Ship-shaped resection with nail matrix destruction: an improved and aesthetical surgical approach for grade II/III ingrown toenails

Abstract

Background

Ingrown nails may cause progressively aggravated pain, discomfort and immobility. We modified the traditional Winograd procedure and proposed an improved surgical method which is ship-shaped resection along with nail matrix destruction. We evaluate the clinical outcome of this improved approach, especially in terms of recurrence and healing time as well as the aesthetical outcomes.

Methods

We retrospectively analyzed the outcomes of 200 consecutive patients with grade II/III ingrown toenails were operated using this method from November 2020 to November 2022. Follow-up data were obtained from routine outpatient clinic controls at postoperative days 1, 14, 30 and 90, as well as a follow-up phone call 1 year after the surgery.

Results

The average operation time was 30 min (range 20–33). There was no important complication except some bleeding. All of these cases were managed well with a complete recovery. The healing time was 12.5 days (range: 10–18). In addition, patients returned to their daily activities in approximately 5 days. Besides, 165 (82.5%) were very satisfied, 35 (17.5%) were satisfied, no patients were dissatisfied. Besides, the recurrence rate was 1% (2 patients) and postoperative local infection was observed in 3 patients (1.5%). 193 (96.5%) patients reflected the appearance after surgery was esthetic, 7(3.5%) patients for moderate and no patients for unesthetic.

Conclusions

Thus, we can conclude that this improved surgical procedure is a promising method to treat grade II/III ingrown toenail with less scarring, aesthetic appearance, low recurrence rate, rapid healing, and high patient satisfaction.

Introduction

Ingrown toenails are one of the most common nail conditions, especially in adolescents and young adults, accounting for approximately 20% of patients for foot diseases [1, 2]. It occurs when periungual soft tissue is compressed and traumatized by the lateral nail edge, causing chronic suppuration and inflammation. Ultimately, long-term chronic inflammatory reaction results in pain, suppuration, foul smelling as well as soft tissue hypertrophy adjacent the nail plate [3]. Some risk factors for ingrown nails have been identified involved in anatomic abnormalities, repetitive toe trauma, constricting shoes and improperly trimmed nails [4].

Ingrown nails may cause progressively aggravated pain, discomfort and immobility if not properly managed [5]. However, there are still no consensus on best therapy for ingrown toenails even though various methods available, such as taping, packing, nail extractions and electrosurgical or chemical nail matrixectomies [4, 6]. Clinical classification based on severity may help guide the course of treatment. Heifetz classification is commonly used in evaluate the severity of the ingrown nails [7]. Grade I (inflammatory phase): mild redness, swelling, and tenderness in the lateral nail fold; Grade II (abscess stage): local redness, severe tenderness, obviously swelling nail fold and purulent secretion with foul odor; Grade III (granulation stage): formation of abscess and granulation tissue covering the lateral nail fold [8]. Generally, conservative treatments are recommended for mild ingrown toenails (grades I), while surgical approaches are typically applied in those moderate or severe cases (grades II/III) [9, 10]. Previous studies indicated that surgical interventions are superior to non-surgical interventions in preventing recurrence [11, 12]. According to surgical techniques, the pressure of the nail plate on the nail fold is eliminated, which could extremely remove the repetitive trauma and chronic inflammatory reaction. Numerous surgical procedures for ingrown nails have been proposed including Ross procedure, Winograd procedure, Zadik procedure and Vandenbos procedure, of which the Winograd procedure is the most widely used technique [13]. Winograd procedure is proposed by Winograd in the Journal of the American Medical Association in 1927, which has been modified over the years [14]. It entails that partial nail plate excision, wedge excision of the nail fold with nail matrix destruction. Based on previous studies, those patients who accept the Winograd method have faster recovery time and return to work compared to those who accept the Vandenbos procedure [13, 15]. However, there are some disadvantages to this approach. Excessive wedge excision of nail plate with nail matrix destruction will inevitably result in narrow nail and the straight, rough edges of nails, which also might result in nail spicule. Besides, to fully expose the nail matrix, traditional Winograd procedure is always accompanied by the relatively large surgical incision on nail root, resulting to significant scar [16]. Furthermore, severe ingrown nail is often accompanied by excessively curve of the distal nail and invaginate into the nail bed, which is known as distal nail embedding [17]. Traditional Winograd procedure cannot solve this problem well.

Based on this, we modified the traditional Winograd procedure and proposed an improved surgical method which is ship-shaped resection along with nail matrix destruction. In this study, we will share our experience acquired from 200 patients undergoing this improved surgical method and evaluate the clinical outcome of this improved approach, especially in terms of recurrence and healing time as well as the aesthetical outcomes.

