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Salaja HoSpitalPrajasakthi Nagar, Vijayawada 500 010

Phones: 0866-2474774 / 2476500 / 040-23403736

7thPSAAPCONFERENCE

www.salaja.comwww.bodycontouring.in

Learn anySurgeryaLone withCreativityboLdneSS andkindneSS

lakshmi Saleem’s tribute to late prof. C. Balakrishnan

LASAwith

CBK

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Ekalavya 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

Arjuna, the favoured pupil of Drona. Hence Ekalavya is often

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

Dr. Lakshmi Saleem MS, MCh.

Editor-cum-President

Ekalavya

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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. Lakshmi Saleem MS, MCh.

Dr. M A Saleem, MS, FICS

Salaja Hospital, Vijayawada

Rhinoplasty was performed as the commonest Cosmetic surgical procedure in 492 patients in

our exclusive plastic surgery set-up over a 25-year period. This is a study of Rhinoplasty performed in the South Indian population whose characteristics are a combination of Caucasian and African noses. Simple and Standard techniques performed are described for the correction depending on the appearances in Frontal, Basal and Lateral views. Augmentation of the nasal bridge to increase the height is performed using bone graft from ileac crest. Excising the fat and thick areolar tissues narrows the bulbous nasal tip. Approximating the lateral crura of alar cartilages by non-absorbable suture helps in producing grooves on the flat looking alar rim and also helps in narrowing the tip thus giving a better appearance. Nasal width in the basal view is corrected by a wedge excision of the alar rims at the lateral ends. Lengthening of the columella was performed either by adding a L-shaped bone graft along with augmentation of the bridge and also a V-Y plasty. Long term follow up results of bone graft are gratifying with minimal resorbption, if any. The aim has always been to do the entire correction in single stage. Complication rate was negligible-less than 1% lack of satisfaction among the Augmentation group and less than 0.5% among all rhinoplasty procedures.

Introduction

There is not much data available in the rhinoplasty literature regarding a conventional and accepted approach for specific problems of South Indian noses. South Indians have a combination of Caucasian and African nasal characters. The common complaints include:

Depressed and wide nasal bridge, which lacks •anterior height

Flared alae nasi with increased interalar distance •and wide nostrils

Blunt and ill-defined nasal tip without alar •grooves and projection

Thick skin in some individuals along with gross accumulation of areolar and fatty tissue and attenuated alar cartilages account for the blunt and bulbous tip. Flaring of the alae nasi and flattened alar cartilages account for the increased width of the nares. These problems are discussed with the patient in detail with the aid of three basic views of photographs – Frontal, Basal and Lateral. Possible corrections are suggested before embarking on the procedure for the fullest satisfaction of the patient. Simpler techniques are chosen to fulfill the criteria. Most of the patients preferred to have the entire correction performed in a single stage.

Material & Method

Salaja Hospital, Vijayawada is an exclusive Plastic Surgery set-up in the region of South India where cosmetic surgery is performed along with other plastic surgery procedures and burns management. This unit is accessible to an approximate population of over 60millions. Nearly almost all our patients are South Indians.

The nasal index popularized by Topinard in 1890 for anthropological determinations of the race, is the ratio of the nasal width to the length multiplied by 100. These measurements define the frontal view of the nose as triangle and the dimensions vary according to the racial background. The spectrum

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of the south Indian noses lie somewhere between Negroid and Caucasian noses.

Broadbent and Mathews describe ideal nasal alignment to be such that the lateral attachment of the ala to the cheek lies within longitudinal lines drawn through the inner canthi. Nasal features can be improved by bringing the elements of the nose to lie within a triangle having a base closer to the inner canthal lines. This is seen well in the frontal view.

The inferior triangle is formed by the tip and the lateral attachments of the alae nasi to the cheek in the Basal view. It is most aesthetically pleasing when this triangle is narrow based, slightly taller than wide.

Flare can be defined as that portion of the ala, extending lateral to the alar attachment to the cheek. The inferior triangle can be altered by increasing the height of the tip or by lessening the flare of the alae.

Augmentation of the dorsum or raising the tip alters the nasal axis to best suit the patient 492 Rhinoplasties performed between 1984 and 2007 are considered in this review.

Operative procedures

Three views of the nose are considered whenever a

Rhinoplasty is planned – Frontal view, Basal view and Lateral view.

Frontal view: The appearance of nose in the frontal view is considered to be pleasing if the triangle is narrow based, slightly taller than wide, with minimal alar flare. By augmenting the dorsum or by reducing the tip, the nasal axis can be altered to suit the patient. Aesthetically a pleasing nose is 1/3 of one’s face in length or the length of one’s own thumb and limits itself in width up to both the medial canthal lines.

Depending on these factors, the surgical plan can be summarized as follows. One can narrow the triangle by dorsal augmentation with a bone graft (Ileac crest). Very rarely nasal bone infracturing is done to the same effect. Base can be altered by nasal base reduction and inter alar reduction.

Basal view: Tip projection and definition can be improved by suturing the lateral crura of alar cartilages by non-absorbable mattress sutures with 4-0 proline. Alar base reduction also changes the inferior triangle.

While planning the procedures the wide difference in individual anatomy, relation of the nose & face and variation in patients’ complaints and desires are to be considered to get a complete patient and surgeon satisfaction.

Patient’s Complaint

Frontal View

Bone graft

rearrangementInteralar reduction

Alar baseresection

Basal view

reductionCrural fixation

Tipreduction

Lateral view

Columellaradjustment

Alar Re-adjustmentWedge Bone graft

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List of operative techniques: Operative techniques are decided depending on the appearances in the frontal, basal and lateral views.

Operative techique

If only augmentation is planned, a right alar incision is given on the mucosal aspect commencing medially near the columella and extending laterally for a few mms on the undersurface of lateral crus of alar cartilage. If associated procedures are to be performed for the tip, bilateral alar incisions are given. Or a ‘V’ incision is given at the base of columella extending to both sides and the columella is lifted like an elephant trunk like in open rhinoplasty. In either case, a plane is created and the periosteum of the nasal bone is stripped off making the recipient bed ready.

Bone graft of about 2 inches long is obtained from the ileac crest. The graft is carved to the required size and shape with the help of a bone nibbler and a scalpel. Complimentary shaping of both recipient site and inner surface of graft achieve stabilization. The bone graft thus carved is firmly placed in the subperiosteal plane on the dorsum of the nose. No rigid fixation is done with pin or screw. The incision is closed with 4-0 chromic catgut on the mucosal side. In cases where extended skin incision is given, the skin is closed with 5-0 proline.

Post-operative splinting is by couple of layers of plaster of Paris or a ready-made nasal splint that is retained for five days. Drain from the bone graft donor site is removed after 24 hours and the patient discharged.

In those patients who have an increased alar flare and increased width, alar base resection is done as a wedge at the junction where the ala meets the cheek. Suturing is done with 4-0 vicryl and 5-0 proline.

