Dr Lakshmisaleem 7th PSAAP Conference

7
th
PSAAP
CONFERENCE

LASA
with
CBK

Learn any
Surgery
aLone with
Creativity
boLdneSS and
kindneSS
lakshmi Saleem’s tribute to
late prof. C. Balakrishnan

Salaja HoSpital
Prajasakthi Nagar, Vijayawada 500 010
Phones: 0866-2474774 / 2476500 / 040-23403736
www.salaja.com
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www.bodycontouring.in

Ekalavya

E kalavya is a character in the famous epic of India,
Mahabharata. He is focused and dedicated pupil of his guru
Drona. He is taken as an example for hard work, perseverance
and sacrifice. Though his guru denies to teach him the art of
archery, Ekalavya excels in it with concentrated and dedicated
practice of archery in front of the statue of his guru. But when
his guru comes to know of his skills, he demands Ekalavya’s
thumb as gurudakshina (fee) so that ekalavya cannot surpass
Dr. Lakshmi Saleem Arjuna, the favoured pupil of Drona. Hence Ekalavya is often
MS, MCh.
Editor-cum-President
quoted as an epitome of virtuous, unselfish and dedicated
pupil. Every one of us may not have the opportunity to learn
from great gurus in our Plastic and Cosmetic surgery. Some of
us have the fortune of working with such gurus, some may have
access to literature written by them few may have access to the
procedures in the form of videos and I am sure some may only
hear directly or indirectly about certain procedures. I chose the
logo which says “Self learning for perfection” only to encourage
ourselves towards dedicated learning and pursuit of perfection
like Ekalavya.

It may be easy to record the procedures and techniques
surgeries done, but it is difficult to quantify the efforts for
the achievements. Following the foot steps of late Prof. C.
Balakrishnan I would like to pass on what I had learnt from
him and the messages given by him for plastic surgeons before
they are washed off by the tide of time. The most precious
lesson one can learn from a senior colleague of his stature in
plastic and cosmetic surgery is the way to find a solution to a
particular problem or a cosmetic need taking into consideration
the social, cultural and financial background of the patient. One
should be able to visualize the three dimensional view of tissues
to be altered and rearranged with an ability to analyse the

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complex surgical problem with a thorough anatomical
knowledge and then choose a simple procedure with bold and
creative thinking tempered with common sense. Success in
cosmetic surgery can be achieved with meticulous planning,
patience in communicating the surgical outcome to the
patient, and accurate documentation (with good photographs).

Following the teachings of Prof. C. Balakrishnan, over the
years I have made protocols for each procedure based on the
requirements of most of our patients keeping the ethnic,
racial, financial, and social backgrounds of the patients
in mind. I share with my colleagues my experience in
mammoplasty and Rhinoplasty over the years in this note.

Being a woman plastic surgeon, I did come across many
women approaching for mammoplasty which may not be
entirely for beautification as is the case in the western
countries. I have followed a simple algorithmic approach to
visualize the ultimate result and outcome of each surgery
in three dimensional view. I share with my colleagues my
experiences in mammoplasty over the years in this Souvenir.

Perfection and perseverance like Ekalavya

Dr. Lakshmi Saleem MS, MCh.
Editor-cum-President
PSAAP-2008

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Algorithmic approach of aesthetic rhinoplasty:
basing on personal evaluation of 25 years
Dr. M A Saleem, MS, FICS
Salaja Hospital, Vijayawada

R hinoplasty was performed as the commonest
Cosmetic surgical procedure in 492 patients in
our exclusive plastic surgery set-up over a 25-year
• Depressed and wide nasal bridge, which lacks
anterior height

• Flared alae nasi with increased interalar distance
period. This is a study of Rhinoplasty performed in
and wide nostrils
the South Indian population whose characteristics
are a combination of Caucasian and African noses. • Blunt and ill-defined nasal tip without alar
Simple and Standard techniques performed are grooves and projection
described for the correction depending on the
Thick skin in some individuals along with gross
appearances in Frontal, Basal and Lateral views.
accumulation of areolar and fatty tissue and
Augmentation of the nasal bridge to increase the
attenuated alar cartilages account for the blunt and
height is performed using bone graft from ileac
bulbous tip. Flaring of the alae nasi and flattened
crest. Excising the fat and thick areolar tissues
alar cartilages account for the increased width of
narrows the bulbous nasal tip. Approximating the
the nares. These problems are discussed with the
lateral crura of alar cartilages by non-absorbable
patient in detail with the aid of three basic views of
suture helps in producing grooves on the flat
photographs – Frontal, Basal and Lateral. Possible
looking alar rim and also helps in narrowing the
corrections are suggested before embarking on the
tip thus giving a better appearance. Nasal width
procedure for the fullest satisfaction of the patient.
in the basal view is corrected by a wedge excision
Simpler techniques are chosen to fulfill the criteria.
of the alar rims at the lateral ends. Lengthening
Most of the patients preferred to have the entire
of the columella was performed either by adding
correction performed in a single stage.
a L-shaped bone graft along with augmentation
of the bridge and also a V-Y plasty. Long term Material & Method
follow up results of bone graft are gratifying with
minimal resorbption, if any. The aim has always Salaja Hospital, Vijayawada is an exclusive Plastic
been to do the entire correction in single stage. Surgery set-up in the region of South India where
Complication rate was negligible-less than 1% lack cosmetic surgery is performed along with other
of satisfaction among the Augmentation group and plastic surgery procedures and burns management.
less than 0.5% among all rhinoplasty procedures. This unit is accessible to an approximate population
of over 60millions. Nearly almost all our patients are
Introduction South Indians.

There is not much data available in the rhinoplasty The nasal index popularized by Topinard in 1890 for
literature regarding a conventional and accepted anthropological determinations of the race, is the
approach for specific problems of South Indian noses. ratio of the nasal width to the length multiplied
South Indians have a combination of Caucasian and by 100. These measurements define the frontal view
African nasal characters. The common complaints of the nose as triangle and the dimensions vary
include: according to the racial background. The spectrum

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of the south Indian noses lie somewhere between Rhinoplasty is planned – Frontal view, Basal view
Negroid and Caucasian noses. and Lateral view.

