(music)>How are my toes doing? This is Jonathan, aka the Toe Bro, and I’m back with another video with me kind of discussing what’s going on. There’s always been a lot of comments on the videos and unfortunately in the last two, three weeks I’ve been pretty poor at responding to all of you guys, so I really apologize for that. I’m gonna try to set a time aside every single day to answer Facebook messages, Instagram messages and of course YouTube comments. So again look out for my responses because I’ll be trying to be on top of that because I really want to answer as many questions as I can for you guys. So today is the video of the last surgery I ever performed in my old office. If you haven’t seen it check it out. It’s called “Leaving my Dad’s Office Forever”. It was a pretty emotional video, and I just from the bottom of my heart, I want to thank all you guys for all the amazing comments and support and messages on, on YouTube, Facebook, email… It’s been incredible and it really gave me a lot of strength to push forward and and have a positive attitude while going through all the move. So here’s the procedure that I did on my last day. It’s an elderly woman. She’s suffering with a very painful, thickened toenail. She’s had this for many, many, many years, and she’s tired of it. It’s been causing problems in her shoes. It’s hard to cut. She doesn’t like the look of it. So when we see a thickened toenail like this, there’s only two things that we can do: a conservative treatment or more of a permanent procedure. The conservative treatment consists of us trimming the nail as short as possible and using my electric file with that watered spray to file the nail down as thin as possible. This is called “nail debridement”. This is gonna make the toenail much thinner but much shorter as well because of half of that nail’s probably lifted off the nail bed. That’s the only thing you can do because we’re not stopping the nail from growing. So, so repetitive treatment is required to maintain this toenail. The other option is to remove the toenail completely. This is the surgical procedure we’re doing today. There’s going to be no more nail growing back. That’s because we’re using a chemical called “phenol” to kill the nail matrix, which creates new nail cells. So by destroying this nail matrix, no more nail, no more conservative treatment, or nail trimming. No more worrying about the toenail and that’s what the patient wanted today. So a quick little insight about the injection itself. Each toe actually has four nerves; two on the top, two on the bottom. So what we do is we have to do two injections, one on either side of the toe. I go on one side of the toe and I put the needle in and drop a little bit of anesthetic to numb the first nerve then I go deeper down to the bottom of the toe to numb the nerve that’s right underneath the top nerve. Then we go to the other side of the toe and do the exact same thing: numb the top nerve then go down to the bottom nerve and that’s why there’s two injections needed at the top and bottom the foot. That’s all you need to do. If you do that, the whole toe will be numb. A lot of people are worried about the injection that it’s super painful or if had experiences where they’re super painful. Technique plays a big part and the equipment that you’re using . The thinner the needle the less pain you’re gonna get. Actually the slower you inject, the less pain you’re gonna get. You’re not forcing all this fluid to fill up the toe very, very fast and of course technique making sure you’re in the right placement will make the injection bearable. Of course everyone’s pain threshold is different. Some people have no problem with the injections, some people find it very very painful. But the truth of the matter is once the toe’s numb, you don’t feel anything so it’s a little bit of sacrifice for a bigger result. I’m still waiting for a few pieces of furniture for the new office and once the office is set, I’m gonna give you guys all a tour, so don’t worry you guys are gonna be seeing the new office very, very soon. Just want to give a little shout out to my new Toe Bro instruments. They’re in. I got two lines. I’m showing you the fancy line right now, the upgraded line. I haven’t updated the product photos for these tools but they’ll be up there in one to two days. But check them out. They’re the same tools I’m using in my office now. So if you guys are looking for something that’s a little bit more heavy duty to help either in your personal life or if it’s for professional use, these things can do the job. Take a look. I appreciate all the support. So what you guys don’t see is after the injection, I bring in a tray. I set up all the equipment, I create my sterile field, pull out my sterile instruments, and then I test the toe. Once I know the toe’s completely numb, then I put on the surgical gloves, get ready to put on the tourniquet. So the tourniquet, as most of you know (laughs) because my “toes” are pretty good, is to push out the blood in the toe and we’re doing this for a few reasons. Number 1, we want to have a bloodless field so the chemical that we use does not get diluted. If the chemical gets diluted, it might not be effective and allow for a regrowth so that’s number one and probably the most important reason we want to have the acid work to kill the nail so it never grows back again.