Narrowing the tip, can be achieved by bringing the alar cartilages together with a single 4-0 proline mattress suture through alar incisions on both

sides. First bite is taken through the caudal edge of lateral end of lateral crus of alar cartilage from outside in. A tunnel is created with the curved artery forceps connecting the two medial ends of the alar incisions, passing through the membranous septhum. The needle is transferred from right nostril to the left through the tunnel and a similar bite is taken of caudal edge of the lateral crus on the left side (first from inside out and next from outside in), to get a good hold on tip of the lateral crus. The needle is brought back to right nostril through the previously mentioned tunnel. Another bite is taken through the rt side cartilage close to the first one so that the knot comes on the outer side. The suture is tightened as for the required projection of the tip, recreating an alar groove. It is to be remembered while tightening that often there is only a fine line between a tip that remains too bulbous and one that is pinched.

Results

A series of 492 rhinoplasties PERFORMED OVER 25 YEARS has been reviewed. Patients were predominantly female and frequently in the age group of 16 and 30 years. Average follow-up varied from a few months to 10 years.

Of this series, only 291 patients had bone graft from ileac crest. 155 patients had soft tissue correction alone, with cartilage graft when needed.

Complications

Out of the 291 patients of bone graft, 2 patients opted for the removal of the graft as they did not like it.

4 patients required nasal splint for more than two weeks to maintain the desired position of the graft.

Conclusion

Rhinoplasty procedure performed in 492 patients in a period of 25 years is reviewed. This study

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included Rhinoplasty performed in the South Indian population whose characters are a combination of Caucasian and African noses. Standard but simpler techniques are chosen. A clinical approach of the patients’ complaints and the appearances in Frontal, Basal and Lateral views guided the technique to be followed. Augmentation of the nasal bridge to increase the anterior height is performed using bone graft from ileac crest. Excision of the fat and thick areolar tissues in the bulbous tip helped to narrow the nasal tip. Approximating the medial nasal alar cartilages in the midline by non-absorbable suture helps in producing grooves on the alar rim and also helps in narrowing the tip

thus giving a better appearance. Nasal width in the basal view is corrected by a wedge excision of the alar rims at the lateral ends. Lengthening of the columella was performed by adding a L-shaped bone graft along with augmentation of the bridge whenever required and also a V-Y plasty. Long term follow up results of bone graft are gratifying with minimal resorbption, if any. The aim has always been to do the entire correction in single stage to facilitate the patients’ compliance and satisfaction. Complication rate was negligible-less than 1% lack of satisfaction among the Augmentation group and less than 0.5% among all the rhinoplasty procedures performed.

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

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Anaesthesia

Local anaesthesia is preferable to general anaesthesia if the patient will tolerate it since the voluntary movement of the levator muscle aids in the identification of lid structures and a better operative assessment of lid level is possible.

Method

Mark the skin crease.1.

Evert the lid and inject 1 or 2 cc of local 2. anaesthetic immediately under the conjunctiva just above the upper border of the tarsal plate.

Give a subcutaneous injection in the region of 3. the skin crease.

Note

a. Adrenalin in the local anaesthetic helps to reduce bleeding but stimulates Mulller’s muscle.

b. A frontal nerve block is not usually necessary and runs a risk of affecting the function of the levator muscle.

Ptosis surgery Dr. Devendra K Gupta MS, MCh.

Derendra Hospital, Bareilly (UP)

Levator resection

The eyelid elevation which can be obtained by shortening the levator complex depends primarily on the levator function. The result required depends on the circumstances, i.e. the diagnosis, Bell’s phenomenon etc. The optimum result in a patient with simple congenital ptosis is for the eyelid levels to be the same in the primary position of gaze, but lower level may be acceptable in a patient with a partial third nerve palsy, a dry eye, or progressive external ophthalmoplegia etc. A resection of the following amount of aponeurosis and levator muscle should lift the eyelid to an acceptable level:

Levator function 8-10 mm: 14-18 mm resection.

Levator function 6-7 mm: 18-22 mm resection.

Levator function 4-5 mm: 22-26 mm resection.

These measurements are approximate. They include both aponeurosis and levator muscle and are taken from just below the upper border of the tarsal plate. The extent of the resection is modified by the degree of ptosis, thus 2 mm of ptosis will warrant

>10mm

Degree of ptosis

Aponeurosis Surgery

>2mm

Fasanella Servat

<2mm

<10mm

Levator Function

Brow Suspension

<4mm

Levator Resection

>4mm

Levator Function

Normal 15-18mm

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a lesser resection than 4 mm of ptosis if the levator function is the same. If the superior rectus muscle is weak the resection should be increased by about 4 mm. The adequacy of the resection can be confirmed at operation. Under general anaesthesia the eyelid should stay at approximately the level which is achieved at operation if the levator function is about 7 mm. If the levator function is better than this the lid will tend to rise post-operativcly and to fall if the levator function is worse. Under local anaesthesia the lid should be set 1-2 mm higher to compensate for the paralysis of the orbicularis muscle.

Anterior approach levator resection (fig.1)

Principle

The levator muscle is approached through a skin incision. The septum is divided and when the pre-aponeurotic fat is retracted the whole levator complex can be examined directly for any defects. The muscle is shortened and sutured directly to the tarsus. Any excess skin can be excised and the skin crease reformed with interrupted sutures which pick up the underlying levator muscle.

Indications

A ptosis with 4 mm or more of levator function; skin excision; lid – exploration; maximum levator resection; preservation of tarsus and conjunctiva; lash ptosis; entropion; skin crease defect.

Method

1. Mark the skin to match the crease on the uninvolved side and make an incision through the skin with a blade (Fig.1 a).

2. Pick up the skin on either side of the incision in the centre of the lid with two pairs of toothed forceps and make a cut through the orbicularis muscle with a pair of scissor aimed towards the tarsal plate.

3. Undermine the orbicularis medially and laterally and cut it with scissors along the line of the skin incision.

4. Clean the anterior tarsal surface sufficiently to suture the aponeurosis or levator muscle to

it. Stop 2 mm from the lid margin to prevent damage to the lash roots (Fig.1 b).

5. Dissect the pre-septal orbicularis muscle from the lower part of the orbital septum. The septum can be identified by:

a. its attachment to the orbital rim which can be felt as a firm band when traction is exerted on it.

b. orbital fat can sometimes be seen behind it.

c. pressure over the lower lid may help to make the orbital fat more obvious.

6. Open the orbital septum to expose the pre-aponeurotic fat pad beneath which is the aponeurosis (Fig.1 c). This can be seen to move when the patient looks up, if the operation is under local anaesthesia.

