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What all we do ?

Face

Acne or Pox Marks
Scars from Injuries or Surgery (In Detail)
Vitiligo or Pigmented patches
Wrinkles and Folds
Rhinoplasty - Nose Surgery (In Detail)
Chemosurgery (In Detail)

Breasts

Breast Augmentation for small breasts (In Detail)
Breast Reduction-for large breasts (In Detail)
Breast Lift/Mastopexy (In Detail)

Abdomen

Obesity-Liposuction (In Detail)
Abdominoplasty (In Detail)

Limbs

Filarial limbs

Tissue Expansion

APPEARANCE - THE LAST BASTION OF DISCRIMINATION

Facial disfigurements and deformities are common causes of human sufferings, much commoner than one would imagine or even hope to see in a Plastic Surgeon’s clinic as many afflicted, far from seeking cure, would choose to hide from public gaze. While accurate figures do not exist, given the known incidences of congenital, traumatic and malignant facial conditions, together with skin diseases - every general practitioner will frequently encounter this problem. The question is, how many of them are genuinely helping these patients who are seeking their professional advice ! 

At the root of the patient’s distress lies the pressure in the modern cosmopolitan society to confirm to idealized appearances. Image and beauty are marketing tools portraying a particular ‘supermodel’ as the desired ‘look’, diminishing the value of the individuals who deviate  from the face or form of the moment.

Visuals of beauty queens walking down the catwalks in Paris, Rome and  Sun City interspersed with the emaciated skin draped skeletons from Ethiopia, Somalia and Sudan provide the two extremes of the  World Pageant on our television screens, although honestly which is which is getting more and more difficult to recognize. 

Stigmatization by appearance is reinforced at every stage in our education. Children’s books and fables invariably portray the evilest character to be the ugliest one -  the wolf in Grand-ma’s bed, Iago in Aladdin, Skeletor in He-Man are all bad and ugly. Pantomime Ugly Sisters equate ugliness with evil and films and videos have villains like Freddy ( in Nightmare on Elm Street ), Mogambo ( in Mr. India ) etc. to reinforce this definition. Were film makers to tackle race or sex in the way they tackle beauty or ugliness they would be subject to prosecution. Yet incitement to pick on the disfigured is widespread. The shameful use of achondroplasic dwarfs in our circuses and films is best not discussed in greater details. 

More subtle judgment based on appearance are widespread. The media attention to the fresh looks of  Diana , The Princess of Wales, the youthful charms of Rajive Gandhi or the hair style of Tony Blair more recently are all marketed to build a particular image of that time. The obsession with  the idea to match this image marginalizes those who fall short of these perceived ideal, and those with visible disfigurement, being furthest down the ladder of beauty, are challenged most. 

Victims of society’s cultural attack may simply adopt a defensive style of behaviour and hide from public gaze or approach their doctors. To the clinician they may present a complain that is clearly directed towards a specific abnormal facial feature like a crooked nose or thick lips or small sized breasts or heavy thighs or their true problem may be obscured as a part of  depression or anxiety. It should be appreciated that the impact on the patient is not proportional to the magnitude of disfigurement but depends on other psychological parameters, family environment, and how much it interferes with his or her life. These are not frivolous complains, and as many tears may be shed in the doctor’s chamber as when confronting a fatal illness. 

Negative coping strategies may include avoidance of social contact, alcohol misuse and aggressiveness but these patients are not mad. It is as dangerous for a doctor to dismiss a complain of this nature as it would be to ignore blood in one’s sputum, as both may ultimately result in fatality. Dissatisfaction with appearance seems to be a factor in many suicides - when concern is far out of proportion to the deformity some psychiatric counseling may also be of help. As with other conditions like heart diseases, some patients may imagine that they have a problem when none exists and a few professional words of reassurance is all that they are seeking, but an abrupt rebuke is just not needed. 

To take a stance that “Cosmetic Surgery “ is not to be encouraged in a poor country like ours seems to be an extreme view of a few self appointed high priests of our society, and it is depriving many patients of an improved quality of life. One should not start categorizing other’s problems as morally worthy and unworthy, even removal of a tattoo may return a patient to gainful employment as many employers think it to be the trade mark of an irresponsible man. 

