The aesthetic approach to hammertoe surgery involves the correction of deformity through a minimalistic approach, with care being taken to improve appearance and function, but with no obvious scars. Hammertoe deformities often result in prominent knuckles at the proximal and distal interphalangeal joints, which can become painful due to callous formation and shoe pressure.
From the aesthetic perspective, the goals are to flatten the toe at the proximal interphalangeal joint while maintaining a natural looking curvature in the sagittal plane. This will usually require the surgeon to perform a hemi-phalangectomy of the proximal phalanx head. The traditional approach of a transverse incision placed at the level of the proximal interphalangeal joint takes advantage of the normal transverse skin creases found in this area. However, these transverse incisions often result in chronic edema of the toe, and a thick circumference in this area.
Alternatively, a longitudinal incision can be utilized that helps to prevent the edema and can also be used to remove redundant skin, thereby narrowing the toe. In fact, the longitudinal elliptical incision is an effective tool for a variety of debulking and slimming procedures of the toe, whether it is performed as part of a hammertoe correction, or simply to improve the aesthetic appearance of the toes.
More recently, the use of an interspace incisional approach has helped to avoid the dorsal incision completely. A simple longitudinal incision at the level of the proximal interphalangeal joint can be used to gain access to this joint without disruption of the flexor and extensor tendons. Through the interspace incision, the joint can be released and the distal portion of the toe dislocated, in order to bring the head of the proximal phalanx through the incision and into view. Once exposed, the hemiphalangectomy is easily performed, and the toe subsequently can be relocated and stabilized.
Regardless of the approach taken to access the deformed joint, one could argue that the closure technique is just as critical at achieving a good cosmetic result. Typically, deep repair of the flexor tendon is performed with a 3-0 or 4-0 absorbable suture. However, in my experience, 1 or 2 sub-cuticular stitches is all that is needed to re-approximate the skin, and/or intentionally narrow the toe. When it comes to the final skin closure, a non-absorbable suture such as nylon will be the least reactive, and therefore the least scarring. Typically, I remove these sutures after 2-3 weeks, but cover with steri-strips for up to 6 weeks, in order to help maintain position, and produce the thinnest and least bulky scar possible.
The techniques described here are fundamental to aesthetic foot surgery. Physicians who may be interested in learning these important methods in more detail are invited to join our society, and learn how to perform these critical procedures.