7. Dissect the aponeurosis from the tarsus (Fig.1 d) and Muller’s muscle from the conjunctiva (Fig.1 e).

8. Cut the medial and lateral attachments (horns) of the levator complex under direct vision. Curve the scissors centrally towards the levator muscle to avoid the trochlea medially and the lacrimal gland laterally (Fig.1 f).

9. Try to preserve Whitnall’s ligament and advance the levator muscle under it (Fig.1 g).

Note: The ligament can be sutured directly to the tarsus to act as an internal sling in cases with poor levator function as an alternative to a brow suspension. This does create a relatively static lid with a marked degree of asymmetry on down gaze in unilateral cases.

10.Pass a double-armed 6 ‘O’ polyglycolic acid/vicryl suture into the anterior tarsal surface at the intended apex of the lid curve.

Measure the aponeurosis and levator to be resected and pass each needle of the suture through the centre of the levator muscle just above the site of the planned resection. Tie the suture with a slip knot and cut the muscle (Fig.1 h).

11.Check the height and curve of the lid and adjust the suture if necessary. Cut the suture and use each arm to suture the muscle to the tarsus on 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 orbicularis muscle.

13.Excise any excess skin from the upper skin flap.

14.Close the skin and reform the crease with 6 ‘O’ absorbable sutures which pass front the edge of the lower skin flap, into the levator muscle, and out through the edge of the upper skin flap (Fig.1 j).

Note: Absorbable sutures are preferable since skin crease sutures may be difficult to remove completely and the scar is buried in the crease.

15.Use a Frost suture.

Aponeurosis surgery

Aponeurosis surgery is indicated for patients with an aponeurotic defect and good levator function (i.e. better than 10 mm). The approach is very similar to that for a levator resection but the surgery is not so extensive, the horns of the levator complex arc not cut, and a Frost suture is rarely necessary to protect the cornea. Local anaesthesia should be used if at all possible and the lid set at operation to the same level or a little higher than the other side. In the immediate post-operative phase the lid will be low due to recovery of the orbicularis muscle function and oedema, but since the levator function is good the lid will subsequently rise.

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The pathophysiology of breast hypertrophy is due to an abnormal end organ response to circulating

estrogens and it is due to the hypersensitivity of the some women during puberty and pregnancy. Breast enlargement consists of fibrous tissue and fat while the glandular elements remain quite small. Sometimes a familial pattern can be traced back as members of the same family are affected. Breast hypertrophy produces considerable functional disability and affects the quality of life due to disproportionate body disposition. Significant improvement of the individual self esteem and self confidence are noted in all the patients and symptomatic improvement in the postural disability, neck and shoulder pain relief were also noted. The aims of breast reduction is to reduce, recontour reshape to suit the woman’s needs and desires.

Selection of the procedure depends on the type of breast, surgeon’s comfort with the surgical skill, scars and a long lasting aesthetic result. Important points to consider are how much tissue need to be removed and the final nipple position depends on the breast tissue that is left behind. With 30 years of experience and understanding of the problem few

Selection of procedure for reduction mammoplasty

Dr. Lakshmi Saleem MS, MCh.

Salaja Hospital, Vijayawada

simple guidelines are taken into consideration and the problem is classified as follows:

Grade 1: Teenage girls with increased areola and ptosis requiring reduction of less than 200 grms.

Grade 2: Young women, who may need reduction up to 500 grms.

Grade 3: Women who may need excision of up to 1000 grms

Grade 4: Women who may need massive reduction of more than 1000 grms.

With 30 years of experience of reduction mammoplasty various techniques, a simple procedure has been recognized which is easy to execute with the long lasting aesthetic effect. Classically it incorporates the superiomedial pedicle with a vertical scar, and excision of the gland with the skin from the inferior quadrant with extension onto the medial and lateral segments, depending on the requirements of the excison. This procedure has been found to be technically easy, safe, quick to perform with minimal complications and safety. It can be undertaken for major resections of more than 1000 gms also.

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Markings for surgery

The patient is made to stand erect with the hands tucked behind. Keeping the BMI in mind, the desired size is discussed with the patient, and the mid-sternal line is marked first. followed by drawing of the breast meridian.The nipple postion is noted. The distance measured from the midsternal notch to the nipple position is also noted. The desired new nipple position is marked from the midsternal notch. The areola is marked with the diameter of 3.5 to 4 cm with a nipple marker depending on the need. The new nipple is marked with distance of 19 to 22 cm depending on height of patient keeping the diameter 0.5 cm more than the previous marking. An ellipse is drawn taking the top of the new areola as the highest point The lowest point of the ellipse is kept 1cm above the inframammary crease. The maximum width of the ellipse is equal to the diameter of the existing areola.

Procedure

1. Infiltration of the breast tissue with saline adrenaline, avoiding the injection in the upper, medial quadrant and the area that needs de-epethelisation

2. Areola is incised and de-epethelisation started going away from areola.

3. The lower “V” cut is deepend keeping the skin intact.

4. The medial and lateral flaps raised with 0.5 cm thickness, upto the medial most and lateral extent of Breast tissue.

5. The lower part of V is raised from below upwards, exposing the pectoral fascia upto 0.5 cm below the de-epethelised sub areolar region.

6. The medial and lateral segments of breast tissue which need to be excised is included with the V segment as one en-bloc of tissue.

7. The whole block of tissue is excised from the upper part of breast protecting the nipple, areolar complex.

8. Both the lateral and medial flaps are brought together with skin hooks and any excess skin is excised as an ellipse from the lateral segment.

9. The aeolar complex is shifted up to the new position and if there is difficulty in moving it up relaxing incision given on the lateral part of de-epethelised segment.

10. After areola is fixed with 3-0 monocryl and lower breast tissue is brought together with 3-0 monocryl subdermal sutures.

11. After fixing the drains, the areola is sutured with 6-0 vicryl and the lower incision is sutured with subcuticular 3-0 monocryl.

12. With this technique, the vascularily of nipple was never compromised and the only complication that was seen was delay in healing at the lower most part of incision, when excison was more tran 800 gm.

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

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Hypospadias is a congenital defect resulting from incomplete tubularisation of the urethral plate.

The meatus may be found any where along the penile shaft and down on to the perineum. Hypospadias with an incidence of 0.8 – 8.2 per 1000 live male births is a common clinical problem. In the majority of cases (80%) abnormal meatus is situated in the glanular, coronal and subcoronal levels or in the proximal part of the shaft.

The goal of hypospadias repair is a functional penis with a normal cosmetic appearance. Established procedures to correct the distal hypospadias are the Thiersch-Duplay, Mathieu, Mustarde, meatal advancement and glanuloplasty (MAGPI) and tubularized incised plate (TIP) urethroplasty. Of the various procedures Tip urethroplasty (Snodgrass repair) most reliably creates a normal appearing penis. At many centres it is now the preferred method of repair since it creates a vertical slit like normal appearing meatus, unlike a horizontally oriented and rounded meatus (‘Fish mouth’) produced by the meatal based (Mathieu) and onlay island flap repairs. In addition this procedure allows construction of neourethra from the existing urethral plate without additional skin flaps. The technique is versatile and suitable for almost all distal lesions.

