A novel cosmetic approach for partial matricectomy in treating ingrown toenails

Toenails play a great part in protecting toes and peripheral soft tissues, simultaneously playing a cosmetic role. The ideal treatment should result in a functional and aesthetic outcome.


| INTRODUC TI ON
An ingrown toenail, called onychocryptosis, also represents a frequently seen phenomenon that debilitates the person. It will occur in the case of lateral nail edges penetrating the skin. 1 Onychocryptosis is commonly seen during childhood, adolescence and young adulthood. Notably, it is common among male patients and affects the big toenails. 2,3 Factors possibly causing ingrown toenails are genetic factors, trauma, tight shoes, infections, hyperhidrosis, obesity, and diabetes. 1,4 It is suggested that foreign body reactions or secondary infections in the nail plate edge-penetrated lateral/medial nail folds account for a mechanism underlying its formation. 2,5 Treatment should be selected according to disease stage as well as severity. Heifetz said ingrown toenails were divided into 3 stages (Figure 1), and conservative treatment could hardly cure patients in stages 2 and 3. 6 For such a patient population, surgery should be performed. The surgical treatment options are partial matrix excision, electrocoagulation, carbon dioxide laser vaporization, and phenol cauterization. [7][8][9][10] The above treatments focus on totally removing partial germinal matrix, the ingrown nail plate origin.
At present, toenails can safeguard toes and neighboring soft tissues and have a crucial cosmetic effect for people, especially for females. 11 Consequently, a good choice of treatment should involve aesthetic considerations. The ideal approach is that remove the partial germinal matrix without an incision. This study describes a better technique than other procedures to treat ingrown toenails with granulation tissue (Stage III) without affecting proximal nail folds.

| Patients
Based on Heifetz classification, data was collected from cases experiencing big toe ingrown toenail at stage III. All were treated using this surgical procedure. 353 patients were treated at our department by two surgeons (N.Z. and JD.Z) from June 2014 to March 2020. There were 189 males and 164 females (

| Methods
1% lidocaine was applied for the digital nerve block anesthesia, followed by a tourniquet. Firstly, this work utilized a scalpel to excise lateral granulation tissues ( Figure 2A). Secondly, soft tissues were isolated from ingrown nails through blunt dissection until reaching their lateral edge. Thereafter, small pointed scissors were utilized to cut the nail. After removing granulation tissue, a huge void was left between the nail and its lateral edge ( Figure 2B). As a result, it was not challenging to detect germinal matrix following the clamp-based blunt dissection, as long as the clamp was utilized to retract the corner between proximal and lateral nail folds ( Figure 2C).
Later, the scalpel was also used to make an incision surrounding the exposed germinal matrix, without skin damage. Later, the germinal matrix was excised, and the periosteum was left. No incision or resection of proximal nail fold was made. Additionally, partial germinal matrix removal was accomplished using one block ( Figure 2D). Nonetheless, it might be fragile in some cases due to chronic inflammation. Any portion left was excised under the direct vision. After the surgery, we pressed the nail fold towards nail bed to retract it. As a result, the void between the nail fold and the nail bed is smaller. Thereafter, the total nail fold was repaired postoperatively ( Figure 2E).
Oral antibiotics (amoxicillin 0.5 g twice daily for 3 days) and nonsteroidal anti-inflammatory drugs (celecoxib 0.2 g once daily for 3 days) were given after the use of compression bandages. Closed shoes were avoided for 2 weeks postoperatively. The same surgeon assessed the patients at 2-day intervals in dressing changes F I G U R E 1 Heifetz classification of ingrown toenails. A rapid onset of discomfort, redness, swelling and tenderness of one of the nail folds (A). A frank bacterial infection with subsequent accumulation of pus (B). A stage of formation of granulation tissue around the nail folds (C). and 1-month intervals thereafter. For these cases, their average follow-up time was 27.5 ± 2.8 months. All cases were contacted through WeChat App, telephone, or email during the follow-up.
No cases were lost to follow-up. The average period prior to work resumption, recurrence rate (amount of recurrent patients/amount of total patients), and infection rate (amount of infected patients/ amount of total patients) were measured. Mean satisfaction Visual Analogue Scale (VAS) was used to evaluate the satisfaction of foot appearance. The patient's amount of satisfaction ranges across a continuum from no satisfaction (score 0) to extreme satisfaction (score 10).

| Statistical analysis
Statistical analysis was preformed using the Statistical Package for Social Sciences software, version 19.0 for Windows (SPSS Inc.). All the data meet the normality. Data was reported as mean ± standard deviation (SD) for continuous variables, and number of subjects (n) and percentage (%), respectively, for categorical variables. Paired t-test was used to test the null hypothesis for continuous numeric data; p < 0.05 was defined statistically significant.

| RE SULTS
Their average period prior to work resumption was 2.2 ± 2.1 days (range, 0-7 days) for these cases. In addition, 98.4% of them expressed satisfaction with toenail shape without any scar at more than 2 years of follow-up. Recurrence occurred in 7 incisions of 6 cases (1.6%), which were seen in 88.3 ± 15.5 days (range, 75-120 days). Four cases underwent a second operation, and the remaining two cases recovered with the mupirocin ointment. Two patients reported infection after surgery, which improved after dressing changes for 4 weeks. No spicule formation was observed.