The second thing is we want to have as little blood in the area while we’re working so we can see everything very, very well. If it’s too bloody, it’s hard to see if there’s any piece left behind and just to make sure we clean the toe really well. The last reason is probably just to reduce the amount of blood loss during the procedure. There’s no need for someone to bleed out or have excessive bleeding with this type of procedure so the tourniquet does control that. Once the tourniquet is on and the toe has been wiped down with an antibacterial scrub, the first step is to separate the nail from the nail bed. We’re just doing this to make the procedure as least damaging to the tissue as possible. Even though we’re gonna be removing the toenail permanently, it’s still good to be gentle. If you have a normal toenail, and you have a nail surgery like this and it’s very rough or there’s a lot of damage to the nail bed while they were removing the nail, this will cause the nail to grow back thick. This is the main reason why toenails grow thick and that’s because of damage. Whether you drop something on your toe, you wear tight shoes, or you have you know some sort of rough procedure done, it will cause the nail to grow back thick. Nails are so fragile and once the nail grows thick, it’s always gonna grow thick so This is something to keep in mind, guys, to keep your toenails safe from trauma. So this is the instrument I always used to remove ingrown toenails or even to cut a thickened nail in half for my nail surgeries. It’s called an “English anvil”. But for some reason, this procedure, this nail, I could not cut through this nail. It was so thick and so hard I even resorted to holding the instrument in two hands which is something I don’t normally have to do, but it would not cut it so I actually had to improvise I had to get another nail nipper, my everyday nail nipper, to actually trim this nail in half just because it was too, too, too thick. Sometimes I will cut the nail in half, like I’m doing now, and then remove each half separately . Sometimes I remove the whole nail in one go. It all depends on how tight the nail is, how thick, and how damaged. I just filmed another surgery of removing a very long, thick, and damaged toenail and I left that in one piece I guess just for a dramatic effect but because we’re removing a nail permanently, it doesn’t really matter how you get the nail off. Again, if we were removing this nail and allowing it to grow back, it’s very important that you’re very gentle. You don’t just rip the nail out and that’s where I definitely would cut the nail in half and take my time with each side. So after removing the toenail, I’m just making sure that there’s no leftover nail left behind. I’m trying to remove any tissue, hardened callous that has formed over the many years of pressure between the nail and the nail bed. So just trying to create a really clean environment. I try to dry the area as well since there is a little bit of blood, which is normal after exposing the nail bed as we have even though there’s a tourniquet. So the goal, like I said, make it nice and clean. Make sure there’s no nail left behind. Reduce any sort of bleeding and that way it will be prepared and ready for the acid. So the patient is completely numb. They’re not feeling a single thing so that’s why you can take your time and make sure the area is prepared carefully and nothing’s left behind. This will lead to a more successful post-operative look for the toe. So now I’m applying the acid. So number one: one of the most common questions is “What kind of acid am I using?” It’s something called “phenol”. It’s a very, very strong acid and it’s basically causing a chemical burn to the nail matrix and these are the cells responsible for growing nail. So by us damaging the nail matrix, there’s gonna be no more nail. We normally do three to four applications of the acid for around 30-45 seconds to even a minute. I tend to be a little bit more aggressive with the acid just because I don’t want any chance of a regrowth. Again, it’s very important that there’s very little to no blood in the area, or else it will dilute the acid. So as you can see the tissue is turning white and that is the reaction with the tissue to the phenol acid. It is very, very strong so you have to be very careful and what we use after we’ve applied the acid is rubbing alcohol or isopropyl alcohol to neutralize the acid, just try to limit the amount of damage that’s created with this chemical. Some of the questions that I always see on these videos is ,”Will the nail grow back?” No. The purpose of this procedure is to stop the nail from ever growing back. It’s possible that we might have a little regrowth, but it’s very rare. The next thing that always people ask is, “Will it affect the way you walk?” No. The nails don’t really help us too much with walking as it did in the past. Before