The other day, I was in the process of consenting a patient for a bunionectomy, a reasonably routine situation for a podiatrist. During the discussion, though, the patient asked about fixing hammertoes that were painless. The patient disliked the hyperpigmentation overlying the proximal interphalangeal joints, but otherwise had no issues. As would be true for many podiatrists in the United States, I suggested avoiding fixing them and focusing on the painful bunion. I have maintained this practice for the 12 years of my active clinical practice since graduating residency. But this situation has me reflecting on the prospect of cosmetic foot surgery. Is it reasonable and appropriate for foot and ankle surgeons to refuse to do foot surgery when the only goal is perceived improved cosmesis? Why not do cosmetic foot surgery?

Let’s define a list of procedures or services that may fall into the “cosmetic” realm. I’ll clarify at the start that any of the procedures below may also be non-cosmetic (treating painful deformities that affect walking, shoeing, or foot function). The definition of cosmetic here is limited to performing procedures purely to improve aesthetic appearance in the absence of pain. In fact, all surgeons attempt to create as cosmetic an appearance as possible when doing any surgery. However, in this case, we are talking about improving appearance and not function as the primary goal.

So, here’s our non-comprehensive list:

I hesitate to include bunionectomies and hammertoe correction to this list because these are both always pathological (if not always symptomatic), and the scientific evidence does not help us answer the question of whether or not to do surgery on painless deformities. Does hallux valgus predispose to later osteoarthritis? Probably. Should this be surgically fixed to prevent later issues? Probably not always, but no one really knows the answer, and we likely never will due to the impracticality of doing the necessary long term studies.

Currently, our national podiatric and orthopedic professional organizations take different positions regarding performing procedures for purely cosmetic reasons. According to the American Podiatric Medical Association (APMA) position statement:

“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.”¹

The APMA cautions patients to seek those who are trained in these procedures. I don’t love the wording of this statement because it starts with what sounds like a firm condemnation of cosmetic surgery (surgery is for pain relief, restoration of function, and deformity correction with aesthetics being a side benefit) but then backs off and defers to consult-a-podiatrist wording. Although this creates an ambiguity of opinion, there is clearly NOT a “no cosmetic surgery” statement here.

On the other hand, the orthopedic community, represented by the American Orthopedic Foot and Ankle Society (AOFAS), takes a much stronger anti-cosmetic surgery stance stating, “The medical literature does not support the practice of cosmetic foot and ankle surgery”.²

I have to mention here that the AOFAS statement is a much stronger statement than the APMA’s in that it includes commentary about specific issues, including bunions, hammertoes, silicone injections, and liposuction, and provides evidence to support their views with a references section. Granted, few to no patients will ever go through the references and read the studies, but this is a much more professional appearing public communication. However you slice it, the APMA and the AOFAS appear to have differing opinions on this topic.

This leaves me a bit ambivalent. On the one side, there are quite a few arguments in favor of cosmetic foot surgery. Why shouldn’t patients have the right to undergo procedures to improve the appearance of their feet? Plastic surgeons do various aesthetic procedures. Should they stop doing breast augmentations and Botox facial injections because they’re cosmetic? Who are we to tell patients that they shouldn’t have the surgery they desire? Additionally, most surgical procedures have at least some aspect of cosmesis to their procedures. If this were not the case, then we would always do giant incisions and never do percutaneous procedures.

On the other hand, the counter to the idea of cosmetic foot surgery comes from a quick search of the Internet which shows various physicians using heavily rhetorical sales techniques that, frankly, appear somewhat seedy. It seems very easy to go from helping a person to preying on their insecurities for the sake of heavy monetary profits. Obviously, the medicolegal risks are high as well. A patient who walks in to the office without pain but with an unsightly deformity, then hobbles out with a straight but painful foot, may be more likely to sue. I have to admit here that predatory doctors are absolutely not isolated to the aesthetic surgery world. There have been many surgeons over the years that have done questionable procedures for uncertain motives that have nothing to do with physical appearance.

I suggest a modified moderate view that takes these issues into account.

Moderate Policy on Cosmetic Foot Surgery

I’d like to see a much more developed approach to this subject by the leadership of all organizations dealing with the lower extremity. Improved evidence, greater regulation, clear clinical practice guidelines, and a concerted effort to fight predatory advertising would be a giant step forward toward resolving this controversy.