Emerging Concepts In Cosmetic Foot Surgery

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.

Assessing The Pros And Cons Of Minimally Invasive Surgery

Minimally invasive surgery is re-emerging in the medical field. Thirty years ago, the term “minimally invasive” described an approach at bunion surgery through a small incision. Surgeons like the idea in part due to the decreased healing time and lesser wound complications but also due to the fact that smaller incisions are more cosmetically pleasing. This trend fell out of favor as there were a high number of complications and recurrences associated with it due to the fact that the deformity was not correctly addressed.4-8

   One should only attempt minimally invasive surgeries when the procedures can correct the underlying condition. Podiatric surgeons still offer minimally invasive surgeries for almost all common podiatric procedures. When it comes to addressing bunions, tailor’s bunions, hammertoes, neuromas, corns, ingrown toenails, fungal toenails and soft corns, these are all surgeries that can occur through a minimal incision approach. New approaches and advancements in technology are allowing surgeons to revisit this field with promising results. However, more research is needed in the area.

   Surgeons may also perform tarsal tunnel releases through an arthroscopic approach, which greatly reduces the length of incision required and therefore reduces scar tissue formation. This approach is gaining in popularity due to the fact that the long incision traditionally associated with tarsal tunnel release is prone to wound dehiscence. The added benefit from this is that the smaller scars are more cosmetic.

   The drawback to this procedure is that it is technically demanding with a very high learning curve. Ensuring proper release and thereby minimizing the risk of recurrence is not easy through an arthroscopic approach. Currently, there is no widespread training in this technique.

What About Toe Shortening?

Toe shortening is another common procedure that has a cosmetic appeal. Surgeons can shorten toes at either the level of the toe or the metatarsal. Surgeons commonly perform these procedures to help prevent ulcerations and relieve metatarsalgia. While not recommended in the absence of symptoms, toe shortenings are becoming more common for a solely cosmetic purpose. Whenever an osteotomy occurs, such as in a bunionectomy, there is an amount of shortening that occurs from the saw blade. In order to correct this, one may employ several methods ranging from slightly plantarflexing the first ray to shortening of the lesser toes and/or metatarsals.

   A common procedure that shortens toes is the Weil osteotomy or a metatarsal shortening osteotomy. When one performs the Weil osteotomy in combination with other surgeries, the osteotomy helps preserve the metatarsal parabola and a normal functioning foot. When one performs the Weil osteotomy without adjunctive procedures, it can shorten a long digit to help relieve plantar pressures. Toe shortening in this fashion is becoming more popular among women who want to fit into smaller shoes with less toe space.

A Closer Look At Lasers For Onychomycosis And Nail Restoration

Laser treatment for onychomycosis has been gaining in popularity for the past several years. In October 2010, the FDA granted 510(k) approval for the PinPointe FootLaser (PinPointe USA), noting that the device is “indicated for the temporary increase of clear nail in patients with onychomycosis.” In clinical data the manufacturer presented to the FDA, 81 percent of patients experienced sustained improvement at 12 months.9 The procedure is reportedly painless with a typical treatment time of approximately 30 minutes. Treating patients with the laser can also avoid the side effects that have been documented with pharmaceutical treatments.

   The cost could be prohibitive for many people with an average price tag of $1,000 per treatment. According to PinPointe’s Web site, most patients only require one treatment but the risk of re-infection remains.10 The procedure does not give immediate gratification, however, as it may take up to 12 months for the nail to grow out to a more normal looking nail.

   The KeryFlex nail restoration system (Pod-Advance) is another type of non-invasive service being offered to hide unsightly fungal nails in conjunction with laser or pharmaceutical treatment. KeryFlex is a composite resin gel that works by creating a flexible, non-porous artificial nail while allowing the remaining natural nail to re-grow. Proponents say the nail looks and feels natural, and even allows patients to paint the nail while in use.11 It typically lasts six to eight weeks before one needs a touch-up or reapplication. While prices vary per office, the price is reportedly comparable to that of nail treatment at a salon.

Key Insights On Laser Hair Removal And Sclerotherapy For Telangiectasias

Laser hair removal works by directing a laser beam through the skin to an individual hair follicle. The laser damages a hair follicle by creating intense heat, which inhibits future hair growth. The success of laser hair removal depends on the type of laser one uses. Lasers operate on a wavelength that is better suited to certain skin tones or hair color. Multiple treatments are required for laser hair removal given the cyclical nature of hair growth. Many non-physician supervised “aesthetic centers” around the country are offering laser hair removal with complications reported in the literature of first-degree burns and hyperpigmentation.12,13

   Sclerotherapy is a treatment for telangiectasias or smaller varicose veins, which are typically asymptomatic and therefore treated cosmetically. The surgeon would inject individual veins with a small amount of sclerosing agent that irritates the vessel’s lining, causing it to become inflamed, harden and eventually be resorbed by the body completely. Anesthesia is not required and walking after treatment is encouraged. Many injections or even multiple treatments are necessary since 1 inch of vein will likely require one injection.