Broadbent and Mathews describe ideal nasal Frontal view: The appearance of nose in the frontal
alignment to be such that the lateral attachment view is considered to be pleasing if the triangle
of the ala to the cheek lies within longitudinal is narrow based, slightly taller than wide, with
lines drawn through the inner canthi. Nasal features minimal alar flare. By augmenting the dorsum or
can be improved by bringing the elements of the by reducing the tip, the nasal axis can be altered
nose to lie within a triangle having a base closer to suit the patient. Aesthetically a pleasing nose
to the inner canthal lines. This is seen well in the is 1/3 of one’s face in length or the length of one’s
frontal view. own thumb and limits itself in width up to both the
medial canthal lines.
The inferior triangle is formed by the tip and the
lateral attachments of the alae nasi to the cheek Depending on these factors, the surgical plan can be
in the Basal view. It is most aesthetically pleasing summarized as follows. One can narrow the triangle
when this triangle is narrow based, slightly taller by dorsal augmentation with a bone graft (Ileac
than wide. crest). Very rarely nasal bone infracturing is done
to the same effect. Base can be altered by nasal
Flare can be defined as that portion of the ala,
base reduction and inter alar reduction.
extending lateral to the alar attachment to the
cheek. The inferior triangle can be altered by Basal view: Tip projection and definition can
increasing the height of the tip or by lessening the be improved by suturing the lateral crura of alar
flare of the alae. cartilages by non-absorbable mattress sutures with
4-0 proline. Alar base reduction also changes the
Augmentation of the dorsum or raising the tip
inferior triangle.
alters the nasal axis to best suit the patient 492
Rhinoplasties performed between 1984 and 2007 While planning the procedures the wide difference
are considered in this review. in individual anatomy, relation of the nose & face
and variation in patients’ complaints and desires
Operative procedures are to be considered to get a complete patient and
Three views of the nose are considered whenever a surgeon satisfaction.

Patient’s Complaint

Frontal View Basal view Lateral view

Bone graft Wedge Alar base Tip Bone graft Alar Re-adjustment
resection reduction
rearrangement reduction Columellar
Interalar reduction Crural fixation adjustment

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List of operative techniques: Operative techniques sides. First bite is taken through the caudal edge
are decided depending on the appearances in the of lateral end of lateral crus of alar cartilage from
frontal, basal and lateral views. outside in. A tunnel is created with the curved
artery forceps connecting the two medial ends of
Operative techique the alar incisions, passing through the membranous
If only augmentation is planned, a right alar septhum. The needle is transferred from right
incision is given on the mucosal aspect commencing nostril to the left through the tunnel and a similar
medially near the columella and extending laterally bite is taken of caudal edge of the lateral crus on
for a few mms on the undersurface of lateral crus the left side (first from inside out and next from
of alar cartilage. If associated procedures are to outside in), to get a good hold on tip of the lateral
be performed for the tip, bilateral alar incisions crus. The needle is brought back to right nostril
are given. Or a ‘V’ incision is given at the base through the previously mentioned tunnel. Another
of columella extending to both sides and the bite is taken through the rt side cartilage close to
columella is lifted like an elephant trunk like in the first one so that the knot comes on the outer
open rhinoplasty. In either case, a plane is created side. The suture is tightened as for the required
and the periosteum of the nasal bone is stripped projection of the tip, recreating an alar groove. It
off making the recipient bed ready. is to be remembered while tightening that often
Bone graft of about 2 inches long is obtained from there is only a fine line between a tip that remains
the ileac crest. The graft is carved to the required too bulbous and one that is pinched.
size and shape with the help of a bone nibbler and
a scalpel. Complimentary shaping of both recipient Results
site and inner surface of graft achieve stabilization. A series of 492 rhinoplasties PERFORMED OVER
The bone graft thus carved is firmly placed in the 25 YEARS has been reviewed. Patients were
subperiosteal plane on the dorsum of the nose. predominantly female and frequently in the age
No rigid fixation is done with pin or screw. The group of 16 and 30 years. Average follow-up varied
incision is closed with 4-0 chromic catgut on the from a few months to 10 years.
mucosal side. In cases where extended skin incision
Of this series, only 291 patients had bone graft from
is given, the skin is closed with 5-0 proline.
ileac crest. 155 patients had soft tissue correction
Post-operative splinting is by couple of layers of alone, with cartilage graft when needed.
plaster of Paris or a ready-made nasal splint that
is retained for five days. Drain from the bone Complications
graft donor site is removed after 24 hours and the Out of the 291 patients of bone graft, 2 patients
patient discharged. opted for the removal of the graft as they did not
In those patients who have an increased alar flare like it.
and increased width, alar base resection is done as 4 patients required nasal splint for more than two
a wedge at the junction where the ala meets the weeks to maintain the desired position of the
cheek. Suturing is done with 4-0 vicryl and 5-0 graft.
proline.

Narrowing the tip, can be achieved by bringing the Conclusion
alar cartilages together with a single 4-0 proline Rhinoplasty procedure performed in 492 patients
mattress suture through alar incisions on both in a period of 25 years is reviewed. This study

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included Rhinoplasty performed in the South Indian thus giving a better appearance. Nasal width in
population whose characters are a combination of the basal view is corrected by a wedge excision of
Caucasian and African noses. Standard but simpler the alar rims at the lateral ends. Lengthening of
techniques are chosen. A clinical approach of the the columella was performed by adding a L-shaped
patients’ complaints and the appearances in Frontal, bone graft along with augmentation of the bridge
Basal and Lateral views guided the technique to whenever required and also a V-Y plasty. Long term
be followed. Augmentation of the nasal bridge to follow up results of bone graft are gratifying with
increase the anterior height is performed using minimal resorbption, if any. The aim has always
bone graft from ileac crest. Excision of the fat and been to do the entire correction in single stage to
thick areolar tissues in the bulbous tip helped to facilitate the patients’ compliance and satisfaction.
narrow the nasal tip. Approximating the medial Complication rate was negligible-less than 1% lack
nasal alar cartilages in the midline by non- of satisfaction among the Augmentation group
absorbable suture helps in producing grooves on and less than 0.5% among all the rhinoplasty
the alar rim and also helps in narrowing the tip procedures performed.

