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					           NEWSLETTER
               ASSOCIATION OF PLASTIC SURGEONS OF INDIA – U.P.CHAPTER
                 MAY, 2006                                  VOL 2/06


EDITORIAL
                                                            evaluation. Isolated microtia is now considered a
CRANIOFACIAL MICROSOMIA                                     microform of Craniofacial microsomia and should
                                                            prompt thorough evaluation before undertaking
        raniofacial microsomia is a spectrum of             cosmetic repairs. In addition, when there is a

C       morphogenetic abnormalities involving
        structures derived from the first and second
branchial arches. It is the second most common facial
                                                            significant facial bone hypoplasia, patients can develop
                                                            airway obstruction called sleep apnea. Untreated, this
                                                            can lead to poor weight gain, small stature, cerebral
                                                            hypoxia, and even death.
birth defect after cleft lip and palate. Fourteen terms
describing this malformation complex can be found in
the literature including First and Second Branchial         Most patients with Craniofacial microsomia have some
Arch Syndrome, Hemifacial Microsomia, Dysostosis            degree of mandibular hypoplasia that is seen clinically
otomandibularis, Congenital oto-cephalic syndrome,          as a deviated chin, occlusal cant and an asymmetry in
Auriculo-branciogenic dysplasia, Oto-cranio cephalic        the position of the corners of the mouth. Patients with
syndrome and Goldenhar-Gorlin Syndrome. Goldenhar           mandibular growth disturbances can present at any age.
syndrome is a variant of Craniofacial microsomia and        The challenge in treating many of these patients lies in
has cervical (neck) and rib anomalies and epibulbar         the variability of age and associated pathology of other
dermoids                                                    facial structures such as the maxilla, the muscles of
                                                            mastication, the zygoma, etc. All of these elements
Paramount to the understanding of Craniofacial              have a well-orchestrated interplay with one another,
microsomia is an appreciation of head and neck              and therefore, the type of treatment chosen to address
embryology. Development of the branchial arches,            the individual deformity must be specific to the
facial growth, and differential craniofacial growth         patient's needs.
contribute to the formation of the facial structures. All
structures derived from the 1st. and 2nd Branchial arches   Classification:
– bones, muscles, cranial nerves, organs and glands can
be involved. The collected group of deformities that        The classification system of mandibular hypoplasia
make up this syndrome may vary greatly in extent and        most frequently used is that of Pruzansky: Grade 1
degree covering a wide spectrum ranging from mild           mandibles are normal in configuration, but reduced in
underdevelopment of the lower jaw to severe deformity       size. Grade 2 mandibles demonstrate hypoplasia plus
of the skull and face. Characteristically this deformity,   mal-development of the associated condyle and
as the name implies (hemifacial), involves one side of      coronoid processes. Kaban, et al later sub-classified the
the face, however involvement of both sides to some         latter group as either 2a or 2b. Grade 2a mandibles
degree can be observed in as high as 15% of all cases.      have hypoplastic and malformed condyles, but the
The most obvious deformity involves the lower jaw           condylar head/glenoid fossa spatial relationship is
and ear, but soft tissue deficiency, maxillary              spatially maintained in the sagittal dimension similar to
hypoplasia and even orbit and skull anomalies may           that of the contralateral side. In these patients the
also be present. Lack of development of the external        misshapen condyle is functional and can be used in the
ear is a common feature with the severity of the ear        mandibular reconstruction. Grade 2b mandibles have a
deformity proportional to the jaw deformity. The            severely hypoplastic and malformed condyle, which is
parotid can be malformed or missing, auricular and          displaced outside of the sagittal plane of the
facial nerve abnormalities have been reported in up to      contralateral temporal mandibular joint (TMJ). These
fifty percent of affected children, and hearing loss to     patients frequently have restricted TMJ function. Grade
varying degrees present cause for otolaryngologic           3 mandibles are severely hypoplastic and lack a
condyle, coronoid process and glenoid fossa. This           Incidence:
classification system can be applied to patients with
unilateral or bilateral mandibular hypoplasia. Any          Craniofacial Microsomia has an incidence reported
treatment plan constructed for these patients must          between 1/3500 to 1/26,550 live births. The male to
factor in the age of the patient and the degree of          female and right to left sided ratios are both 3:2.
skeletal hypoplasia in order to optimize long-term          Bilateral involvement occurs in roughly ten percent of
results.                                                    cases. The majority of cases are sporadic with no
                                                            definite inheritance being proven in the literature.
Meurman, in 1957, proposed the first classification         Recurrence risk is consistently reported at 2-3 percent
scheme for Craniofacial microsomia based on auricular       for subsequent pregnancies.
findings. Murray has proposed a new scheme based on
skeletal abnormalities, which has proven useful in          Aetiopathology:
planning surgical management in this diverse group of
patients. Type one patients have small mandibles with
                                                            In a paper published in 1973, Poswillo attributed the
normal shape, a normal glenoid fossa and a short
                                                            development of facial deformities consistent with
mandibular ramus. Type two findings include an              Craniofacial microsomia to disruption of the stapedial
anteriorly and medially displaced temporomandibular         artery. The stapedial artery functions as a stopgap
joints (TMJ), a short and abnormally shaped ramus,
                                                            vascular channel during days 33-45 of embryologic
and an abnormally contoured TMJ cavity. Complete
                                                            development. Poswillo fed pregnant rats triazene and
absence of the mandibular ramus and glenoid fossa, no
                                                            pregnant monkeys thalidomide and showed the
TMJ and the body of the mandible ending at the molar
                                                            consistent maldevelopment of first and second
region classifies type three patients.                      branchial arch structures. Robinson in 1987 supported
                                                            Poswillo's theory by demonstrating carotid flow
David, Mahatumarat and Cooter propounded the most           abnormalities in two and defects related to vascular
comprehensive classification in 1987 from the               disruption in a third child with Craniofacial
Australian Cranio-Facial Unit of Adelaide, Australia.       microsomia.
Three categories were sought in each patient –
Skeletal, Auricular and Soft tissue. The 5 Skeletal
                                                            Pre-operative evaluation:
categories are:
                                                            The evaluation of Craniofacial microsomia includes a
        S1 – Small Mandible of normal shape                 thorough history and physical examination,
        S2 – Condyle, Ramus and Sigmoid Notch               photographic and cephalometric analysis, and three-
        identifiable but grossly distorted. Mandible
                                                            dimensional computed tomographic study. Family
        strikingly different in size and shape from
                                                            history of consanguinity, intrauterine exposure to
        normal
                                                            infection and toxins, and problems with delivery
        S3 – Mandible severely malformed, ranging
                                                            should be explored. Physical exam should focus on
        from poorly identifiable ramal component to         facial asymmetry as well as on isolated findings
        complete agenesis of ramus                          consistent with this syndrome. Photographs and
        S4 – S3 Mandible + Orbital involvement –
                                                            cephalometry allow for monitoring of facial symmetry
        gross posterior recession of lateral and
                                                            over time and aid in planning surgical approaches to
        posterior orbital rims
                                                            individual patients. Three-dimensional computed
        S5 – S4 defect + Orbital dystopia, hypoplasia
                                                            tomography provides accurate reconstruction of
        and asymmetrical neuroranium and a flat             patients' craniofacial skeletons and alleviates the need
        temporal fossa                                      for constructing physical models. This allows for faster
The 4 auricular categories are:
                                                            and more accurate surgical planning.
        A0 – Normal
        A1 – Small malformed auricle, retaining all
        features                                            Treatment:
        A2 – Rudimentary Auricle, with hook at
        cranial end corresponding to the helix              Treatment of Craniofacial microsomia is
        A3 – Malformed lobule + absent rest of pinna        individualized. Principles basic to all cases include
And the 3 soft tissue categories are:                       treating bony tissue deficits first, followed by soft
        T1 – Minimal contour defect with no cranial         tissue augmentation. The mandible is addressed
        nerve involvement                                   initially since correction of mandibular malformations
        T2 – Moderate defect                                often stimulates maxillary growth. Maxillary growth is
        T3 – Major defect, obvious facial scoliosis,        further enhanced with the use of maxillary activators.
        severe hypoplasia of cranial nerves, parotid,       Costochondral grafts must be used in TMJ
        Ms of mastication, eye involvement + facial         reconstructions. Soft tissue deficits are corrected with
        clefts                                              local and microvascular free flaps. Facial nerve defects
                                                            usually are permanent and hearing must be assessed
                                                            early to allow for hearing augmentation.



