Toe Bro: What's up, guys? How are my toes doing out there?
This is Jonathan AKA The Toe Bro and I am back for another video.
It's been a long time since my last video so I really apologize for that, guys, it's been a pretty busy month.
I was doing a little bit of traveling, some for business, some for pleasure but I'm back and I'm here to give you guys
something new, something exciting - another surgical procedure.
Before we get started with the surgical procedure, I just want to say thank you for all the support,
all the love, all the likes, all the comments, all the dislikes, all the criticism.
I'll take it all, I'll take everything I can get from you guys. I tried my best this week to respond to as many
comments as I could and give you guys as much info, the support and the interaction has been amazing.
I can't believe how much these videos are growing and it really motivates me this month to put a lot more content out so I'm trying to working on--
I'm trying to work on scheduling more content on a more regular basis.
I have, like, 40 or 50 videos I filmed over the last month/two months of all these different procedures, surgical procedures,
routine care, thick nails, corns, calluses, whatever I've been doing in my office, I've been trying to film it
so it's now just a matter of me sitting down, editing them and making them really presentable and informative and fun for you guys.
So based on the feedback from you guys, I'm gonna do something a little bit different with this video.
I'm just gonna go right into it, no music, talk everything out, explain what's going on,
keep it simple, let you guys be able to hear me clearly
and then we'll see how you guys like this one and, from that, we will decide what the next video is gonna be like.
We have a really exciting, interesting case today so let's go into a little bit of a background information on the patient:
So we have a young mother of three. She's early forties, all her-- her patient-- all her children have seen me,
she had great results with her children with the issues that they had - some foot pain, some--
some plantar warts, everything's gone so she's suddenly starting to complain of some pain herself in her right fifth baby toe.
So in the first appointment, we take the look at her foot and we could see
this yellow hard circular lesion on the inside of a right baby toe so, from first glance,
it looks pretty much to be like a corn and a corn is usually hard skin with a little central
core portion that's caused because of too much pressure from the baby toe
touching the other toe and this is usually caused because of tight or narrow footwear.
So our patient today, she's-- loves wearing high heels, loves wearing pointy shoes so from the background
information and just from first glance, it really does look to be a corn-- to be a corn so
how we normally treat corns is we remove as much of the dead skin, we try to enucleate or
core-- or take out the core from this yellow hardened portion and that's what's gonna give the patient relief.
So, during that first treatment, as I was removing the core, I found that it was extremely soft
and it wasn't a perfect circle and it was very fleshy and normally a corn is pretty firm and just hard dead skin,
so even though it's between the toes and there's a lot of moisture, when I'm usually taking out a corn it is a hard core of dead skin.
So when I noticed that it was a little bit fleshy and soft not like a typical corn,
a few flags went off in my head and I said, you know, "how long have you had this?"
and it was just a recent time, she said, you know, "just a month or so"
and she's been wearing high heels for a long time so, again, something that just popped up.
I asked her if there was any new shoes, any new activity; nothing changed.
I'm very honest with my patients so-- and I'm very open and I speak out loud to them so I told her right away,
"I have a feeling this may not be just a normal corn"
and she asked, you know, "what could it be?" I said, "you know what? I have a feeling it could possibly be a wart"
and she says, you know, "my kids had warts, I've seen warts before, don't they have tons of little black dots?
Don't they look a little bit different?" and I said, "they do but because of the location,
you know, the fact that it just popped up, the way the fleshiness of the-- of the lesion that I just took out,"
I said, "it doesn't seem like a normal corn."
So, this is the game plan - we're gonna try to treat it like a corn, we're gonna try to avoid tight pointy shoes,
we're gonna add a spacer in between. I'm gonna see how it grows back or how it feels with time.
If it comes back very quickly, with a lot of pain and if it still has this fleshy look to it,
even though you're wearing better footwear, I feel that it may be a wart and we might have to surgically remove it.
