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                 MAY, 2005                                  VOL 2/05

FACIAL NERVE PALSY                                          ipsilateral unilateral sub-total paralysis. The
                                                            characteristic appearance comprises of:
                                                              i. Absent forehead wrinkles on the paralyzed side

        he seventh cranial nerve or the Facial nerve is
        predominantly a motor nerve with sensory taste           and excessive wrinkling on the unanalyzed side
        fibers from anterior 2/3 of tongue and secreto       ii. Drooping of paralyzed eyebrow and excessive
motor fibers to lachrymal and salivary glands. The               lifting of unanalyzed eyebrow
nerve innervates the muscles of facial expression.         iii. Wide palpebral fissure on paralyzed side
These muscles are in two groups superficial and deep             unaffected by facial expressions
and are derived from the 2nd. branchial arch. The           iv. Lagophthalmos on paralyzed side – LPS
superficial group comprises of Frontalis, Orbicularis            unopposed by paralyzed orbicularis occuli
occuli, Quadratus labii superioris, Zygomaticus major        v. Paralyzed lower lid falls away from the globe as
& minor, Quadratus labii inferioris and Orbicularis              Orbicularis occuli is paralyzed and a central ear
oris. The deep group has two muscles – Corrugator and            lake is formed with epiphora
Buccinator. These muscles of facial expression are          vi. Paralytic ectropion results in turning out of the
unique because they move the soft tissue of the face             inferior punctum and its stenosis by exposure –
rather than acting to move the underlying bones.                 epiphora
Aetiology and Site of Lesion:                              vii. Exposure Keratitis – further lachrymal secretion –
Congenital – Isolated nuclear paralysis or associated            further adds to epiphora
with other Cranial nerve palsies e.g. Mobius Syndrome     viii. Attempt to close the eye is often incomplete and
Acquired – These are best described as we trace the              the eyeball rolls up with a lot of sclaral show –
course of the nerve. They can be Supranuclear, Nuclear           Bell’s Sign
and Infranuclear.                                           ix. Paralyzed cheek sags and nasolabial fold gets
  1. Beyond the Stylo-mastoid foramen – Parotid                  erased
     cancer, Parotid surgery, Facial laceration              x. Plosives are grabled in speech as air pressure is
  2. At the Stylo-mastoid foramen – Bell’s Palsy                 lost because of blowing out of the paralyzed side -
  3. Intra-temporal bony canal – Middle ear tumours,             buccinator paralysis
     inflammations and middle ear surgeries                 xi. Non paralyzed cheek is hyperactive – an
      Proximal to Chorda Tympani Nerve– Taste from              objectionable grimace results
       anterior 2/3 of tongue absent                       xii. The nose and philtrum are deviated to the
      Proximal to Stapedial Nerve – Hyperaccusis                nonparalyzed side
      Proximal to Genicular ganglion – Secretomotor      xiii. The lip angle sags on the affected side and is
       fibers to tear glands –ve                                 hyperactive on the non paralyzed side
  4. At internal auditory meatus – VIII nerve is also     xiv. Drooling of liquids from the paralyzed angle of
     involved – Acoustic Neuroma or Surgery                      mouth
  5. Cerebello-pontine angle - Tumours                      Treatment: A majority of Bell’s Palsy recovers
  6. Nuclear – In the Pons -Stroke, Infantile nuclear       spontaneously and requires no surgery. Trypsin
     paralysis – VI nerve is also involved                  Chymotyrpsin (Chymoral Forte) and steroids may be
  7. Supranuclear – In the cerebrum - Stroke,               helpful along with some facial muscle stimulation by
     Meningitis, - only lower face is involved.             Electrical stimulus and by massage to prevent wasting
                                                            protection of the cornea by Leucoplast eyelid supports.
                                                            Eyes need to be protected from exposure keratitis.
Clinical Picture: The infranuclear paralysis of the VII     Surgical decompression of the facial canal may also be
nerve is the most common one and it presents as an          tried.
Surgical treatment can be categorized into Nerve                  nuclear and supranuclear palsy however remains
surgeries and Reconstructive procedures.                          treatment of the aetiology if that is possible.
Nerve Surgeries: Repair of any part of the facial nerve,
severed during facial trauma or parotid surgery should

