34 Su r g ic a l D iS e a Se S iSSN 2413-6077. iJMMr 2017 Vol. 3 issue 1 dOI 10.11603/IJMMR.2413-6077.2017.1.7291 chRONIc mYcOTIc-AssOcIATEd sURGIcAL NAIL PAThOLOGY cOmPLIcATEd WITh INGROWN NAIL (NAIL INcARNATION): ThE ANALYsEs Of cLINIcAL cAsEs ANd cOmPLEX TREATmENT A. R. Vergun, B. M. Parashchuk, M. R. Krasnyy, Z. M. Kit, O. M. Vergun DANYLO HALYTSKY LVIV NATIONAL MEDICAL UNIVERSITY, LVIV, UKRAINE Background. Conservative treatment of secondary recurrent unguis incarnatus are not very effective and Dupuytren’s method, Emmert-Schmiden surgeries etc. are very traumatic, disfigure nail bone, distort anatomic and functional unity of a nail. Objective. The aim of our research was the optimal sequence of holiatry, surgical moving away of nails, local and system therapy after excision of the staggered nails in case of destructive onychomycosis complicated by secondary ingrown nail for some patients with complicated mycotic defeat of nails. Clinical options of surgical treatment were clarified; morphologic changes were studied; causes of unsatisfactory outcomes of chronic pathology complex treatment were analyzed for prospective approaches to preventing of relapses. Methods. The analysis justifies the feasibility of establishing of predictive relationships between clinical variants of chronic purulent necrotic infections and combined comorbidity. System therapy by itraconazole before operative treatment (basic onychial defeats sanation) and in a postoperative period was carried out. Types of operative treatment applied may be divided into five statistic groups. Results. over a five-year period (2010-2015) 436 unguis incarnates diagnosis (325 cases of incarnated onychomycosis) in 259 men and 177 women aged 12-67 were performed, 38 of them with incarnated onychogryphosis had diabetes mellitus and 24 had metabolic syndrome. Analysis of subonychial scraping allowed stating the prevalence of red trichophytia in 31% of cases with the bacterial flora. Patients with combined pathology got 4-5 five-day system ‘pulses’ of 400 mg/day itraconazole therapy. In patients with primary advantage of providing low-impact methods of nail excision with access via onycholisation structure a nail extirpation and marginal matricectomy was carried out; dermatophytoms and stratification on a nail bed were deleted. Conclusions. Type of onychectomy wound cytograms in the study group on the 10th day was defined as regenerative-inflammatory in 24.81%, regeneratory in 75.19% (p=0.031). The methods of surgical treatment of mycotical recurrent nail incarnation have been improved considering patho- and morphogenetic properties of destructive onychomycosis. KEy wORDS: destructive onychomycosis; secondary recurrent ingrown nail; antimycotic therapy; surgical nail removal. Introduction Dermatophytes, infecting a nail matrix, were determined as the dystrophic changes of nail and a subnail hyperkeratinization and der- matophytoms [2, 3], surgical nail pathology, that compress a nail that is the driving noso- tropic member of the secondary ingrowing and has an influence on curative tactics [4], in par- ticular on the necessity of the surgical moving away [8, 21]. The pathogenetic links leading to increase of the probability of occurrence and development of feet mycosis and onychomy- cosis for diabetic patients include the pathol- ogy of cardiovascular and nervous systems [10], disruption of glycolysis, resulting in lower en- ergy supply of skin cells and changes in me- tabolism, skin dysfunction, determining rapid progression and chronic mycosis [18, 20]. The objective was to study certain peculi- arities of mycosis-associated pathology and treatment, including surgical removal of nails in patients with onychogryphosis and recurrent ingrown with underlying diabetes mellitus [20]. the results of determining of vitamins В1, В2, РР, В6 and С in blood and their derivatives are analysed [22]. Some 50-year-old patients, who have high mycotic surgical nail pathology, have Corresponding author: Andriy Vergun, Department of Out- patient Care, Family Medicine and Dermatology, Venerology, Danylo Halytsky Lviv National Medical University, 1 Konovaltsya Street, Lviv, Ukraine, 79013 Phone number: +380322757632 E-mail: plagiamail@meta.ua a. R. Vergun et al. International Journal of Medicine and Medical Research 2017, Volume 3, Issue 1, p. 34–40 copyright © 2017, TSMU, All Rights Reserved 35 Su r g ic a l D iS e a Se S iSSN 2413-6077. iJMMr 2017 Vol. 3 issue 1 a. R. Vergun et al. the endothelial dysfunctions and polyvitamin disturbances that are some factors from clinical corrections [10, 12, 22]. The study involves peculiarities of treatment, some indicators of