The effect on satisfaction and functional perception of showing preoperative photographs during follow-up after ingrown toenail surgery

Abstract

Introduction

Ingrown toenail surgery is a standard procedure that can significantly affect a patient’s quality of life. While preoperative photo demonstration has been proven to enhance patient satisfaction in other surgical fields, its potential in ingrown toenail surgery remains unexplored. The primary objective of this study is to investigate whether exposure to preoperative photographs influences the perception of postoperative outcomes in patients undergoing ingrown toenail surgery using the Winograd technique.

Methods

This retrospective study included 126 patients who underwent ingrown toenail surgery using the Winograd technique between January 2022 and August 2024. Patients were divided into two groups based on whether standardized preoperative clinical photographs were shown: Group 1 (photographs shown) and Group 2 (photographs not shown). All patients were followed up for 12 months. Clinical and functional outcomes were assessed using the Visual Analog Scale (VAS), Dermatology Life Quality Index (DLQI), Manchester–Oxford Foot Questionnaire (MOXFQ), and the Patient Satisfaction Scale (PSS). Both groups were compared using these scores and recurrence rates.

Results

Significant postoperative improvements were observed in both Group 1 (n = 57) and Group 2 (n = 69) in VAS, DLQI, MOXFQ, and PSS scores (p < 0.001). The postoperative VAS score was significantly lower in Group 1 (2.15 ± 2.07) compared to Group 2 (3.01 ± 2.20) (p = 0.015). The postoperative PSS score was significantly higher in Group 1 (7.95 ± 2.64) than in Group 2 (6.19 ± 2.95) (p < 0.001). No statistically significant difference was found between the groups regarding recurrence rates (p > 0.05).

Conclusions

Preoperative photograph presentation may modify patients’ perception of postoperative outcomes, rather than directly improving clinical results. This approach may be considered a potential adjunct to the patient education process, offering a promising avenue for improving patient outcomes.

Introduction

An ingrown toenail, or onychocryptosis, is a common condition characterized by pain, swelling, erythema, and local infection. It occurs when the lateral or medial edge of the toenail penetrates the adjacent periungual skin [1]. Conservative treatment is typically indicated in early phases, whereas surgical intervention is reserved for advanced cases or when conservative measures fail [2]. Selective proximal matricectomy is one of the standard surgical techniques, particularly for early-stage cases that do not respond to conservative therapy [3]. In patients with hypertrophic nail folds, partial excision of both the ingrown nail and the adjacent fold is the most widely used surgical approach [4].

In addition to impairing quality of life, ingrown toenails may contribute to psychological distress, including anxiety and reduced self-esteem, primarily due to pain-related immobility and cosmetic concerns [5, 6]. Existing literature on ingrown toenails predominantly focuses on surgical techniques. There is a relative paucity of studies addressing patient satisfaction, cosmetic outcomes, and quality-of-life measures [7, 8]. Patient satisfaction and quality of life have recently been recognized as important indicators of treatment success [9].

A growing body of literature has focused on enhancing patient satisfaction following surgery [10]. Preoperative photo demonstration techniques (designed to improve patients’ visual understanding of their condition) have positively influenced perceptions and satisfaction [11]. Previous studies in scoliosis surgery and total knee arthroplasty have demonstrated that showing patients pre- and postoperative images can improve satisfaction and self-confidence [11, 12]. To date, however, no studies have evaluated the effectiveness of this method in ingrown toenail surgery. The present study aimed to investigate whether exposure to preoperative photographs influences the perception of postoperative outcomes in individuals undergoing surgery for ingrown toenails. We hypothesized that patients who viewed preoperative clinical photographs would report higher satisfaction scores than those who did not.

Materials and methods

Patient selection

This study was designed as a retrospective analysis including prospectively collected data and was conducted after obtaining approval from the institutional ethics committee (Approval No: 2024-13/11; Approval Date: 21 August 2024). All eligible patients were identified through a retrospective review of the clinic’s patient record system, which contained demographic information, surgical details, and available preoperative photographs. Group allocation was not randomized and was based on the availability of preoperative photographs.

