 South County Trail, Suite 101, East Greenwich, RI 02818, or e-mail: [email protected] com

1. Lee EH, Nehal KS, Dusza SW, Hale EK, et al. Procedural dermatology training during dermatology residency: a survey of third-year

3. Lahham S, Tu K, Ni M, Tran V, et al. Comparison of pressures applied by digital tourniquets in the emergency department. West J Emerg Med 2011;12:242–9. 4. Tang WY. A latex finger strip and nylon zip-tie combo as a tunable digital tourniquet. Dermatol Surg 2007;33:713–5. 5. Cox C, Yao J. Tourniquet usage in upper extremity surgery. J Hand Surg Am 2012;35:1360–1. 6. Walsh ML, Shipley DV, de Berker DA. Survey of patients’ experiences after nail surgery. Clin Exp Dermatol 2009;34:e154–6.

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Nail surgery among Mohs surgeons: prevalence, safety, and practice patterns.

Among US dermatologists, Mohs surgeons perform most of the nail surgeries. The specific practice patterns and safety precautions have not been formall...
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