be done immediately foe best results. Replacement of a
segment of Facial nerve sacrificed during oncological
resection should be ideally done in the same sitting
using Sural nerve graft by microneural anastomosis.
When proximal nerve end is unavailable and peripheral
nerve branches are present nerve cross grafting using
Hypoglossal, Spinal Accessory or Phrenic nerve are                ABOUT MAYO CLINIC
tried. The procedures are less desirable because of the
mass movement produced and donor nerve morbidity
that is encountered. This can be eliminated by cross              Around the turn of the century, Dr. Charlie and Dr.
facial nerve grafts using Facial nerve twigs of the               Will Mayo organized medical professionals in a new
normal opposite side. Nerve surgery is usually                    way to better care for patients. They created a system
unsuccessful if more than a year has elapsed after the            that allowed doctors to take the time to thoroughly
onset of paralysis.                                               investigate patient problems and to quickly and easily
Reconstructive Procedures: There is no one single                 get help from other specialists. The system was built on
surgery that can correct all the elements of Facial nerve         the idea that two heads are better than one and five are
palsy. Forehead, eyebrows, eyelids, eyes, cheeks and              even better. It also encouraged a continual search for
lips of both the affected and the normal side need our            better ways of diagnosis and treatment. Patients
attention. The procedures that are practiced may be               flocked to the Mayos because of their ability to find
divied into 4 categories:                                         answers to their problems. Doctors, too, came to
Static                                                            observe and learn at "the Mayo's clinic."
1.Insertion suspension – Fascia lata, tendons or
alloplastic material used to suspend eyelids, cheeks,             Mayo Clinic is a charitable, not-for-profit organization
lips from fixed points like orbital rim, zygomatic arch           based in Rochester, Minnesota. Its mission is to
or temporalis fascia                                              provide the best care to every patient every day
2. Intrinsic suspension – Use of local tissue like in             through integrated clinical practice, education and
Medial and lateral canthoplasty (tarsorraphy)                     research. A 31-member Board of Trustees composed of
3. Excision suspension – Excision of local tissue –               public members and Mayo physicians and
supra-orbital excision to raise eyebrows, face-lift or            administrators governs it. Mayo's principal entities
nasolabial fold excision to suspend lips.                         include: Mayo Clinic, Rochester, Minnesota, a 1,626-
Dynamic                                                           physician group practice, Mayo Clinic, Jacksonville,
1.On the paralyzed side                                           Florida, a 325-physician group practice, and Mayo
   (i) Muscle transfer – Temporalis, Masseter, Digastric          Clinic, Scottsdale, Arizona, a 332-physician group
   anterior belly to move lips, eyelids, cheeks                   practice. Besides this there are Saint Mary’s Hospital,
   (ii) Muscle division – Transection of LPS to reduce            Rochester, Minnesota, St. Luke's Hospital,
   lagophthalmos                                                  Jacksonville, Florida, Mayo Clinic Hospital, Phoenix,
   (iii) Muscle transplant – Gracilis Muscle                      Arizona, Charter House, Rochester, Minnesota and
   Neurovascular anastomosis to cross facial nerve graft          the Mayo Health System, a network of clinics and
    (iv) Nerve transfer – Cross facial nerve graft directly       hospitals in 64 communities in southern Minnesota,
   neurotizing paralyzed muscles                                  northern Iowa, and western Wisconsin.
 2. On the normal side
       (i) Muscle transplant – Previously denervated              There are over 2,700 staff physicians and medical
autogenous muscle graft with muscle belly on normal               scientists, around 520 clinical and research associates
side for neurotization and tendons arranged on                    and fellows, 1,875 residents and students and over
paralyzed side to move forehead, eyelids, cheek and               37,000 administrative and allied health staff working
lips                                                              tirelessly to attend a deluge of patients who come to
       (ii) Muscle excision – Excision of blocks of facial        these premises seeking cure. In the year 2003 the clinic
muscles around the lips to reduce grimacing                       had 511,000 unique patients, 2,253,513 total outpatient
       (iii) Nerve division – Transection of VII nerve            visits, 127,300 hospital admissions and 595,300
branches to muscles of forehead and lips to reduce                hospital days of patient care.
       (iv) Nerve paralysis – Bortulinum toxin or Botox           Biomedical research at Mayo Clinic includes strong
– Transient palsy, to be repeated after 6 months.                 programmes in basic and clinical research. Most Mayo
3.Dissimulative: Surgical creation of wrinkles in                 medical staff participate in some research activity.
forehead and naso-labial folds                                    With 2,516 research personals and a research grant of
4.Mechanical: Gold weights over upper eyelids                     351 million dollars in 2003 there is an ongoing
As is apparent by the plethora of surgical options no             research programmes to improve patient care and to
one procedure can deliver all the goods and so usually            benefit society.
a combination of options are chosen. Treatment of