Method

The penis is degloved with a U shaped incision extending along the edges of the urethral plate to healthy skin 2 mm proximal to the meatus.The lateral borders of the distal urethral plate are separated from the glans by parallel longitudinal incisions. The glanular wings are further mobilized laterally for subsequent tension free closure. The urethral plate is then incised in midline from the hypospadiac meatus distally. Incised plate is then tubularised over a 6-8F stent using continuous subcuticular

6-0 chromic catgut suture. Neourethra is then covered with a vascularized dartos flap harvested from subcutaneous tissue of dorsal penile skin and preputial skin. The granular wings, mucosal collar and ventral shaft skin are closed in the midline. The stent provides urinary drainage for 10 days.

With its simplicity, versality, excellent cosmetic and functional results and a low complication rate, TIP urethroplasty is the procedure of choice for most of the distal defects. Since most of the patients with midshaft and penoscrotal defects have a supple urethral plate, a midline incision consistently widens the plate and enables tubularisation. This makes TIP plasty a versatile technique in repairing the proximal hypospadias as well.

Contraindications to TIP plasty are severe chordee requiring plate excision for straightening the penis and unhealthy urethral plate that appears thin or is insufficiently widened after incision. Complications are rare. Fistula can be avoided by interposition of a vascularised dartos flap between the neourethra and overlying glans and shaft skin closures. Closure of the first layer is done in a running subcuticular fashion with efforts made to invert the epithelium completely.

Bracka’s Versatile Two Stage

Hypospadias RepairAesthetic quality of the hypospadias repair with natural looking glans and slit shaped terminal meatus after multiple failed hypospadias repairs remains a formidable challenge in reconstructive surgery.

I Bracka’s (1995) two stage hypospadias repair offers versatility, reliability and refinement and can

Repair of mid to distal penile hypospadias by the tubularised incised plate urethroplasty

Dr. Devendra K Gupta MS, MCh.

Derendra Hospital, Bareilly (UP)

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be used for almost any hypo spadias deformity be it primary repair in child or salvage surgery in an adult.

Timing of surgery

1. At 18 months: Offers psychological advantage to child. Better anaesthesia required

2. Before school at 4 years: We use most of the time the second option for surgical correction. Tissues are better developed

Operative steps

Stage 1

Anaesthesia: Caudal epidural anaesthesia. Advantages are smooth recovery, postop analgesia and less risk of postoperative bleeding and haematoma. Then the assessment is done-of position and size of abnormal meatus, the presence of chordee, the quality and width of urethral plate and the configuration of glans penis. 4/0 silk stay stitch is applied to the glans and presence and degree of chordee is assessed. Meatal assessment is done using urethral dilators. Tourniquet is applied after dilatation. If required, meatotomy is done to split the thin layer of urethra to the spongiosum covered urethra. The suturing of urethral mucosa to skin is done after meatotomy using 6/0 chromic catgut. Two more stay 5/0 sutures are applied on either side of the midline over the distal aspect of the glans which will be used as traction during glans split and later as first tie-over suture.

Release of chordee is done from the proposed neo-meatus to the ventral aspect of the abnormal meatus. From the sub coronal part of the vertical incision, lateral incisions on either side are done to correct the chordee. This is done by a combination

of incision and excision of tissues using scalpel and fine scissors. The chordee correction is achieved in this manner in the majority of cases. In cases of residual chordee further correction is done by extending the sub coronal incisions to circumcoronal incision and stripping the penis. A full thickness preputial graft was taken and accurately tailored into the defect using 6/0 chromic catgut. A firm “tie-over” dressing was placed for 7 davs and a urethal catheter for 7-10 days.

Stage 2 after at least 6 months to allow for graft maturity and neovascularity. Neourethra was fashioned from the supple grafted skin bed. The meatus was reconstructed first by joining the ventral point, the rest of the urethra was then tubed around K-90 or K-91/NEL-CATH (Romsons) catheter with a combination of interrupted and continuous extraluminal inverting 6/0 chromic catgut sutures. The repair is protected and reinforced using an intermediate vascularised fascial layer dissected from the dorsal aspect following circumcoronal incision and stripping of penis. This vascular layer helps the healing process and avoids suture lines in contact with each other and thus reduces the risk of fistula formation. The successful reconstruction depends on proper planning, gentle handling of tissues with fine instrumentation, usage of fine suture materials, inverting sutures of neo-urethra and usage of intermediate vascular layer of tissues

The glans and skin repaired and dressing was done. Catheter was removed on the 10th day.

The urinary catheter is fixed on the lower abdomen with a “mesenteric type” of tape fixation so that the catheter is directed upwards away from the ventral suture line.

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Obesity Management – a plastic surgeon’s perspective!

Dr. Lakshmi Saleem MS, MCh.Consultant Plastic & Cosmetic Surgeon

Over 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 for being obese. They belonged to both genders and also of different ages. In the early days it was not only difficult to convince people to follow a disciplined life pattern and take proper diet but it was a tough task to dissuade them from seeking surgical option. Some were genuinely odd in their figure having either bulky arms or heavy thighs, some had heavy breasts and some were disproportionately large in the upper or the lower parts of the body. Some boys had heavy breasts resembling female pattern, some girls even just around puberty had such heavy breasts that embarrassed them both physically and psychologically. Where do we draw a line to decide who are the candidates for surgery? How can you assure them that even if some fat is removed from the parts of their body, what is the guaranty that it does not re-accumulate due to their indulgence in either over-eating or lazy life pattern.?

Here comes the honesty on our part to decide and classify who falls in the category called ‘obese’.

What is obesity?

When the body weight of a person is more than 25% of the expected weight in the case of a man and is more than 32% in the case of a woman, that person is considered obese. Another definition is that any person with 40 Kg more than the expected weight is considered obese for any individual.

But the best way to measure is by the specific term called Body Mass Index. This is nothing but a calculation at any age and for any gender wherein the body weight (in Kg) is divided by height (in Meters squared).

B M I = Weight (kg) / Height (m2)

Accordingly a person is determined to be:

Healthy if BMI is 20 – 25

Overweight if BMI is 26 – 30

Obese if BMI is 30 – 35

if BMI is Morbidly obese 35 – 40or above

Obesity and over weight have been recognized to be global problems affecting over a billion adults and 17.6 million children under 5 years of age. Obesity is presently considered as a chronic illness, in addition to be a cosmetic problem. It is associated with many other chronic diseases ranging from Arthritis to Diabetes, Cardiovascular problems to frank Heart failures, Neurovascular problems to Alzheimer’s, Chronic depression to Dementia, Chronic skin diseases to Cancers.

What causes obesity?