Patients and methods

The study protocol was approved by the Medical Ethics Committee of Shanghai Medical College within Fudan University (Shanghai, China) and were carried out in accordance with the ethical standards of the Helsinki Declaration of 1975. We retrospectively analyzed and compared the outcomes of 200 consecutive patients with ingrown toenails in stages 2 or 3 were operated using this method from March 2020 to March 2022. The patients diagnosed as stages II/III ingrown toenail according to Heifetz classification, and follow-up of longer than 12 months were included in this study. The exclusion criteria were dystrophic nails, onycholysis, onychomycosis, diabetes mellitus or peripheral vascular disease, cardiac insufficiency and pregnant or lactating women. Informed consent was signed by each patient before surgical intervention.

Data including demographics, history of local trauma and other predisposing factors were documented via computer-based Health Information System search. The patient was referred to the hospital for dressing change the day after surgery, and sutures were removed in 7–10 days after surgery. Follow-up data were obtained from routine outpatient clinic controls at postoperative days 1, 14, 30 and 90, as well as a follow-up phone call 1 year after the surgery. We recorded the operative time, the incidence of postoperative infection and the time required to return to regular activities. Furthermore, the recurrence and the degree of satisfaction were evaluated, and patient satisfaction was categorized as follows: very satisfied, satisfied, dissatisfied, and very dissatisfied. In addition, the aesthetic evaluation was categorized as follows: esthetic, moderate, unesthetic.

Surgical techniques

All surgical procedures were performed by the same surgeon in outpatient operating room conditions. Surgical interventions are suggested to be performed under local proximal digital block anesthesia procedure.

New surgical approach for stages II/III ingrown toenail is performed as detailed below:

• 1. After skin preparation and draping, the operative incision was marked with Evans blue, as shown in Fig. 1, the incision was designed as ship-shaped incision. The medial margin is designed along the border of the nail. The outer edge is along the outer edge of hypertrophic nail fold and granulation tissue.

• 2. Localization of proximal nail fold incision. As shown in Fig. 1, Point A is the intersection between the visible outer edge of the nail plate and the nail epithelium. Point B is located on the extension line on the outer edge of the nail plate, which is midpoint between the Point A and the intersection between the outer edge of the nail plate and the first hallux stripe. Point C is located outside point A, 1 mm away from point A. Connect point A and point B, point B and point C with markers, respectively, to form the “fore part” of the “ship-shaped incision”.

• 3. Localization of distal nail fold incision. As shown in Fig. 1, divide the nail plate into three equal parts, Point D is located on the extension line of the border line between the middle third and the outer third. The height of Point D could be adjusted based on the extent of tissue swelling. Connect the Point D and the medial edge as well as the outer edge with markers, respectively, which contribute to the “stern part” of the “ship-shaped incision”.

• 4. After local proximal digital block anesthesia with 1% lidocaine, a constricting band is applied to obtain an exsanguinated toe and clear surgical view. A vertical incision was created along the previously made marker line. The ship-shaped ellipse of soft tissue including the foreign body granuloma tissue and hypertrophic nail fold were completely removed.

• 5. Treat the curling edges of nails. Unlike traditional Winograd methods, we try our best to preserve the width of nail plate for aesthetical outcomes. In addition, in this improved approach, only the inward curling edge of the nail is removed. We do not recommend to treat nail edge routinely if the nail edge is smooth and neat. Nevertheless, if the curling edges of nails is observed, the nail plate outside the vertical line passed through point A should be delaminated and removed to ensure a smooth nail edge without any spicules.

• 6. Nail matrix destruction. Remove the skin among the Point A, B and C, then find the nail matrix by the extended incision in the proximal nail fold and destroy the nail matrix using a needle-like tungsten wire unipolar electro-coagulator unique to plastic surgery. Note that minimize the damage of peripheral tissue and normal nail matrix as much as possible. Next, a small random pattern skin flap should be created by appropriately dissecting the skin outside the line connecting points A and C, which facilitates subsequent suturing and minimizes tension.

• 7. Closed incisions with Nylon 3–4/0 sutures using “Four stitches suture”. First, suture the incision on the proximal nail fold. As shown in Fig. 2, suture site is located in the middle and lower third of the line connecting point A and point C. Then, transverse mattress suture is applied to fixate lateral margin of the nail plate on the outer edge of incision, which could help the formation of more natural nail groove. Next, suture the distal of nail plate lateral margin using interrupted suture. Finally, close the incision at the distal hallux along previously marked line to avoid the potential distal nail embedding (Fig. 1).