Medical education is yet another front in which Mayo              If a child had a horrible facial injury or was burned by
Clinic has always been in the forefront. The oldest of            thermal or chemical agents or had a facial tumour
Mayo's five schools, the Mayo School of Graduate                  removed, the distortion and the calamity of such an
Medical Education has trained more than 16,000                    occurrence, whether it's from trauma, a burn or a
alumni in virtually all medical specialties since 1915.           tumor, are inordinate. One just can't measure it. Dr.
Mayo Graduate School has granted about 425 graduate               Levin’s passion is to have this type of technology offer
degrees in seven specialties since 1917. Mayo Medical             a solution to such patients.
School has trained and graduated more than 1,000
students since 1972. Established in 1973, Mayo School             The technical side of the equation is complete and a
of Health Sciences enrolls approximately 816 students             face transplant could be done at Duke right now, but it
each year in 32 allied health science programs. Mayo              will still be some time before this sort of surgery is
School of Continuing Medical Education formally                   performed on a human. The issues are: what immune
became a school in 1996. It offers approximately 275              suppression protocol is the patient going to be on; what
courses and 6,500 hours of continuing medical                     are the ethical issues; and what are the long-term issues
education each year.                                              for the patient. The surgery has successfully been
                                                                  performed on rats at The Cleveland Clinic. The surgery
Mayo provides the best care to every patient every day            is obviously not for everyone, and so, if the technique
through integrated clinical practice, education and               is approved, there will be a seriously scrutinized
research. The needs of the patient come first. Mayo               patient selection process.
specializes in virtually everything. Mayo's strength is           VOICE LIFT
its comprehensiveness, its ability to provide "one-stop
shopping" for the diagnosis and treatment of virtually
any medical problem. Mayo's expertise includes more               The latest luxury for aging baby boomers looking for
than 100 medical and surgical specialties and                     the fountain of youth is the so-called "voice-lift,"
subspecialties.                                                   designed to make patients' voices sound more youthful.
                                                                  In the past, doctors have mostly performed vocal chord
In 1919, the Mayo brothers dissolved their partnership            surgery on people with voice-robbing diseases or
and turned over the clinic's name and assets, including           injury. Now cosmetic surgery for the voice — the
the bulk of their life savings, to a private, not-for-            voice lift — is becoming more widely known among
profit, charitable foundation. They dictated that any             an aging population, dismayed to notice hoarseness
earnings from the practice, beyond those needed to                that makes them sound older creeping into their voices.
operate and perpetuate the clinic, should be used for             Professionals who use their voices — including
medical education and research. Such has been the case            performers, lawyers and telephone operators — are
ever since. All Mayo staff members, including doctors,            seeking out the procedure, hoping to shave years off
are paid a salary and there is no profit-sharing. The last        the sound of their voice.
family member on the medical staff was Charles W.
Mayo, Dr. Charlie's son, who retired in 1963. Robert              There are two general kinds of voice lifts: In some
Walters, a great-grandson of Dr. Will Mayo, is an                 cases, implants inserted through an incision in the neck
administrator at Mayo Clinic Jacksonville.                        bring the vocal cords closer together. Doctors also use
                                                                  injections of fat, collagen or other substances to plump
                                                                  up the cords and make them more limber, so that the
                                                                  voice sounds younger.

FACE TRANSPLANTATION                                              But doctors are warning against doing cosmetic
                                                                  surgery on normal, but aging, vocal cords. There are
                                                                  risks to the procedures. Dr. Steven Zeitels, an associate
It sounds like science fiction, but it could change the           professor at Harvard Medical School and a
face of plastic surgery, literally. Dr. Scott Levin, a            laryngologist at the Massachusetts Eye and Ear
Duke University Plastic Surgeon, is helping to advance            Infirmary in Boston is of the opinion in an attempt to
research for a revolutionary surgical procedure that              actually bring the vocal folds together they may
could offer hope to victims of catastrophic injuries like         become over-closed and then the voice can get worse.
burns or gunshot wounds. He is helping researchers at
The Cleveland Clinic study techniques referred to as              To produce sound, the vocal cords must meet each
‘face transplantation’. The procedure is a composite              other at a rate of between 120 and 220 times a minute,
tissue allo-transplantation and it means it is possible to        and that high level of usage takes its toll. Unlike skin,
transplant the face of a donor to the skull of a recipient.       the surfaces of vocal cords don’t sag as we age — they
Patients, however, would not look exactly like the                get stiffer, which makes them more difficult for them
donor. The brain activates muscles of facial expression           to vibrate. Over time, from the use of the voice, they
and the bone structure that is the platform. It's the             actually decrease in pliability. Singing, smoking and
facial skeleton, in many ways, that dictates appearance.          just day-to-day speaking can make vocal cords less
But is the public ready for that?                                 limber and speech less recognizable. Vocal Changes
                                                                  are a Red Flag and shouldn't be ignored or written off