Apart from the various hormonal causes like Hypothyroidism, Hypercorticosteroidism, hormonal changes due to pregnancy or menopause, the primary factor that leads to obesity is imbalance between calorie in take to that of calorie consumption superadded by a sedentary type of life style with no physical activity. Heredity and depression of course play some role as the causative factors.

How to prvent obesity?

Like in the case of many health problems, prevention has the best role to eradicate obesity. Childhood obesity has an alarming increase across the globe and cause for concern as this predisposes to adulthood obesity.

The teaching and training should start at home wherein the parents are taught about balanced

15

and nutritious diet for their children. The school environment should provide proper physical activity to the children. They should be made aware of the problems of energy rich salty foods, soft drinks containing large quantities of sugar and large quantity of dairy products and ice creams. They should be taught to restrict such foods. Children must also be made aware of the ill effects of sedentary life styles. The role of yoga or meditation or such disciplining activities are definitely among the much needed.

How to cure obesity

In spite of the best efforts to prevent obesity, if it still is a problem, the steps to cure obesity are again giving emphasis on life style changes and altering environmental factors. Dietary modification like low calorie, high fiber diet associated with enhancing physical activity is mandatory. Chronic stress or chronic depression may both lead to obesity and hence such of the factors that lead to these psychological changes should be brought under control. These can best be achieved by either Yoga or Meditation. It is all the more important that emphasis is laid to self motivation. A self motivated obese person is on the right track to cure him / her self of obesity.

Who needs surgery to cure obesity?

The choice of surgery depends on the severity of the problem of obesity. Arbitrarily it can be said that having tried all the physical, dietetic and psychological methods to curing the problem of obesity, the choice of surgery falls into two categories.

One is just the removal of fat or the excess of tissue, which is usually preferred in only those that fall in the group of overweight up to a BMI of 30. The procedures that can be carried out in this method are Liposuction or Lipectomy.

Two is for those who fall into the category of severely obese or who suffer morbid obesity with a BMI of 40 or more needing Bariatric surgery where the food intake is either restricted or malabsorption

is created. However people with BMI of 30 – 35 associated with one or two co-morbid condition may also need bariatric surgery.

The role of a cosmetic surgeon in taking care of an over weight or obese individual cannot be overemphasized. One should insist on an overweight person with a BMI of 26 – 35 to reduce his/her weight by about 5 Kg by proper diet, exercise and change in life style. This gives the plastic surgeon to assess the genuineness in commitment on the part of the individual how much the obese person is going to follow the instructions and how effective the cosmetic surgical method be useful to such an individual in the long run.

Even after the Bariatric surgery there is a role for a Cosmetic surgeon in contouring the body for the residual or consequential effects.

Liposuction and lipectomy

Liposuction is one of the surgical options for the obesity if the person is well motivated and willing to maintain the weight. By doing the liposuction of the certain areas, like inner thighs and the sides of the chest, it enables the obese person to go for walks and exercises with out much difficulty. Certain areas where there is localized obesity like the arms, side of flanks and thighs or buttocks need liposuction.

Some times the liposuction itself can stimulate the basal metabolic rate so much that the person can start losing weight with a greater speed. It was observed that liposuction itself can make an overall reduction of 10 to 15 Kgs.

Abdominal girth increase or looseness due to post partum obesity does need to be addressed with plastic surgery in the form of Abdominoplasty or tummy tuck procedure. The same might be the case in those obese people who underwent bariatric surgery and lost weight but developed loose skin folds and so on.

Gynaecomastia

Abnormal male breast development is seen in some of the obese individuals and they invariably

16

present with these localized deposits of fat. These can be classified as grades 1 to 3 depending on the severity. Liposuction alone may be enough to treat the mild deformities with out much of central core of breast tissue being removed in Gr 1 cases. In Gr 2 cases, liposuction along with surgical excision may be needed. In Gr 3, the obese person may need mastopexy to correct the excessive sagging of the skin after excision of the gland.

Bilateral breast reduction

Breast hypertrophy (overgrowth) in women produces considerable functional disability and affects the quality of life due to disproportionate body, leading to pain in the breasts, secondary back, shoulder or neck pain. Skin below the breasts may be seen to be macerated with or without infection. This problem compounds the overall obesity of the individual. Reduction mammoplasty wherein the breast size is reduced to a reasonable level and also liposuction of other obese parts of body can be combined with it. The aim of reduction of breast is to reduce and re-contour to suit the woman’s needs and desire and to make the individual comfortable. Significant improvement of the individual self-esteem, self-confidence is noted in every patient who had undergone breast mammoplasty and postural disability is reduced greatly. The gain in confidence levels is encouragingly very high in younger individuals where they can fit into right sized garments and be more presentable.

Body contouring after massive weight loss following the bariatric surgery

In morbid obesity, contour deformities of the abdomen are common after bariatric surgery and radical weight loss. Traditional techniques fail to improve the shape as there are lateral hip rolls

and flanks leaving the patient with a lot of lateral redundancies and dog-ears. A modified vertical abdominoplasty, combining with the transverse approach, a single stage procedure for resection are needed without undermining the tissues.

Neo-umbilicoplasty (reforming umbilicus in the new position) is to be planned with care. If associated hernia is present, this also can be dealt with in the same sitting. Lower body lift and thigh lift can be attempted together, but in spite of the tight approximation of the sub-cutaneous facial system, the saddle deformity and mid thigh laxity cannot be corrected well.

In conclusion we can say that the following are the steps to face the problem of obesity:

Evaluation of the cause of obesity•

Assessing the extent of obesity in terms of BMI •and also marking if the obesity is localized.

Dietary regulation and shift to low calorie and •high fiber diets and avoiding indulgence in improper diets.

Regular and constant exercises.•

Change of life style with regularity and discipline •in the diet and physical activities.

Liposuction or lipectomy in the people with over •weight or obese individuals of less than 30 BMI.

Suggesting Abdominoplasty for those who have •trunkal obesity.

Suggesting and guiding the individuals with BMI •of 40 or 35 with co-morbid conditions to undergo bariatric surgery.

Taking care of the residual or consequential •effects of bariatric surgery.

17

Management of ObesityDr. M A Saleem MS, FICS

Consultant & Head of DepartmentGeneral Surgery, Surgical Gastroenterology and Laparoscopic SurgeryCare Hospital, Banjara Hills, Hyderabad

Obesity is a chronic disease and is also associated most of the times with medical illnesses like diabetes, hypertension, hyperlipidemia, chronic arthritis and so on. The prevalence of obesity cannot be questioned and its worldwide increase at an alarming rate is noticed in both developed and developing countries. In US the studies show an incidence of overweight of 66%, obesity of 32% and morbid obesity of around 5%. In Europe obesity prevalence ranges from 20% in men and 25% in women. Although well established statistics are not available in India, one of the surveys by All-India Institute of Medical Sciences showed that 76% of women in the capital, New Delhi, suffer from abdominal obesity. NFHS analysis showed that 12% men and 16% women suffer from obesity in India.