                                                        2
Reconstruction of middle ear structures is often                An intraoral mucosal incision along the oblique line of
delayed until craniofacial reconstruction is complete.          the ramus is used for placement of both intra and
                                                                extraoral devices.
The UCLA Craniofacial Clinic Protocol and the
Australian Cranio-Facial Unit Protocol are aimed at             Intraoral incision and subperiosteal dissection is
maximizing results and minimizing the number of                 employed to elevate the entire lateral periosteal surface
procedures. The timing and types of procedures may              with a sharp-ended elevator. After the region of the
vary depending on the severity of the deformity and the         osteotomy is exposed, the reciprocating saw is used to
individual patient. Typically, corrections include many         create lateral, anterior, and posterior corticotomies. The
of the following:                                               direction of the osteotomy is based solely on the bony
1) Preauricular skin tags: (age under 1 year): Excision;        pathology as well as the position of tooth follicles. The
2) Macrostomia or wide mouth: (age under 1 year):               vector of the distraction is also a variable. Distraction
Commisuroplasty;                                                can occur in the vertical, horizontal, or oblique vectors
3) Mandibular hypoplasia: (5-8 years of age): Internal          (based on the relationship of the vector to the long axis
distraction osteogenesis is used to lengthen the lower          of the mandibular body). A vertical vector of
jaw. (For severe cases with absence of mandibular               distraction is preferred for lengthening a deficient
condyle and ramus, a rib graft may be necessary).               ramus in a vertical dimension or for transporting the
4) External ear deformity or absence: (6-8 years of             condyle up into the glenoid fossa. The horizontal
age): Staged ear reconstruction with a rib graft                vector along the long axis of the mandible is chosen in
framework, elevation, lobule (ear lobe) and tragus              order to lengthen the mandible in a purely horizontal
(front of ear) reconstruction are performed.                    plane, as in bilateral micrognathias whose deficiency is
5) Orbital dystopia (asymmetric eyes): (6-11 years of           predominately in the mandibular body. If an oblique
age): Although rarely required, repositioning of the            vector (a direction between the vertical and horizontal
orbit and/or advancement of the forehead and brow               vectors) is chosen, the osteotomy is placed anterior to
(fronto-orbital advancement) may be performed.                  the coronoid in order to prevent impingement of the
6) Jaw asymmetry: (15-18 years or age of skeletal               coronoid on the zygomaticomaxillary buttress during
maturity): Preoperative orthodontics followed by jaw            distraction. An oblique distraction vector not only
(orthognathic) surgery with Le Fort I (upper jaw) and           lengthens, but also vertically elongates the mandible.
mandibular sagittal-split (lower jaw) osteotomies are           Before converting the corticotomy into an osteotomy,
often necessary.                                                the pins are placed. If the intraoral device is used, a
7) Soft tissue asymmetry: (after jaw surgery): Final            single percutaneous stab incision is made for the
facial contouring with autogenous fat grafting, dermal          placement of the screwdriver. For the extraoral device,
fat grafts or even a fascial-fat free flap from the upper       a two-holed trocar is used for percutaneous placement
back are often necessary after other corrections.               of the posterior pins. The second anterior pair of pins is
                                                                placed so that the skin between the two pin sites is
Mandibular distraction:                                         compressed, thereby reducing the amount of tension on
                                                                the wound and the length of the scar. The device is
Distraction has the advantage over other techniques in          attached to the pins. A 3 mm osteotome completes the
that it requires minimal operative time, carries little         medial wall osteotomy, liberating the mandibular
risk, minimizes hospitalization time, obviates the need         segments for distraction. The wounds are closed in
for blood transfusion, bone graft and intermaxillary            layers with absorbable sutures.
fixation, and has minimal relapse rates. In a typical
mandibular distraction, anesthesia can be administered          After a delay of 5 to 7 days (termed the latency period),
by either oral or nasal endotracheal intubation, but            distraction commences at a rate of 0.5 mm twice a day
nasal intubation is preferred. The mandibular border is         (termed the activation phase). This rate is continued
outlined on the skin surface with a surgical marker as a        until the mandibular length is overcorrected by several
point of reference. Based on the patient's pathologic           millimeters. During distraction, the vertical or oblique
anatomy, the decision is made whether to use an                 vector will typically become more horizontal, due to
intraoral or extraoral distraction device. Patients who         the counterclockwise pull of the muscles of
require only unidirectional lengthening and have                mastication. At this time orthodontic intermaxillary
adequate mandibular bone stock are ideal candidates             elastics may be used to mold the regenerating bone and
for intraoral distraction. Patients with severe                 optimize the occlusion (termed molding the
mandibular deficiencies require distraction in multiple         regenerate). The device is left in place to serve as an
dimensions and are best treated with an extraoral               external fixator for 8 or more weeks, until there is
device. In addition, patients who have previous                 radiographic evidence of mineralization. This stage is
external scars from other procedures are treated with an        known as the consolidation phase.
extraoral device. With an extraoral approach, care is
taken not to damage soft tissue that may be needed for          In patients with unilateral Craniofacial microsomia
future surgeries, such as external ear remnants or              undergoing distraction, it is important that a dental
microvascular soft tissue augmentation. Any incisions           impression be taken and a bite block placed in the
are placed in areas that can incorporate the distraction        surgically created posterior open bite when the device
pins, so a second percutaneous pin site is unnecessary.         is removed. This will allow the orthodontist to level the

                                                            3
maxillary occlusal plane by allowing for eruption of             involved a Le Fort I osteotomy followed by ipsilateral
the ipsilateral maxillary dento-alveolar complex.                lengthening of the mandible with bone grafts and a
Distraction will also affect the entire facial milieu: the       contralateral impaction. The deficient maxilla can be
soft tissue envelope bulk will increase due to a                 distracted in conjunction with the mandible. In this
combination of soft tissue expansion and muscle                  technique, a Le Fort 1 corticotomy is made at the time
hypertrophy and leveling of the oral commissure are              of the mandibular osteotomy and placement of the
usually noted.                                                   distraction device. The upper and lower jaws are wired
                                                                 into intermaxillary fixation. After a 5-day latency
Age is also a factor in developing a treatment plan.             period, distraction is commenced at the rate of 1
Under 2 years of age, mandibular distraction is not              mm/day. At the conclusion of maxillary/mandibular
usually performed because it is difficult to identify            distraction, the device is left in place for 8 weeks to
tooth buds at this age, and therefore permanent dental           allow for bone consolidation. Using this technique, we
injury is a likely occurrence. Secondly, distraction at          have had excellent soft tissue and bony results with
this age can be a daunting experience for the patient            complete leveling of the dental occlusion.
and the parents. The exception to this would be when             Intermaxillary fixation is not employed during the
early mandibular distraction is used to prevent                  latency period; instead heavy guiding elastics are
tracheotomy in a newborn with micrognathia that is               placed at the time of distraction. The bands are
causing severe airway obstruction.                               modified throughout the process to obtain optimal
                                                                 dental alignment.
Final Orthognathic surgery and Free Composite
Tissue Transfer                                                  Summary:

Children with S3, S4 and S5 (absent ramus, condyle,              Craniofacial microsomia is a syndrome with diverse
and/or glenoid fossa), are initially treated with an             presentation. The majority of cases are sporadic with
autogenous costochondral rib graft reconstruction at             stapedial artery disruption being considered the most
approximately 3-4 years of age (first stage). The                likely etiology. The ACFU Classification based on
costochondral graft will increase mandibular length,             skeletal, external ear and Soft Tissue abnormalities is
reconstruct the condyle, and form a pseudoarthrosis              most comprehensive and treatment specific. Treatment
with the glenoid fossa. In a second stage, at least 6            schemes are adapted to the specific dysmorphology of
months after removal of the fixation, distraction of the         individual patients. Distraction histiogenesis,
rib graft can be performed. At the time of skeletal              Orthognathic surgeries, Composite Free Tissue
maturity however microvascular free tissue transfer is           Transfer along with good pre and postoperative
offered to create absent parts of the mandible. When             orthodontics and timely reconstruction of external ear
the glenoid fossa is absent, a new one is constructed            and other facial clefts and soft tissue blemishes
with rib grafts fixated to the zygomatic arch. From age          completes the treatment.
6 to the teen years, during the period of mixed
dentition, orthodontic treatment is needed to promote
growth of the affected dentoalveolus and to aid in the
proper eruption of the permanent teeth. Indications for
surgery in the teen years include: 1) residual post
surgical skeletal deficiency due to surgical relapse or
abnormal growth, 2) unsatisfactory bone contour, 3)
malocclusion, or 4) absence of previous treatment. Any
                                                                 VIEWS
appropriately chosen maxillofacial surgical procedure
could be performed during this time ranging from
sagittal split osteotomies, to bone grafting, to
distraction. In patients with minimal mandibular                 FACE TRANSPLANT – SCIENCE FOLLOWS
deformities, classic orthognathic procedures are                 THE ADVENTUROUS SURGERY
indicated. Mandibular distraction should be considered
in patients with moderate to severe skeletal deficiency,
or bilateral disease, in whom pressure from the soft             In the first peer-reviewed, scientific studies of their
tissues would significantly increase the risk of                 kind, U.S. plastic surgeons demonstrated how to
postoperative graft resorption or skeletal relapse.              successfully complete full facial tissue transplantation
                                                                 from one human body to another, reports the March
                                                                 issue of Plastic and Reconstructive Surgery. (PRS), the
Restricted mandibular growth is frequently associated
                                                                 official medical journal of the American Society of
with abnormal maxillary development. The ipsilateral
                                                                 Plastic Surgeons (ASPS).
maxilla and dento-alveolar processes are often
deficient in the vertical dimension. In mild cases this
can be treated with a bite block and orthodontic                 "For the first time, we have scientific data that takes us
therapy as described above; however, in more severe              beyond traditional reconstructive techniques and partial
circumstances a maxillary (Le Fort I) leveling                   facial transplantation," said ASPS President Bruce
procedure may be considered. Traditionally, this has             Cunningham, MD. "What we thought of as a