lipid exchange of patients with diabetes mellitus [9, 10, 18, 20], metabolic syndrome accompanied by destructive onycho- mycosis and secondary nail ingrowth. Clinical options of in-patient and out-patient surgical treatment for nail ingrowth (mono-lesions; com- plicated and combined mycotic-associated processes and relapses) were clarified; morpho- logic changes were studied; causes of unsatisfac- tory outcomes of chronic pathology complex treatment were analysed for prospective ap- proaches to preventing relapses. If the infection involves the eponychium as well as the lateral fold, it is called eponychia [15, 17]. Its extension to the opposite side of the fingernail, which is uncommon, is called run- around abscess. In these cases, the paronychia is compressed along the nail edge, trapping the abscess. All procedures that successfully treat paronychia separate it from the hard nail [23, 24]. If the infection is limited to less than one- half of the eponychium, a single incision placed to drain the paronychium and to elevate the eponychial fold for excision of the proximal one- third of the nail is satisfactory. If the entire eponychium is involved, two incisions are re- quired. The relevance of the problem of the ingrown nail (onychocryptosis, unguis incarna- tus) in an urgent outpatient purulent surgery is caused by the increased frequency of its oc- currence, chronicity, complications, not uncom- mon early and late postoperative relapses [8, 15, 17]. Conservative and orthopedic treatment of incarnatus surgical nail pathology are not very effective while Dupuytren’s method, Em- mert-Schmiden surgeries etc. are very trau- matic, disfigure nail bone, [4, 5, 21, 24] distort anatomic and functional unity of a finger and in 2–20% of cases (depending on absence or presence of onychocryptosis and fungal agents) cause a relapse. The clinical features and ways to optimize the treatment of patients with onychomycosis and destructive secondary ingrown nails are clarified in the article. the results of complex treatment of the patients with nail trichophy- tosis, associated with ingrown toenail, submit- ted according to dependence on a nail plate and eponycheal changes are presented in the publication. The aim of our research is the optimal se- quence of holiatry, surgical moving away of nails, local and system therapy after moving away the staggered nails in cases of destructive onychomycosis complicated by the secondary ingrown nail for some patients with the com- plicated mycotic defeat of nails. Methods Certain peculiar features of the clinical course and comprehensive treatment were studied, including surgical removal of the nails in patients with onychogryphosis associated with an ingrown nail (onychocryptosis, nail in- carnation). Results of ingrown nail surgical correction were studied to improve the results of complex treatment. Over a five-year period (2010–2015) 436 unguis incarnates diagnosis (325 cases of incarnated onychomycosis) in 259 men and 177 women aged 12–67 were per- formed. In 182 patients late relapses of onych- ocryptosis were confirmed after previous sur- geries at other clinics. Conservative treatment was recommended only at early stages of in- growth. Removal of the affected nails was performed for patients with mycotic lesions (local and systemic fungicide therapies were used). Investigation of the morphogenesis of destructive aspect of the mycotic lesions was carried out. A variety of factors, aetiology, and pathogenesis of chronic purulent necrotic le- sions of the foot, contributing to the occur- rence, progression and recurrent course of these diseases, creates objective difficulties of diagnosis [14, 16, 19]. the analysis justifies the feasibility of establishing predictive relation- ships between clinical variants of chronic puru- lent necrotic infections and combined comor- bidity [1, 25]. System therapy by itraconazole in operative treatment (basic onychial defeats sanation) and in a postoperative period was carried out [12, 25]. The applied types of op- erative treatment of surgical nail pathology may be divided into five main groups: 1 – Emmert- Schmiden type surgeries (marginal excision of nail plate and eponychia with marginal re- moval of the growing part via partial matricec- tomy); 2 – Dupuytren’s type surgeries (onych- ectomy – complete removal of nail plate); 3 – Bartlett type surgeries (local tissue plastic re construction); 4 – marginal resection of mar- ginal section of nail plate; 5 – Meleshevych surgery; 6 – our modifications (with previous block-type eponychectomy). Results Over the five-year period we examined and treated 98 patients of 52–86 years old with in- 