Referral to a Plastic Surgeon should never be made with a promise for the moon. Contrary to popular belief and irrespective of what countless soap operas might suggest, scars, anywhere in the body , can not be made to vanish. The very name of the surgery is scar revision and not scar removal - we exchange the big , ugly and obvious scar with a small, fine and hidden one. Similarly breast reduction or augmentation surgeries are also not scar-less - but these scars are hidden and very fine. Abdominal obesity is perhaps the most satisfying surgery in terms of the resultant scar - it is a fine panty-line scar never to be seen in the briefest of the outfits. Scars of face lifts and baggy eyelids are also virtually invisible because of their placement. 

Facial appearance and body contour remain the last bastions of discrimination and a proper and professional handling of the problem will go a long way to eliminate them !

ACNE
These are common skin disorders seen in adolescents and young adults which consist of seborrhea, small comedones, and inflammatory papules and pustules or cysts which leave behind extensive scarring on the facial skin. Topical medication and oral antibiotics tide over the active phase. After the patient has been under optimal dermatological regimen, which has kept the face acne free for some time, dermabbrasion in selected cases has been useful in reducing the scarred appearance of the face. Dermabbrasion can be repeated after 18 to 24 months to improve the results.Pox marks on the face if generalized are also treated similarlyby dermabbrasion.

SCARS
Post traumatic and post surgical scars are very common cause of concern if they are on exposed areas. While small scars can be excised in toto and replaced by a better looking hair-line scar, for larger scars tissue expansion is the method of choice. In this method we expand the nearby normal skin for 4-6 weeks by a gradually expanding tissue expander and subsequently excise the unsightly scar and replace it with the expanded adjacent skin, which invariably has the same colour and texture.

A multi-staged method of scar excision is also practiced, which aims at excising the scar slice by slice, from an area which will not allow a one stage excision of a scar without causing a secondary deformity. This is called serial excision. Large depigmented scars or tattoos can also be excised and resurfaced by a split skin graft. Smaller scars on the face can be excised and resurfaced by Wolfe grafts for better colour and texture match. Scars can never be made to vanish, they can only be replaced by a softer and a better one. Hence the surgery is called scar revision and not scar removal. (In Detail)

VITILIGO
These are white depigmented patches found in isolated areas or generalized all over the body surface. Treatment with oral and topical drugs should be tried first. Those in exposed areas are best treated surgically if they are resistant to medical treatment and are of a stable size for the last 2 years. Tattooing of patches in the fingers and toes are useful if colour matching pigments are available. Surgery for vitiligo is the same as it is for other scars. (see Scars)

PIGMENTED PATCHES
These are giant port wine coloured stains or Giant Hairy Nevus. The only available treatment is surgical. Surgery is the same as it is for other scars (see Scars).

Giant Hairy Mole
Pre-Operation	Post-Operation

 

WRINKLES AND FOLDS
These can be treated surgically or by silicon injections. Surgeries like face-lifts, brow lifts and blepharoplasties can also take away the folds and wrinkles (In Detail).

RHINOPLASTY
(RECONTOURING OR RESHAPING OF THE EXTERNAL NOSE)

Rhinoplasty is one of the most common operations performed by Cosmetic Surgeons today. This operation is designed to improve the general appearance of the nose by doing any one or more of the following procedures to the nose:
1. Reducing the forward projection of the nose
2. Removal of hump
3. Correction of depressed nose
4. Correction of deviation of nose
5. Narrowing of the upper nose
6. Narrowing of the tip of the nose
7. Narrowing of the lower nose
8. Reducing the nostril size
9. Lifting the lip higher.
Many patients have a fear that the nasal change will be so great as to create a subject of discussion among their family or friends. In reality, neither the patient nor the patient's friends or relatives really remember the original shape of the nose, a few weeks after the surgery.