as just "old age." Vocal changes can be the first signs           of the meeting, and is presented to the health ministry
of polyps, a paralyzed voice chord, or even cancer                and plastic surgery society of each member country.
larynx. So watch out!
                                                                  In this last decade of high tech and the advent of more
                                                                  sophisticated equipment, our responsibility as surgeons
                                                                  to evaluate the safety of these new technologies
EQUAM                                                             becomes increasingly important. The interaction
                                                                  between clinicians, scientists and manufacturers prior
                                                                  to and during the implementation of new technologies
Moris Topaz, MD, Secretary-General, EQUAM –                       is essential in order to ensure the safe application of
Personal communication with the editor                            these technologies in clinical use. It is imperative that
                                                                  EQUAM continue its vigilance and scientific
                                                                  evaluation of both old and new technologies, devices
The introduction of new technologies to medicine is
                                                                  and surgical procedures, for the assurance of safety and
essential for its progress, yet imposes unforeseen risks.
                                                                  enhancement of patient education. EQUAM thus
Past experience with the ultrasonic- assisted
                                                                  serves to reassure patients, physicians, medical bodies
liposuction (UAL) technique, Trilucent (soybean oil-
                                                                  and the general public of the commitment to safety and
filled) breast implants, and the silicone gel-filled breast
                                                                  high standards on the part of the plastic surgery
implant crisis in the U.S.A., have pointed to a need for
basic scientific data supporting their biosafety. There
are new devices constantly being introduced into the
market, some of which apply advanced technologies.
European And International Committee For Quality                  NEWS
Assurance of Medical Technologies And Devices In
Plastic Surgery (EQUAM) is an
association with a mission to evaluate the safe use of
medical devices, technologies and procedures in plastic           ISCLP&CA 4th.ANNUAL CONGRESS
surgery, and the guarantee of safety and well being of
EQUAM was founded by a group of plastic surgeons                  The 3rd. Annual Meeting of Indian Society of Cleft Lip
headed by Drs. Marita Eisenmann-Klein of Germany                  Palate & Cranio-Facial Anomalies was held IN THE
and Jean-Philippe Nicolai of the Netherlands, and now             Nizam Institute of Medical Sciences, Hyderabad from
comprises over 40 European, Central and South                     January 12 to 16, 2005. The highlight of this
American, African, Southeast Asian and Middle-                    Conference was
Eastern countries. Representatives participating at
meetings are plastic surgeons, scientists, manufacturers          NABICON 2005
and representatives from governmental bodies involved
in the development and surveillance of advanced
technologies, devices and techniques in the field of              The International Society of Aesthetic Plastic Surgery
plastic surgery.                                                  held an instructional course in ‘Technologies in

The previous Consensus Conferences, which are held                JOINT CONFERENCE OF PAPS and PSSH
once in two years, have focoused on the
recommendation by the British Medical Devices
Agency (MDA) for the recall of the TrilucentTM                    The 10th. Annual Conference of the Pakistan
breast implant, and on the European Parliament’s                  Association of Plastic Surgeons and that of Pakistan
assessment of the continuing use of the silicone gel-             Society of Surgery of the Hand was held jointly in the
filled breast implant and their demand to ban its use.            beautiful city of Rawalpindi from February 5 to 8,
Other key topics discussed were the growing                       2005. The conference started with State of the Art
experience with the use of Botulinum toxin in aesthetic           Lectures by Mr. Brian Sommerland, and Mr. Michael
surgery, the implementation of an international breast            J. Early from U.K. and Prof. Grace Warren from
implant registry (IBIR), the use of silicone gel-filled           Australia. Mr. Sommerland talked about the evoluation
breast implants, and last updates regarding safety                of his technique of Cleft Palate Surgery and Mr. Early
issues of ultrasound-assisted lipoplasty (UAL). Various           dwelled on the role of Cranio-facial surgery in
resorbable and non-resorbable injectable materials for            congenital anomalies, trauma and Head & Neck
soft tissue augmentation are available at present.                tumour management. Prof. Grace Warren had a video
Substantial biochemical and biophysical differences               presentation on intrinsic replacement using Paul
exist. Not all of the non-resorbable materials have               Brand’s many tail sublimis transfer. This was followed
withstood the test of time, and some should still be              by a very interactive operative session in which Mr.
considered experimental.                                          Sommerland operated a Cleft Palate, Mr. Early
At the close of EQUAM meetings, a Consensus                       operated on an unilateral Tessier IV cleft using
Declaration is drawn up summarizing the conclusions               calvarial bone grafts to form the missing orbital floor
                                                                  and correct the malar hypoplasia and Prof. Tehseen A.