                                                             4
possibility - reconstructing the entire face of someone         REGAINING VIRGINITY BY PLASTIC
with a severe facial disfigurement, in one surgery, from        SURGERY
one complete facial skin flap taken from a donor - is no
longer just theory, but will become an actuality."
                                                                Could you put a price on virginity? Is it too late? Well
"Through these particular studies we have determined            now, one can buy it back! There is a surgical
that full facial tissue transplantation is a successful         procedure that will re-install virginity.
approach in helping patients horribly disfigured by
burns, accidents and other trauma," said study lead             This is not a joke. This is real. It isn‟t cheap, either.
author Maria Siemionow, MD, director of plastic                 The procedure will set you back about $2,000 in the
surgery research at the Cleveland Clinic. "The                  U.S. And as everyone knows, it only takes a moment
transplantation of a facial tissue flap from one cadaver        to lose, even if it‟s for the second time. A bonus: This
to another has allowed us to do the following: estimate         magical re-virginization surgery is available and not
the time it takes to perform this particular                    difficult to master! Dr. Marco Pelosi, a GYN and
transplantation, perfect our technique and visually             plastic surgeon in beautiful downtown Bayonne,
confirm that a facial tissue flap is a match when               performs 10 hymenoplasties each month, according to
covering severe burns and other trauma."                        the London Times.

Although traditional methods for facial reconstruction,         The technique was only perfected five years ago, by
which include skin grafts and flaps, are reliable and           Beverly Hills plastic surgeon Dr. David Matlock. He
effective techniques for reconstructing the face, they          trained a handful of doctors who have set up shop
may not be ideal, according to the studies. It is nearly        nationally, and in Canada. Hymenoplasty is not
impossible to match the skin quality, texture and color         licensed by any credited plastic surgery or
of the face with any other tissue available on the body.        gynecological association (quashing my belief that, to
In addition, it takes multiple grafts and surgeries to          doctors, there is no such thing as unnecessary surgery).
successfully reconstruct the entire face. Many patients         All the operations have been paid for by the individual.
are left with a patchy, unfavorable appearance,                 And yet, there are customers who have gotten the
including large scars and mismatched skin. The studies          surgery and loved it so much that they feel like singing
found the only way to surgically match facial skin              their hymenoplasties‟ praises from the rooftops.
texture, pliability and color is through facial                 Thousands of dollars, and it lasts a few seconds when
transplantation.                                                challenged. And still it‟s becoming more popular
                                                                among those that can afford it.
"There is no doubt that facial transplantation can
                                                                Bayonne‟s Dr. Pelosi says his clientele are "upper-class
improve the quality of life for patients, however, facial
                                                                ladies coming in from Manhattan, getting ready for a
transplantation will not replace traditional techniques,"
                                                                second-honeymoon cruise...or some women had a
said Rod Rohrich, MD, editor of PRS. "This is an
                                                                disappointing time the first time they were deflowered
exciting time in plastic surgery, but it is important to        and now they have found someone special they would
remember that, at least in the near future, facial              really like to give it up to." Bigger picture: could this
transplantation will be a last resort procedure
                                                                popular, new surgical procedure be evidence that we
performed on carefully selected patients on a case-by-
                                                                are moving backwards in time?
case basis."
                                                                Well it is a mad mad world out there, who are we to
In the studies, doctors used cadavers to perform mock           judge?
facial transplantations in order to outline the necessary
steps to transplant a human face. Through these trials,
they were able to visually show the full extent of the
procedure's outcome.
                                                                EXPANSION AUGMENTATION
During the procedure it took surgeons approximately
five hours to perform the mock facial transplantation,
                                                                Expansion-augmentation was first developed for
this did not include vessel and nerve repair. In living
                                                                reconstructive reasons but was soon used for cosmetic
recipients, the authors estimate the total length of
                                                                reasons as well. After years of development,
surgery will be approximately 11-15 hours.
                                                                expansion-augmentation will now normally involve a
                                                                permanent saline expander. When using the expansion-
"Plastic surgeons have historically been at the forefront       augmentation technique, the expansion-augmentation
of transplantation medicine," said Dr. Cunningham.              patient has the ability to adjust the final size post-
"The first successful hand transplantation was                  operatively.
performed by a plastic surgeon in 1998, as was the first
kidney transplant in 1954. The idea of tissue                   According to the conclusion of a three-year study
transplantation has opened a new era in this field of           following women with breast implants, it was shown
medicine."                                                      that a large amount of women returned to plastic

                                                            5
surgeons in order to change the implant size. The                         conditions such as asthma and bronchitis. The
advantage of choosing the expansion-augmentation                          U.S. Food and Drug Administration (FDA)
technique is that it will allow the women to more easily                  have banned this agent because it can raise
alter her implants to a more desirable result.                            blood pressure, heart rate and metabolic rate,
                                                                          ultimately causing heart attacks, heart
Another advantage of expansion-augmentation is that it                    arrhythmia, stroke and even death.
is able to better adjust breast asymmetries that can                     Echinacea is often used for the prevention and
commonly exist. Using expansion-augmentation,                             treatment of viral, bacterial and fungal
volume differences, nipple positions, base widths, and                    infections, as well as chronic wounds, ulcers
ptosis or pseudoptosis can be more appropriately                          and arthritis. However, it can trigger
attuned, which can be difficult to achieve with alternate                 immunosuppression, causing poor wound
breast augmentation techniques.                                           healing and infection.
                                                                         Glucosamine, often offered in conjunction
Since every woman will have individual factors                            with chondroitin, contains chemical elements
influencing how the breast augmentation will turn out,                    that mimic human insulin, and may artificially
expansion-augmentation has the ability to allow for a                     cause hypoglycemia during surgery.
more predictable outcome. Some women's breast
augmentation results will be influenced by their natural         Other common supplements taken by patients in the
shape and personal traits, as well as by the surgical            study that may cause dangerous side effects included
procedure like scarring and other unforeseeable results,         gingko biloba, goldenseal, milk thistle, ginseng, kava
expansion-augmentation might be a good option for                and garlic.
women that have risk of producing unpredictable
outcomes.                                                        In addition to having a greater tendency toward taking
                                                                 herbal supplements, 35 percent of plastic surgery
                                                                 patients were more likely to engage in homeopathic
                                                                 practices, including acupuncture, hypnosis,
                                                                 chiropractic manipulation, massage, yoga and Pilates.
HERBAL SUPPLEMENTS – A SMOKING GUN                               Only six percent of the general population practiced
                                                                 homeopathies on a weekly basis.
Natural herbal supplements are supposed to help boost
our immune systems, give us more energy and make us              Patients should be encouraged to tell doctors about all
generally healthier. However, many of these                      of the medications they are taking – natural or
"harmless" supplements could cause dangerous side                prescribed. Only then can we safely suggest the
effects during plastic surgery, reports a study in               appropriate discontinuation period, which can range
February‟s Plastic and Reconstructive Surgery®, the              from 24 hours to one month. Taking this precaution is
official medical journal of the American Society of              essential to a safe surgery and smooth recovery.
Plastic Surgeons (ASPS). In fact, the study found
approximately 55 percent of plastic surgery patients,
compared to 24 percent of the general public, take
supplements but often do not tell their surgeons. When
patients are asked about the medications they are
taking, many do not mention medicinal herbs because
they assume that they are safe. What many
unsuspecting patients don‟t know is that the natural
herbs they are taking may cause serious complications            NEWS
during and after surgery."