Presented at British Associate of Plastic Surgeons, Winter Meeting – December 2007

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Ptosis surgery
Dr. Devendra K Gupta MS, MCh.
Derendra Hospital, Bareilly (UP)

Anaesthesia Levator resection
Local anaesthesia is preferable to general The eyelid elevation which can be obtained by
anaesthesia if the patient will tolerate it since the shortening the levator complex depends primarily
voluntary movement of the levator muscle aids in on the levator function. The result required depends
the identification of lid structures and a better on the circumstances, i.e. the diagnosis, Bell’s
operative assessment of lid level is possible. phenomenon etc. The optimum result in a patient
with simple congenital ptosis is for the eyelid levels
Method to be the same in the primary position of gaze, but
1. Mark the skin crease. lower level may be acceptable in a patient with a
partial third nerve palsy, a dry eye, or progressive
2. Evert the lid and inject 1 or 2 cc of local external ophthalmoplegia etc. A resection of the
anaesthetic immediately under the conjunctiva following amount of aponeurosis and levator muscle
just above the upper border of the tarsal plate. should lift the eyelid to an acceptable level:
3. Give a subcutaneous injection in the region of Levator function 8-10 mm: 14-18 mm resection.
the skin crease.
Levator function 6-7 mm: 18-22 mm resection.
Note Levator function 4-5 mm: 22-26 mm resection.
a. Adrenalin in the local anaesthetic helps to reduce These measurements are approximate. They include
bleeding but stimulates Mulller’s muscle. both aponeurosis and levator muscle and are taken
b. A frontal nerve block is not usually necessary from just below the upper border of the tarsal
and runs a risk of affecting the function of the plate. The extent of the resection is modified by the
levator muscle. degree of ptosis, thus 2 mm of ptosis will warrant

Levator Function

Normal 15-18mm

>10mm <10mm

Degree of ptosis Levator Function

<2mm >2mm >4mm <4mm

Fasanella Servat Aponeurosis Surgery Levator Resection Brow Suspension

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a lesser resection than 4 mm of ptosis if the levator it. Stop 2 mm from the lid margin to prevent
function is the same. If the superior rectus muscle damage to the lash roots (Fig.1 b).
is weak the resection should be increased by about
5. Dissect the pre-septal orbicularis muscle from
4 mm. The adequacy of the resection can be confirmed
the lower part of the orbital septum. The septum
at operation. Under general anaesthesia the eyelid
can be identified by:
should stay at approximately the level which is
achieved at operation if the levator function is about a. its attachment to the orbital rim which can be
7 mm. If the levator function is better than this the felt as a firm band when traction is exerted on it.
lid will tend to rise post-operativcly and to fall if the b. orbital fat can sometimes be seen behind it.
levator function is worse. Under local anaesthesia the c. pressure over the lower lid may help to make the
lid should be set 1-2 mm higher to compensate for orbital fat more obvious.
the paralysis of the orbicularis muscle.
6. Open the orbital septum to expose the pre-
Anterior approach levator resection (fig.1) aponeurotic fat pad beneath which is the
aponeurosis (Fig.1 c). This can be seen to move
Principle when the patient looks up, if the operation is
The levator muscle is approached through a skin under local anaesthesia.
incision. The septum is divided and when the 7. Dissect the aponeurosis from the tarsus (Fig.1 d) and
pre-aponeurotic fat is retracted the whole levator Muller’s muscle from the conjunctiva (Fig.1 e).
complex can be examined directly for any defects.
The muscle is shortened and sutured directly to the 8. Cut the medial and lateral attachments (horns)
tarsus. Any excess skin can be excised and the skin of the levator complex under direct vision. Curve
crease reformed with interrupted sutures which pick the scissors centrally towards the levator muscle
up the underlying levator muscle. to avoid the trochlea medially and the lacrimal
gland laterally (Fig.1 f).
Indications 9. Try to preserve Whitnall’s ligament and advance
A ptosis with 4 mm or more of levator function; the levator muscle under it (Fig.1 g).
skin excision; lid – exploration; maximum levator Note: The ligament can be sutured directly to the
resection; preservation of tarsus and conjunctiva; tarsus to act as an internal sling in cases with
lash ptosis; entropion; skin crease defect. poor levator function as an alternative to a brow
suspension. This does create a relatively static
Method lid with a marked degree of asymmetry on down
gaze in unilateral cases.
1. Mark the skin to match the crease on the
uninvolved side and make an incision through 10.Pass a double-armed 6 ‘O’ polyglycolic acid/
the skin with a blade (Fig.1 a). vicryl suture into the anterior tarsal surface at
the intended apex of the lid curve.
2. Pick up the skin on either side of the incision in the
Measure the aponeurosis and levator to be resected
centre of the lid with two pairs of toothed forceps
and pass each needle of the suture through the
and make a cut through the orbicularis muscle with
centre of the levator muscle just above the site of
a pair of scissor aimed towards the tarsal plate.
the planned resection. Tie the suture with a slip
3. Undermine the orbicularis medially and laterally knot and cut the muscle (Fig.1 h).
and cut it with scissors along the line of the skin
11.Check the height and curve of the lid and adjust
incision.
the suture if necessary. Cut the suture and use
4. Clean the anterior tarsal surface sufficiently each arm to suture the muscle to the tarsus on
to suture the aponeurosis or levator muscle to either side of the central first suture (Fig.1 i).

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12.Thin the lower skin flap by excising a strip of Aponeurosis surgery
orbicularis muscle.
Aponeurosis surgery is indicated for patients with an
13.Excise any excess skin from the upper skin flap. aponeurotic defect and good levator function (i.e.
better than 10 mm). The approach is very similar to
14.Close the skin and reform the crease with 6 ‘O’
that for a levator resection but the surgery is not so
absorbable sutures which pass front the edge
extensive, the horns of the levator complex arc not
of the lower skin flap, into the levator muscle,
cut, and a Frost suture is rarely necessary to protect
and out through the edge of the upper skin flap
the cornea. Local anaesthesia should be used if at
(Fig.1 j).
all possible and the lid set at operation to the same
Note: Absorbable sutures are preferable since level or a little higher than the other side. In the
skin crease sutures may be difficult to remove immediate post-operative phase the lid will be low
completely and the scar is buried in the due to recovery of the orbicularis muscle function
crease. and oedema, but since the levator function is good
15.Use a Frost suture. the lid will subsequently rise.