the nails would help our feet and hands grab, grip, but because we’re wearing shoes, we live in a different time period, we don’t really need our nails too much for walking or for stability. The one thing that the nail really does, it does protect the nail bed. So let’s say something sharp was to fall directly on your toe. Yes, you wouldn’t have any protection. So let’s say a knife fell with a point down right on the tip of your toe then yes, you wouldn’t have any protection but beside that the nail doesn’t really help you too much. Another interesting question I always see is about the pain after this procedure. So the toe’s going to be numb for around 6 to 10 hours. I use a longer acting anesthetic just to give the patient as much relief as possible. When it does wear off, it’s the first 24 hours where you have people feel a lot of throbbing or pulsating sensations in their toe. Once that comes down after the 24 hours, the toe’s really most sensitive due to pressure. So as long as you’re not wrapping your toe too tight or wearing tight shoes, it’s a manageable discomfort. Most people just need to take extra strength Advil or Tylenol. I am NOT able to prescribe strong pain medication. But if I’m doing a procedure where I know there’s gonna be a lot of discomfort or very large removal of tissue, this is something where I would tell the patient and write a little note to go to their family doctor to get the appropriate pain medicine, uh, before the procedure and that’s gonna help them with the discomfort level. And again, just to go over that some people say, “Why would you ever want to have your toenail removed?” Again, this thick toenail was causing her pain. She’s an elderly woman, and she’s tired of the discomfort, so if she wanted to have it conservatively treated, she’d have to be coming in every two three months for routine care. She did not want that; she just wanted the toenail gone. And it’s a great option because there will be no more new nail to cause you discomfort or pain in your foot where once the healing process is complete, you’re good to go. No care needed. Nothing to worry about anymore.
People think it will look funny from first glance. Actually the nail bed becomes a little bit firm and smoother, almost like a slight scar. So it almost looks like a false nail. So overall it’s a much better look than having this thickened, deformed nail. Nails again are very, very sensitive. They get damaged, you drop something on them, you get stepped on…this could make your nail grow thick for the rest of your life. So instead of dealing with this deformed, thickened toenail, here is a one permanent solution: to have this procedure done. And the last topic I’m gonna get to is just the cost of it because I do see it come up every now and then. In Ontario, my services as a chiropodist are not covered by OHIP, which is a provincial health care plan. So most people have sort of, sort of health insurance or work insurance to pay for this procedure. This procedure costs, in my office, starting at around four hundred and seventy five dollars. (Canadian dollars) That would include the consultation, the surgery, and two follow-ups afterwards. I don’t know how much other people are charging in my industry. I know it’s roughly the same, so I’m not too far off. But it’s a relatively simple procedure; it takes around 20 minutes from start to finish. And you walk right out of the office and you pretty much can continue your normal daily activities after 2-3 days. Only thing you really have to do is just make sure you dress the toe very well for the first one to two weeks until we get a scab. Once we have the scab form, you guys are good to go. So I really appreciate all the help, the love, the support. As you can see, the channel is growing like crazy! We’re gonna be at 80,000 toes very ,very soon! It’s crazy to think back that I posted my first video on April 30th! So it’s almost gonna be one year, and I’m so close to that hundred thousand in one year! So it’s crazy, crazy how much this channel has grown. So again, I really appreciate all the love and support. I wouldn’t be anywhere without you guys. So I’m hoping to do another livestream at the end of this month. I’ll give you guys a little heads up before but probably the last week of this month I’m gonna do another livestream so hopefully you guys can join me for that. I got my new instruments in; they look amazing! I haven’t updated the pictures on my website, but please check them out. They are so, so beautiful. I’m gonna say it, “They look sexy.” I got two lines. I got a standard line and then a little bit more of a fancy designer line just to give that little, upscale look. They’re professional nail nippers. They’re the same ones I’m using in my office now. I’ve changed all my equipment, so I’m really excited so you guys take a look. Thank you for all the support. You guys take care. Toe Bro out.