Cheema demonstrate a classical Buck Gramco                     results while deliberating on the finer details of hair
pollicisation of index finger.                                 transplant surgery. The International Laser Hair
A very lively Head & Neck symposium was the                    Transplant Surgery Centre is a professionally managed
highlight of this conference. Dr. Tahir Ahmed, a               center with overseas affiliation and branches in Lahore,
surgical oncologist from C.M.H. Rawalpindi                     Islamabad and Karachi and a very informative website
deliberated on the approaches and extent of surgical  A few papers on Rhinoplasty and
resection and Dr. S. Bhattacharya of Lucknow talked            Non-surgical facial rejuvenation using Botox were also
about recent modifications in soft tissue reconstruction       presented.
and discussed at length about the reconstruction of the
symphyseal segment of mandible. Dr. Tariq Nadeem               The last day of the conference was dedicated to Hand.
Ansari, oncologist of C.M.H. Rawalpindi discussed the          A symposium on Hand trauma with panelists Prof.
role of adjuvant therapy in Head & Neck Cancers. Dr.           Tahseen A.Cheema, Mr. Michael J.Early and Dr. S.
Mamoon Rashid from the host unit showed some                   Bhattacharya discussed a few problem cases with the
outstanding reconstructive options using microvascular         audience. Dr. Haluk Duman looked after the problem
technique. Dr. Shahab Ghani of Karachi then presented          of soft tissue coverage; Dr. Shahab Ghani discussed the
50 free flaps used in Head & Neck cancer surgery. This         fingertip injuries, Dr. Mabroor Bhatti of Karachi
was followed by an interactive session in which the            deliberated on tendon injuries and Dr. Mamoon Rashid
host unit presented a few problem Head & Neck cancer           from the host Unit talked about replantations. Dr.
cases and both the audience and the panelists                  Bhattacharya presented an overview of the injured
deliberated on them.                                           hand and Dr. M. Amin Cheema presented his
                                                               experience of thumb restoration. Dr. Aun Mohammed
Chaired by Prof. Abdul Hameed, President of P.A.P.S.           and Dr. Sohail Hafeez of the host unit presented some
the next session on Trunk and Perineum had Dr. Haluk           excellent free papers on limb salvage surgery in
Duman from Turkey deliberating on immediate and                Ewing’s Sarcoma. Prof. Grace Warren’s lecture on
delayed breast reconstruction using TRAM flap, Dr.             ‘Severe motor deficits in forearm – have we exhausted
Obaidullah of Peshawar sharing his enormous                    all options for tendon transfer?’ was most informative
experience of Hypospedias surgery, Dr. Sultan                  an eye opener.
Muzaffar discussing correction of congenital chest wall
defects and Dr. S. Bhattacharya of Lucknow                     The Pakistan Association of Plastic Surgeons is a small
demonstrating a wide range of reconstructions                  society, much like we were 15 years ago. Everyone
performed in the perineal region. There were quite a           knows each other by his / her first name and the
few brief communications.                                      atmosphere is very homely. Academics are of the
Mr. Earley’s academic lecture on Nasal Reconstruction          highest quality and professionalism, particularly
and Prof Grace Warren’s lecture on Temporalis                  amongst the younger surgeons is worth emulating. Col.
transfer for Facial palsy were highly appreciated. Mr.         Mamoon Rashid and his team had organized a hugely
John P. Gowar of the U.K. delivered an outstanding             successful conference in C.M.H. Rawalpindi, which
presentation on ‘The vicissitudes faced by the                 the delegates will remember for a very long time.
Birmingham Burns Unit over two decades’ and it left
everybody with a lot of food for thought.
Other interesting papers which caught ones                     UP-APSICON2005
imagination were Dr. A.H.Babar’s effort of controlled
tissue expansion in post burn scars, Dr. Saad ur               The Annual Conference of the U.P. Chapter of
Rehman’s work on mandibular distraction, Dr.                   Association of Plastic Surgeons of India was held at
Mughese Amin’s paper on ‘Honour Amputation of                  Pushpanjali Hospital in ancient Mogul city of Agra on
Nose’ Dr. Md. Zia ul Islam’s work on healing wounds            March 5 and 6, 2005. The Conference comprised of
using the modified and much economical VAC system              two workshops – one on aesthetic facial surgery and
and Dr. Tehseen A. Cheema’s experience with Sural              one on Hypospadias. Inaugurating the conference, Prof
flaps.                                                         Rajive Ahuja, the President of APSI, praised the efforts
The highlight of the Cleft session was a very                  and ongoing activities of the Chapter, which makes it
informative lecture by Mr. Sommerland ‘Cleft Palate            the most vibrant Chapter of our Association.
closure and Maxillary Growth, does it always have to           The first day was dedicated to Aesthetic facial surgery
be a compromise?’ Units from Peshawar, Karachi and             with Dr, Kulwant Bhangoo from the U.S.A. as the
Faislabad presented some very good work on Cleft Lip           guest operator. He performed a traditional Face-lift
and Palate surgery. Dr. Ashraf Ganatra lamented on the         with Blepharoplasty in a 45 years old lady, a Septo-
quality of surgery conducted in some Cleft camps by            rhinoplasty in a patient with bulbous nasal tip with
foreign surgeons and showed how he has countered               deviated nasal dorsum and septum and a bilateral upper
this menace by conducting better camps under the               and lower lid Blepharoplasty in a patient with baggy
banner of P.A.P.S. with better follow up treatment.            eyelids. There was a very lively discussion between the
                                                               operator and the audience, who watched every step on
Mostly surgeons performing hair restoration in Lahore,         a giant screen in the comfort of the conference room.
Islamabad, Karachi and Multan occupied the cosmetic            The second day was for Hypospadias surgery and Prof.
section. Dr. Humayun Mohammud, Dr. Sajjad Khan,                H.S. Asopa of Agra single handedly carried the day.
Dr. A. Taroor and Dr. M. Amin showed some excellent            The viewers were first given an idea about the

