Is A Bunionectomy Ever A Purely Cosmetic Procedure?

A controversy exists in our profession as to whether one can perform a bunionectomy procedure for purely cosmetic reasons.

If a patient does not experience joint or bump pain, and he or she is interested in surgical intervention, should we consider that medically necessary or cosmetic? In foot surgery, cosmetic approaches are emerging and moving full steam ahead. 

On one hand, you have the American College of Foot and Ankle Surgeons (ACFAS) recommending against aesthetic treatment for a bunion, saying it “should not be undertaken because it carries risks without medical benefit."¹ On the other hand, you have well-trained, board-certified foot and ankle surgeons performing correction of foot deformities for bunions and hammertoes on patients who are interested in the ability to fit better into shoes, and have a narrower, aesthetically appealing foot.

There are several terms used in marketing cosmetic bunion procedures but be careful of terms like "Cinderella procedure." Frankly, I find these terms to be only marketing tools used to grab the attention of the public. As foot surgeons, we know that whatever name we use, these are the same procedures we all studied: metatarsal osteotomies with digit arthrodesis. There is nothing different or fancy. This is a bunionectomy and hammertoe repair with a discreet incision to hide the scar. 

Whether you are in favor of cosmetic foot surgery or not, whether you use the marketing tools with fancy names or not, I have been consistent with my stance over the years. It is our obligation to the patient to disclose all potential risks, complications, pros and cons; carefully outline the proposed course of treatment; and provide the best surgical outcome we can.  

Some bunionectomies are medically necessary and other bunions are an aesthetic concern. Nonetheless, bunions are legitimate concerns of your patient population and these patients have come to you for advice.

When patients present to your office for a bunion consultation, I have found three main reasons they have taken an initiative in making the appointment. 

First are the patients who have noticed a change in the position of the foot and are interested in finding out what has occurred. These patients have no pain and no limitation of activity. Most have no problems when they are in shoes. In this patient subset, I educate the patient about the condition and discuss all options. We review the best way to slow the progression. I recommend a custom orthotic and keep the patient active. If patients are interested in a permanent correction, I have them return in three months after they have done some of their own research and attempted the recommended conservative care. Then I make an educated decision. If patients return for surgery after the waiting period, I will gladly provide the care they desire.

The second group of patients are those who have pain in their joint. Conservative care has failed and they are ready for surgery. Clearly, this is not cosmetic and these patients have surgery to reduce their symptoms and get back to pain-free activity. 

The last patient group includes the bunion patient who relates limited pain in the joint but has an unsightly bunion. These patients often relate an inability to fit into their shoes.

I believe this is the gray area of controversy. If the patient cannot fit into shoes, does this support the need for surgery? If the patient has a wide forefoot and a narrow rearfoot, he or she is limited with shoe choice. Although there are many wider shoes that are on the market, it is often difficult to find a shoe that fits. Often a person with a normal foot, free of any orthopedic deformity, has a difficult time finding shoes that fit perfectly. In this scenario, does the surgeon who does not believe in bunion correction for a pain-free foot now agree that the procedure is warranted?

What about other considerations? What if the bunion condition limits the shoe buyers to standard orthopedic shoes or sneakers, and they cannot wear dress shoes? What if the patients do not care for the design and styles available to accommodate the bunion? How about when the workplace demands a certain type of shoe, such as a clog or a high heel? In what circumstance is it alright to agree that this is a viable indication for bunion correction?

Historically in practice, I have asked my patients three questions. One, does the bunion bother you on a daily or weekly basis so you cannot perform activities you want to perform? Two, does the foot bother you on a daily to weekly basis so you need to take oral medication to relieve your symptoms? Three, does the bunion bother you on a daily to weekly basis and you cannot wear the shoes you own or want to wear?

I have found that if the patient answers “yes” to two out of the three questions, surgery is indicated. I have become more lenient in practice and now believe if patients are fully aware of the pros, cons, risks and benefits as well as the change in foot function and healing time, and they decide to proceed with the procedure, I will support their desires. 

No matter which side of the discussion you agree with, the bottom line is always to practice with sincerity and ethics, disclosing all relevant information to your patients. #walkwithcomfortandlookgreatdoingit.

Reference

1. American College of Foot and Ankle Surgeons. Cosmetic foot surgery: fashion’s Pandora’s box? Available at https://www.acfas.org/Media/News-Releases/Surgery/Cosmetic-Foot-Surgery--Fashion%E2%80%99s-Pandora%E2%80%99s-Box-/ . Published June 26, 2014.