Excess body weight is the sixth most important risk factor contributing to the health burden of the world. There seems to be a positive correlation between economic development and obesity: as a country becomes richer, many people in that country become fatter making them seek medical help. Prosperous people tend to live sedentary lives. This seems to be the case in India also. If you are rich, you can pick up a phone and order a pizza; you have a car, you don’t need to walk to many places. Many children no longer take lunch-boxes to school. They drink colas and other soft drinks and eat burgers. There is no awareness among parents that this is a problem. With obesity come related problems, from diabetes to heart failure. An estimated 25 million Indians have diabetes, and this is forecast to grow to 57 million by 2025.

Morbid obesity has acquired epidemic proportions in the country with 5 per cent of the population suffering from it. Problem is high among schoolchildren as indicated from a study in Hyderabad. Obesity seen and known from those seeking medical help is only the tip of an iceberg; the incidence of obesity in the

country is much higher and the is growing faster, according to medical experts.

Obesity amplifies the risks of type 2 diabetes, hypertension, cardiovascular disease, dyslipidemia, arthritis, and several cancers and is estimated to reduce average life expectancy. In the United States alone, it is estimated that obesity-related health problems account for about 300,000 deaths per year. The medical expenses and cost of lost productivity due to obesity in the USA are estimated to be greater than $100 billion per year.

Patients with obesity seek medical attention either for cosmetic reasons or for cure of associated medical conditions. The surgical treatment of obesity till recently revolved primarily around cosmetic procedures like liposuction or abdominoplasty. However, these methods were purely cosmetic in that they did not address the basic pathophysiology behind the development of overweight in the first place. Consequently, they were associated with recurrences and suboptimal results.

Increasing magnitude of this problem prompted extensive research into the pathophysiology of the development of obesity. This lead to a better understanding of the disease process and subsequently to the development of comprehensive modalities for its treatment.

Definition

Various parameters have been evaluated to objectively assess the amount of excess body adipose tissue stores. Presently, obesity is defined and classified based on the Body Mass Index (BMI).

BMI is calculated as:

Weight (in kg) / Height (m2) OR

Weight (in lbs) x 704 / Height (in2)

18

People with BMI between 25 and 30 kg/m2 are considered overweight, and those with a BMI greater than 30 kg/m2 are considered obese. Obese persons are at a higher risk for adverse health consequences than those who are overweight. The prevalence of obesity-related diseases such as diabetes begins to increase at BMI values beyond 25.

Classification by Body Mass Index

Weight Classification Obesity Class

BMI (kg/m2)

Risk of Disease

Underweight <18.5 Increased

Normal 18.5-24.9 Normal

Overweight 25.0-29.9 Increased

Obesity (mild) I 30.0-34.9 High

Obesity (moderate) II 35.0-39.9 Very High

Obesity (severe/morbid) III ≥40.0 Extremely High

Another factor that modifies the risk of obesity-related complications is weight gain during adulthood. In both men and women, weight gain of 5 kg or more since the ages of 18 to 20 years increases the risk of developing diabetes, hypertension, and coronary heart disease and the risk of disease increases with the amount of weight gained.

Treatment modalities

Treatment of obesity now includes a multi-pronged approach involving:

life-style modification•

dietary alterations•

medical treatment and •

surgical procedures•

A comprehensive approach to an individual patient involves choosing the optimal combination of modalities based on the response to the treatment.

Life-style modification & Physical activity

Physical activity should be an integral part of the comprehensive obesity management and should be individually tailored to the degree of obesity, age, and presence of comorbidities in each subject. Physical

activity not only contributes to an increased energy expenditure and fat loss, but also protects against the loss of lean body mass. It improves cardiorespiratory fitness, reduces obesity-related cardiometabolic health risks, and evokes sensation of well-being. Physical activity of a moderate intensity, 30 min in duration, performed 5 days a week is recommended. To optimize weight loss, exercise should be increased to 60 min for 5 days a week.

When obesity is a result of a lack of daily habitual physical activity, activities such as walking, cycling, and stair climbing should be encouraged. Engagement of physical activity in weight management is positively related to the level of education and on the other hand, inversely associated with the occurrence of serious comorbidities, with age and with degree of overweight.

Psychological factors influence both weight loss and more importantly, long-term weight loss maintenance. Behavioral modification of lifestyle should be included in the weight management strategies. Behavioral management includes several techniques such as self monitoring, stress management, stimulus control, reinforcement techniques, problem solving, rewarding changes in behavior, cognitive restructuring, social support, and relapse prevention training.

Behavioral therapy can be provided in clinical and commercial settings or as self help programs. Group counseling results in comparable long-term weight loss but initial individual counseling is sometimes preferred for severely obese subjects. Data on the efficacy of behavioral programs carried out in controlled settings show that weight losses average nearly 9% in trials lasting 20 weeks. The major limitation of these programs is the high likelihood that individuals will regain weight once the behavioral treatment is ended. Behavioral modification of lifestyle, especially self-control over daily energy balance, plays a crucial role in long-term success of weight management. Self-monitoring of weight, dietary intake and daily physical activity on a regular basis is an important determinant of weight loss maintenance. Consistent eating patterns, including

19

regularly eating of breakfast, also influence the outcome of weight management. It is obvious that special attention should be paid to patients who are prone to failure in long term weight management. More frequent dietary counseling contributes to a better outcome of long-term weight management. This counseling might be traditional-patient visits or can be provided by phone, e-mail or Internet chat applications. Psychological support is necessary for patients with depression or dietary disinhibition. Psychologist should train patients how to cope with situations triggering dietary disinhibition (e.g., stress, anxiety, and depression).

Dietary modifications

A low-energy diet recommended for the treatment of obesity should be of low fat (30% of daily energy intake), high carbohydrate (55% of daily energy intake), high protein (up to 25% of daily energy intake) and high fiber (25 g/day). Recently, several studies evaluated the role of low-carbohydrate diets in weight management. These diets have been advocated because they induce many favourable effects such as a rapid weight loss, a decrease of serum triglyceride levels, and a reduction of blood pressure as well as a higher suppression of appetite (partly due to ketogenesis, partly due to a higher protein intake). However, several unfavorable effects of low-carbohydrate diet administration also have been demonstrated, such as an increased loss of lean body mass, increased levels of LDL cholesterol and uric acid and an increased urinary calcium excretion. Long term studies are needed to evaluate the overall changes in nutritional status. Increased content of protein in a diet contributes to better weight loss maintenance because proteins are more satienting and thermogenic than carbohydrates and fats.

Drug Treatment

Anti-obesity drugs have been developed to assist weight loss in combination with life-style management to improve weight loss maintenance and to reduce obesity-related health risks. Anti-obesity drugs affect different targets in the central nervous system or peripheral tissues and aim to

normalize regulatory or metabolic disturbances that are involved in the pathogenesis of obesity.