   Compression stockings are typically recommended following treatment to “compress” treated vessels and to prevent new telangiectasias. Mild itching and burning following treatment is normal. Complications include allergic reaction to the sclerosing agent or infection. More serious complications are reported with poor injection technique. These complications include formation of small ulcers at the injection site.13

What You Should Know About Fat Pad Injections

Fat pad injections are another practice that is gaining momentum. The plantar fat pad absorbs much of the pressures that our feet must endure. However, over time, this fat pad wears down and the cushion that we enjoyed in youth flattens. This causes painful calluses and areas that can lead to more serious complications such as ulcerations in some patients. Some of the more conservative approaches to dealing with this unpleasant certainty of fat pad atrophy include orthotics, gel cushion inserts or changes in shoe gear.

   There has also been a large movement to inject silicone to the atrophied sites that has shown success. A randomized, double blind, placebo-controlled study showed that plantar silicone injections reduced the risk factors related to diabetic foot ulcers although follow-up studies have confirmed that the results do not last long and the patient requires multiple injections.14

   Autologous fat can augment plantar fat pad atrophy with some relative success. In 2009, Rocchio used GraftJacket (KCI), an acellular human dermal allograft, to augment the plantar fat pad.15 According to the author, this method solves the problem of fat pad atrophy in the patient with diabetes “permanently and practically.”

   With the relative success of silicone injections and the new possibilities of GraftJacket, the practitioner and surgeon have new and exciting possibilities to turn back the clock and give patients a soft step to the future.

Final Words

While there are many surgeons who offer cosmetic foot surgery, we feel that patients should not enter into surgery for the sole purpose of cosmesis. One should only attempt surgery when pain interferes with daily activities, when all conservative treatment has failed or when the condition threatens life or limb. While all surgery carries an inherent risk, there is an especially high risk with cosmetic surgery in the foot and ankle from the standpoint that we rely on our feet so much during daily activities. Complications from surgery can be debilitating.

   One should always weigh the risks versus the benefits of the surgery. It is our opinion that the risk always outweighs the benefit when it comes to cosmetic procedures of the foot and ankle.

   Dr. Grossman is a Fellow of the American College of Foot and Ankle Surgeons, and a Diplomate of the American Board of Podiatric Surgery and the American Board of Podiatric Orthopedics. Dr. Grossman is a member of the teaching faculty with the Pinnacle Health System and is in private practice in Harrisburg, Pa.

   Dr. Nakai is a third-year resident with the Pinnacle Health System in Harrisburg, Pa.

   Dr. Sweeley is a third-year resident with the Pinnacle Health System in Harrisburg, Pa.

   Dr. Merrill is a first-year resident with the Pinnacle Health System in Harrisburg, Pa.

References

1. Beck M. Toe the line: doctors fight cosmetic foot surgery. Wall Street Journal. July 27, 2010.
2. Available at https://www.acfas.org/Media/Content.aspx?id=294 .
3. Available at https://bit.ly/hZEHi3 .
4. Maffulli N, Longo UG, Marinozzi A, Denaro V. Hallux valgus: effectiveness and safety of minimally invasive surgery. A systematic review. Br Med Bull. 2010 Aug 14. [Epub ahead of print].
5. Roukis TS, Schade VL. Minimum-incision metatarsal osteotomies. Clin Podiatr Med Surg. 2008; 25(4):587-607, viii.
6. Van Enoo RE. Soft-tissue bunionectomy with first metatarsal ostectomy using minimal incision technique. Clin Podiatr Med Surg. 1991; 8(1):71-80.
7. White DL. Minimal incision approach to osteotomies of the lesser metatarsals. For treatment of intractable keratosis, metatarsalgia, and tailor's bunion. Clin Podiatr Med Surg. 1991; 8(1):25-39.
8. White DL. Minimal incision approach to osteotomy of the hallux. Clin Podiatr Med Surg. 1991; 8(1):13-24.
9. Available from: www.patholase.com/news/multi-center-trial
10. Available from www.patholase.com
11. Available from https://keryflex.com/index.php/home.html
12. Davidson D, Ritacca D, Goldman MP. Permanent hyperpigmentation following laser hair removal using the dynamic cooling device. J Drugs Dermatol. 2009 Jan;8(1):68-9.
13. Vano-Galvan S, Jaen P. Complications of nonphysician-supervised laser hair removal: case report and literature review. Can Fam Physician. 2009; 55(1):50-2.
14. Van Schie CH, Whalley A, Vileikyte L, Wignall T, Hollis S, Boulton AJ. Efficacy of injected liquid silicone in the diabetic foot to reduce risk factors for ulceration: a randomized double-blind placebo-controlled trial. Diabetes Care. 2000; 23(5):634-8.
15. Rocchio TM. Augmentation of atrophic plantar soft tissue with an acellular dermal allograft: a series review. Clin Podiatr Med Surg. 2009; 26(4):545-57.

   For further reading, see “Laser Care For Onychomycosis: Can It Be Effective?” in the May 2010 issue of Podiatry Today or “Injectable Silicone: Can It Mitigate Plantar Pedal Pressure?” in the September 2008 issue.