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Selection of procedure
for reduction mammoplasty
Salaja Hospital, Vijayawada

T he pathophysiology of breast hypertrophy is due
to an abnormal end organ response to circulating
estrogens and it is due to the hypersensitivity of the
simple guidelines are taken into consideration and
the problem is classified as follows:
Grade 1: Teenage girls with increased areola and
some women during puberty and pregnancy. Breast
ptosis requiring reduction of less than 200 grms.
enlargement consists of fibrous tissue and fat while
the glandular elements remain quite small. Sometimes Grade 2: Young women, who may need reduction up
a familial pattern can be traced back as members to 500 grms.
of the same family are affected. Breast hypertrophy Grade 3: Women who may need excision of up to
produces considerable functional disability and 1000 grms
affects the quality of life due to disproportionate
body disposition. Significant improvement of the Grade 4: Women who may need massive reduction
individual self esteem and self confidence are noted of more than 1000 grms.
in all the patients and symptomatic improvement in With 30 years of experience of reduction mammoplasty
the postural disability, neck and shoulder pain relief various techniques, a simple procedure has been
were also noted. The aims of breast reduction is to recognized which is easy to execute with the long
reduce, recontour reshape to suit the woman’s needs lasting aesthetic effect. Classically it incorporates
and desires. the superiomedial pedicle with a vertical scar, and
Selection of the procedure depends on the type of excision of the gland with the skin from the inferior
breast, surgeon’s comfort with the surgical skill, quadrant with extension onto the medial and lateral
scars and a long lasting aesthetic result. Important segments, depending on the requirements of the
points to consider are how much tissue need to be excison. This procedure has been found to be
removed and the final nipple position depends on technically easy, safe, quick to perform with minimal
the breast tissue that is left behind. With 30 years complications and safety. It can be undertaken for
of experience and understanding of the problem few major resections of more than 1000 gms also.

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Markings for surgery 5. The lower part of V is raised from below
The patient is made to stand erect with the hands upwards, exposing the pectoral fascia upto
tucked behind. Keeping the BMI in mind, the 0.5 cm below the de-epethelised sub areolar
desired size is discussed with the patient, and the region.
mid-sternal line is marked first. followed by drawing 6. The medial and lateral segments of breast
of the breast meridian.The nipple postion is noted.
tissue which need to be excised is included
The distance measured from the midsternal notch
with the V segment as one en-bloc of tissue.
to the nipple position is also noted. The desired
new nipple position is marked from the midsternal 7. The whole block of tissue is excised from the
notch. The areola is marked with the diameter of upper part of breast protecting the nipple,
3.5 to 4 cm with a nipple marker depending on the areolar complex.
need. The new nipple is marked with distance of 19
to 22 cm depending on height of patient keeping 8. Both the lateral and medial flaps are brought
the diameter 0.5 cm more than the previous together with skin hooks and any excess
marking. An ellipse is drawn taking the top of the skin is excised as an ellipse from the lateral
new areola as the highest point The lowest point segment.
of the ellipse is kept 1cm above the inframammary
crease. The maximum width of the ellipse is equal 9. The aeolar complex is shifted up to the new
to the diameter of the existing areola. position and if there is difficulty in moving it
up relaxing incision given on the lateral part
Procedure of de-epethelised segment.
1. Infiltration of the breast tissue with saline 10. After areola is fixed with 3-0 monocryl and
adrenaline, avoiding the injection in the lower breast tissue is brought together with
upper, medial quadrant and the area that 3-0 monocryl subdermal sutures.
needs de-epethelisation
11. After fixing the drains, the areola is sutured
2. Areola is incised and de-epethelisation with 6-0 vicryl and the lower incision is
started going away from areola. sutured with subcuticular 3-0 monocryl.
3. The lower “V” cut is deepend keeping the skin 12. With this technique, the vascularily of nipple was
intact.
never compromised and the only complication
4. The medial and lateral flaps raised with 0.5 that was seen was delay in healing at the lower
cm thickness, upto the medial most and most part of incision, when excison was more
lateral extent of Breast tissue. tran 800 gm.

Presented at British Associate of Plastic Surgeons, Summer Meeting-2008

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Repair of mid to distal penile hypospadias
by the tubularised incised plate urethroplasty
Dr. Devendra K Gupta MS, MCh.
Derendra Hospital, Bareilly (UP)

H ypospadias is a congenital defect resulting from
incomplete tubularisation of the urethral plate.
The meatus may be found any where along the penile
6-0 chromic catgut suture. Neourethra is then
covered with a vascularized dartos flap harvested
from subcutaneous tissue of dorsal penile skin and
shaft and down on to the perineum. Hypospadias preputial skin. The granular wings, mucosal collar
with an incidence of 0.8 – 8.2 per 1000 live male and ventral shaft skin are closed in the midline. The
births is a common clinical problem. In the majority stent provides urinary drainage for 10 days.
of cases (80%) abnormal meatus is situated in the
glanular, coronal and subcoronal levels or in the With its simplicity, versality, excellent cosmetic and
proximal part of the shaft. functional results and a low complication rate, TIP
urethroplasty is the procedure of choice for most of
The goal of hypospadias repair is a functional penis the distal defects. Since most of the patients with
with a normal cosmetic appearance. Established midshaft and penoscrotal defects have a supple
procedures to correct the distal hypospadias are urethral plate, a midline incision consistently
the Thiersch-Duplay, Mathieu, Mustarde, meatal widens the plate and enables tubularisation. This
advancement and glanuloplasty (MAGPI) and makes TIP plasty a versatile technique in repairing
tubularized incised plate (TIP) urethroplasty. Of the proximal hypospadias as well.
the various procedures Tip urethroplasty (Snodgrass
repair) most reliably creates a normal appearing Contraindications to TIP plasty are severe chordee
penis. At many centres it is now the preferred method requiring plate excision for straightening the penis
of repair since it creates a vertical slit like normal and unhealthy urethral plate that appears thin or is
appearing meatus, unlike a horizontally oriented insufficiently widened after incision. Complications
and rounded meatus (‘Fish mouth’) produced by the are rare. Fistula can be avoided by interposition of
meatal based (Mathieu) and onlay island flap repairs. a vascularised dartos flap between the neourethra
In addition this procedure allows construction of and overlying glans and shaft skin closures. Closure
neourethra from the existing urethral plate without of the first layer is done in a running subcuticular
additional skin flaps. The technique is versatile and fashion with efforts made to invert the epithelium
suitable for almost all distal lesions. completely.