All 55 percent of plastic surgery patients who used
herbal supplements took at least two different                   AESURG 2006
supplements and at least one on a daily basis. The most
popular herbal supplements were chondroitin (18                  The International Conference on Aesthetic Surgery,
percent), ephedra (18 percent), echinacea (14 percent)           held in Golden Park Hotel, Kolkata from February 3 to
and glucosamine (10 percent).                                    5 was attended by over 150 delegates and will be
                                                                 remembered both for its scientific content and social
        Chondroitin is often used to treat                      engagements for a very long time to come. The
         osteoarthritis. People using chondroitin may            Conference Operative Workshop was held at Garden
         suffer from bleeding complications during               Reach Hospital and Rhinoplasties of five different
         surgery, particularly when used in                      types were on the list. Dr. S.P. Arumugam of the US
         combination with doctor-prescribed blood-               performed an Augmentation of the nasal dorsum with a
         thinning medications.                                   silicon implant and later on showed his technique of
        Ephedra has been known to promote weight                dealing with a cleft lip nose. Dr. K.S. Bhangoo of the
         loss, increase energy and treat respiratory tract       USA gave an excellent disposition of reduction
                                                                 rhinoplasty and later on went on to show the thread lift

                                                             6
technique of rejuvenating the forehead and mid face.                importance of dissecting in correct plane around the
Dr. Vakis Konotes of Greece performed a rhinoplasty                 inguinal region to preserve the lymphatics, and showed
in a post traumatic crooked nose, previously operated               that the abdominal flap was raised only up to the
with less than optimal result, and he showed the utility            umbilicus and supra umbilical blunt dissection only
of the „Turkish delight‟ cartilage graft technique. Dr.             was being done for flap mobilization and closure.
Devansh of New Delhi demonstrated the Radio
Frequency facial rejuvenation and later on made a                   The session on Rhinoplasty had Dr. S.P. Arumugam
small presentation on the same topic. Dr. S.C. Vyas of              and Dr. K.S. Bhangoo speak on Augmentation and
the USA also was amongst the guest operators and he                 Reduction Rhinoplasty respectively. Dr. S.C. Vyas
demonstrated a routine hump reduction and alar base                 emphasized the importance of spreader grafts and Dr.
resection. Dr. A.R. Lari of Kuwait concluded the day‟s              Vakis Kontoes gave his views on the surgery, the way
proceedings with demonstration of the use of fillers in             it is practiced in Greece. Dr. Devansh talked about
the correction of acne marks and scars on the face. All             Open Rhinoplasty and the best lecture in this series
the surgeries were very well demonstrated and                       was delivered on Cleft Lip Rhinoplasty y Dr. R. B.
moderators from the floor made the discussion between               Ahuja in which after defining the morbid anatomy and
the audience and the operators very lively. The day                 establishing a clear perspective of the effects of growth
ended with a banquet on a steamer as it gently cruised              and primary lip repair he went ahead to define clear
up and down the expanse of a tranquil river Hooghly.                steps of the surgical correction in the form of exposure,
                                                                    alar cartilage modification, septal correction,
The symposium on Surgical rejuvenation of the face                  osteotomy, dorsal augmentation, tip definition and
had 6 speakers. While Dr. Manish Gupta of the US                    maxillary augmentation.
emphasized on a balanced approach to mid face
rejuvenation, dwelling at length on assessment,                     The session on Lasers had 3 speakers; Dr. L.D. Dhami
planning, technique and complications, Dr. S.P.                     of Mumbai discussed the treatment of pigmented
Arumugam talked about „Short scar face lifts‟                       vascular lesions, Dr. Kuldeep Singh deliberated on hair
reiterating that this was less traumatic, has lesser                removal in resistant and secondary cases and Dr.
complications and yet give equally good results. He                 Manoj Johar while talking about the role of lasers in
also advised adding contour thread lifts whenever                   aesthetics cautioned that one should not be too keen in
necessary to give better and longer lasting results.                learning the tricks of the trade but instead try to learn
Thread lift was discussed at length with videos and still           the trade itself. The symposium on Breast aesthetic
slides by Dr. K. S. Bhangoo and right throughout his                surgery saw most of the speakers choosing the vertical
discussion he kept on emphasizing that this was not a               scar technique, when opting for breast reduction. Dr.
substitute or alternative to face lift. It can elevate ptotic       Ashok Gupta and Dr. D. Panfilov of Germany gave us
malar fat pads, improve contour, is minimally                       the benefit of their vast experience of breast
detectable, leaves minimal scar, has no downtime, is                augmentation and Dr. Suresh Gupta walked down the
simple and effective, can be combined with other                    memory lane of breast reduction techniques.
procedures and doesn‟t burn any bridges for future
intervention. Lectures on Lip Contouring by D. Ashok                The session on Hair restoration had Dr. R. Rajput of
Gupta using dermo-fat graft and soft tissue fillers and             Mumbai deliver a very informative talk on medical
Current techniques in blepharoplasty by Dr. S.C. Vyas               management of hair loss by a cyclical treatment
were very well composed. Dr. Vakis Konotes then                     schedule, emphasizing that not only the graft
gave a video demonstration on facelift, blepharoplasty              requirement goes down but also at times surgery can be
and CO2 resurfacing of face with interesting bits of                avoided. Discussing the current trends in this surgery
discussion interjected in between.                                  Dr. K. Ramchandran of Chennai talked about the
                                                                    importance follicular units, cautioned against the use of
The Symposium on Non surgical facial rejuvenation                   „biofibers‟ as the often cause scalp infections and
had 4 speakers; D. S.P. Arumugam talked about is                    peeped into the future of hair follicle culture and stem
cream Programme, Dr. Devansh discussed the utility of               cell research. Dr. Humayun Mohammad of Pakistan
Radio frequency facial rejuvenation, Dr. Kuldeep                    showed the importance of naturalness of hair transplant
Singh of New Delhi gave an excellent disposition of                 surgery, particularly the frontal hairline, the density,
what all can be achieved by fillers by addressing static            the angle of exit from the scalp, the temporal peak and
skin folds, lip sculpturing, volume augmentation and                the fronto-temporal angle. Lectures on complications
scar revisions, and finally Dr. B. S. Chandrashekhar of             in Cosmetic Surgery by Dr. L.D. Dhami, and
Chennai deliberated on Long term hair removal L.H.E                 Autologous Fat transfer by Dr. D. Panfilov were also
– a new non laser life technology. A session on                     very interesting.
Liposuction and Abdominoplasty had two speakers
with beautiful video presentations. Dr. A.R. Lari                   A very well arranged conference with excellent extra-
discussed the finer details of his mega-liposuctions, his           curricular activities, a trip to the Eden Gardens, a light
technique of umbilicoplasty, and buttock contouring by              and sound show at the Victoria Memorial and some
injecting fat, harvested from the abdomen into the                  excellent culinary delights were all made possible by
gluteal muscles. Dr. Mohan Rangaswamy of Oman                       the untiring efforts of Dr. Manoj Khanna and is team of
then showed his short scar high-tension                             Plastic Surgeons of the West Bengal Chapter of APSI.
lipoabdominoplasty in which he emphasized the