36 Su r g ic a l D iS e a Se S iSSN 2413-6077. iJMMr 2017 Vol. 3 issue 1 carnated onychogryphosis (fig. 1): 67 men (68.37%) and 31 women (31.63%) of the exam- ined patients, 38 of them had diabetes mellitus and 24 had metabolic syndrome. Three variants of dermatophytoma are differentiated: front centre, with up to 25% of eroded nail – 45 cases, subtotal, from 25 to 70% (without capturing the growth plate) – 38 cases, total from 70 to 90% (with affected growth plate of the nail) – the other 15 cases. In all cases, dermatophytoma affected distal and central part of the nail bed. Analysis of subonychial scraping allowed stat- ing the prevalence of red trichophytia [3, 4]: in 74% of cases it was associated with mold, in 26% of cases – with yeast fungi; in 31% of cases – with bacterial flora [1]. Conglomerate of nail plate and subungual hyperkeratosis and trichophytosis calcinated completely, forming onychogryphosis with deformation [6, 7] (Fig. 2) and secondary recur- rent ingrown nail [15, 16, 22, 23]. In patients with onychomycosis, especially in severe destructive forms of subungual hy- perkeratosis, large deterioration of microcircu- lation was noted. Rheographic prevailed spas- tic type curves (p<0.01) [9, 10]. Index of open capillaries was reduced by 31%. Patients in both groups mainly were affected with hallucis on left foot – in 188 people, the other – on right foot (133 patients), the presence of pathological ingrown nail plates of hallucis of both feet [12, 15, 17] and otherfingers were examined in other patients. Mycotic associated hyponychial panaritium was diagnosed in 16 patients with onych- ogryphosis (16.33%), purulent paronychia was diagnosed in 11 patients (11.22%), the other 5 patients of this group suffered from eponych- ial abscess (5.10%). Patients of the main group underwent a three-day adjuvant systemic fun- gicide therapy: 400 mg itraconazole daily, dur- ing 4 days (the first 2 postoperative days) as pulse therapy. A similar dose at weekly intervals was carried out following five-day 2–3 cycle pulse [23, 25]. Removal of the affected nails for patients with polyonychomycosis was performed in suc- cessive stages at add-back of certain systemic ‘pulses’ with itraconazole. Patients with such combined pathology got 4–5 five-day system ‘pulses’ of 400 mg/day itraconazole therapy together with a simultaneous use of hepato- protectors and correction of comorbid pathol- ogy [21–23]. Provided adequate surgical treat- ment, in addition to standard decompression stage (complete removal of the nail plate), contained antirecurrent component to prevent from repeated ingrowth. Along with antimy- cotic therapy and correction of comorbid pa- thology the following procedures were carried out: cutting pathologic eponychial tissues, hy- pergranulations and necroses [22, 24] (Fig. 3); removing nail plate with partial marginal ma- Fig. 1. Trichophytial polyonychomycosis, onychogryphosis. Clinical case. 81-year-old woman. Fig. 2. Total nail dermatophytosis (Tr. Rubrum), polyony- chom ycosis. Big polyonychial gryphosis. Clinical case. 82-year-old man. Fig. 3. Surgical nail pathology, subnail subungual hyper- keratosis and dermatophytosis, big dermatophytoma, hypergranulations and local necroses. Intraoperation photo. Trichophytial polyonychomycosis, incarnated ony- chogryphosis. Clinical case. 81-year-old woman. a. R. Vergun et al. 37 Su r g ic a l D iS e a Se S iSSN 2413-6077. iJMMr 2017 Vol. 3 issue 1 a. R. Vergun et al. trixectomy in the ingrowth area [2, 3, 20]. Non- invasive methods of nail excision and marginal nail resection were preferred for patients with diabetes mellitus. During the five-year period we examined and treated 38 patients with onychogryphosis and diabetes mellitus type 2. We provide the research on the characteristic features of the pathological process to create the optimal scheme of complex treatment for patients with abnormal ingrowth of nail plate with underlying diabetes mellitus type 2 [9, 18]. 