The surgical indication was based on the Heifetz classification. The Heifetz system is a classification for ingrown toenails comprising three stages: Stage 1, mild inflammation and swelling of the nail fold; Stage 2, acute infection with discharge; and Stage 3, chronic infection with granulation tissue and hypertrophy of the nail fold [13]. If there was no clinical improvement after three weeks of conservative treatment for early-stage patients (Stages 1–2), surgery was indicated. Surgical intervention was performed at the initial presentation for advanced-stage cases (Stage 3) due to chronic inflammation, granulation tissue, or infection. Inclusion criteria were: (1) age between 15 and 50 years, (2) surgical treatment for ingrown toenails using the Winograd technique, and (3) availability of regular postoperative follow-up.

Exclusion criteria were: (1) use of a surgical method other than the Winograd procedure, (2) bilateral ingrown toenails, (3) presence of skin diseases (e.g., atopic dermatitis or onychomycosis), or (4) history of prior foot surgery.

Initially, 256 patients who underwent surgical treatment for ingrown toenails between 1 January 2022 and 1 August 2024 were identified. The study ultimately included 126 patients after applying the inclusion and exclusion criteria. The patient selection process is illustrated in Fig. 1.

Fig. 1.

Flowchart of patient selection process

During the initial assessment, demographic data, including age, gender, affected side, nail border involvement, and body mass index (BMI), were recorded. Patients were evaluated using the Visual Analog Scale (VAS), the Dermatology Life Quality Index (DLQI) [14], the Manchester–Oxford Foot Questionnaire (MOXFQ) [15], and the Patient Satisfaction Scale (PSS). PSS was created by modifying the visual analog scale (VAS). The linear visual format of the VAS was retained, but it was used to assess cosmetic satisfaction instead of pain. Patients were told that a very poor image was rated “0” and a perfect image “10”. They were shown their preoperative foot photographs and asked to rate their current (postoperative) toenail appearance in comparison with these images on the scale (Fig. 2). This score reflected the patients’ subjective perception of the cosmetic appearance of their toenails. This approach was chosen to provide a simple and clinically applicable assessment of patient-perceived cosmetic satisfaction, and similar VAS-based methods have been reported in the literature [16].

Fig. 2.

Patient satisfaction scale

All questionnaires (VAS, DLQI, MOXFQ, and PSS) were administered both preoperatively and at the 12-month postoperative follow-up visit. The patients themselves completed the forms under the supervision of a single investigator who was not involved in the surgical procedures. At the 12-month visit, patients in Group 1 filled out the forms immediately after viewing their preoperative photographs, whereas those in Group 2 completed them without photo presentation. Group allocation was not randomized and was based on the availability of preoperative photographs.

Photography of clinical appearance

Preoperative clinical photographs were not routinely obtained during the earlier period. Following the establishment of a dedicated podiatry clinic, standardized photographic documentation became part of routine clinical practice. Therefore, the availability of preoperative photographs was associated with the timing of treatment rather than patient-specific factors.

Before the surgical procedure, four standardized clinical photographs were taken of each patient in the operating room, approximately 30 cm away under consistent ambient lighting conditions. The images were captured from four views: above, front, medial, and lateral. All photographs were stored in the digital medical record system for later reference (Fig. 3).

Fig. 3.

Standardized preoperative clinical photographs. (a) Above, (b) front, (c) lateral, and (d) medial views of the affected hallux demonstrating typical clinical features of an ingrown toenail

Surgical method

Four orthopedic surgeons following a standardized Winograd technique performed all procedures. A single dose of intravenous cefazolin was administered 30 min before surgery for infection prophylaxis. The operations were carried out under local anesthesia using 2% prilocaine without adrenaline, with a digital tourniquet applied. A partial nail avulsion and wedge resection of the affected nail matrix and adjacent granulation tissue were performed, followed by primary closure with non-absorbable sutures (Fig. 4). All patients were discharged on the same day, and sutures were removed at the second postoperative week.