So, sure enough, after a week or so, I get another call--
office gets a call from her saying, you know, "the pain's back, the lesion has fully filled up."
So even though we removed quite a bit amount of that dead skin, she says that it filled up, it's flat again, it's very, very painful.
Even when I do normal corns, when when we remove the corn, there should be relief for at least a few weeks, more than--
more than just one week. So I told her, "you know what? I think that's a sign
that we might have to do a surgery to surgically remove this lesion and
possibly get rid of this wart that might be here, okay? Cause it's not normal for a corn to react like that."
We booked an appointment where she knew ahead of time that we're gonna do the procedure,
so what would happen with any sort of excision for this kind of lesion - the toe would be numb,
she doesn't feel anything from the procedure, she's able to drive home
and she's just ready for a little bit of discomfort possibly for the first couple days
and for the toe to be a little bit sore for the first week. So we booked an appointment
knowing what was about to happen and let's continue with the video seeing how the whole procedure works from start to finish.
So here we are, guys - we're in office about to do the procedure so the first thing we got to do
is freeze this baby toe.
So, a little background information on-- on how to freeze a toe - so actually each toe has four nerves:
two on the top,
two on the bottom.
So what we're going to be doing is injecting from the top of the toe
to freeze the top nerve, what will happen after we freeze a top nerve (is) I push the needle a little bit deeper
to reach the bottom nerve on that same side.
So to completely numb a toe, we have to do two injections on either side of the toe, we drop freezing on the top portion
and on the bottom portion on that one side and this will completely numb the toe
and there will be no pain or any sensation during any sort of procedure.
So what I'm using is a mixture of anesthetic, a short-acting anesthetic that-- that kicks in very fast
with a mixture of a long-acting anesthetic so this is something that will
allow the toe to stay numb for up to 10 to 12 hours.
So the reason I use this kind of mixture is to allow the patient to have very little to no discomfort after the procedure.
So, as you can see, it's very quick, very simple - toe's numb.
After the injection is complete and I've tested the-- the toe to make sure it's completely numb,
I will prep all my instruments and I get everything ready and off we go.
So what I'm putting on right now is a tourniquet and this tourniquet is very important anytime I do any sort of
surgical excision or removal of a potential growth.
The reason for that we want to minimize the amount of blood loss during the procedure and I also want to have
a very clear vision of the field that I'm working in. Any time a lesion is bleeding too much, it's very hard to see
the area that you're working on to make sure that you've removed any sort of bad or unwanted growth,
so by having this little bit of a tourniquet on the toe is gonna accomplish all those things.
Little to no blood loss and I can see the area I'm working in very clearly.
The tourniquet is on, it's secure. I'm just wiping down the toe with an antibacterial disinfectant.
Now it's time for the fun part.
So what that is is starting to prepare the area for the removal of this mass so the way I do that is by using
a scalpel blade and I lightly score an area around the lesion and I leave around 2 to 3 millimeters of healthy skin
just outside that bad circle to make sure we get everything out.
So what I'm doing right now is lightly scoring the skin just to create a little bit of an incision
where I can use a curette to pull out this lesion.
I'm not going deep; the problem is if you go too deep, you might cut into deeper tissue
and create more of a scar or wound than we really need to.
If this is a wart - which I really do think it is - we just have to pull off the wart from the bottom layer of the skin.
So, right now, I'm taking out the curette, I'm putting it in the little groove that I made and I'm starting to pull
the wart off of what we call "the basement membrane."
The moment I started to lift the lesion, I was 100% confident that it was truly a wart and the reason for that:
a wart, when we excise it or cut it out, it's an encapsulated mass so, as you can see, it's basically a lump of very hard firm skin.
It comes usually off in one piece with good technique, I literally just have to scrape or pull the wart
off the basement membrane and it should come off in one piece.
The reason that there's a little bit of blood that's because a wart is full of vascular tissue.