                                                                7
CRANIOCON 2006                                                 performs under operating microscope with beautiful
                                                               muscle dissection of the soft palate and subsequent
                                                               intra-velar veloplasty. All the steps of his repair were
The Annual Conference of UP Chapter of APSI this               magnified many times on the screen and were very
year took the shape of CRANIOCON 2006, a                       easy to follow and understand. Prof K.S. Goleria a
wonderfully interactive conference and Workshop on             Cleft Lip repair with alveolar bone grafting and a Cleft
Craniofacial Surgery. The three-day extravaganza               Lip Rhinoplasty and later on delivered a lecture in the
started on March 11, 2006 in the Post Graduate                 memory of Swami Vivekananda on Cleft related
Department of Plastic Surgery, King George‟s Medical           craniofacial surgery. Drawing from his vast experience
University, coinciding with the Foundation day of the          of treating these patients and the fact that he remains a
Department, with a brainstorming lecture session. Dr.          teacher par excellence his contribution to this
S. Bhattacharya started the proceedings with a lecture         conference was acclaimed by all the delegates.
on Craniofacial Microsomia in which he showed the              The final day started with a Symposium on
versatility of a classification system propounded by the       Craniofacial Surgery in which Prof. K.S. Goleria
Australian Cranio-facial Unit in terms of predicting the       discussed the salient points of setting up of a
treatment protocol and also presented the changing             Craniofacial Unit, Dr. K. Sridhar talked about the
trend in the treatment from bimaxillary surgeries in           approach and planning of a Craniofacial Surgery, Prof.
adulthood to distraction histiogenesis during the period       R.K. Sharma cautioned about the complications of
of adolescence. Dr. A.K. Singh of Lucknow then                 Craniofacial Surgery and suggested precautions to
presented his experience of managing the complex               avoid them ad Dr. Rohit Khanna, an eminent
problem of Hypertelorism, discussing a few interesting         Orthodontist of Lucknow, deliberated at length about
per-operative details of the management of nasal               Orthodontics in Cleft Lip ad Palate patients.
bridge and dorsum.                                             The surgical feast continued with Prof. G.S. Kalra
Mr. Brian Sommerland of U.K delivered the                      demonstrating two Lefort I osteotomies with maxillary
prestigious Prof. R.N. Sharma Memorial Oration on              advancement, Dr. K. Sridhar and Prof. R.K. Sharma
„The World Wide Challenge of Cleft Lip & Palate‟ and           demonstrating a hypertelorism correction and Prof.
with his experience of having operated on these                K.S. Goleria showing a Secondary Lip correction in a
patients in all continents except Antarctica; no one was       Cleft Lip cripple. Live telecasts of these surgeries were
better suited to present this perspective. Prof. K.S.          made further lively by an excellent interaction between
Goleria discussed about Craniosynostosis, its diagnosis        the operators and the moderators and a very
and management protocol, Prof. G.S. Kalra of Jaipur            enthusiastic bunch of delegates The Department of
talked about a wide variety of Splints and Appliances          Neurosurgery under the stewardship of Prof. D.K.
used in Orthognathic Surgery, their indications, design        Chabra were always around to help and so were the
mechanics and fabrication, and Prof R.K. Sharma of             staff of Vivekananda Polyclinic.
Chandigarh deliberated upon the various osteotomies            The conference could have been conducted in any 5
that are performed in Orthognathic Surgery, their              star facility but by purposely bringing it to the pious
morbid anatomy, indications, operative procedures and          ambience of this charitable institution, run by the world
pitfalls.                                                      famous Ram Krishna Seva Sansthan, the organizers
The best part of the day was however saved for last            wanted to show the delegates how efficiently and
when 16 patients, complete with all investigations and         selflessly health care of the highest order can be
Orthodontic work up were presented one by one in a             catered to the poorest of the poor without making any
Planning Session by the host Plastic Surgeons and              compromises in its quality. Swami Muktinathanand ji
Orthodontist Dr. Rohit Khanna. The Operating Faculty           and his dedicate team deserve our special word praise
and the delegates, numbering more than 100, discussed          and salutation for helping the UPAPSI to organize such
at length about the treatment options and marveled at          a wonderful conference.
the excellent homework that was done by the
organizers.
The venue shifted to the beautiful Vivekananda
Polyclinic the next day, and the proceedings started           5th ANNUAL CONFERENCE OF ISCLP & CA
with a very informative lecture on Velopharyngeal
Incompetence, delivered by Mr. Brian Sommerland in
which he discussed at length about the aetiology,              (Personal communication to the Editor from Prof.
investigations and treatment of this condition. The live       Mukund Thatte, President, ISCLP & CA and Dr. D.N.
operative sessions that followed were conducted                Uppadhayya, Plastic Surgery Trainee, K.G.M.U.
simultaneously in three operating theatres and                 Lucknow)
transmitted live in three different halls. Prof. G.S.
Kalra operated upon a child with bilateral Tessier 12          The 5th Annual Congress and International Update of
cleft with bilateral encephaloceles and hypertelorism,         the Indian Society of Cleft Lip, Palate and Craniofacial
and Dr. K. Sridhar of Chennai along with Prof. R.K.            Anomalies was held in Guwahati from the 23rd to 26th
Sharma operated a child with Fronto-nasal meningo-             of March, 2006 at the Administrative Staff College,
encephalocele with asymmetrical hypertelorism and              Khanapara.
telecanthus. Mr. Brain Sommerland demonstrated his
technique of Palate repair in 2 patients, which he

                                                           8
Though, as desired by the President, Dr. Mukund                 results at length and demonstrated the good outcome of
Thatte, the monopoly of the Metro cities was broken             his surgery.
and the conference was taken to a smaller city, the             In the last symposium of the day Dr. Gunvor Semb of
psychological barrier of distance seemed non existant           U.K. spoke on “Orthodontic treatment options for
as the conference drew faculty from all across the              patients with complete cleft lip and palate” and
globe including international luminaries like Dr. Ian           demonstrated how our understanding of the role of
Jackson, Dr. Michael Karsten, Dr. Brian Sommerlad,              orthodontics in the treatment of cleft patients had
Dr. Gunvor Semb, Prof. Peter Mossey, Dr. Jean Clude             changed radically after the preliminary results of the
Talmant and Prof. William Shaw and all over the                 Eurocran project started trickling out. She spoke at
country like Prof. Mukund Reddy, Dr. K. Shridhar,               length about how the project was mooted and how it
Prof. A.K. Singh, Dr. Rajiv Ahuja, Dr. Ramesh                   has grown with time and is providing very exciting
Sharma, Dr. Mukund Jagganathan, Dr. Jyothsana                   data that will change our perception of cleft
Murthy, Dr. Mukund Thatte, Dr. S.P.Bajaj, Dr.                   management. Braithwaite Oration by Prof William
Gunasheelan Rajan and Dr. Krishna Shama Rao.                    Shaw of Manchester who spoke of the WHO initiative
                                                                for cleft research and collaboration amongst all
The first day started off with addresses by Prof.               countries. Day 2 ended with the free paper sessions and
N.N.Barman and Dr. M. Jagganathan, Chairman,                    poster presentations.
National Scientific Committee. This was followed by a
Video Operating session with some excellent                     Day 3 began with the Millard Oration by Prof. Michael
expositions on various topics by Prof. C. Thomas from           Carsten, in which he stressed the radical changes that
Oman, Dr. S.Gosla Reddy, Dr. M. Jagganathan, Dr.                are coming about in the field of craniofacial surgery
Krishna Shama Rao and Dr. Ian Jackson. Dr N.J.                  after BMP has become a reality. He spoke on
Mokal's and Dr M. Jagannathan's videos were notable             Developmental field repair ---a new concept in Cleft
for its clarity but all were very well illustrated.             thinking---where embryology drives surgical
This was followed by a Symposium on “The Advances               technique. He painted a picture of the not-so-far-
in Cleft and Craniofacial Surgery”.                             away-future where BMP will play a very important
The symposium and indeed the whole meeting was                  role in every aspect of craniofacial surgery.
characterized by the fact that all plenary sessions were        In a symposium on Craniofacial surgery – The Orbit,
multi disciplinary including all faculties involved in          the main speakers were Prof Ian Jackson and Dr. R.K.
cleft care. Prof. Michael Carsten spoke at length about         Sharma who spoke on Horizontal and Vertical orbital
the breakthroughs that they have been achieving with            dystopias and presented picture examples to prove their
the use of “Bone Morphogenetic Protein” and how this            point.
is radically transforming craniofacial surgery and our          Dr Subramani gave a talk on a new classification of
concept of bone regeneration. He stressed that BMP              Cranio Facial Clefts and Dr Sridhar gave the first
will soon replace all bone grafts and break exciting            analysis of his work on the TN survey that was
new frontiers in this field of plastic surgery.                 fascinating.
Prof. Peter Mossey narrated his experiences with cleft          This was followed by another symposium on
patients and spoke about the Eurocran project going on          “Multicentric studies and Protocols” in which the main
in Europe.                                                      participants were Dr. Gunvor Semb and Dr. John
The day ended with Dr Tambwekar giving the                      Clark, both from U.K.
Founder's oration based on his thinking about normal            The last item of business was case presentations by
and abnormal anatomy.                                           various experts in “Ask the Experts”.
Formal inauguration took place in the evening at the
hands of Mr. Saikia the noted littérateur from Assam.
The Presidential Speech followed this where he
stressed the fact that it was important to get out of the       INTERNATIONAL WORKSHOP AND
metro circuit of conferences and spread our message to          SYMPOSIUM ON HYPOSPADIAS, EXSTROPHY
more deprived regions.                                          AND EPISPADIAS

Day 2 saw Prof. Ian Jackson and Dr. Brian Sommerlad
deliver their lectures on “Bilateral Cleft Management”.         Personal communication to the Editor from Prof. A.
Dr. Brian Sommerlad dwelled into the details of his             Wakhlu, Organizing Secretary of the Workshop and
technique of cleft palate closure and the protocol that         Professor of Paediatric Surgery, K.G.M.U. Lucknow)
he follows and answered the many queries that
followed thereafter. Dr. Jean Claude Talmant of France          This three day Operative Workshop and Lecture
spoke on the Delaire approach of Cleft lip repair. Other        session was held in the royal ambience of the
symposia included one on “Inadequately addressed                Administrative Block of King George‟s Medical
issues in Cleft management” followed by one on                  College, Lucknow. The academic session began with
“Secondary deformities in cleft patients”.                      the AK Wakhlu Oration delivered by Dr Richard
Later on in the day Dr. Brian Sommerlad spoke on                Grady, Associate Professor of Urology at the
“Management of Velopharyngeal Incompetence”. He                 University of Washington School of Medicine. He
demonstrated how he diagnoses, treats and follows the           summarized the embryology, history of treatment and
patients with VPI due to cleft palate. He discussed his         current concepts in the treatment of this difficult