Currently, only three anti-obesity drugs have been successfully used in long-term weight management. It is expected that lifelong treatment with anti-obesity drugs will be required to specifically target the particular abnormality. Current potential to treat obesity by drugs is limited in comparison to the drug treatment of other complex diseases such as hypertension, diabetes, and dyslipidemia. The U.S. FDA has approved the drug Orlistat for use in children and adolescents. Orlistat, as an inhibitor of lipase, reduces fat absorption in the intestine. Patients treated with Orlistat and life-style modification exhibited a greater weight loss and a significant reduction in diabetes incidence compared with those who underwent life-style modification and received placebo.

Sibutramine, as a serotonin and norepinephrine reuptake inhibitor, induces satiety and prevents diet-induced decline in metabolic rate. Continued use of sibutramine maintained weight loss almost completely for this period of time.

Rimonabant administration leads to significant weight reduction and improvement in cardiometabolic risk profile in four randomized double-blind clinical trials conducted in overweight or obese adults.

Recently, the anti-epileptic drug Topiramate was discovered to have beneficial effects on weight control and is being investigated as a weight loss drug.

Weight loss induced by currently available anti-obesity drugs is only modest, reaching usually 5–8% of initial body weight. Assignment of patients to a particular anti-obesity drug should respect their licensed indications and contra indications; i.e., Sibutramine should not be administered to patients with uncontrolled hypertension, Orlistat should not be administered to patients with cholestasis and centrally acting drugs should be indicated with caution in patients with depression. Drugs should be administered to patients who adequately responded to the initial phase of treatment over a 1.5 to 3 month period.

20

Surgical Management

Life-style intervention programs with diet therapy, behavior modification, exercise programs and pharmacotherapy are widely used in various combinations. Unfortunately, with extremely rare exceptions, clinically significant weight loss is generally very modest and transient, particularly in patients with severe obesity. In a recently published randomized study, in adults with mild to moderate obesity (BMI 30–35 kg/m2), surgical treatment was found to be significantly more effective than non-surgical therapy in reducing weight, resolving the metabolic syndrome and improving quality of life.

Till recently, surgical procedures conduced in obese patients were usually cosmetic procedures like liposuction/lipoplasty, aimed at reduction of body fat. However, they do not prevent weight regain following the surgical procedure. With better understanding of the pathophysiology behind development of obesity, various procedures are developed aimed at either restricting the intake of food, promoting malabsorption or both, thus ensuring long term weight reductions.

Bariatric surgery

Bariatric surgery is the most effective treatment for morbid obesity in terms of weight loss, health risks and improvement in quality of life. It should be considered for patients with BMI >40 kg/m2 or with BMI between 35 and 40 kg/m2 with comorbidities. Obesity surgery should be conducted in centers that are able to assess patients before surgery and to offer a comprehensive approach to diagnosis, assessment, treatment, and long-term follow-up. Bariatric surgery could be carefully considered in severely obese adolescents who have failed to lose weight in a comprehensive weight management programs carried out in a specialized center for at least 6 -12 months and for those who have achieved skeletal and developmental maturity.

Centers performing bariatric surgery in adolescents should have a good experience with such treatment in adults and should be able to provide a multidisciplinary team that possesses paediatric skills related to surgery, dietetics and psychological management. In elderly patients (>60 years), the

risk-to-benefit ratio should be considered on an individual basis. It is necessary to emphasize that the primary objective of surgery in elderly patients is to improve quality of life as surgery per se is unlikely to increase lifespan.

In bariatric surgery, restrictive procedures as well as procedures limiting absorption of nutrients are currently available. The magnitude of both weight loss and weight loss maintenance is increasing with the following procedures: gastric banding, vertical banded gastroplasty, proximal gastric bypass, biliopancreatic diversion with duodenal switch, and biliopancreatic diversion. Although sufficient evidence-based data to suggest how to assign a particular patient to a particular bariatric procedure is slowly coming up, for patients with BMI of 50 kg/m2, gastric bypass or biliopancreatic diversion brings more benefits. Pure restrictive procedures are not recommended for patients with a significant hiatal hernia or severe gastro oesophageal reflux disease. Gastric banding cannot contribute to further substantial weight loss in patients in whom a significantly diminished food intake has been verified before the surgery. On the other hand, it should be considered that a laparoscopic adjustable gastric banding is the safest bariatric procedure associated with only minor peri-operative surgical risks.

Bariatric surgery has been proved as the most effective way of treating Type-2 Diabetes in severely obese patients. More than 10 years ago, it has been demonstrated that 83% of patients with diagnosed Type-2 Diabetes exhibited normal blood glucose and normal glycosylated hemoglobin levels 7.6 years after bariatric surgery. Further, 99% patients with impaired glucose tolerance normalized a glucose tolerance after bariatric surgery. The 10-year follow-up in the Swedish Obese Subjects (SOS) study demonstrated that a bariatric surgery is a viable option for the treatment of severe obesity, resulting in long-term weight loss, improvement in lifestyle, and except for hypercholesterolemia, amelioration of cardiometabolic risk factors.

After 10 years, in the SOS study the average weight loss from baseline was 25% after gastric

21

bypass, 16% after vertical banded gastroplasty, and 14% after gastric banding. The group that had undergone surgical intervention had lower incidence rates of diabetes, hypertriglyceridemia, and hyperuricemia in comparison to the control group. The most important recent finding of the Swedish Obese Subjects study is a reduction of overall mortality by 24.6% in the surgery group versus control subjects.

Pylorus

ExcisedStomach

Gastric“Sleeve”

Pylorus

The schematic representation of various bariatric surgical procedures is given below. All the surgical procedures are now being conducted laparoscopically, thus decreasing the operative morbidity. However, best results are obtained when the procedures are conducted in a center with a multi-specialty team involving bariatric surgeon, anesthetist, endocrinologist, psychiatrist, dietician, physiotherapist, intensivist, plastic surgeon and a good nursing team.

