If only we could order up scar-less, painless, bloodless bunion surgery.  Well not quite yet, Captain Kirk. Scarring after bunion surgery, hammertoe surgery, heel pain surgery, or any other type of foot or ankle surgery is a common and a quite valid concern that I often hear as a NYC foot surgeon and podiatrist.  And while a scar is somewhat inevitable after any type of surgery anywhere on the body, with the right technique, the results can be quite aesthetically pleasing.

First, for some basics.

The upper layer of skin is a 4 or 5 layer collection of dead cells and other assorted items known as the epidermis, which, as my kids will tell you, is showing.  Going deeper we encounter the two-layer dermis, full of live cells and capillaries, among other stuff, and just beneath this layer is a thin protective membrane of tissue.  The skin is also aligned in certain patterns, known as relaxed skin tension lines.  This is visible to the naked eye – take a look at your hands and you will see how the lines of the skin form.

Knowing the anatomy of the skin and how the lines are arranged is the key to achieving a cosmetic postoperative scar.  Generally any incision that remains superficial, or above the basement membrane below the dermis will not leave a permanent scar.  Once the basement membrane is invaded, there is a much greater chance that a permanent scar will form.  An injury or laceration to the foot or ankle during which the foot is cut in a pattern that does not follow the relaxed skin tension lines also carries a much greater risk of permanent scar.  That is why foot surgeons in NYC will generally plan an incision along the skin lines.

And that is the first step.

The skin incision is continued through the tissue in layers, handled carefully and delicately, as each thin layer of skin is identified and protected.  This is called anatomic dissection. Since the tissue has been separated and protected, closure of the skin, from the deep tissue to the superficial skin is completed in layers, which serves to restore the original anatomy, minimize the tissue disruption, and allow the body to do what is does best: heal.

Suture selection is also important.  Dissolving stitches are used for deep tissue, and where possible, for skin.  If non-absorbable stitches are used, they are removed at an appropriate interval after surgery to minimize scarring.

Of course incision placement is equally important. For my bunion surgeries, using a cosmetic or medial approach where the incision is made on the side of the big toe is often the best location.  All this maximizes the chances of a more cosmetic postoperative result.  And what can be done if by chance the scar is less than cosmetic?  Stay tuned for next week’s blog…

See you in the office.

Ernest Isaacson