• 8. The operative field was applied with aureomycin ointment and wrapped tightly for good haemostasis. Noting that expose the free margin of nail to observe blood supply of hallux. The stitches were removed in 7–10 days after surgery. All patients were encouraged to wear loose shoes, and to walk and return to work or school as soon as possible.

Fig. 1

Schematic diagram of improved ingrown toenail surgery. Surgical incision design diagramed from a top-down perspective (left). Anterior view of surgical incision design (Middle). Illustration of surgical incision closure (right)

Fig. 2

Photos that show ship-shaped resection during the surgical procedure. Preoperative photo of ingrown toenail (above). Intraoperative photo of ship-shaped resection in improved surgical procedure (below). Patient 1

Statistical analysis

Statistical analyses were undertaken using STATA (College Station, TX, United States).

Results

A total of 200 consecutive patients with ingrown toenails in stages 2 or 3 were enrolled in this study. 118(59%) of these patients was male, while 82(41%) was female. Mean age of men was 29 years and 26 was for women. 96% of these patients are younger than 50 years, while only 8 patients were middle-aged and elderly patients.

The average operation time was 30 min, including local anesthesia (range 20–33). There was no important complication except some bleeding. All of these cases were managed well with a complete recovery. According to our records, the healing time of our patients accepted the improved surgical method was 10–18 days (mean time: 12.5 days). In addition, patients returned to their daily activities in approximately 5 days. Postoperative pain is one of limitations of surgical technique to manage ingrown toenail. According to our clinical experience and previous feedback from patients, postoperative pain occurs mainly within 3 days after surgery. In addition, we request routinely ask our patients to take oral Diclofenac sodium for 3 days after surgery. Thus, none of our cases reflected severe post-operative pain in this study in this study. Besides, in this study, the extent of patient satisfaction was measured based on functional, pain. According to the follow-up, 165 (82.5%) were very satisfied, 35 (17.5%) were satisfied, no patients were dissatisfied or very dissatisfied. As for the aesthetic evaluation, 193 (96.5%) patients reflected the appearance after surgery was esthetic, 7(3.5%) patients for moderate and no patients for unesthetic. Besides, the results of follow-up indicated that recurrence rate was 1% (2 patients) and postoperative local infection was observed in 3 patients (1.5%) (Table 1).

Table 1 Clinical characteristics of patients

Discussion

Ingrown nails may cause progressively aggravated pain, discomfort and immobility if not properly managed [18]. According to the electronic health records of our patients, the risk factors for ingrown toenails including incorrect nail-trimming, tight-fitting footwear, trauma, obesity, genetic factor, etc. Among them, incorrect nail-trimming is the most common risk factor for ingrown toenails. Furthermore, ingrown toenails caused by trauma accounted for a higher proportion of male patients than female patients.

There are still no consensus on best therapy for ingrown toenails even though various methods available even though various methods available [19]. Non-surgical technique of phenolization is commonly used at present, which has numerous advantages including less trauma, lower postoperative pain, and easier operation. The only fly in the ointment is that the exudative phase is too long and it has been reported that the exudative phase of individual patients is as long as 1–2 months [20]. Due to the general lack of individual medical knowledge among our patients, there is excessive fear and worry about the exudative period. We believe that patient education is needed for this approach to become widespread. Winograd procedure, the most widely used surgical technique, which has been modified over the years. It entails that partial nail plate excision, wedge excision of the nail fold with nail matrix destruction [21]. Based on previous studies, the recurrence rate of Winograd procedure is much lower compared to that of only nail plate excision. However, there are some disadvantages to this approach [22]. Excessive wedge excision of nail plate with nail matrix destruction will inevitably result in narrow nail and the straight, rough edges of nails. Besides, to fully expose the nail matrix, traditional Winograd procedure is always accompanied by the relatively large surgical incision on nail root, resulting to significant scar. Furthermore, severe ingrown nail is often accompanied by excessively curve of the distal nail and invaginate into the nail bed, which is known as distal nail embedding [17]. Traditional Winograd procedure cannot solve this problem well. Besides, traditional procedure performs matrixectomy via solely surgical curettage, which might not be enough to completely destroy the productive center of toenail, causing a relatively high recurrence rate of the ingrown toenail [23].