Method
The penis is degloved with a U shaped incision
Bracka’s Versatile Two Stage
extending along the edges of the urethral plate to Hypospadias Repair
healthy skin 2 mm proximal to the meatus.The lateral
Aesthetic quality of the hypospadias repair with
borders of the distal urethral plate are separated
natural looking glans and slit shaped terminal
from the glans by parallel longitudinal incisions.
meatus after multiple failed hypospadias repairs
The glanular wings are further mobilized laterally for
remains a formidable challenge in reconstructive
subsequent tension free closure. The urethral plate
surgery.
is then incised in midline from the hypospadiac
meatus distally. Incised plate is then tubularised I Bracka’s (1995) two stage hypospadias repair
over a 6-8F stent using continuous subcuticular offers versatility, reliability and refinement and can

12

be used for almost any hypospadias deformity be of incision and excision of tissues using scalpel and
it primary repair in child or salvage surgery in an fine scissors. The chordee correction is achieved
adult. in this manner in the majority of cases. In cases
of residual chordee further correction is done by
Timing of surgery extending the sub coronal incisions to circumcoronal
1. At 18 months: Offers psychological advantage to incision and stripping the penis. A full thickness
child. Better anaesthesia required preputial graft was taken and accurately tailored
into the defect using 6/0 chromic catgut. A firm
2. Before school at 4 years: We use most of the time “tie-over” dressing was placed for 7 davs and a
the second option for surgical correction. Tissues urethal catheter for 7-10 days.
are better developed
Stage 2 after at least 6 months to allow for graft
Operative steps maturity and neovascularity. Neourethra was
fashioned from the supple grafted skin bed. The
Stage 1
meatus was reconstructed first by joining the
Anaesthesia: Caudal epidural anaesthesia. Advantages ventral point, the rest of the urethra was then
are smooth recovery, postop analgesia and less risk tubed around K-90 or K-91/NEL-CATH (Romsons)
of postoperative bleeding and haematoma. Then the catheter with a combination of interrupted and
assessment is done-of position and size of abnormal continuous extraluminal inverting 6/0 chromic
meatus, the presence of chordee, the quality and catgut sutures. The repair is protected and
width of urethral plate and the configuration reinforced using an intermediate vascularised
of glans penis. 4/0 silk stay stitch is applied to fascial layer dissected from the dorsal aspect
the glans and presence and degree of chordee is following circumcoronal incision and stripping of
assessed. Meatal assessment is done using urethral penis. This vascular layer helps the healing process
dilators. Tourniquet is applied after dilatation. If and avoids suture lines in contact with each other
required, meatotomy is done to split the thin layer and thus reduces the risk of fistula formation. The
of urethra to the spongiosum covered urethra. The successful reconstruction depends on proper
suturing of urethral mucosa to skin is done after planning, gentle handling of tissues with fine
meatotomy using 6/0 chromic catgut. Two more instrumentation, usage of fine suture materials,
stay 5/0 sutures are applied on either side of the inverting sutures of neo-urethra and usage of
midline over the distal aspect of the glans which intermediate vascular layer of tissues
will be used as traction during glans split and later
as first tie-over suture. The glans and skin repaired and dressing was done.
Catheter was removed on the 10th day.
Release of chordee is done from the proposed
neo-meatus to the ventral aspect of the abnormal The urinary catheter is fixed on the lower abdomen
meatus. From the sub coronal part of the vertical with a “mesenteric type” of tape fixation so that the
incision, lateral incisions on either side are done to catheter is directed upwards away from the ventral
correct the chordee. This is done by a combination suture line.

13

Obesity Management
– a plastic surgeon’s perspective!
Consultant Plastic & Cosmetic Surgeon

O ver two decades of my practice in Plastic and
Cosmetic surgery, I have come across quite a
number of people who have come to me seeking help
B M I = Weight (kg) / Height (m2)
Accordingly a person is determined to be:
for being obese. They belonged to both genders and Healthy if BMI is 20 – 25
also of different ages. In the early days it was not only Overweight if BMI is 26 – 30
difficult to convince people to follow a disciplined Obese if BMI is 30 – 35
life pattern and take proper diet but it was a tough if BMI is Morbidly obese 35 – 40
task to dissuade them from seeking surgical option. or above
Some were genuinely odd in their figure having
either bulky arms or heavy thighs, some had heavy Obesity and over weight have been recognized to be
breasts and some were disproportionately large in global problems affecting over a billion adults and
the upper or the lower parts of the body. Some 17.6 million children under 5 years of age. Obesity is
boys had heavy breasts resembling female pattern, presently considered as a chronic illness, in addition
some girls even just around puberty had such heavy to be a cosmetic problem. It is associated with
breasts that embarrassed them both physically and many other chronic diseases ranging from Arthritis
psychologically. Where do we draw a line to decide to Diabetes, Cardiovascular problems to frank Heart
who are the candidates for surgery? How can you failures, Neurovascular problems to Alzheimer’s,
assure them that even if some fat is removed from Chronic depression to Dementia, Chronic skin
diseases to Cancers.
the parts of their body, what is the guaranty that it
does not re-accumulate due to their indulgence in What causes obesity?
either over-eating or lazy life pattern.?
Apart from the various hormonal causes like
Here comes the honesty on our part to decide and Hypothyroidism, Hypercorticosteroidism, hormonal
classify who falls in the category called ‘obese’. changes due to pregnancy or menopause, the primary
factor that leads to obesity is imbalance between
What is obesity? calorie in take to that of calorie consumption
superadded by a sedentary type of life style with no
When the body weight of a person is more than 25% physical activity. Heredity and depression of course
of the expected weight in the case of a man and is play some role as the causative factors.
more than 32% in the case of a woman, that person
is considered obese. Another definition is that any How to prvent obesity?
person with 40 Kg more than the expected weight is Like in the case of many health problems, prevention
considered obese for any individual. has the best role to eradicate obesity. Childhood
But the best way to measure is by the specific obesity has an alarming increase across the globe
term called Body Mass Index. This is nothing but a and cause for concern as this predisposes to
adulthood obesity.
calculation at any age and for any gender wherein
the body weight (in Kg) is divided by height (in The teaching and training should start at home
Meters squared). wherein the parents are taught about balanced