evolution of Hypospadias surgery in the last 5 decades                   Don't like that sticky-out belly button?
in a brilliant presentation and later 7 cases were                        Umbilicoplasty turns that "outy" inwards.
operated to demonstrate a different technique each time                  Men can have their "man breasts" reduced -
for a different problem. Thus he started with MAGPI                       and those who dream of a gym-fit body can
operation for glanular and coronal Hypospadias, and                       opt for silicone pectoral implants.
the continued with Snodgrass operation for distal                        Stiletto-wearers can have their feet padded
penile Hypospadias with wide urethral plate and                           and toes shortened to make those Manolos
Snodgrass with buccal mucosa flap for distal penile                       more comfortable.
Hypospadias with narrow urethral plate. Later he                         For improvements of a particularly intimate
showed an urethroplasty with a prepucial patch in a                       nature, surgery can offer practically any kind
mid penile Hypospadias with minimal chordae and                           of increase or decrease in size or alteration to
another urethroplasty with a prepucial tube in yet                        shape.
another patient in whom the continuity of urethral plate
could not be maintained during chordae correction.
                                                                 One part of the body where cosmetic surgery is still in
Lastly in a Hypospadias cripple with multiple fistulae
                                                                 its infancy is the feet, but not for long perhaps. Dr
and remnant chordae and ventral curvature, after
                                                                 Suzanne Levine has made a name for herself among
correction of the entire chordae when the penile shaft
                                                                 the style conscious women of Manhattan, who turn to
could still not be straightened he demonstrated the
                                                                 her when they can't fit into designer high heels. "It's up
dorsal plication technique, and resurfaced the ventral
                                                                 to patients to be able to enjoy their lifestyle," says Dr
surface of the penis with prepucial shin flap for an
                                                                 Levine, who performs a range of operations such as toe
urethroplasty at a later date. An Epispadias case was
                                                                 shortening at her Institute Beauté clinic. So-called claw
also operated and the reconstruction of the urethra and
                                                                 toes stick out beyond the big toe. They are
its ventral transposition was very beautifully
                                                                 incompatible with pointy shoes and can be shortened
                                                                 with bone removal. Other foot options include
The organizers had not only arranged an excellent
                                                                 narrowing and collagen injections.
academic feast but also had the foresight of presenting
each of the delegates with three CDs of procedures
shown in this Workshop but performed earlier by the              It has echoes of the ancient Chinese practice of foot
operators. Prof. Asopa also presented a coloured atlas           binding, yet her patients are anything but enslaved.
of Hypospadias surgery to each of the delegates, which           Many are "baby-boomer" career women in their 50s,
itself is a collector’s item.                                    whose feet have weathered a lifetime of discomfort in
The Organizing Secretary, Prof. Rahul Sahai and his              what the doctor calls "limousine shoes" - precipitously
team of Surgeons managed an outstanding academic                 high with virtually no structure.
event, which can challenge any National Conference.
The bar has been raised a few notches and the                    Dr Levine resets the bones in the foot, and, with lasers,
subsequent organizers will find it difficult to improve          returns a healthy glow to the skin. Dr Magdi Greiss, a
upon his mark.                                                   leading foot surgeon in the UK, frowns on such
                                                                 procedures. "A 16-year-old girl asked me to remove
                                                                 the inherited bunions on her foot because her boyfriend
                                                                 didn't like them," says Dr Greiss. "Do they hurt, I