23 patients with ingrown onychogryphosis and underlying diabetes mellitus, diabetic mi- cro and macroangiopathy (prospective mate- rial, the treatment group), and onychogrypho- sis and recurrent incarnation of toenail (pathol- ogy being clinically dominant and manifesting through pain syndrome) and multiple destruc- tive mycotic lesions of other nail plates of both feet: 14 men and 9 women, 55–80 years old were involved in the surgery. The other 15 people with onychogryphosis of the first toe (hallux) and fungus of other nails constituted the control group. The duration of clinically- manifesting nail mycotic process in all studied cases exceeded 5 years. Mycosis-associated acute purulent pathology [19, 21, 23] was con- firmed in 13 patients (34.21% of the examined, 52% cases) of the treatment group and in 5 patients of the control group (13.16% of the examined, 30% cases) correspondingly. Sys- temic adjuvant pulse therapy with 400 mg itraconazole was applied during two days be- fore the initial surgical treatment and during the first three days of postoperative period [19]. Remediation of other affected nails in order to prevent from mycosis reinfection was carried out with antimycotic amorolfine 5% lacquer and ciclopirox 8% nail lacquer solution [2, 11–13, 22]. Removal of other nails affected by hyperkera- tosis with trichophytosis was performed through onycholysis by separate successive stages, where certain ‘pulses’ of therapy were supported with itraconazole [19, 21]. We prospectively examined 93 patients with metabolic syndrome [9, 10], associated with surgical nail pathology, destructive onychomy- cosis and secondary ingrown toenails. All pa- tients underwent a comprehensive treatment of comorbid pathology, corrected using the systemic antimycotic therapy and terbinafine antifungal liniments, ciclopirox nail lacquer [11, 13] and surgical methods for removing nail plates [8, 9, 12, 22]. We studied lipid metabolism that manifested biochemical change indicators in the lipid profile, as well as their relations, which were significantly higher in both groups of patients (the main and control group), p<0.01 for both groups; we evidenced the positive cor- relation between the level of total cholesterol and leptin (p<0.01). The concentration of high- density lipoprotein cholesterol in patients of the main group was 1.12±0.06 mmol/L com- pared with patients in the control group – 1.07±0.06 mmol/L. The average content of ni- trogen oxide in the study group (metabolic syndrome) was higher than in the healthy pa- tients – 15.06±0.97 mcmol/L, p<0.05. Significant decrease of HOMA-index of β-cell function and increase of hOMa-index of insulin resistance [18, 20] (10.21±1.9 in the treat- ment group and 4.12±1.12 in the control group, p<0.01) was detected in patients with underly- ing diabetes mellitus type 2 (the treatment group) with polyonychomycosis and trichophy- tosis onychogryphosis, and recurrent incarna- tion of the nail edge. High total cholesterol over 5.18 mmol/l was detected for all patients of the main group, i.e., 7.28±0.07 mmol/l, and 5.45±0.12 mmol/l in the half of the control group; the deviation of laboratory parameters of low and high density lipoprotein cholesterol was also confirmed. Polyonychomycosis and big trichophytic subungual hyperkeratosis with secondary nail ingrowth [6-9] were diagnosed in the main group comprising 62 patients with type 2 dia- betes mellitus (48 males and 14 females, aged 42-65). Metabolic syndrome was confirmed in the comparison group comprising 53 patients with arterial hypertension and complicated mycotic nail damage. The rest 276 patients constituted the control group. We studied bio- chemical findings, lipid blood spectrum: total cholesterol, high-density lipoprotein choles- terol, low-density lipoprotein cholesterol; nitric oxide of blood plasma; leptin [9]. Lipid blood spectrum and nitric oxide level [10] were deter- mined before and after pharmacotherapy along with continuous antihypertensive therapy (cor- rection of intercurrent and comorbid patholo- gy). The objective criterion of insulin resistance was the HOMA-IR index (the Homeostasis Model Assessment) involving glucose and in- sulin levels on an empty stomach divided by 22.5 coefficient. Patients of the main and the comparison groups with polyonychomycosis and trichophytic subungual hyperkeratosis with secondary ingrown nail experienced consider- able decrease of hOMa-index of β-cells function and increasing HOMA-index of insulin resist- 38 Su r g ic a l D iS e a Se S iSSN 2413-6077. iJMMr 2017 Vol. 3 issue 1 ance (8.11±1.1 in the main group, 5.89±2.1 in the comparison group and 2.23±1.18 in the control group, p1=0,01; p2=0.01). Considerable positive correlation between all indicators of carbohydrate exchange was identified in groups comprising patients with type 2 diabe- tes mellitus: glucose and insulin (r=0.51; p=0.01), and the HOMA-index (r=0.70; p=0.01), and glycolyzed haemoglobin (r=0.75; p=0.001); insulin and the HOMA-index (r=0.73; p=0.01) and glycolyzed haemoglobin (r=0.65; p=0.01); the HOMA-index and glycolyzed haemoglobin (r=0.67; p=0.01). Considerable increase of cir- culating insulin was identified directly after surgical treatment (in the main group and the comparison group correspondingly 15.33±0.23 and 8.24±1.18 mkMO/l, p=0.01), the HOMA-in- dex of insulin resistance (p=0.05) and the HO- Ma-index of β-cells function (p=0.05) in com- parison with the control group with further tendency to some decrease in the process of treatment. We determined disturbances in lipid exchange, insulin resistance, lipid blood spec- trum changes that were considerably higher in both groups of patients (the main and com- parison groups), p=0.01 for both groups in comparison with the control group. Discussion On one hand the subungual hyperkeratosis and dermatophytosis caused compression of the central part of the nail, epionychium edges ‘ingrew’ to periungual walls thus recurrent ingrown nail was formed; on the other hand, constant compression caused destruction of central part of nail bed; this process was typical for 32 (84.32%) cases. Methods of surgical treat- ment of uncomplicated onychogryphosis [6, 7] and onychogryphosis complicated with recur- rent nail incarnation [8, 15] were improved considering patho- and morphogenetic proper- ties of destructive onychomycosis [16, 17]; re- moval of the mycotic affected nails of these patients should reasonably be conducted through onycholized structures with simultane- ous removal of dermatophytoma, hyperkera- tosis, and ingrowth areas with hypergranula- tion. Surgical treatment was performed accord- ing to the standard algorithm due to patholo gical eponychial changes in the patients with primary advantage of providing low-impact methods of nail excision with access via onych- olisation structure and wedge resection of the nail [2, 20]. When combined incarnation of onychomycosis and acute eponychial abscess comply with disclosure abscess, excision of abnormal tissue eponychial hypergranulation and focal necrosis, and removal of the nail plate, enlarged partial marginal matrixectomy in the ingrowth area are performed. When combined with onychomycosis and nail incarnation acute eponychial abscess, an autopsy ulcer, excision of abnormal tissue eponychial hypergranula- tion and focal necrosis, and removal of the nail plate, enlarged partial marginal matrixectomy in the ingrowth area are made. Other patients (the control group) underwent a typical nail removal – operations such as Dupuytren's: complete removal of the nail plate under the guise of ‘classical’ pulse therapy by itraconazole and terbinafine [13, 21]; in 45 cases this inter- vention combined with simultaneous excision of the modified cuticle and plastic – operations such as Bartlett (plastic local tissue) and Mele- shevich. The processes of destruction of the nail in patients with trichophyton onychomycosis and type 2 diabetes mellitus / metabolic syndrome is much faster and is characterized by a more pronounced morphological variants of mycotic nail destruction that determine the occurrence of secondary ingrowth and attachment with intercurrent flora with the emergence of der- matophythoma with centres of decay and ne- crotic foci in the nail bed. A nail extirpation and partial marginal ma- tricectomy mechanical carving and diathermo- coagulation with the further scraping off by the Folkman’s spoon were carried out; dermato- phytoms and stratification on a nail bed were deleted. Sanation of other nails for prevention of mycotic reinfection was carried out by ciclopirox nail lacquer [11]. Application of sys- tem enzymic protheolitical therapy allows to considerably improve the primary results of holiatry of the complicated subnail hyperkerati- nization, diminish a perifocal edema and in- flammation; stimulate the necrolitical and re- parative processes in an operating wound that clinically shows up to the accelerations of its granulation and epithelization; accelerate cic- atrization of surface, abbreviate the terms of temporal non-operability. For patients with type 2 diabetes mellitus (the main and comparison groups) with polyonychomycosis and derma- tophytoms as well as secondary ingrown nail, subnail hyperkeratinization were performed for certain significant [20] reduction of the hOMa- index of function and the increase of the HOMA- index of insuline resistance. The chart of holia- try applied proved the effectiveness of treat- ment of bad resistance cases of destructive a. R. Vergun et al. 39 Su r g ic a l D iS e a Se S iSSN 2413-6077. iJMMr 2017 Vol. 3 issue 1 a. R. Vergun et al. poly onychomycosis by a subnail hyperkeratini- zation and secondary ingrown nail, in particular for patients with the type 2 diabetes mellitus [9]. Arguing that the removal of the nail plate in the patients with destructive onychomycosis with secondary incarnation nail advantageous- ly carried out through onycholisation structure with simultaneous correction of pathological bed changes and cuticle, which