Fig. 4.

Key intraoperative steps of the standardized Winograd procedure. (a) Achievement of hemostasis using digital tourniquet compression. (b) Excision of the ingrown nail segment and adjacent granulation tissue. (c) Removal of the proximal nail matrix with the wedge resection technique. (d) Wound closure using non-absorbable interrupted sutures.

Patients were followed up in postoperative months 1, 2, 3, 6, 9, and 12. During the 12-month follow-up, patients were divided into two groups based on whether preoperative clinical photographs were present in their medical records. Group 1 consisted of patients with standardized preoperative photographs, while Group 2 included those without.

In Group 1, the preoperative photographs were shown once during the 12-month follow-up visit for satisfaction assessment using the PSS. The photographs were shown on a digital screen in the same examination room. The same investigator, who had not participated in any of the surgical procedures, performed the presentation. After viewing their photographs, patients were asked to rate their satisfaction with the cosmetic appearance of their toenail using the PSS. The demonstration was performed only once.

Following this evaluation, postoperative VAS, DLQI, MOXFQ, PSS scores, follow-up durations, and recurrence rates were recorded for both groups. The data were then statistically compared to assess the effect of preoperative photo demonstration on clinical outcomes and patient satisfaction.

Statistical analysis

A post hoc power analysis was performed using G*Power (version 3.1.9.7, Universität Düsseldorf, Düsseldorf, Germany) based on postoperative PSS values. Descriptive statistics were expressed as mean ± standard deviation (SD) for continuous variables and as frequency and percentage for categorical variables. The Kolmogorov–Smirnov test was used to assess the normality of data distribution. For within-group comparisons of continuous variables, the paired samples t-test was used for normally distributed data. At the same time, the Wilcoxon signed-rank test was applied for non-normally distributed data. Depending on the distribution characteristics, between-group comparisons were conducted using the independent samples t-test or the Mann–Whitney U test. The chi-square test was used to compare categorical variables between groups. A p-value of less than 0.05 was considered statistically significant. All statistical analyses were performed using SPSS version 26.0 (IBM Corp., Armonk, NY, USA).

Results

The study included 126 patients (54 females and 72 males) with a mean age of 26.56 ± 11.83 years. The two groups had no significant differences regarding demographic characteristics or follow-up duration (p > 0.05). Further demographic details are presented in Table 1.

Table 1.

Demographic characteristics of the study population

Variable	Entire study population(n = 126)	Group 1 (n = 57 )	Group 2 (n = 69)	P
Age, years (mean ± SD)	26.56 ± 11.83	28.19(±)12.97	25.21 ± 10.71	0.262
Gender, n (%)  Female  Male	54(%42.9) 72(%57.1)	24(%42.1) 33(%57.9)	30(%43.5) 39(%56.5)	0.877
Side, n(%)  Right  Left	56(%44.4) 70(%55.6)	24(%42.1) 33(%57.9)	32(%46.4) 37(%53.6)	0.631
Affected nail border, n (%)  Medial  Lateral  Bilateral	18(%14.3) 84(%66.7) 24(%19.0)	7(%12.3) 39(%68.4) 11(%19.3)	11(%15.9) 45(%65.2) 13(%18.8)	0.842
Heifetz classification  1  2  3	8(%6.3) 12(%9.5) 106(%84.1)	5(%8.8) 7(%12.3) 45(%78.9)	3(%4.3) 5(%7.2) 61(%88.4)	0.346
BMI (mean ± SD)	24.39(±)3.67	24.68(±)3.91	24.15(±)3.47	0.456

SD, Standard Deviation; BMI, Body Mass Index

Compared to preoperative values, postoperative scores for the Visual Analog Scale (VAS), Dermatology Life Quality Index (DLQI), and Manchester–Oxford Foot Questionnaire (MOXFQ) were significantly lower, and the Patient Satisfaction Scale (PSS) scores were significantly higher, indicating better outcomes in the overall cohort (p < 0.001), as shown in Table 2.