A wart is a virus and uses the body's blood supply to grow and multiply so it's normal, even with the tourniquet,
to have a little bit of bleeding but, as you can see, there's no steady blood flow once I get that mass out,
there's very little to no blood.
So what I'm doing now is I'm cleaning the area, removing as much of that warty tissue
that was attached to this area from the healthy skin and you can see how important it is to have a good tourniquet -
this is what's gonna allow me to see that all that's left behind is normal tissue.
The basement membrane is a nice thin layer of white tissue, it's very, very smooth and so
I can see that I'm on the basement membrane, I'm pulling off all the dead warty tissue that's around the area, making sure that there's nothing left behind.
We want to stay above this layer of skin, underneath this layer that's where all the fat cells are,
that's where the muscle and deeper structures can be found.
Once we go past that level, that's where we can definitely increase our chance of having a scar or further damage to structures that don't need to be affected.
So, at this point, I've continued to clean out the area, I feel pretty confident that there's nothing left behind,
it's looking much healthier, there's no blood. So once I'm confident that everything is out, there's no more potential warty tissue,
I'm gonna apply two things to make sure that this wart tissue doesn't grow back -
number one is electrocautery and I'm using a disposable electrocautery tool that will
control temperature, burn or damage that tissue, ensuring that any wart tissue left behind is killed
and, after that, I'm gonna be applying a chemical called Phenol
and this is the same chemical I use during my nail surgeries to prevent any nail from growing back
and the reason I use these two steps is really to try to eliminate the chance of a regrowth.
Even when performing a surgery like this, it's-- it's possible for the wart to grow back
so the more aggressive I am now with removing as much tissue as I can
and then applying electricity and an acid will help increase our chance of the wart never coming back.
The wart has been removed, I don't see any warty tissue left behind, I used the electrocautery,
I used the chemical cautery to try to kill any remaining wart tissue, so all that's left now is just to dress the wound.
So, again, I'm using Betadine, or call it Iodine, which is an antibacterial ointment that will help try to prevent any sort of infection
and keep the area relatively dry during the healing process so I'm gonna apply a gauze and a self-adhesive wrap to-- to cover this toe.
So, this patient's gonna be numb for the next 10 to 12 hours. When the freezing wears off, she might feel
a little bit of discomfort, throbbing sensation in the toe but as long as she wears open-toed shoes,
there should be little discomfort. The hardest time would be the first 24 hours,
that's where she usually-- a patient usually feels the most discomfort
and then it really just goes down after that, it just really depends on the matter-- the type of shoe she's wearing
and how much pressure she's putting on this toe.
She's gonna be using an ointment that I prescribed for her twice a day every day until she comes back to see me for 1 week.
After that, we should start to see a scab to form and she'll be coming back to the office
usually 3 to 4 weeks after that and, by then, we should see pretty much a healed area with a scab
and that's really gonna give us the first look to-- to see if there's any warty tissue left behind.
Sometimes, if there is, we do a second round of treatment but I usually don't do another surgical procedure;
it'd be something like an-- an acid, a topical treatment or laser treatment that I offer in my clinic.
So there you guys have it, another procedure done.
Something a little bit interesting, at least to me that is.
Looks, from first glance, it looks like a corn, a very common place for a corn but ended up being something very different.
Not a very common place to find a wart but it was.
We were able to handle it effectively, efficiently. Wart's gone, patient's feeling great and
hope you guys enjoyed seeing something a little bit different, hope the video's a little bit more enjoyable,
it wasn't distracting without any music, very, very simple.
So I have the next video planned and I'm thinking of doing a nail cutting of extremely thick and long nails.
I just recorded it 2 days ago and I'm gonna probably leave the voice-- the banter in between me
and the patient because people always love to hear that natural environment.
So that one I'll put out pretty quick because it's not gonna take too much editing.
So, again, thank you guys for all the love, all the support.
Give me the feedback, I'll be watching, I'll be listening, I'll be responding.
You guys are great.
Toe Bro out!