Demographics and location of lesions
The number of patients (n = 353) Recurrence (n = 6)

| R E PR E S E NTATI V E C A S E
A 23-year-old man presented with ingrown toenails in bilateral sides of the right toe for 10 months was analyzed ( Figure 3A). No recurrence was observed after the bilateral partial germinal matrix excision in the 2-year follow-up examination ( Figure 3B).

| DISCUSS ION
Ingrown toenails are a condition that negatively impacts patient life quality, especially for young adults, which will induce severe labor loss or even psychological distress. 12 Ingrown nails commonly result in paronychia. It will cause redness, discomfort, nail fold tenderness, and swelling ( Figure 1A) since the barrier consti- In most procedures, proximal nail fold incision and opening are necessary for obtaining a favorable field of view (FOV). 13 If the proximal nail folds are not incised, it will be not easy to validate visually whether the deepest portion of the germinal matrix is eliminated.
Wedge resection with an incision in the nail fold and eponychium, is called Winograd method, which was depicted in 1929 and still in use today. 14 However, the destruction of the proximal nail fold and the high recurrence rate reduce its practicability. 9 On the contrary, the favorable FOV can be gained if cutting and opening proximal nail folds; nonetheless, this procedure will be relatively invasive, giving rise to an unfavorable aesthetic appearance. Other procedures that utilize minor incision or no incision, such as electrocoagulation, can hardly verify the adequate ablation of germinal matrix. 15 When the electrocoagulation was performed, a monopolar type of cautery at 50-V was applied for 10 seconds. 16 But aggressive electrocoagulation may hurt the periosteum, which can cause inflammation, heat osteonecrosis and consequent long-term pain. 17 For the chemical matricectomy with the phenol approach, there are also drawbacks.
The ventral proximal/lateral nail folds will be cauterized during phenol cauterization, and massive necrotic tissues within the wound will be left, and the cure time will be prolonged. 8 Of the approaches mentioned above, excision using scissors and scalpel represents the most common and creditable approach for removing germinal matrix.
Nonetheless, according to the above analysis, a favorable surgical FOV can hardly be obtained if proximal nail folds are not resected. Concerning our method used in ingrown toenails with granulation tissue, the germinal matrix can be easily visualized and excised after removing the granulation tissue. In the procedure described in this study, the granulation tissue is removed first, leaving a large enough space between the plate nail edge and lateral nail folds.
When a clamp is utilized to perform blunt dissection, the germinal matrix becomes very apparent to the naked eye.
Ideally, ingrown toenails should be treated by a facile, costeffective and efficient approach that will induce minimum discomfort after treatment and accelerate post-treatment functional recovery. The treatment should also have low pain and relapse rates, with acceptable cosmetic outcomes. 11,18,19 An ingrown toenail is a recurring disease when treated incorretly. 20 Notably, insufficient germinal matrix excision, rather than ventral proximal/lateral nail fold, should be responsible for spicule formation and relapse, conforming to prior works. 4,13,21 The recurrence rates with the partial matrix excision techniques are greatly different across diverse articles. As mentioned by Gerritsma-Bleeker and colleagues, the relapse rate was 21% following partial matrix excision. 22 Kim et al reported a combination of the original Winograd procedure and matrixectomy using electrocoagulation, and the sum of the recurrence rate and the infection rate is 6.58%. 23 Cöloğlu and coworkers reported a novel approach referred to as the "lateral folds advancement flap" besides, the authors prospectively compared this approach to partial matrix excision. 24 As a result, the partial matrix excision group reported a relapse rate of 8.1%. Aydin and colleagues described a 6.5% recurrence in their series. 25 In contrast, we found scarce relapse after this procedure during the follow-up periods (1.6%). Turn-over of nail plate occurs within 6 months. As a result, if there is a relapse, it will appear in 6 months, so the 6-month period is appropriate for the follow-up to determine relapse. In our study, the follow-up period is longer than 6 months; therefore, the expectation of no recurrence is creditable. In addition, the level of postoperative pain is another indicator of functional efficacy. In the study, the pain F I G U R E 3 Photographic image of a foot of a 23-year-old patient suffered from bilateral ingrown nails preoperatively (A) and at 2 years follow-up (B). to nail asymmetry or an incision scar in the prominent nail. In our study, the satisfaction VAS improved from 1.5 ± 1.3 points to 9.2 ± 0.6 points after surgery, which showed the patients reported from "large effect on life" to "no effect on life." It indicated that the scar did not affect the patient's cosmetic results and everyday life.

TA B L E 2 Function and appearance evaluation.
Patients treated with minimally invasive partial matricectomy do not undergo the proximal nail folds incision, which maintains the original structure. This approach yields satisfactory results.

| CON CLUS IONS
Herein, we present a novel, valid, and minimally invasive approach for the treatment of ingrown toenails with granulation tissue. This approach can provide enough space to resect the involved germinal matrix after granulation tissue removed, which finally resulted in good effects. Particularly, the patients obtained a good cosmetic appearance. As a result, this approach may be alternative for treating ingrown toenails with granulation tissue.

AUTH O R CO NTR I B UTI O N S
Yifan Wang, Yong Hu, and Jiadong Zhang conceived of the presented idea. Ning Zhang and Jiadong Zhang performed the surgery.
Yifan Wang, Xiaolu Li, Xiaohan Li and Cong Chen contributed to the investigation of the outcomes postoperatively. All authors discussed the results and contributed to the final manuscript.

ACK N OWLED G M ENTS
The authors will thank all the colleagues of Department of Foot and Ankle Surgery of The Second Hospital of Shandong University for their great help.

FU N D I N G I N FO R M ATI O N
None.

CO N FLI C T O F I NTER E S T S TATEM ENT
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

DATA AVA I L A B I L I T Y S TAT E M E N T
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

E TH I C S S TATEM ENT
The Medical Ethical Commission of The Second Hospital of Shandong University approved this study. The ethical approval number is KYLL-2022 (LW) 033. Informed consent has been obtained from all the participants above 16 years of age and also from legal guardians / parents of participants below 16 years of age. This work was conducted strictly following the Declaration of Helsinki.

CO N S E NT TO PA RTI CI PATE
All participants signed informed consent form before participation.