SURGICAL PROCEDURE:
This operation is performed in the hospital. It takes about 11 hours to 3t hours for the surgery, depending upon what has to be done. Some corrections can be done as outpatient surgery where as others require 1 to 2 days stay in the hospital.
Rhinoplasty is done under local anesthesia. Sedation is also given just prior to surgery to help the patient be relaxed.
The incisions for reshaping or recontouring the external nose are usually made inside the nose. The nasal skin is lifted away from the cartilage and bone and reducing or adding or lifting is done. In reduction of the nose, the bone, the cartilage, and the excess tissues are removed. The nasal bones are usually narrowed. The excessive skin left by the reduction of the underlying bone and cartilages usually readapts itself to the new framework.
For depressed nose, after lifting the skin, enlargement or augmentation is done with cartilage from car or with bone from rib or leg or with silicone rubber.To reduce the width of the lower part c.' the nose or to reduce the nostril size, skin is removed from the nose close to the cheek attachments.
If -the chin is smaller and disproportionate when compared to the nose and the rest of the face, chin enlargement could be done at the same time. Also, if the lips are too thick, they could be made thinner at the same lime.

AFTER SURGERY:
Immediately after the surgery, a restricting splint and/or dressings are placed on the nose and will remain in position for approximately five days.The operative procedure and the postoperative period are not exceedingly painful. Since there will he packing in the nose for several days following the surgery, the patient will breathe through the mouth. This will give the feeling of having a minor cold and may cause drying membranes of the mouth. The nose may feet congested for of the several weeks following the surgery due to internal swelling.

SWELLING AND DISCOLOURATION:
After the nose surgery, there is moderate to marked swelling of the nose, eyelids, cheeks, upper lip and forehead. In most patients the swelling will increase gradually and reach to a maximum at the end of 48 hours after surgery. From the third day the swelling and the discoloration will start to decrease and most of the swelling would have subsided by the end of 10-14 days however, it takes 3 - 6 months for all the swelling to disappear.
Occasionally the whites. Of the eyes will be blood shot and upper lip will feel "Stiff' and unnatural for a varied -period of time. Some numbness over the tip of the nose would persist for 2 - 3 months.

RESULTS:
Some results of the nasal operation will be noted when the splint and/or dressings are removed. But. It takes about 8 to 10 weeks to know the result of the surgery. Even after 10 weeks small changes occur over a period of 4 to 8 months. (In Detail)

AUGMENTATION MAMMOPLASTY (SURGICAL BREAST ENLARGEMENT)

Cosmetic Breast enlargement is done by surgical placement of a breast implant behind the breast area muscles. The breast implants are available in many sizes and shapes. All the breast implants are made with Silicone envelope (bag). Many of them contain just Silicone gel. The inflatable implant comes empty and after placing in the body, it is filled with saline, there are other implants that will have silicone gel in the inner compartment and saline in the outer compartment. There are limitations in regards to the size the breast could he enlarged. It depends upon the amount of available skin. However, most patient's wishes and desires are fulfilled. If there is excessive sagging of the breast, breast tightening with reshaping could be done at the same time of the breast enlargement.

Because the implants are placed behind the breast tissue and the muscles, usually there are no problems in breast examination after enlargement. Also, there is no problem in breast-feeding after this surgery. To-date, there is no recorded increased evidence of breast cancer after silicone implant surgery.

SURGICAL PROCEDURE:
This surgery is performed in the hospital as an outpatient or as one-day surgery, either under local anesthesia or under general anesthesia. The surgery takes approximately 2.5 hours.

Approximately a two inch long incision [cut) is made above the breast folds or at the lower part of the areola, [the dark skin that surrounds the nipple]. A cavity is created behind the breast area muscles. A satisfactory size implant is placed in the cavity and wounds are sutured in many layers. A snug dressing is applied and left in place for 5 to 6 days. The stitches are removed in stages from the seventh day after surgery.

AFTER SURGERY:
One may experience some discomfort during the first few days post operatively. These will he similar to a muscle pain after strenuous physical activity. Even though the patient is required to stay only one day in the hospital one should stay within the close reach of my office for 14 days for follow up care.

POSSIBLE COMPLICATIONS:
Occasionally. Complications Such as bleeding, infections change in sensations. Asymmetry, rupture of implants, psychological problems. Healing problems, unsatisfactory scars, etc., can occur. Firmness or hardness of the breast in varying degrees can also occur in a few patients. On extremely rare occasions, it may be necessary to remove an implant due to rejection by the body. (In Detail)

BREAST REDUCTION
Breast reduction is a surgical procedure that reduces the size and reshapes the contour of large breasts by removing excess breast skin and under- lying tissue. It may include reducing the size of the areola (the dark pink skin surrounding the nipple), which frequently becomes enlarged as breasts develop. The desired result is smaller, better shaped breasts that are in proportion with the rest of the body.