Table 2.

Within-group comparison of preoperative and postoperative outcome scores

	Group 1			Group 2
	Preoperative (mean ± SD)	Postoperative (mean ± SD)	p	Preoperative (mean ± SD)	Postoperative (mean ± SD)	p
VAS	6.80 ± 1.34	2.15 ± 2.07	< 0.001	6.52 ± 1.46	3.01 ± 2.20	< 0.001
DLQI	21.54 ± 3.49	7.09 ± 4.20	< 0.001	20.65 ± 4.72	7.19 ± 5.48	< 0.001
MOXFQ	72.77 ± 4.35	15.67 ± 2.00	< 0.001	72.20 ± 5.07	15.82 ± 1.99	< 0.001
PSS	1.15 ± 1.26	7.95 ± 2.64	< 0.001	1.43 ± 1.23	6.19 ± 2.95	< 0.001

SD, Standard Deviation; VAS, visual analog scale; DLQI, dermatology life quality index; MOXFQ, Manchester–Oxford foot questionnaire; PSS, patient satisfaction scale

Bold values indicate statistically significant differences (p < 0.05)

No statistically significant differences were found between the two groups regarding preoperative VAS, DLQI, MOXFQ, or PSS scores (p > 0.05). However, postoperative VAS scores were significantly lower (p = 0.015), and PSS scores were significantly higher (p < 0.001) in Group 1 compared to Group 2 (Table 3). Recurrence was observed in 15 out of 126 patients (11.9%). No revision surgery was performed in any patient during the 12-month follow-up period. The recurrence rate did not significantly differ between the groups (p > 0.05).

Table 3.

Between-group comparison of preoperative and postoperative scores

Preop. VAS	Group 1 (mean ± SD)	Group 2 (mean ± SD)	p
	6.80 ± 1.34	6.52 ± 1.46	0.159
Postop. VAS	2.15 ± 2.07	3.01 ± 2.20	0.015
Preop. DLQI	21.54 ± 3.49	20.65 ± 4.72	0.316
Postop. DLQI	7.09 ± 4.20	7.19 ± 5.48	0.768
Preop. MOXFQ	72.77 ± 4.35	72.20 ± 5.07	0.640
Postop. MOXFQ	15.67 ± 2.00	15.82 ± 1.99	0.912
Preop. PSS	1.15 ± 1.26	1.43 ± 1.23	0.152
Postop. PSS	7.95 ± 2.64	6.19 ± 2.95	< 0.001

SD, Standard Deviation; Preop., preoperative; Postop., postoperative; VAS, visual analog scale; DLQI, dermatology life quality index; MOXFQ, Manchester–Oxford foot questionnaire; PSS, patient satisfaction scale

A post-hoc power analysis based on postoperative PSS values revealed that, with an effect size of 0.63 and a type I error rate of 5%, the study had a statistical power of 99.9%.

Discussion

One of the main findings of this study is that, despite no significant differences between the groups in baseline characteristics and Heifetz classification, patients who were shown their preoperative photographs reported higher satisfaction levels and lower postoperative pain scores under the specific assessment conditions of the study. However, these findings should be interpreted with caution, as the observed differences may primarily reflect a perception-driven effect influenced by visual comparison, rather than a true improvement in postoperative clinical outcomes. In particular, the immediate presentation of preoperative photographs prior to outcome assessment may have introduced cognitive biases such as anchoring and framing, potentially leading to a temporary or context-dependent enhancement in reported satisfaction and pain perception. Bahar et al. previously demonstrated that preoperative photo presentation in patients with hallux valgus was associated with improved functional outcomes and reduced pain levels [17]. Similarly, Del Basso et al. observed higher satisfaction rates in patients whose preoperative foot deformities were visually reviewed before hallux valgus surgery [18].

