Finding The Right Foot For Aesthetic Surgery

Stephen Barrett DPM FACFAS

“Dong, dong, dong.” The bell tower clock had just finished ringing in the new midnight. The prince quickly ran outside to the front steps of the palace to find the beautiful lass who had captivated him that night. He could not find her. She had disappeared into the dark, still night as quickly as she had stolen his heart.

Sitting on the top of the steps with his head resting in his hands, in a posture of defeat and disappointment, he looked up and saw something shimmering in the light at the bottom of the cascade of marble steps. It was a glass slipper, obviously left behind by the hastily exiting beauty. He quickly scaled down the stairs and picked it up. Peering at it, he knew by the haute couture designer nature of the shoe, its tininess and extremely pointed toe, that it could be a virtual fingerprint for his future soul mate. He carefully made his way back to the palace and summoned all his guards.

“Find the beautiful woman who has the foot to fit into the slipper and bring her to me by dusk tomorrow evening,” he bellowed. The guards scurried away willy-nilly, knowing they had to round up the whole village and find that damn foot.

The next day passed very slowly for the prince as he paced back and forth in the palace, waiting for his legion to bring back his beauty. The time came and he heard the clatter of horses’ hooves on the cobblestones leading into the gate. He looked down and saw them. Why, there was more than one. In fact, the guards were escorting more than 30 women of all shapes and sizes.

“What in the hell are you doing?” he barked out to the general. “I told you to bring me the one foot which fits this shoe perfectly and you have brought virtually the whole village.”

The general cowered. In a muted and respectful voice, he told the prince that all of the women’s feet fit the glass slipper.

“You’ve got to be kidding me. Look at that one. She must have a BMI of 33 and you tell me her foot fits into the slipper?”

“Yes, sir,” he demurred.

“It can’t be!” The prince ran out into the crowd and started putting the glass slipper on the women, one after another. Sure enough, every foot slid easily into the slipper. The general tugged at the sleeve of the prince, urging him to come away from the crowd.

“Here is the deal, your highness. There is a barber/surgeon out by the farrier’s station who has developed this new surgery to make women’s feet beautiful and smaller so they can fit in more stylish shoes,” he informed the prince. Totally flummoxed, the prince scratched his head and started pacing again. “The dude calls it Cinderella surgery,” the general advised him.

The prince looked back out at the group again, knowing now that his “fingerprint” was no longer valid. He might never find the lady who had the keys to his heart …

Dissecting The Myths Of Podiatric Surgery

God, how I love the smell of a controversy in foot surgery. It is better than the smell of napalm in the morning. This one is a doozy and I can’t wait to begin dissecting this one apart (pun intentional). I will preface this upcoming harangue with the statement that I have officially donned my objectivity goggles (no rose-colored ones I assure you). Let’s let her rip.

Now, first I want to list some of the comments posted on the list serves (I think that is what they call newsletter blasts to the profession. It sounds techy anyway.

“We are not trained to do aesthetic surgery.” Really? Yes you are. You learned how to perform ideal skin closures for the least amount of scarring, and you learned anatomy and wild things like rotational flaps and even relaxed skin tension lines. Remember those? That is plastic surgery, folks, and I am not talking polyethylene or silicone here. Many in our profession are trained in microsurgery and can repair tiny vessels with 1 mm lumens.

So it is disingenuous to go out and make a declarative statement that “we” are not trained to do something when, in fact, it may be “you” who are not trained or failed to remember what they taught you.

Now maybe you aren’t doing free flaps (except when the insurance company doesn’t pay you), but much of what we do, even though it is almost always guised in “functional repair,” is to give the patient a nice looking closure. Anti-aesthetic doc, let me ask you one simple question. Do you have a laser in your office to treat onychomycosis? If so, it is best not to spout off anymore. I cannot recall any substantive evidence-based medicine showing that a discolored toenail causes an antalgic gate.

“Most surgery should be for painful conditions.” Okay, I would probably generally agree with that but there are many exceptions. For example, what about treating a condition like hallux valgus, which is not painful if the patient does not wear shoes? Don’t we have societal paradigms that lead to certain shoe demands? Granted, some shoes out there are beyond ridiculous but what if your patient has no pain in flip-flops, but cannot wear a shoe because of the deformity? Should you correct it? I would.

Now I have just wiped off the steamy goggles of objectivity and I see a new aspect. In the quiet of your monkey mind (reference is to a mind filled with needless self chatter, not a reference to evolution), I want you to ask yourself one question. Have you ever shortened a toe or derotated one that really was not that painful, but the patient really implored you to do the surgery? If you say “no,” you have about as much credibility as “Baghdad Bob,” who told us the Iraqi forces were holding the Americans at the border while the statue of Saddam was toppling in the background.

“Undergoing foot surgery solely for cosmetic reasons raises serious concerns.” Doesn’t all surgery, be it foot or neck, cosmetic or functional, raise serious concerns? This is especially true for foot surgery, which is one of the most difficult “arts” there is in the surgical arena because of the overwhelming biomechanical forces that are against us. Are we not obliged to inform the patient, take measures to ensure medical risk management, prevent infection, monitor healing and give everything to ensure the best possible outcome on every surgery?

If you ever make an incision for anything and you do not have a serious concern, maybe retirement should be in your near future. If patients present with a “cosmetic” concern, it is a real concern for them. Call them crazy or nuts, but they sought care for something that really bothered them. Maybe it is minor to you and you dismiss it like a pesky fly at the picnic table. However, if patients took the time and spent the money to come to your office, maybe it is a real problem for them. You do not have to operate on them if you think they are nuts but do not dismiss them, thinking that they do not have a problem because they do.

The Moral Of The Story

So what did the goggles finally allow me to see? The prince never found his soul mate because the whole town had cosmetic foot surgery. One guy was sad and 29 ladies were happy. (One lady was not happy because there was some stiffness in the pinky toe. It did look great though.)

In reality, we are highly trained surgeons who can do these techniques effectively, whether they are for “function” or “aesthetic” purposes, and there is a huge blurred line in everything between. One could argue that improved cortical function results from improved aesthetics. The bottom line is that if you are trained to do the techniques and there is no physical pain but psychological pain, you need to assess the whole patient and then do the right thing. By the way, I am still trying to find the “painometer” so I can be sure the next patient I correct a bunion for really does have some pain.

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