14

and nutritious diet for their children. The school is created. However people with BMI of 30 – 35
environment should provide proper physical activity associated with one or two co-morbid condition
to the children. They should be made aware of the may also need bariatric surgery.
problems of energy rich salty foods, soft drinks
The role of a cosmetic surgeon in taking care of
containing large quantities of sugar and large
an over weight or obese individual cannot be
quantity of dairy products and ice creams. They
overemphasized. One should insist on an overweight
should be taught to restrict such foods. Children
person with a BMI of 26 – 35 to reduce his/her
must also be made aware of the ill effects of
weight by about 5 Kg by proper diet, exercise and
sedentary life styles. The role of yoga or meditation
change in life style. This gives the plastic surgeon
or such disciplining activities are definitely among
to assess the genuineness in commitment on the
the much needed.
part of the individual how much the obese person
is going to follow the instructions and how effective
How to cure obesity
the cosmetic surgical method be useful to such an
In spite of the best efforts to prevent obesity, if individual in the long run.
it still is a problem, the steps to cure obesity are
Even after the Bariatric surgery there is a role for
again giving emphasis on life style changes and
a Cosmetic surgeon in contouring the body for the
altering environmental factors. Dietary modification
residual or consequential effects.
like low calorie, high fiber diet associated with
enhancing physical activity is mandatory. Chronic
stress or chronic depression may both lead to Liposuction and lipectomy
obesity and hence such of the factors that lead Liposuction is one of the surgical options for the
to these psychological changes should be brought obesity if the person is well motivated and willing
under control. These can best be achieved by either to maintain the weight. By doing the liposuction of
Yoga or Meditation. It is all the more important that the certain areas, like inner thighs and the sides of
emphasis is laid to self motivation. A self motivated the chest, it enables the obese person to go for walks
obese person is on the right track to cure him / her and exercises with out much difficulty. Certain areas
self of obesity. where there is localized obesity like the arms, side
of flanks and thighs or buttocks need liposuction.
Who needs surgery to cure obesity?
Some times the liposuction itself can stimulate the
The choice of surgery depends on the severity of basal metabolic rate so much that the person can
the problem of obesity. Arbitrarily it can be said start losing weight with a greater speed. It was
that having tried all the physical, dietetic and observed that liposuction itself can make an overall
psychological methods to curing the problem reduction of 10 to 15 Kgs.
of obesity, the choice of surgery falls into two
Abdominal girth increase or looseness due to post
categories.
partum obesity does need to be addressed with
One is just the removal of fat or the excess of tissue, plastic surgery in the form of Abdominoplasty or
which is usually preferred in only those that fall tummy tuck procedure. The same might be the case
in the group of overweight up to a BMI of 30. The in those obese people who underwent bariatric
procedures that can be carried out in this method surgery and lost weight but developed loose skin
are Liposuction or Lipectomy. folds and so on.
Two is for those who fall into the category of
severely obese or who suffer morbid obesity with a Gynaecomastia
BMI of 40 or more needing Bariatric surgery where Abnormal male breast development is seen in
the food intake is either restricted or malabsorption some of the obese individuals and they invariably

15

present with these localized deposits of fat. These and flanks leaving the patient with a lot of lateral
can be classified as grades 1 to 3 depending on the redundancies and dog-ears. A modified vertical
severity. Liposuction alone may be enough to treat abdominoplasty, combining with the transverse
the mild deformities with out much of central core approach, a single stage procedure for resection are
of breast tissue being removed in Gr 1 cases. In needed without undermining the tissues.
Gr 2 cases, liposuction along with surgical excision
Neo-umbilicoplasty (reforming umbilicus in the new
may be needed. In Gr 3, the obese person may need
position) is to be planned with care. If associated
mastopexy to correct the excessive sagging of the
hernia is present, this also can be dealt with in
skin after excision of the gland.
the same sitting. Lower body lift and thigh lift can
Bilateral breast reduction be attempted together, but in spite of the tight
approximation of the sub-cutaneous facial system,
Breast hypertrophy (overgrowth) in women produces the saddle deformity and mid thigh laxity cannot be
considerable functional disability and affects the corrected well.
quality of life due to disproportionate body, leading
to pain in the breasts, secondary back, shoulder In conclusion we can say that the following are the
or neck pain. Skin below the breasts may be seen steps to face the problem of obesity:
to be macerated with or without infection. This • Evaluation of the cause of obesity
problem compounds the overall obesity of the
individual. Reduction mammoplasty wherein the • Assessing the extent of obesity in terms of BMI
breast size is reduced to a reasonable level and also and also marking if the obesity is localized.
liposuction of other obese parts of body can be • Dietary regulation and shift to low calorie and
combined with it. The aim of reduction of breast is high fiber diets and avoiding indulgence in
to reduce and re-contour to suit the woman’s needs improper diets.
and desire and to make the individual comfortable.
Significant improvement of the individual self- • Regular and constant exercises.
esteem, self-confidence is noted in every patient • Change of life style with regularity and discipline
who had undergone breast mammoplasty and in the diet and physical activities.
postural disability is reduced greatly. The gain in
confidence levels is encouragingly very high in • Liposuction or lipectomy in the people with over
younger individuals where they can fit into right weight or obese individuals of less than 30 BMI.
sized garments and be more presentable. • Suggesting Abdominoplasty for those who have
trunkal obesity.
Body contouring after massive weight loss
following the bariatric surgery • Suggesting and guiding the individuals with BMI
of 40 or 35 with co-morbid conditions to undergo
In morbid obesity, contour deformities of the
bariatric surgery.
abdomen are common after bariatric surgery and
radical weight loss. Traditional techniques fail to • Taking care of the residual or consequential
improve the shape as there are lateral hip rolls effects of bariatric surgery.

16

Management of Obesity
Dr. M A Saleem MS, FICS
Consultant & Head of Department
General Surgery, Surgical Gastroenterology
and Laparoscopic Surgery
Care Hospital, Banjara Hills, Hyderabad