                                                            9
anomaly in his 30-minute lecture. This was followed              narrow bladder outlet, ischaemic injury in epispadias
by a lecture on the embryology of Exstrophy Bladder              repair and complications of continence producing
by Dr Sylvie Beaudoin from Paris, essentially a                  procedures were also dealt with exhaustively. The last
surgeon she presented their studies on embryology of             part of the lecture covered gynecologic issues in
this anomaly. Aided by experimental and embryologic              females and male infertility. Mr. Justin Kelly detailed
studies they have demonstrated that the pelvic ring and          the technical points and principles of his own
the vesico urethral unit develop in a coordinated                technique,” radical soft tissue mobilisation in the repair
manner and the cloacal membrane, previously thought              of Exstrophy bladder in the next lecture, this extensive
to be the chief structure related to the exstrophy group         operation is said to give better results than some of the
of anomalies is actually more concerned with the                 conventional methods of repair it involves soft tissue
development of the anorectum. The lecture on                     mobilisation in the pelvis and also the anterior
embryology was followed by Dr Grady‟s talk on                    abdominal wall for a tension free closure. Mr. Prasad
surgical treatment of epispadias, this lecture                   Godbole, consultant pediatric urologist a the Sheffield
summarized the anatomical principles involved in                 Children‟s Hospital then lectured on the methods of
epispadias repair. He also described the different               improving continence in patients with bladder
techniques of epispadias repair and their modifications          exstrophy, he detailed bladder neck reconstruction,
practiced over the years. The next lecture by Dr Ranjiv          bladder augmentation, endourethral injection of
Mathews detailed the anatomical aspects of exstrophy             bulking agents and the artificial urinary sphincter. Dr
bladder specially the rarely described abnormal                  Anurag Krishna discussed the quality of life issues
anatomy of the bony pelvis. This excellent lecture               such as functional closure of the bladder, cosmesis and
detailed all the different types of osteotomies                  body image future sexual function and psychosocial
performed for exstrophy bladder including the methods            impact of the operation; he also highlighted the total
of external fixation. In addition Dr Mathews also                absence of any state support in the management of
detailed the pelvic floor anatomy, bladder anomalies,            these unfortunate children and the tremendous financial
genital defects and penile anomalies found associated            and psychological burden on the family.
with epispadias and exstrophy. Following this session
on Exstrophy came a lecture on the anatomy and                   Dr Govind Datar, pediatric surgeon from Pune,
principles of Hypospadias repair by Dr GG Singhal,               lectured next on the vexing issue of the failed
Consultant Asopa Hospital Agra. Dr Singhal outlined              Exstrophy Repair he began with a definition of failure
the detailed penile anatomy in Hypospadias together              of the exstrophy repair not only in terms of breakdown
with the prerequisites of the operating surgeon, his             of the wound but also failure to achieve adequate
familiarity with several operative techniques and their          continence, failure of adequate sexual function etc. Dr
results. He then described the relevant details of the           Ranjiv Mathews, Associate Professor of Pediatric
commonly used operative techniques for repair of                 Urology at Baltimore, detailed their technique of
Hypospadias. This was followed by a lecture on the               staged repair of bladder exstrophy with the use of
staged repair of Exstrophy by Dr Veeresh Bhatnagar,              osteotomy. He was the only surgeon among the faculty
who detailed the operative techniques and post                   who favoured the use of bilateral single or double
operative care of patients undergoing staged repair of           osteotomies to aid bladder closure beyond the neonatal
bladder exstrophy. This lecture also described the               period. Both osteotomies are performed on the iliac
surgery for bladder neck reconstruction, bladder                 bone, and are the posterior vertical and anterior
augmentation and mentioned epispadias repair. The                horizontal. Dr Mathews also detailed the subsequent
next lecture by Dr S N Kureel described his experience           stages of bladder neck reconstruction and epispadias
with single stage reconstruction of exstrophy bladder.           repair concluding that staged repair of bladder
Illustrated with color illustrations in the workbook this        exstrophy remains the gold standard for this condition.
talk focused on the finer technical points, which govern
successful outcome in single stage reconstruction of             The final lecture of the academic session was by Prof
exstrophy.
                                                                 Bharti Kulkarni, from Sion hospital Mumbai who
                                                                 described her pioneering technique for single stage
Having covered the various aspects of the conventional           reconstruction of exstrophy bladder, the modification
and recent treatment of exstrophy, epispadias and                involves transposition of skin flaps from the ventral the
Hypospadias the academic sessions went on to the                 dorsal aspect of the penis thus normalizing the
lectures discussing the associated procedures in these           distribution of hair bearing skin. In addition
conditions and the surgery and management of                     mobilization of these flaps permits deep dissection
complications. Dr Minu Bajpai lectured on the                    ventral the crura of penis thus one can dissect the
management of vesicoureteric reflux in patients with             bulbospongiosus muscle and the external urethral
bladder exstrophy he highlighted the factors                     sphincter and mobilize them completely to wrap them
responsible for VUR, the indications and technical               round the membranous urethra. The technique is
considerations of surgery for VUR in bladder                     characterized by normalization of pubic hair
exstrophy and the technique of ureteric reimplantation.          distribution, normalization of the penoscrotal angle and
Dr Sudipta Sen, Professor of Pediatric Surgery at                increasing dry intervals in the patients in short term.
Vellore, detailed the complications of the various               None of the patients have reached school age yet for
operative and urinary diversion procedures used in               actual continence to be commented upon.
bladder exstrophy. The complications of wide and

                                                            10
1st INTERNATIONAL TUTORIAL SERRIES IN                             classroom sessions) have been compiled into a set of
AESTHETIC SURGERY                                                 educational DVD‟s for aspiring aesthetic surgeons and
                                                                  are available on request. Please contact
(Personal communication to the Editor from Dr. Neeta              neetapatel@hotmail.com or
Patel, Member, Organizing Committee and Faculty)                  aesthakg@bom5.vsnl.net.in for the same.

The 1st International Tutorial series in Aesthetic
Surgery was held between the February 6 to 15, 2006
at the Bombay Hospital. This tutorial series being first
of its kind was conducted with the sole purpose of
updating and enhancing the skills and knowledge of all
                                                                  ACROSS SEVEN
the plastic surgeons interested in aesthetic surgery.
The course essentially consisted of live surgeries,               SEAS
deferred surgeries (surgeries done during the course
but not relayed live), operative videos, didactic lectures        PLASTIC SURGERY TOURISM
and conventional classroom sessions. An expert faculty
of both international and national repute contributed all
of these. These included Dr. Thomas Biggs from USA,               So how did the women find a way to make their
Dr. Claude Lassus from France, Dr. Paraskevas                     surgical dreams come true on a budget? All they had to
Kontoes from Greece, Dr. Daniel Cassuto from Italy,               do was become part of the multi-million-dollar
Dr. Panfilov Dimitri from Germany, Dr. Abdul Reda                 lipotourism trade, a business built around two ideas:
Lari from Kuwait, Dr. Ayman Hajjar from UAE, Dr.                  foreign doctors who offer cut-rate surgery and
Bacci from Italy, Dr.Al Khairy from Pakistan, Dr.                 Americans who are willing to go overseas to go under
Brandi from Italy, Dr. Wolfgang Funk from Germany,                the knife. Who wouldn't be tempted by the idea of sun,
Dr.Satish Vyas from USA, Dr. Castillo from Mexico                 fun and surgery at unbeatable prices? Consider this: A
and Dr. Nijjadah from Kuwait. The Indian faculty                  tummy tuck in the United States would set you back at
included besides Dr Ashok Gupta (Course Director) Dr              least $6,000, but in Costa Rica it's only $2,000. A
Baman Daver, Dr Lokesh, Dr Ramchandran, Dr Manoj                  facelift in the U.S. costs up to $9,000. In Malaysia it
Johar, Dr Sattur, Dr Nitin Mokal, Dr Manoj Khanna,                costs a third of that. And a breast augmentation in the
Dr A.P Chitre, Dr Mani Varghese, Dr Vahanvala, Dr                 U.S. costs $7,000, but in the Dominican Republic, only
Raman Goel, Dr MufiLakdawalla, Dr Satish Arolkar                  $2,000.
and Dr Neeta Patel.
Dr. Tom Biggs who was the course preceptor not only
contributed individually but also moderated the                   In fact, the Dominican Republic is fast becoming the
sessions so as to make them learning friendly to the              Caribbean Mecca of lipotourism. Eighty percent of the
rapt audience. Each day also saw a two-hour afternoon             plastic surgery patients there come from abroad lured
class where doubts and problem cases were discussed               by low prices and a seductive climate. But as the
freely between him and the audience. There was also a             lipotourism in the Dominican Republic grows, some
boot workshop with emphasis given to the practical                American doctors are concerned about the quality of
tips and tricks used for better results.                          care patients who go there receive. And, as we found,
This course had a registration of 120 members from                choosing one questionable doctor can lead to tragic
our fraternity but we also had about 50 registrations             consequences. You can find ads for clinics in the
exclusively for the facial plastic surgery conference             Dominican Republic on Web sites, but much of the
which was conducted during the same period between                business is drummed up by word of mouth in an
the 7th and 9th of Feb. Besides plastic surgeons we also          unusual setting that is anything but clinical -- mom and
had ENT and maxillofacial surgeons attending the                  pop beauty salons. Dateline went to one in Manhattan
conference. Three symposia was conducted during the               with our hidden cameras last November. There were
conference namely on Rhinoplasty, lasers and                      dozens of women jammed in the salon, many of them
orthognathic surgery The topics and surgeries                     waiting for an appointment. And it wasn't just any
conducted covered all aspects of aesthetic surgery right          appointment. They were prepared to wait for hours, if
from hair restoration, face rejuvenation both surgical            they had to. They had paid the manager of the salon
and non-surgical, breast aesthetics, liposuction and              $15 to meet a plastic surgeon who was pitching his
body contouring as well as less presented topics such             clinic in the Dominican Republic.
as penile lengthening, fat transplant, mid face lift
through blepharoplasty approach, obesity related                  And business is good. The salon owner tells us about
procedures, sex reassignment and legal and ethical                the doctor's busy schedule. She was a walking talking
problems in aesthetic surgery practice                            advertisement for the doctor's work. While they waited
The entire course was well received by the audience               to meet him, many of the women were just as open to
with requests for conducting it on a regular annual               talking about the surgery they want. There were lots of
basis. The faculty was also very encouraging in this              laughter and anticipation among the women, but what
respect and they have assured us they would help us               we didn't hear was anyone talking about what could go
conduct it in future. The proceedings of the entire               wrong.
course (operative sessions, lectures, workshops and