in combination with antifungal treatment provides positive dynamics of regenerative type cytologic picture and shorter healing onychectomy wounds in 18 – 27 days to 12-25 days, with good early and long-term results. The type of transaction cy- tograms of onychectomy wounds in the study group on the 10th day of post-operative period is defined as the regenerative-inflammatory in 24.81%, as regenerative in 75.19% (p=0.031). In these embodiments, in the control group the indicators were respectively 53.12% and 46.88%. The advantage of regenerative option of cyto- logical picture proves the correct choice of treatment strategy and accelerates wound healing after removing nail in patients of the main group. the factors that influence the oc- currence and progression of incarnations, and disease recurrence after surgical treatment require further study [3, 4]. We have studied the results of onychocryp- tosis surgeries of surgical type 1 correction in 84 patients, type 2 – in 66 patients, type 3 – in the other 50 cases, type 4 – in 42 persons, type 5 – in another 27 patients, type 6 – in 56 patients (with the use of our modification of surgical treatment). Three types of trichophytosis have been differentiated: frontal central – with ero- sion of up to 25% of nail area, subtotal – from 25 to 70% (without touching upon growth area), total – from 70 to 90% (with affected growth area). In 65 mycotic trichophitis patients with secondary nail incarnation a standard itra- conazole pulse therapy was applied. The pres- ence of onycholytic focuses and degradation of hyperkeratotic areas which result in lamination of a part of nail plate proves the feasibility of performing low-trauma onychectomy for pa- tients with trichophyton onychomycosis with secondary incarnation via onycholized structure with the single-stage sequential removal of dermatophyte and ingrowth areas with changed eponychial folds. Relapse causes after Meleshevych, Emmert-Schmiden, Bartlett sur- geries were technical faults of surgical tools, intraoperative nail bed trauma, faults of post- operative anti-relapse treatments, surgical area trauma, wearing tight shoes, non-compliance with doctor’s recommendations for correction of orthopaedic pathology, onychomycosis. We believe that the less traumatic removal of nails through onycholysis should be pref- ered, particularly after such treatment, the patients with diabetes mellitus experienced healing time of operative wound (crust forma- tion) during 16-23 days (average healing dura- tion is 19 days) and had the indices tend to the control group; indices of the patients with dia- betes and ‘classical’ nail removal (onicectomia) were normal in 24-30 days (average healing duration is 26 days), indices of the control group – in 14-22 days (average healing duration is 18 days). Conclusions In all cases of mycotic onychocryptosis (secondary ingrown toenail) the patients un- derwent a comprehensive treatment of comor- bid pathology corrected by the systemic anti- mycotic therapy and terbinafine antifungal liniments, ciclopirox nail lacquer and surgical methods for removing nail plates, supple- mented the eponychial resections and partial marginal matrіxectomy. System therapy of itraconazole before op- erative treatment (basic onychial defeats sana- tion) and in a postoperative period was carried out. Patients with combined pathology got 4-5 five-day system ‘pulses’ of 400 mg/day itra- conazole therapy. In patients with primary advantage of pro- viding low-impact methods of nail excision with access via onycholisation structure a nail extir- pation and partial marginal matricectomy mechanical carving and diathermocoagulation with the further scraping off by the Folkman’s spoon were carried out; dermatophytoms and stratification on a nail bed were deleted. Sana- tion of other nails for prevention of mycotic reinfection was carried out by ciclopirox nail lacquer. Methods of surgical treatment of uncom- plicated onychogryphosis and onychogryphosis complicated with recurrent nail incarnation have been improved considering patho- and morphogenetic properties of destructive onychomycosis; removal of the mycotic af- fected nails of these patients should reasonably be conducted through onycholized structures with simultaneous removal of dermatophyto- ma, hyperkeratosis, and ingrowth areas with hypergranulation. Type of onychectomy wounds cytograms in the study group on the 10th day of the post-operative period was 40 Su r g ic a l D iS e a Se S iSSN 2413-6077. iJMMr 2017 Vol. 3 issue 1 proved as the regenerative-inflammatory in 24.81%, regeneratory in 75.19% (p=0.031). 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