Recall bias refers to the possibility that patients may not accurately remember their preoperative symptoms months after surgery. This bias may result from patients forgetting specific details of their preoperative clinical condition over time or from acquiring new and misleading information about their previous condition [19, 20]. Aleem et al. compared patient-reported questionnaires completed one year after cervical spine surgery with the recorded preoperative scores and demonstrated that patients’ recollections differed significantly from the actual baseline measurements [21]. In the present study, presenting patients with their preoperative photographs may have reduced recall bias by providing a more objective visual basis for comparison. However, this effect may not be limited to improved recall alone. Viewing preoperative photographs may also have influenced patients’ perception of postoperative improvement through framing or anchoring effects. This may partly explain the higher satisfaction scores observed in the photo presentation group.

The impression formed based on a single positive or negative attribute that influences other independent evaluations and the overall opinion is referred to as the “halo effect” [22, 23]. Atsavapranee et al. reported that private room conditions improved not only domains directly related to the physical environment but also many other aspects of patient experience scores not directly related to the room itself, and that this widespread impact could be explained by the halo effect [24]. Similarly, in our study, preoperative photograph presentation may have contributed to greater esthetic satisfaction. This positive perception may have influenced patients’ reported pain perception through a halo effect mechanism. Patients who were satisfied with the postoperative appearance of their feet may, because of this effect, have been inclined to report lower pain levels.

Although postoperative pain scores were lower in the photo presentation group, the clinical relevance of this difference should also be considered. To our knowledge, a minimal clinically important difference (MCID) for VAS pain scores in ingrown toenail surgery has not yet been established in the literature. However, previous studies of foot and ankle conditions have reported MCID values of approximately 1.2 points for the VAS after hallux valgus surgery [25] and 8.5 points on a 100-point VAS scale for plantar heel pain [26]. In the present study, postoperative VAS scores were 3.01 ± 2.20 and 2.15 ± 2.07 in the two groups. Although the 0.86-point difference between groups reached statistical significance, it is close to the MCID values reported for comparable foot and ankle conditions and may fall below certain thresholds. Therefore, the observed difference may represent limited or borderline clinical significance and should be interpreted with caution. Further studies are needed to establish disease-specific MCID thresholds for pain outcomes following ingrown toenail surgery.

Studies on treating ingrown toenails have predominantly focused on comparing the effectiveness of various surgical and conservative methods. In addition, previous research evaluating patient satisfaction has primarily investigated the impact of different surgical techniques on satisfaction rates and recurrence outcomes [27–32]. To our knowledge, the present study is the first to evaluate the effect of preoperative photo demonstration on patient satisfaction in ingrown toenail surgery. By introducing a novel approach to preoperative patient communication, this study offers a new perspective on factors that may influence postoperative satisfaction assessments, which has traditionally been assessed solely in terms of surgical methods or recurrence risk.

Different tools have been utilized in the literature to assess patient satisfaction following ingrown toenail treatment [9]. In a study evaluating the cosmetic outcomes of the Winograd procedure, Kose et al. applied a binary subjective assessment in which patients responded either “Yes, I am satisfied” or “No, I am not satisfied” [7]. Dabrowski et al. used the Surgical Satisfaction Questionnaire, a simplified scale comprising three binary-response items [3]. In contrast, the present study employed a modified version of the Visual Analog Scale (VAS), the Patient Satisfaction Scale (PSS), which offers a broader scoring range and enables the quantification of satisfaction on a continuous numerical scale. This method allows for more nuanced data analysis compared to dichotomous response systems.

Recurrence rates reported in the literature following the Winograd technique vary across studies. Pamuk reported a recurrence rate of 5.2% [33], while Shang et al. found a rate of 7.69% in a cohort of 42 patients treated with the classical Winograd technique [34]. Karacan and Ertilav conducted a more extensive study, observing a recurrence rate of 14% among 70 patients who underwent the same procedure [35]. In the present study, the recurrence rate was 11.9%, which falls within the range reported in previous studies and is consistent with the variability observed in the literature.