Obesity is a chronic disease and is also associated country is much higher and the is growing faster,
most of the times with medical illnesses like according to medical experts.
diabetes, hypertension, hyperlipidemia, chronic
Obesity amplifies the risks of type 2 diabetes,
arthritis and so on. The prevalence of obesity
hypertension, cardiovascular disease, dyslipidemia,
cannot be questioned and its worldwide increase
arthritis, and several cancers and is estimated to
at an alarming rate is noticed in both developed
reduce average life expectancy. In the United States
and developing countries. In US the studies show
alone, it is estimated that obesity-related health
an incidence of overweight of 66%, obesity of
problems account for about 300,000 deaths per year.
32% and morbid obesity of around 5%. In Europe
The medical expenses and cost of lost productivity
obesity prevalence ranges from 20% in men and
due to obesity in the USA are estimated to be greater
25% in women. Although well established statistics
than $100 billion per year.
are not available in India, one of the surveys by
All-India Institute of Medical Sciences showed that Patients with obesity seek medical attention either
76% of women in the capital, New Delhi, suffer from for cosmetic reasons or for cure of associated
abdominal obesity. NFHS analysis showed that 12% medical conditions. The surgical treatment of obesity
men and 16% women suffer from obesity in India. till recently revolved primarily around cosmetic
procedures like liposuction or abdominoplasty.
Excess body weight is the sixth most important risk
However, these methods were purely cosmetic in
factor contributing to the health burden of the world.
that they did not address the basic pathophysiology
There seems to be a positive correlation between
behind the development of overweight in the first
economic development and obesity: as a country
place. Consequently, they were associated with
becomes richer, many people in that country become
recurrences and suboptimal results.
fatter making them seek medical help. Prosperous
people tend to live sedentary lives. This seems to be Increasing magnitude of this problem prompted
the case in India also. If you are rich, you can pick up extensive research into the pathophysiology
a phone and order a pizza; you have a car, you don’t of the development of obesity. This lead to a
need to walk to many places. Many children no longer better understanding of the disease process and
take lunch-boxes to school. They drink colas and other subsequently to the development of comprehensive
soft drinks and eat burgers. There is no awareness modalities for its treatment.
among parents that this is a problem. With obesity
come related problems, from diabetes to heart failure. Definition
An estimated 25 million Indians have diabetes, and Various parameters have been evaluated to objectively
this is forecast to grow to 57 million by 2025. assess the amount of excess body adipose tissue
Morbid obesity has acquired epidemic proportions in stores. Presently, obesity is defined and classified
the country with 5 per cent of the population suffering based on the Body Mass Index (BMI).
from it. Problem is high among schoolchildren as BMI is calculated as:
indicated from a study in Hyderabad. Obesity seen
and known from those seeking medical help is only Weight (in kg) / Height (m2) OR
the tip of an iceberg; the incidence of obesity in the Weight (in lbs) x 704 / Height (in2)

17

People with BMI between 25 and 30 kg/m2 are activity not only contributes to an increased energy
considered overweight, and those with a BMI greater expenditure and fat loss, but also protects against the
than 30 kg/m2 are considered obese. Obese persons loss of lean body mass. It improves cardiorespiratory
are at a higher risk for adverse health consequences fitness, reduces obesity-related cardiometabolic
than those who are overweight. The prevalence of health risks, and evokes sensation of well-being.
obesity-related diseases such as diabetes begins to Physical activity of a moderate intensity, 30 min in
increase at BMI values beyond 25. duration, performed 5 days a week is recommended.
To optimize weight loss, exercise should be increased
Classification by Body Mass Index to 60 min for 5 days a week.
Weight Classification Obesity BMI Risk of When obesity is a result of a lack of daily habitual
Class (kg/m2) Disease
physical activity, activities such as walking, cycling,
Underweight <18.5 Increased and stair climbing should be encouraged. Engagement
Normal 18.5-24.9 Normal of physical activity in weight management is
Overweight 25.0-29.9 Increased positively related to the level of education and
Obesity (mild) I 30.0-34.9 High on the other hand, inversely associated with the
Obesity (moderate) II 35.0-39.9 Very High occurrence of serious comorbidities, with age and
Obesity (severe/morbid) III ≥40.0 Extremely with degree of overweight.
High
Psychological factors influence both weight loss
Another factor that modifies the risk of obesity-related
and more importantly, long-term weight loss
complications is weight gain during adulthood. In
maintenance. Behavioral modification of lifestyle
both men and women, weight gain of 5 kg or more
should be included in the weight management
since the ages of 18 to 20 years increases the risk
strategies. Behavioral management includes
of developing diabetes, hypertension, and coronary
several techniques such as self monitoring, stress
heart disease and the risk of disease increases with
management, stimulus control, reinforcement
the amount of weight gained.
techniques, problem solving, rewarding changes in
Treatment modalities behavior, cognitive restructuring, social support,
and relapse prevention training.
Treatment of obesity now includes a multi-pronged
approach involving: Behavioral therapy can be provided in clinical and
commercial settings or as self help programs. Group
• life-style modification counseling results in comparable long-term weight
• dietary alterations loss but initial individual counseling is sometimes
preferred for severely obese subjects. Data on
• medical treatment and the efficacy of behavioral programs carried out in
• surgical procedures controlled settings show that weight losses average
nearly 9% in trials lasting 20 weeks. The major
A comprehensive approach to an individual patient limitation of these programs is the high likelihood
involves choosing the optimal combination of that individuals will regain weight once the behavioral
modalities based on the response to the treatment. treatment is ended. Behavioral modification of
lifestyle, especially self-control over daily energy
Life-style modification & Physical activity balance, plays a crucial role in long-term success
Physical activity should be an integral part of the of weight management. Self-monitoring of weight,
comprehensive obesity management and should be dietary intake and daily physical activity on a regular
individually tailored to the degree of obesity, age, and basis is an important determinant of weight loss
presence of comorbidities in each subject. Physical maintenance. Consistent eating patterns, including

18

regularly eating of breakfast, also influence the normalize regulatory or metabolic disturbances that
outcome of weight management. It is obvious that are involved in the pathogenesis of obesity.
special attention should be paid to patients who are
prone to failure in long term weight management. Currently, only three anti-obesity drugs have been
More frequent dietary counseling contributes to a successfully used in long-term weight management.
better outcome of long-term weight management. It is expected that lifelong treatment with anti-
This counseling might be traditional-patient visits obesity drugs will be required to specifically target
or can be provided by phone, e-mail or Internet chat the particular abnormality. Current potential to treat
applications. Psychological support is necessary for obesity by drugs is limited in comparison to the
patients with depression or dietary disinhibition. drug treatment of other complex diseases such as
Psychologist should train patients how to cope with hypertension, diabetes, and dyslipidemia. The U.S.
situations triggering dietary disinhibition (e.g., FDA has approved the drug Orlistat for use in children
stress, anxiety, and depression). and adolescents. Orlistat, as an inhibitor of lipase,
reduces fat absorption in the intestine. Patients
Dietary modifications treated with Orlistat and life-style modification
exhibited a greater weight loss and a significant
A low-energy diet recommended for the treatment
reduction in diabetes incidence compared with
of obesity should be of low fat (30% of daily energy
those who underwent life-style modification and
intake), high carbohydrate (55% of daily energy
received placebo.
intake), high protein (up to 25% of daily energy
intake) and high fiber (25 g/day). Recently, several Sibutramine, as a serotonin and norepinephrine
studies evaluated the role of low-carbohydrate reuptake inhibitor, induces satiety and prevents
diets in weight management. These diets have been diet-induced decline in metabolic rate. Continued
advocated because they induce many favourable use of sibutramine maintained weight loss almost
effects such as a rapid weight loss, a decrease of completely for this period of time.
serum triglyceride levels, and a reduction of blood
pressure as well as a higher suppression of appetite Rimonabant administration leads to significant
(partly due to ketogenesis, partly due to a higher weight reduction and improvement in cardiometabolic
protein intake). However, several unfavorable effects risk profile in four randomized double-blind clinical
of low-carbohydrate diet administration also have trials conducted in overweight or obese adults.
been demonstrated, such as an increased loss of lean
Recently, the anti-epileptic drug Topiramate was
body mass, increased levels of LDL cholesterol and
discovered to have beneficial effects on weight control
uric acid and an increased urinary calcium excretion.
and is being investigated as a weight loss drug.
Long term studies are needed to evaluate the overall
changes in nutritional status. Increased content of Weight loss induced by currently available anti-obesity
protein in a diet contributes to better weight loss drugs is only modest, reaching usually 5–8% of initial
maintenance because proteins are more satienting body weight. Assignment of patients to a particular anti-
and thermogenic than carbohydrates and fats. obesity drug should respect their licensed indications
and contra indications; i.e., Sibutramine should
Drug Treatment
not be administered to patients with uncontrolled
Anti-obesity drugs have been developed to hypertension, Orlistat should not be administered to
assist weight loss in combination with life-style patients with cholestasis and centrally acting drugs
management to improve weight loss maintenance should be indicated with caution in patients with
and to reduce obesity-related health risks. Anti- depression. Drugs should be administered to patients
obesity drugs affect different targets in the central who adequately responded to the initial phase of
nervous system or peripheral tissues and aim to treatment over a 1.5 to 3 month period.

