Emerging Concepts In Cosmetic Foot Surgery

Allan Grossman, DPM, FACFAS, Jason Sweeley, DPM, Ann Nakai, DPM, and Jeff Merrill, DPM

In recent years, cosmetic foot surgery has become an option for patients seeking aesthetic improvement for lower extremity conditions. Accordingly, these authors discuss the controversy, ethical considerations and techniques for minimizing scars, toe shortening surgeries and fat pad injections among other procedures.

How much are we as surgeons willing to risk in the name of vanity for our patients and where do we draw the line of form versus function?

   Cosmetic foot procedures are becoming increasingly scrutinized by medical professionals following coverage in fashion magazines and newspaper articles such as the Wall Street Journal article, “Toe the Line: Doctors Fight Cosmetic Foot Surgery,” which was published in July 2010.1 Procedures such as laser treatment for onychomycosis and lower extremity hair removal are being offered to those willing to pay the price. Other surgeries advertised by some include narrowing of the feet, lengthening or shortening toes, and injecting the fat pad with collagen.

   Cosmetic foot surgery may improve the size or appearance of the foot or ankle that is functioning properly. Both the American College of Foot and Ankle Surgeons (ACFAS) and the American Orthopaedic Foot and Ankle Society (AOFAS) have issued strong position statements condemning the use of surgery to improve the appearance of the foot. According to the ACFAS statement, “Surgery performed solely for the purpose of improving the appearance or size of the foot or ankle carries risks without medical benefit, and therefore should not be undertaken.”2 The American Orthopaedic Foot and Ankle Society states “… that surgery not be performed simply to improve the appearance of the foot. Surgery should never be performed in the absence of pain, functional limitation, or reduced quality of life.”3

   Cosmetic foot surgery carries with it the same risks and complications as any surgery. These potential risks and complications include infections, problems with anesthesia and wound dehiscence to name a few. Of concern to many podiatrists is the potential for causing lasting pain or deformity in a patient with mainly cosmetic considerations. The medicolegal aspect of surgeries such as this is not fully understood at this time either. As with traditional cosmetic surgery such as breast augmentation or facial fillers, insurance will not cover the cost of cosmetic foot surgery.

   Procedures that make the foot more functional have long been associated with a more aesthetically pleasing foot. For instance, a bunion surgery straightens the foot and gives a more pleasing contour. One can treat hammertoes, brachymetatarsia, adductovarus toes and tailor’s bunions with surgical procedures that not only correct the deformity but also provide an aesthetic improvement. Many commonly performed procedures give the foot an improved appearance. The trick is balancing when surgery is appropriate for relief of symptoms versus for purely cosmetic purposes.

Tips For Minimizing Scars

A common trend among podiatrists offering “cosmetic” foot surgery is the “hidden” or concealed scar surgery. For bunion surgeries, surgeons generally achieve this through placing the incision on the medial aspect of the foot at the juncture of plantar and dorsal skin. The skin in this area heals with a scar that is concealed along the skin line between dorsal and plantar skin. With time, the scar generally fades and is very difficult to detect, especially when the patient wears sandals.

   Another trick that can help minimize scarring is the type of stitch used to close a wound. Generally, subcuticular closure of the skin layer followed by Steri-Strip application provides a better cosmetic outcome. Combining the aforementioned incision placement with this closure technique allows for a more pleasing scar. Most podiatric surgeons who offer such procedures do not offer details about the specifics of the procedures, such as incision placement or closure techniques, but it is conceivable that similar methods are readily available for most common podiatric surgeries.

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