ACROSS SEVEN                                                     asked. No, she replied. So I told her to get a new
                                                                 boyfriend." Yet he concedes that cosmetic foot surgery

SEAS                                                             is creeping to these shores - already some clinics give
                                                                 collagen injections in the feet for high-heel wearers.
                                                                 "Removing a bunion is a serious piece of surgery that
                                                                 involves slicing through the bone. There's a lot of pain.
FOOT FACELIFTS AND MUCH MUCH MORE                                So I say, if it's not painful to start with, don't create
                                                                 more pain."
No longer is plastic surgery limited to facelifts and
tummy tucks. Today's procedures can remodel those
with cash to burn from head to toe:
                                                                 A BRA FOR LIFE
        Breast implants now come coated in
         biocompatible titanium - to reduce the risk of
                                                                 Feminists may have told women to burn their bras 35
         the body rejecting foreign matter. There's no
                                                                 years ago, but a German-based plastic surgeon has
         word on the risk of setting off airport metal
                                                                 come up with another idea: Implanted push-ups made
         detectors.                                              from a material that's been mainly used in space
        Surplus fat can be sucked from the upper arms           shuttles so far.
         and injected into thinning, aging hands.                About three dozen women have so far undergone the
        Gluteal implants fill out a flat rear - these are       90-minute procedure developed by Ziya Saylan, who
         placed just above the sitting area so weight            operates in the western German town of
         isn't placed on them.                                   Düsseldorf. He uses a mesh made from titanium that's

apparently not harmful to the body and has already              The main objection to cosmetic surgery, voiced by
been used for hernia surgery.                                   Brazilian animal welfare groups, is that it might be
Once implanted, the mesh supports the breast from               used to conceal genetic defects. Suzanne Blum offers
below. Saylan says that the operation is an option for          an example: “A dog may have surgery to correct
women of all breast sizes, although he's told reporters         imperfect teeth or a tail. And then it might win a show.
that it works best for "women with small, sagging               At that point, it commands huge stud fees—even
breasts."                                                       though it has a concealed genetic defect.” The most
While Saylan encourages his patients to keep wearing            extreme cases of concealment have involved testicles.
bras for about six months after the operation, he               Unscrupulous vets have been known to disguise the
promises them firm forms sans bra in the end. Not too           fact that an animal has only one testicle by attaching a
firm, though, as he said in an interview with a beauty          suitably shaped prosthesis.
magazine: "A bosom that's too firm can look artificial.         Is canine cosmetic surgery illegal? Brazilian law does
We're going for a natural appearance. Nice breasts can          not address the controversy directly. A statute of 1943
sag a little, as Leonardo da Vinci already discovered."         bans the mutilation of animals, but there is no legal
Some of his colleagues caution that the implant makes           consensus on whether cosmetic surgery should be
it impossible for women to check their breasts for              classed as “mutilation”. Back at his Sao Paulo clinic Dr
tumors themselves. "There can be some problems with             Brito is dismissive of calls for new legislation. “It’s
that," Saylan told DW-WORLD, but said that regular              perfectly reasonable to use simple surgery to make a
mammograms or x-rays would still help to detect                 dog beautiful,” he says. “There’s nothing unethical
cancerous growths at an early stage.                            about that. “But I agree that vets should not conceal
Still, Saylan's unlikely to convince a huge amount of           hereditary defects. It’s not fair on the dog, the judges or
women to abandon their bras. At a price tag of €7,000           the other competitors. “Here at my clinic I would never
($8,450), the operation costs about as much as 150              attach an artificial testicle.”
"bust-holders," as bras are known in German.