19

Surgical Management risk-to-benefit ratio should be considered on an
individual basis. It is necessary to emphasize that
Life-style intervention programs with diet therapy,
the primary objective of surgery in elderly patients
behavior modification, exercise programs and
is to improve quality of life as surgery per se is
pharmacotherapy are widely used in various
unlikely to increase lifespan.
combinations. Unfortunately, with extremely rare
exceptions, clinically significant weight loss is In bariatric surgery, restrictive procedures as well
generally very modest and transient, particularly in as procedures limiting absorption of nutrients are
patients with severe obesity. In a recently published currently available. The magnitude of both weight loss
randomized study, in adults with mild to moderate and weight loss maintenance is increasing with the
obesity (BMI 30–35 kg/m2), surgical treatment was following procedures: gastric banding, vertical banded
found to be significantly more effective than non- gastroplasty, proximal gastric bypass, biliopancreatic
surgical therapy in reducing weight, resolving the diversion with duodenal switch, and biliopancreatic
metabolic syndrome and improving quality of life. diversion. Although sufficient evidence-based data
Till recently, surgical procedures conduced in obese to suggest how to assign a particular patient to a
patients were usually cosmetic procedures like particular bariatric procedure is slowly coming up,
liposuction/lipoplasty, aimed at reduction of body fat. for patients with BMI of 50 kg/m2, gastric bypass
However, they do not prevent weight regain following or biliopancreatic diversion brings more benefits.
the surgical procedure. With better understanding of Pure restrictive procedures are not recommended for
the pathophysiology behind development of obesity, patients with a significant hiatal hernia or severe
various procedures are developed aimed at either gastro oesophageal reflux disease. Gastric banding
restricting the intake of food, promoting malabsorption cannot contribute to further substantial weight
or both, thus ensuring long term weight reductions. loss in patients in whom a significantly diminished
food intake has been verified before the surgery.
Bariatric surgery On the other hand, it should be considered that a
laparoscopic adjustable gastric banding is the safest
Bariatric surgery is the most effective treatment for bariatric procedure associated with only minor peri-
morbid obesity in terms of weight loss, health risks and operative surgical risks.
improvement in quality of life. It should be considered
for patients with BMI >40 kg/m2 or with BMI between Bariatric surgery has been proved as the most
35 and 40 kg/m2 with comorbidities. Obesity surgery effective way of treating Type-2 Diabetes in severely
should be conducted in centers that are able to assess obese patients. More than 10 years ago, it has been
patients before surgery and to offer a comprehensive demonstrated that 83% of patients with diagnosed
approach to diagnosis, assessment, treatment, and Type-2 Diabetes exhibited normal blood glucose and
long-term follow-up. Bariatric surgery could be carefully normal glycosylated hemoglobin levels 7.6 years
considered in severely obese adolescents who have failed after bariatric surgery. Further, 99% patients with
to lose weight in a comprehensive weight management impaired glucose tolerance normalized a glucose
programs carried out in a specialized center for at least tolerance after bariatric surgery. The 10-year follow-
6 -12 months and for those who have achieved skeletal up in the Swedish Obese Subjects (SOS) study
and developmental maturity. demonstrated that a bariatric surgery is a viable
option for the treatment of severe obesity, resulting
Centers performing bariatric surgery in adolescents
in long-term weight loss, improvement in lifestyle,
should have a good experience with such
and except for hypercholesterolemia, amelioration
treatment in adults and should be able to provide
of cardiometabolic risk factors.
a multidisciplinary team that possesses paediatric
skills related to surgery, dietetics and psychological After 10 years, in the SOS study the average
management. In elderly patients (>60 years), the weight loss from baseline was 25% after gastric

20

bypass, 16% after vertical banded gastroplasty, The schematic representation of various bariatric
and 14% after gastric banding. The group that surgical procedures is given below. All the surgical
had undergone surgical intervention had lower procedures are now being conducted laparoscopically,
incidence rates of diabetes, hypertriglyceridemia, thus decreasing the operative morbidity. However, best
and hyperuricemia in comparison to the control results are obtained when the procedures are conducted
group. The most important recent finding of the in a center with a multi-specialty team involving
Swedish Obese Subjects study is a reduction of bariatric surgeon, anesthetist, endocrinologist,
overall mortality by 24.6% in the surgery group psychiatrist, dietician, physiotherapist, intensivist,
versus control subjects. plastic surgeon and a good nursing team.

Esophagen By passed portion
Proximal Pouch of stomach
of Stomach

“Short” Intestinal
Roux Limb

Pylorus

Duodenum

Gastric Banding Roux-en-Y Gastric By-pass

Gastric
“Sleeve”

Pylorus

Excised
Stomach

Gasric sleeve Resection

21

See where
you stand
as per BMI
and follow
the diet

22

Dr Lakshmisaleem 7th PSAAP Conference

Dr Lakshmisaleem 7th PSAAP Conference

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