This present study has several limitations. First, it was retrospective and included a relatively small sample size. Group allocation was based on the availability of preoperative photographs rather than randomization, which may have introduced selection bias and limited the generalizability of the findings. Since grouping was determined by the temporal availability of preoperative photographs rather than randomized allocation, residual confounding cannot be fully excluded. Although the surgical technique remained consistent throughout the study period and ingrown toenail surgery is a relatively standardized procedure, unmeasured time-related factors such as changes in perioperative communication, patient expectations, or clinical workflow may still have contributed to the observed differences. Second, pain and satisfaction are inherently subjective outcomes, and results may vary across different patient populations. Third, although all surgeries were performed by experienced orthopedic surgeons with at least 5 years of clinical practice, the involvement of multiple surgeons may have introduced variability in surgical technique. Fourth, the Patient Satisfaction Scale (PSS), although adapted from the visual analog scale (VAS), has not been formally validated in the literature. The scale was developed to provide a simple, practical assessment of cosmetic satisfaction in a clinical setting; however, because of the study’s retrospective design, no formal reliability testing (e.g., test–retest) was performed. Although similar VAS-based satisfaction assessments have been used in previous studies, these adaptations do not replace formal validation procedures. Therefore, the generalizability and interpretability of the satisfaction outcomes should be interpreted with caution. Fifth, the lack of standardized preoperative photographs for all patients prevented uniform evaluation across the entire cohort. Sixth, in Group 1, the satisfaction questionnaire was completed immediately after viewing the preoperative photographs, which may have influenced patients’ perception of the surgical outcome and introduced response bias. Future studies could minimize this bias by assessing patient satisfaction using comprehensive clinical outcome measures after patients observe their photographs, thereby avoiding immediate post-photo evaluation, which may obscure patients’ true postoperative perceptions. We acknowledge that the observed effect may be temporary and influenced by cognitive mechanisms related to visual comparison, such as anchoring or framing effects. Therefore, the findings may reflect a modification in patients’ perception of postoperative outcomes rather than a direct improvement in postoperative satisfaction. Further prospective, randomized studies with larger sample sizes are needed to validate these findings and further clarify the clinical relevance of photo-based patient assessment approaches.

In conclusion, the present findings indicate that preoperative photograph presentation may modify patients’ perception of postoperative outcomes, rather than directly improving clinical results. The observed differences in satisfaction should therefore be interpreted as perception-driven effects under specific assessment conditions. Although statistically significant differences in postoperative VAS scores were observed, the magnitude of these differences was relatively small and their clinical relevance remains uncertain when considered alongside MCID values reported for comparable foot and ankle conditions. Future prospective randomized studies are required to determine whether such perceptual changes have any clinically meaningful impact.

Author contributions

G.S. conceived the study idea, designed the study protocol, and supervised the overall project. F.G. contributed to the study design, performed data collection, and assisted with statistical interpretation. Z.G. participated in data acquisition and contributed to the clinical assessment of patients. F.C. assisted with patient follow-up, data collection, and manuscript editing. S.N.A.B. performed patient follow-up, assisted in clinical data collection, and contributed to data organization. S.Y. participated in patient follow-up, contributed to data entry, and supported clinical coordination. S.O. performed the statistical analysis, wrote the main manuscript text, and prepared the figures and tables. All authors reviewed and approved the final manuscript.

Funding

The authors received no specific funding for this work.

Data availability

The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethical approval

This study was approved by the Scientific Research Ethics Committee of Bursa City Hospital, Bursa, Türkiye (Approval No: 2024-13/11). All procedures were conducted in accordance with the principles of the Declaration of Helsinki. Written informed consent was obtained from all participants.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.