                                                             11
                                                                 Blacks: Nose reshaping, liposuction, and breast
10 MILLION COSMETIC PROCEDURES IN 2005                           reduction Asian Americans: Nose reshaping, eyelid
IN THE U.S.                                                      surgery, and breast augmentation Hispanics: Breast
                                                                 augmentation, liposuction, and nose reshaping

In 2005, cosmetic procedures -- including surgery and            The most common cosmetic surgeries for men were
minimally invasive treatments such as Botox injections           nose reshaping, hair transplantation, liposuction, eyelid
and laser hair removal -- were done more than 10                 surgery, and breast reduction. More than 300,000 men
million times in the U.S. That‟s an increase of 11               got Botox and more than 200,000 got
percent from 2004 and 38 percent from 2000,                      micodermabrasion, the report shows.
according to the American Society of Plastic Surgeons.
Add in reconstructive plastic surgery -- such as surgery         For the youngest patients, who were at most 18 years
to remove tumors or mend wounds -- and the grand                 old, nose reshaping led the list. More than 47,300
total tops 15 million procedures. Most cosmetic                  youths had their noses reshaped in 2005, compared
patients were women, whites, and middle-aged adults,             with more than 13,000 who got cosmetic surgery on
the report shows. But more than a million men got                their ears, about 3,000 who got liposuction, about
cosmetic procedures. So did more than 300,000 youths             3,500 who got breast augmentation, and about 4,200
aged 18 and younger.                                             males who had breast reduction surgery.

According to the report, America‟s five most common              SOURCE: News release and statistics report, The
cosmetic surgeries in 2005 were:                                 American Society of Plastic Surgeons.
1. Liposuction: 323,605
2. Nose reshaping: 298,413
3. Breast augmentation: 291,350                                  PLASTIC SURGERY FOR MIGRAINES
4. Eyelid surgery: 230,697
5. Tummy tuck: 134,746
                                                                 During the 35 years she suffered from frequent
                                                                 migraines so severe they made her vomit, Viera Bernat
Facelifts didn‟t make the list. “The facelift is still a
                                                                 said she tried nearly every treatment imaginable. She
highly sought-after procedure. Nearly 109,000 were
                                                                 changed her diet, practiced relaxation exercises and
performed last year,” says American Society of Plastic
                                                                 took a string of powerful drugs, from narcotic
Surgeons president Bruce Cunningham, MD, in a news
                                                                 painkillers to Imitrex, one of a class of medications
release. “However, the fact [that] it didn‟t make the top
                                                                 called triptans.
five surgical procedures can be attributed to increased
                                                                 "Nothing really worked," said Bernat, 62, a family
consumer demand for minimally invasive injectable
                                                                 physician who practices in Solon, Ohio. Despite a high
wrinkle fillers and fighters as a remedy to combat
                                                                 pain threshold, she said, "mostly I suffered." Desperate
facial aging,” Cunningham says.
                                                                 for relief, Bernat tried a new and controversial remedy:
                                                                 plastic surgery.
The report also lists the top five minimally invasive
cosmetic procedures:                                             Nearly three years ago, as part of an experimental
                                                                 study, Bernat had her forehead lifted and her nose
1. Botox: 3,839,387                                              reshaped by Cleveland plastic surgeon Bahman
2. Chemical peel: 1,033,581                                      Guyuron. For several months before the outpatient
3. Microdermabrasion: 837,711                                    surgery, Guyuron had injected the anti-wrinkle drug
4. Laser hair removal: 782,732                                   Botox, also known as botulinum toxin A, into sites on
5. Sclerotherapy (includes injectable wrinkle fillers):          Bernat's face and the back of her neck to determine if
589,768                                                          the paralytic drug reduced her headaches. Based on the
                                                                 results of those injections, Guyuron decided that
The most common reconstructive surgeries were:                   muscles or tissue underlying those spots should be
                                                                 surgically removed to treat her pain.
1. Tumor removal: 3,936,405                                      To Bernat's delight, the surgery worked. Although she
2. Laceration (cut) repair: 344,231                              occasionally gets minor headaches and her forehead
3. Scar revision: 181,011                                        still feels numb, her weekly migraines have stopped. "I
4. Hand surgery: 171,972                                         feel that I have my life back," she said. "I am so
5. Breast reduction: 114,250                                     grateful."
                                                                 No one knows what causes migraines, which affect an
                                                                 estimated 28 million Americans, according to the
Data came from a national online database for plastic            National Institutes of Health. The condition, which
surgery procedures and from an annual survey sent to             often surfaces before age 35, appears to be a
more than 17,000 board-certified specialists in                  neurological problem linked to inherited abnormalities
specialties most likely to perform plastic surgery. The          in genes that affect certain brain cells, rather than the
three most commonly requested cosmetic surgeries                 dilation of blood vessels in the head, as scientists had
varied by ethnic group:                                          long theorized.

                                                            12
Guyuron has another theory: that migraines are                      Login.
triggered by muscles that pinch the trigeminal nerve,               Stephen Silberstein, director of the Jefferson Headache
which studies have shown is activated during a                      Center at Thomas Jefferson University in Philadelphia,
migraine attack. For the past six years he has pursued              agreed. One concern, he said, is Guyuron's reliance on
this theory, publishing in the peer-reviewed journal                Botox, which has been shown to have a high placebo
Plastic and Reconstructive Surgery several studies of               response. About 40 percent of patients in some studies
the surgical treatment he pioneered. Guyuron said he                did as well after being injected with a dummy liquid as
got the idea after several patients casually told him that          with Botox, one reason the Food and Drug
their migraines had vanished after they underwent                   Administration has not approved the wrinkle smoother
cosmetic forehead surgery to smooth wrinkles and lift               as a migraine treatment, according to neurologists.
their brows.                                                        "What I'm concerned about is that migraine patients are
In his most recent study, published in January,                     desperate, and some of them will grasp onto this," said
Guyuron said that 92 percent of 89 patients he operated             neurologist Merle Diamond, associate director of the
on reported that the frequency, intensity and duration              Diamond Headache Clinic in Chicago. "I certainly
of their migraines were reduced by at least 50 percent.             wouldn't want to have people rushing off to get their
In 35 percent of these patients, including Bernat,                  muscles cut."
surgery eliminated the migraines. In a control group of             Jennifer S. Kriegler, a neurologist and co-author of the
25 patients who received saline injections, 15 percent              January study, said that she diagnosed patients. All had
reported a significant reduction in headaches, but none             migraines according to the standard medical definition.
reported that their migraines were eliminated.                      "I will tell you I was as skeptical as anyone," she said.
"It's too early to call it a cure," said Guyuron, a clinical        "To me the biggest issue is going to be long-term
professor of plastic surgery at Case Western Reserve                follow-up."
University, who is following patients to see how they               Surgery, she said, is not a first-line treatment. "These
fare long-term. But many neurologists say they are                  are people who have failed everything" or who cannot
skeptical of Guyuron's hypothesis - that removing                   take triptans.
muscles pressing on nerves will quell migraine pain -               Cost is a major drawback, Stark noted, because
as well as the methodology of his latest study, which               insurance companies would consider the surgery, for
assigned four times as many patients to the treatment               which Guyuron charges $4,000 per site, cosmetic and
group as to the control group. Some critics point out               ineligible for reimbursement, just as they do with
that Guyuron performed a variety of procedures on the               Botox treatments for migraines. Most patients,
patients, making it impossible to evaluate the success              according to Guyuron, need surgery on at least two
of treatment. Nearly all had a forehead lift, which                 sites. He views the issue in a different light. Patients
involved removing the corrugator muscles, while 70                  who undergo surgery, which he has taught to several
percent had an operation to straighten a deviated nasal             plastic surgeons around the country, would save money
septum (the cartilage and bone that separates the                   they now spend on drugs and avoid the side effects of
nostrils) and 38 percent had a portion of the greater               medications.
occipital muscle from the back of the neck removed.                 "The majority," he added, "would benefit from the
"The data is impressive, but the rate of temporary side             aesthetic changes they would experience."
effects was astronomically high," said Stuart R. Stark,
medical director of the Neurology and Headache
Treatment Center of Alexandria, Va., who said that
patients have asked him whether they should have the
surgery.
Among the temporary side effects Guyuron and his
team reported, most related to Botox injections, were
hollowing of the muscles in the temple, which created
a scooped-out appearance (23 percent); a drooping
                                                                    FORTHCOMING
eyelid, also known as ptosis (10 percent); and intense
scalp itching lasting an average of six months (9                   EVENTS
percent)."I've probably had three ptosis patients in the
last five years," said Stark, who uses Botox to control             CONFERENCES IN 2006
migraines in some patients who don't respond to triptan
drugs or who can't take them because they have cardiac
problems. Hollowed temples, he said, "would be                      May 11 & 12, 2006
upsetting to a patient, and it can take many months for             2nd.International Workshop on Cleft Lip & Palate
it to go away."                                                     Venue: Institute of Child Health, Great Ormond Street
Ivan S. Login, a migraine expert and professor of                   Hospital for Children, London, UK.
neurology at the University of Virginia, said he wasn't             Contact: Louise Conn, Cleft Lip & Palate
sure Guyuron's patients had migraines or a different                Coordinator, Great Ormond Street Hospital, London
type of headache caused by sinus or other problems.                 WC1N 3JH, UK.
He also said that the success rate seemed unusually                 Tel: +44 20 7829 7922
high. "Until these results are replicated, it's hard to             Fax: +44 20 7829 7947
know how much validity to put on this data," said                   Email: boshel@gosh.nhs.uk