The ideal approach should be along with a low recurrence rate, have a short interval of return to normal activity, and be easy to operate. Besides, normal appearance and esthetical outcomes were also important for ingrown toenail patients after operation. Based on the above, we modified the traditional Winograd procedure and proposed an improved surgical method which is ship-shaped resection along with nail matrix destruction. In our case, the ship-shaped ellipse of soft tissue including the foreign body granuloma tissue and hypertrophic nail fold were completely removed (Fig. 2). In addition, there was only a linear wound without tension after suture in the proximal nail fold, which greatly reduced the formation of postoperative scar and prevented delayed complications associated with wound healing. According to the results, all patients were satisfied with the outcome of toenails after the new surgical method and the condition of ingrown toenail was improved significantly after surgery (Fig. 3A–D). Besides, the time to return to normal activity was short, and recurrence and adverse reactions rates were relatively low. the recurrence rate of traditional Winograd procedure was reported to range from 7.7% to 17.7% only with the surgical curettage of nail matrix, which might be related to incomplete destruction of the productive center of toenail [24, 25]. In addition, in our improved method, we fully expose the targeted toenail matrix by the tiny incision and destroy the nail matrix using a unipolar electro-coagulator, which could destroy the germinal matrix precisely at the target with decreased risk of damage to the surrounding tissue. According our investigation, both of the two recurrent cases occurred within 2 months after the surgery, which were due to premature strenuous activities after surgery, which caused swelling in the operation area, leading to re-ingrown of the lateral edge of toenail. Examination in outpatient demonstrated that repeated friction between the deck side edge and the incision resulted in local granulation. Thus, extreme activities should be avoided including strenuous running and jumping, some ball games, such as basketball, football and tennis. Because these activities can lead to excessive local wound tension and increased risk of bleeding, causing ultimately poor healing. In our recurrent cases, one patient was cured by wadding cotton between nail plate and nail fold, and the other one accepted another surgery which removed excrescent soft tissues.

Fig. 3

Photos that show postoperative outcomes of the improved surgical procedure. A Preoperative photo of ingrown toenail. Patient 2. B Postoperative photo of toenail in 90 days. Patient 2. C Preoperative photo of ingrown toenail. Patient 3. D Postoperative photo of toenail in 90 days. Patient 3

The proximal nail fold incision is designed via Point A, B and C, which forms “fore part” of the “ship-shaped incision”. Point A is the intersection between the visible outer edge of the nail plate and the nail epithelium. Point B is located on the extension line on the outer edge of the nail plate, which is midpoint between the Point A and the intersection between the outer edge of the nail plate and the first hallux stripe. Point C is located outside point A, 1 mm away from point A. The advantages of this design are as follows. First, this incision could help more fully expose the nail root and the nail matrix. Besides, removing the skin among Point A, B and C are beneficial to cosmetic suture, avoiding “dog-ear” deformity in the end of incision. Furthermore, a small random pattern skin flap is created outside the line connecting points A and C, which facilitates reduce tension and minimizes scar.

Furthermore, narrow nail after surgery and straight, rough edges of nails are one of the most troubling problems for those patients who accepted traditional Winograd procedure due to excessive wedge excision of nail plate. Narrow toenail plates and flattened nail grooves greatly compromise the aesthetic appearance of toenails. In the improved method, we try our best to preserve the width of nail plate for aesthetical outcomes without compromising the effectiveness of the treatment. In addition, only the inward curling edge of the nail is removed and other normal nail plate as well as nail matrix were preserved, which greatly improved the problem of narrow nail after surgery. Besides, transverse mattress suture is applied to fixate lateral margin of the nail plate on the outer edge of incision, which could help the formation of more natural nail groove. According to this study, up to 100% of the patients were satisfied after the surgery and 96.5% patients reflected that the appearances of toenails were aesthetic after surgery, which was higher compared with previous studies.

Besides, distal nail embedding is common in severe ingrown nail. The improved method could also solve the possible distal nail embedding, which is characterized by excessively curve of the distal nail and invaginate into the nail bed [17, 26]. In this study, we proposed ship-shaped incision. As described in the above, some skin in the distal of toenail is removed in the “stern part” of the “ship-shaped incision” and the height of distal nail bed decreased moderately after incision suture, which could flatten the nail bed and prevent the formation of distal nail embedding caused by obstructing the growth of the nail plate.

There are some limitations in this study. First, it is a retrospective study without the control group for comparison. Thus, prospective studies or randomized controlled trials are needed to compare the effectiveness of this improved method with traditional Winograd procedure. Second, it cannot be said that this improved surgical procedure can be suitable for all kinds of ingrown toenails. Comprehensive therapy might be a better way for those with severe thickened or deformed toenail. However, this new surgical procedure could be applied to general cases, which account for the vast majority of grade II/III ingrown toenail cases.

Conclusion

Based on traditional Winograd procedure, we proposed an improved surgical method which is ship-shaped resection along with nail matrix destruction. To summarize, this improved method is a less invasive, simplified, rapid, and effective surgical procedure for grade II/III ingrown toenails, resulting in superior patient satisfaction. Furthermore, because of less surgical scar and more preservation of the nail plate, the proposed surgical technique may be more suitable for those who put priority on aesthetic issue.