1) A marking pen is used to identify an incision site which is equidistant to the adjacent metatarsal heads.  Cross hatches are made to align the incision site during closure.

2) A bold incision is made through the dermal layer using the belly of a #15 blade.

3) Dissection is carried through the subcutaneous layer with care taken to identify and preserve all neurovascular structures.  Ligation is performed if necessary.  I use a metzenbaum scissor during this component of the procedure.

4) A Weitlaner retractor is used to GENTLY retract the superficial tissue.  It can also aid in mildly separating the adjacent metatarsals.  Laminar spreaders can also be used here.

5) Plantar pressure helps to reveal the main body of the enlarged nerve.

6) The deep transverse metatarsal ligament is identified.

7) A Metzenbaum scissor is used to transect the ligament.

Many physicians feel that releasing the ligament will suffice in instances where the problem is not advanced.  I feel that once a nerve is invested in scar tissue, neurectomy and excision is required.

 8) Dissection is carried out to isolate the most proximal portion of the nerve.

9) Once non-bulbous appearing nerve tissue is identified, a proximal neurectomy is performed.  The actual severance of the nerve is done with a sharp #15 blade.

10,11,12,13,14) Dissection of the common digital nerve is carried distally until the individual nerve branches are identified.  If the nerve has been clamped, the neurectomy is performed distal (in this case) to the site.

15) When removing the neuroma, it should be dissected free of the underlying fatty tissue.  This is important to prevent ischemia to the plantar pad.

16) Final Specimen