Cosmetic Surgery:
Should We Treat?

I heard a news story recently about so called "Cinderella surgery" in which the foot is surgically modified to be able to fit into certain designer shoes.^{1, 2} This term was coined by Ali Sadrieh, DPM of Beverly Hills, California, and includes Foot Cosmetic Surgery cosmetic modifications of the foot including bunionectomies, toe lengthening or shortening, and fat pad augmentation, among other procedures. I find this story highly interesting, because it speaks to several important issues in podiatric medicine today.

The obvious first question is, should we do cosmetic procedures? To make this answer official, here's the APMA's position statement:³

Cosmetic Foot Surgery

May 8th, 2014

Surgical procedures of the foot and ankle are generally performed for relief of pain, restoration of function, and reconstruction of deformities. They may have the additional benefit of improved appearance. Surgical procedures performed solely for aesthetic purposes carry the same risks as those performed for medical reasons. Patients considering surgery of the foot or ankle, whether for medical or aesthetic reasons, are advised to consult a member of the American Podiatric Medical Association. Podiatrists performing surgery for medical or aesthetic reasons should have appropriate surgical training, experience, and credentials to properly perform the surgery, manage the post-operative care, and treat the possible complications. Podiatrists are uniquely qualified to diagnose and treat the foot, ankle, and related structures based upon their education, training, and experience.

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For full disclosure, I am an APMA member, but am not on any committees or leadership positions with them. I am also the ACFAS Division one treasurer.

I'll probably get myself into trouble with the APMA, but I have to say this is a relatively weak position statement. If you read it carefully, they don't actually state a position. They include "reconstruction of deformities" as an indication (doesn't rule out cosmetic surgery) and state aesthetic surgery "carries the same risks as those performed for medical reasons." Again, not saying we shouldn't do the surgery, just that it has risks (which everyone already knows). The rest of the statement is basically an ad for podiatry (with which I have no problem).

Ok, so the APMA didn't answer our question. How about AFCAS? Here's their position statement:⁴

ACFAS Position Statement on Cosmetic Surgery

The American College of Foot and Ankle Surgeons promotes the highest standards and ethics on foot and ankle surgery. Members of the College have extensive training and experience in surgical procedures performed for relief of pain, restoration of function, and reconstruction of deformities of the foot and ankle.

All surgery carries risks, and these risks are of increased importance when they have the potential to affect the individual's ability to lead an active life, as they do with surgery of the foot and ankle. Patients considering surgery of the foot or ankle and their surgeons must thoroughly discuss and weigh the risks and benefits of the procedure.

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.

February 2004

Good for you, ACFAS, for taking a clear position.

Perhaps I might now ask the question in a slightly different way. Do you have a problem with breast augmentation surgery? How about abdominoplasty (AKA "tummy tuck")? How about tattooing? How about tattoo removal? What about whitening the teeth? Or for that matter how about the entire plastic surgery specialty and a good portion of dentistry and dermatology? In general, do you have a problem with aesthetic surgery?

I'd like to look at a different facet of this question before coming back to an answer: limb salvage surgery. You're thinking, "What does this have to do with cosmetic surgery?" Well, let me show you.

I had a patient in the hospital recently with osteomyelitis of most of the calcaneus from a neuropathic plantar heel ulcer. After about eight weeks of IV antibiotics, a general surgeon recommended a transtibial amputation. I was then consulted, and I agreed with the general surgeon. However, the patient wanted to do everything he could to save the leg, and we talked about a calcanectomy (it has yet to actually happen). I think it's reasonable to say that many podiatrists would go with the BKA recommendation, but why not try the calcanectomy? If it fails, the patient will have the BKA, ending up right where he started, losing only time (and any potential surgical complications). Considering the poor statistics about life expectancy after BKA, why not try to save the leg? If the patient fully understands the potential risks and complications of the surgery and is still willing to undergo surgery, then why is the surgeon wrong to do so?

Now, apply this same reasoning to cosmetic surgery. Isn't there risk in doing breast augmentation on an otherwise healthy woman? Is there not an increased risk of infectious disease complications (ie, Hepatitis B and C) when we are tattooed? Can't removing an unsightly mole from the face lead to possible problems?

The answer to each of these questions, of course, is yes. There's risk in everything we do when we embark on any procedure to alter our bodies in some way. If both the surgeon and the adult patient are fully cognizant of the risks and are still willing to go through with the surgery, then why stop it?

With these arguments in mind, I'm not against cosmetic surgery, but I'd like to advocate a responsible approach to plastic foot surgery.

First, we as a profession need to take a clear position on the subject, including defining exactly what constitutes aesthetic or plastic foot surgery.

Second, we need to publish in our journals expert reviews of current surgical techniques, including safety profiles. This would allow surgeons and patients to become more educated about these procedures.

Third, our aesthetic foot surgeons need to do research on their outcomes. Something like a registry of results would be beneficial to allow transparency for the public. If they can demonstrate low complication rates and safety for each of these various procedures, they might look more legitimate.

Fourth, there should be national oversight of those who do these procedures just as there is board qualification and certification for the rest of us. Perhaps a Board of Aesthetic Foot Surgery that would include those podiatrists who do the work, members of the APMA and ACFAS, and stakeholders in the public.

For each of us, the question of whether to do a particular surgical procedure is one that remains between the surgeon and the patient. For now, I'll stay away from cosmetic foot surgery. When I can demonstrate to the public a high level of expertise and oversight, as is the case with the current Board model, then I'll consider aesthetics. Until then, I'll remain the aggressive limb preservationist. Good luck with your next aesthetic adventure.

Best wishes,

Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]