                                                               13
May 17 - 20, 2006                                          August 12 & 13, 2006
4th Central European Advanced Course on                    First National Workshop on Propeller Flaps
Aesthetic Plastic Surgery                                  Venue: RIGHT HOSPTITALS, Chennai INDIA.
Venue: Prague, Czech Republic                              Contact: Prof.G.Balakrishnan, Medical Director,
Tel: 420-2-6716-3030                                       RIGHT HOSPTITALS, #1, Prof.Subramaniam street,
URL: aps.cls.cz                                            Kilpauk, Chennai 600 010. Tamil Nadu, India.
                                                           Tel: 91 44 26493939, 91 44 26403999
                                                           Email: righthospitals@yahoo.co.in; gb@eth.net
May 20 & 21, 2006                                          URL: www.righthospitals.com
National workshop on Multidisciplinary approach
in Wound Management and Research
Contact: Dr. Pramod Kumar, Department of Burns             August 12 – 14, 2006
and Plastic Surgery, Kasturba Medical College &            Joint International Conference of Pakistan
Hospital, MAHE, Manipal, 576104. INDIA                     Association of Plastic Surgeons and West Asia
Venue: Conference Hall, 3rd, Floor Shridi Sai Baba         Society of Aesthetic Plastic Surgery
Cancer Hospital and Research Center, Manipal               Venue: Pearl Continental Hotel, Karachi, PAKISTAN.
Tel: 0820 2922286, 2922192                                 Contact: PAPS & WASAPS Conference Office
Fax: 0820 2571934, 2570062                                 20-E, Lane-12, Ittehad Phase 2 Ext.D.H.A
Email: pkumar86@hotmail.com                                Karachi PAKISTAN.
arun.maiya@manipal.edu                                     Tel: 00-92-0333-2102258
                                                           Email: admin@pakconference.com
                                                           www.pakconference.com
June 1 - 3, 2006
ISAPS Venice Postgraduate Instructional Course
Venue: Venice, Italy                                       September 1 - 3, 2006
Contact: Karen Rogerson                                    30th Annual Conference of Indian Society of
Tel: 39-02-480495202                                       Surgery of Hand ISSHCON 2006
Fax: 39-02-43911650                                        Venue: Department of Orthopaedics, Government
Email: venice2006@cq-travel.com                            Medical College & Hospital, Sector 32, Chandigarh,
URL: www.surgerycourse.org/venice2006/                     INDIA.
                                                           Contact: Dr. Ravi Kumar Gupta
                                                           Tel: 91 172 2665545 (Extn. 2311), 2621023
June 2 - 4, 2006                                           Email: issh2006registration@yahoo.co.in
COSMOLASERCON 2006                                         URL: www.gmch.nic.in/issh2006
Venue: Balabhai Nanavati Hospital, Mumbai.
Contact: Dr. L.D. Dhami, C/212 Lancelot, S.V. Road,
Borivli (W), Mumbai 400 092                                September 13 - 20, 2006
Tel: 91-22-56943626, 28016529                              International Workshop on Reconstructive
Fax: 91-22-56943237                                        Microsurgery, 2006 International Conference of
Email: info@iacls.com                                      Plastic Surgery and the 4th. International Workshop
URL: www.iacls.com                                         on Cleft Lip & Palate and Maxillofacial Surgery
                                                           Venue: Chang Gung Hospital, Taipei, TAIWAN
                                                           Contact: Department of Plastic Surgery, Chang Gung
June 14 - 17, 2006                                         Hospital, 5, Fu-Hsing Street, Kuei-Shan, Taoyuan
60th Annual Meeting - Canadian Society of Plastic          (33305), TAIWAN
Surgeons                                                   Tel: (886) 3 3281200 Ext. 3355
Venue: Fairmont Château Frontenac, Québec,                 Fax: (886) 3 3285818
CANADA                                                     Email: adm.cgmh.org.twmicro@d
Contact: Karyn Wagner                                      Website: www.cgmh.org.tw
Email: csps_sccp@bellnet.ca

                                                           September 21 & 22, 2006
August 2 - 6, 2006                                         BAAPS Annual Meeting 2006
ISAPS 18th Congress                                        Venue: Bath, United Kingdom
Venue: Rio de Janeiro, Brazil                              Tel: 44-207-430-1840
Contact: ISAPS Executive Office                            Fax: 44-207-242-4922
Tel: 1-603-643-2325                                        Email: info@baaps.org.uk
Fax: 1-603-643-1444
Email: isaps@sover.net
URL: www.isaps.org                                         September 26 – October 1, 2006
                                                           Australian & New Zealand Head & Neck Society 8th
                                                           Annual Scientific Meeting And New Zealand


                                                      14
Association of Plastic Surgeons Annual Scientific
Meeting
Venue: Duxton Hotel, Wellington, New Zealand
Contact: Karen Williamson AFMEA, Conference
                                                          SECRETARIAT
Manager, Medical Industry Assn of NZ, PO Box 8378,
Symonds Street, Auckland, New Zealand
Tel: +64 9 9173650                                        Department of Plastic & Reconstr. Surgery
Fax: +64 9 9173651                                        Institute of Medical Sciences, B.H.U.
Email: karen@mianz.co.nz                                  VARANASI, INDIA
Website: www.headandneck2006.co.nz
www.plasticsurgery2006.co.nz


October 12 – 14, 2006
The IV International Plastic Surgery Course
Venue: Ekaterinburg, Russia
Tel: 7-343-371-8820                                       EDITORIAL OFFICE
Email: mm@plastic-surgery.ru
Website: www.plastic-surgery.ru                           Dr. Surajit Bhattacharya
                                                          Lucknow Plastic Surgery, Capital Diagnostics,
                                                          Mini Plaza, M2 Gole Market
1-5 November 2006
                                                          Mahanagar, LUCKNOW 226006, INDIA
2nd Annual Bariatric Plastic Surgery Workshop
Venue: Ritz-Carlton, Amelia Island, Florida               Tel: 91 522 2384881 / +94150 81668
Tel: 1-601-815-1313                                       Fax: 91 522 2380550
Email: jbmccraw@surgery.umsmed.edu                        Email surajitb@sancharnet.in
Website: www.bariatricworkshop.com                        URL: http://up-apsi.com/
                                                          www.lucknowplasticsurgery.com
November 20 - 24, 2006
APSICON – 2006 Annual Conference of Association
of Plastic Surgeons of India
Venue: Ramoji Film City, Hyderabad, INDIA
Contact: Prof. D. Mukunda Reddy, Dr. R. Srikanth,
Department of Plastic Surgery, Nizams Institute of
Medical Sciences, Punjagutta, Hyderabad - 500 082,
INDIA
Tel: +91-9848050093, +91-9848098804 91-40-
2339119175
Email: mukundreddy@hotmail.com
info@apsicon.com
URL: www.apsicon.com




                                                     15

				
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