Breast reduction is often performed to ease physical discomfort, such as difficulty in breathing, backache and irritation at the crease of the breasts, and can make, physical activity more comfortable. However, it can be purely aesthetic for women who are self-conscious about their breast size. The procedure is permanent, although breast size can increase due to weight gain, birth control pills or pregnancy. (In Detail)

ABDOMINOPLASTY
Abdominoplasty is designed to remove the excess sagging skin of the abdomen and at the same time, the abdominal wall muscles are tightened to restore the tone lost during pregnancy. So, this operation is helpful for women who have relaxed loose abdominal skin after having children or after loosing excessive amounts of weight by dieting for over weight.
If a patient has excessive fat deposits of the abdomen, then it can be auctioned out by lipolysis. If some one has a combination of excessive fat and loose skin, lipolysis and skin resection can be done at the same time. But, Cosmetic surgery cannot help everyone with bulging abdomen - especially those with relatively thin, snug skin but large abdominal contents.

SURGICAL PROCEEDURE:
It takes approximately 2 to 4 hours for this surgery and it requires general anesthesia (total unconsciousness). The usual hospital stay is 2 to 5 days depending upon the individual's response to the surgery.
There are a variety of incisions that can be used for this operation. A right incision will be selected after careful examination and after considering the requirements of the patient. In most instances, a long horizontal incision just above the pubic bone from one hip to the other hip is used; the umbilicus is repositioned so that there is no loose fold of skin above the umbilicus. In the other common way, in addition to a short horizontal incision, a vertical incision up to the Umbilicus is added. In both the types, the skin is separated and lifted from the abdominal muscles all the way up to just below the lower part of the breasts. The skin is pulled down, the excess resected and sutured. During this process of lifting the abdominal skin from the muscles, the Umbilicus is separated from the surrounding skin and is left in its original place. After lifting the skin and pulling it down, the upper abdominal skin now lies over the Umbilicus. A small hole is made in the skin overlying the Umbilicus and the Umbilicus is brought out through this hole and sutured all around. Many a times, during abdominoplasty fat suctioning or lipolysis is done from the upper abdomen and the sides of the abdomen to recon tour these areas.
Before suturing, drains are placed under the skin and brought out on the sides and left under the dressings. These drains are removed in 24 to 48 hours. After surgery, the patient when on bed is required to keep the head elevated and the hips folded to some extent. This is done for 2 to 3 weeks, so there will not be any tension on the suture line. Also, for the same reason, while walking the patient should walk slightly bent forwards during the first 2 to 3 weeks. Patients are requested to get out of bed and take frequent short walks from the evening of the same day of the surgery. Sutures are removed in 2 to 3 stages starting from the 7th day of the surgery.

AFTER SURGERY:
The patient is restricted to sponge baths for about 10 days. They are requested to wear snug Panty hose or Girdles for a few weeks to apply pressure over the abdomen. Social activities are to be limited for about 4 weeks following the surgery and strenuous activities including sports and games are to be limited for about 8 weeks following the surgery.

RESULTS AND COMPLICATIONS:
After abdominoplasty about 75% to 85% of the patients are very happy with their results, but the remainder are not totally happy, because of their high expectations, technical limitations, healing problems, fluid collections and or poor patient selection. If a transverse incision is used, the resulting scar is usually thin, acceptable and well hidden by the bikini. Some people are poor scar formers, and they could form thick, wide prominent scars than the usual patients. (In Detail)

FILARIAL LIMBS AND FILARIAL PENIS & SCROTUM

These limbs can acquire gigantic proportions. Besides medical treatment limb elevation and wearing pressure garments helps. There are surgeries for residual deformities but results are far from perfect.

Pre-Operation	Post-Operation

Ram-horn penis and filarial scrotum can be managed surgically with excellent results. A functioning penis and a smart neo-scrotum can be reconstructed.

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