As with people, beauty is in the eye of the beholder in
the canine world. “Why shouldn’t a dog be beautiful?”
asks Dr Edgard Brito, who offers wrinkle-reduction,             CONFERENCES IN 2005
eyebrow-correction and facelifts for canines. “Beauty
is desirable. We all like talking to someone who looks
good. It’s the same with dogs.”
On the wall is evidence of Dr Edgard’s success. He is           April 4 – 9, 2005
pictured with a who’s-who of Brazilian models, actors           The 62nd. ACPA Annual Meeting
and television presenters, all of whom have asked the           Venue: Myrtle Beach, South Carolina, U.S.A.
Sao Paulo vet to beautify their favourite pooch.                Tel: +919-933-9044
“He’s a miracle worker,” says Anita Alt, a dog breeder          Fax: +911-933-9604
specialising in miniature schnauzers, visiting the clinic       Email:
with four-year-old Brutus. We imported Brutus to be a           URL:
show dog, but then one of his ears started drooping—
the kind of thing that would disqualify him.”                   April 13 – 15, 2005
Dr Edgard straightened the ear by injecting Restylane.          The 48th. Annual Meeting of JSPRS – Japanese
“You only need one application. The ears will stand up          Society of Plastic and Reconstructive Surgery
forever.” The ear treatment costs about £40. There is a         Contact: Dr. Yoshiaki Osaka, MD. Professor, Showa
detailed price-list of other procedures including Botox         University, Tokyo, JAPAN.
injections to correct facial wrinkling.                         Email: (703) 820-7400
Since undergoing surgery, Brutus has become one of              Fax: (703) 931-4520
Brazil’s most successful competition dogs. “He’s been           URL:
a pan-American champion,” says Anita, “and he’s won
the best-in-show category a few times. But many                 June 10 & 11, 2005
Brazilian dog lovers believe it is unethical for a              3rd. Workshop on Rapid Free Flap Harvest and
surgically enhanced animal to win a top show. “You              Transfer
really hope people won’t bring you dogs like that,”             Host: Department of Plastic Surgery, Nizam Institute
says Suzanne Blum, who has been judging                         of Medical Sciences, Hyderabad, INDIA
competitions for more than a decade. It’s reasonable to         Contact: Prof. Mukunda Reddy
use simple surgery to make a dog beautiful. There’s             Tel: 098480-50093, 098480-98804
nothing unethical about that “At a crowded show the             Email:
judges get only three minutes with each animal.       
“That’s not long enough to tell whether a dog has had

June 16 –18, 2005
ISAPS Nordic Light Course
Venue: The Grand Hotel, Stockholm, SWEDEN
Tel: +46-8-459-6600
Fax: +46-8-661-9125

September 25 - 29, 2005
10th. International Congress on Cleft Palate and
Related Craniofacial Anomalies ICC
Venue: Durban, SOUTH AFRICA
Contact: Inter Action Conferencing, University of
Natal, Graduate School of Business Building, Francois
Road, Durban 4041, South Africa.
August 30, 2005 – September 3, 2005.
10th. Congress ESPRAS 2005
European Society of Plastic, Reconstructive and
Aesthetic Surgery, European section of IPRAS
Venue: Medical University of Vienna, Vienna General
Hospital, A-1090 Vienna, Austria
Contact: Hedwig Schulz, Vienna Medical Academy,
Alser Strasse 4, A-1090 Vienna, AUSTRIA
Tel: +43-1-405 13 83-10
Fax: +43-1-407 82 74

November 6 - 10, 2005
Venue: India Habitat Centre, New Delhi, INDIA
Contact: Dr. Arun Goel, Department of Burns and
Plastic Surgery, Lok Nayak Hospital, Jawahar Lal
Nehru Marg, New Delhi 110 002, INDIA
Tel: +91-11-23231871, 22057186
Fax: +91-11-23222756


Department of Plastic & Reconstr. Surgery
Institute of Medical Sciences, B.H.U.


Dr. Surajit Bhattacharya
Capital Diagnostics, Mini Plaza, M2 Gole Market
Mahanagar, LUCKNOW 226006, INDIA
Tel: 91 522 2384881 / +94150 81668
Fax: 91 522 2380550
URL: www


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