Gastric Banding

By passed portion of stomach

Esophagen

Proximal Pouch of Stomach

“Short” Intestinal Roux Limb

Duodenum

Roux-en-Y Gastric By-pass

Gasric sleeve Resection

22

KEEP COOL, EAT HEALTHY FOOD, SLEEP WELL, EXERCISE REGULARLYMAINTAIN GREEN ZONE

Dr. Lakshmi Saleem, MS MCH Plastic & Cosmetic Surgeon

Mobile: 9949056736Website: www.salaja.com email: lakshmi.saleem@gmail.com, salaja18@rediffmail.com

(A Public Education Service of Salaja)

BODY MASS INDEX (BMI) READY RECKONERHeight (Ft & Ins)

HOSPITALSALAJA HOSPITAL(Salaja Health Care Pvt. Ltd.) Prajasakthinagar, Vijayawada 520 010Ph: (0866) 2474774, 2476500

CLINICSALAJA COSMETIC SURGERY CENTRE

101, Sri Venkatarama Apts. Thakur Mansion Lane

Somajiguda, Hyderabad. Ph: 040-23403736

115114113112111110109108107106105104103102101100

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1.42

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1.44

54535353525251515050494948484747464646454544444343424241414040393938383837373636353534343333323231313030302929282827272626252524242323232222212120201919181817171616151515141413131212

1.46

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1.48

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1.50

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1.52

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1.54

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1.56

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1.58

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1.60

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1.62

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1.64

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1.66

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1.68

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1.70

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1.72

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1.74

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1.76

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1.78

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1.80

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1.82

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1.84

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1.86

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1.88

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1.90

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1.92

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1.94

18,217,1317,1117,917,717,517,21716,1216,1016,816,516,316,115,1315,1115,815,615,415,21514,1114,914,714,514,21413,1213,1013,813,513,313,112,1312,1112,912,612,412,21211,1111,911,711,511,31110,1210,1210,810,610,310,1 9,13 9,11 9,9 9,6 9,4 9,2 9 8,12 8,9 8,7 8,5 8,3 8 7,12 7,10 7,8 7,6 7,3 7,1 6,13 6,11 6,9 6,6 6,4 6,2 6 5,12 5,9 5,7 5,5 5,3 5,1 4,12 4,10 4,8 4,6 4,4 4,1 3,13

62626161605959585857575656555554545352525151505049494848474646454544444343424241414039393838373736363535343433323231313030292928282726262525242423232222212120191918181717161615151414

1.36

60605959585857575656555554545353525151505049494848474746464545444443434241414040393938383737363635353434333332323130302929282827272626252524242323222221202019191818171716161515141413

1.38

59585857575656555554545353525251515049494848474746464545444443434242414140403939383837373636353534343333323231313030292928282727262625242423232222212120201919181817171616151514141313

1.40

Ht (Mts)

UN

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T

HEA

LTH

Y

OV

ERW

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C

LIN

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LLY

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4'5" 6" 7" 8" 9" 10" 11" 5' 1" 2" 3" 4" 5" 6" 7" 8" 9" 10" 11" 6' 1" 2" 3" 4"

Wei

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t (K

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Weig

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Body_Mass_Index_F.indd 1 11/20/2006 12:41:51 PM

See where

you stand

as per BMI

and follow

the diet

KEEP COOL, EAT HEALTHY FOOD, SLEEP WELL, EXERCISE REGULARLYMAINTAIN GREEN ZONE

Dr. Lakshmi Saleem, MS MCH Plastic & Cosmetic Surgeon

Mobile: 9949056736Website: www.salaja.com email: lakshmi.saleem@gmail.com, salaja18@rediffmail.com

(A Public Education Service of Salaja)

BODY MASS INDEX (BMI) READY RECKONERHeight (Ft & Ins)

HOSPITALSALAJA HOSPITAL(Salaja Health Care Pvt. Ltd.) Prajasakthinagar, Vijayawada 520 010Ph: (0866) 2474774, 2476500

CLINICSALAJA COSMETIC SURGERY CENTRE

101, Sri Venkatarama Apts. Thakur Mansion Lane

Somajiguda, Hyderabad. Ph: 040-23403736

115114113112111110109108107106105104103102101100

999897969594939291908988878685848382818079787776757473727170696867666564636261605958575655545352515049484746454443424140393837363534333231302928272625

57575656555554545353525251515050494948484747464645454444434342424141404039393838373736363535343433333232313130302929282827272626252524242323222221212020191918181717161615151414131312

1.42

55555454545353525251515050494948484747464645454444434342424141414040393938383737363635353434333332323131303029292828272727262625252424232322222121202019191818171716161515141414131312

1.44

54535353525251515050494948484747464646454544444343424241414040393938383837373636353534343333323231313030302929282827272626252524242323232222212120201919181817171616151515141413131212

1.46

53525251515050494948484747474646454544444343424242414140403939383837373736363535343433333232323131303029292828272726262625252424232322222121212020191918181717161616151514141313121211

1.48

51515050494948484847474646454544444443434242414140404039393838373736363635353434333332323231313030292928282827272626252524242423232222212120202019191818171716161615151414131312121211

1.50

50494948484847474646454545444443434242424141404039393838373736363535353434333332323232313130302929292828272726262625252424232323222221212020191919181817171616161515141413131312121111

1.52

48484847474646464545444443434342424141404040393938383837373636353535343433333232323131303030292928282727272626252524242423232222222121202019191918181717161616151514141313131212111111

1.54

47474646464545444444434342424241414040393939383837373736363535353434333332323231313030302929282828272726262525252424232323222221212120201919181818171716161615151414141313121212111110

1.56

46464545444444434342424241414040403939383838373736363635353434343333323232313130303029292828282727262626252524242423232222222121202020191918181817171616161515141414131312121211111010

1.58

45454444434343424241414140403939393838383737363636353534343433333232323131303030292929282827272726262525252424232323222221212120202019191818181717161616151514141413131312121111111010

1.60

44434343424242414140404039393838383737373636353535343434333332323231313030302929292828272727262626252524242423232222222121212020191919181818171716161615151414141313131212111111101010

1.62

4342424241414140403939393838383737363636353535343433333332323231313030302929292828282727262626252525242423232322222221212020201919191818171717161616151515141413131312121211111010109

1.64

424141414040403939383838373737363636353534343433333332323231313030302929292828282727262626252525242424232322222221212120202019191918181717171616161515151414131313121212111111101099

1.66

414040403939393838383737363636353535343434333333323232313130303029292928282827272726262625252424242323232222222121212020191919181818171717161616151515141413131312121211111110101099

1.68

40393939383838373737363636353535343434333333323231313130303029292928282827272726262625252524242423232222222121212020201919191818181717171616161515151414131313121212111111101010999

1.70

3939383838373737363635353534343433333332323231313130303029292928282827272726262625252524242423232322222221212120202019191918181817171716161615151514141413131312121111111010109998

1.72

3838373737363636353535343434333333323232313131303030292929282828272727262626252525242424232323222222212121202020191919181818181717171616161515151414141313131212121111111010109998

1.74

373736363636353535343434333333323232313131303030292929282828272727262626262525252424242323232222222121212020201919191818181717171616161515151514141413131312121211111110101099988

1.76

36363635353534343433333333323232313131303030292929282828272727272626262525252424242323232222222121212120202019191918181817171716161615151515141414131313121212111111101010999988

1.78

35353535343434333333323232313131313030302929292828282727272726262625252524242423232323222222212121202020191919191818181717171616161515151514141413131312121211111110101010999888

1.80

3534343434333333323232313131303030302929292828282727272726262625252524242424232323222222212121212020201919191818181817171716161615151514141414131313121212111111111010109998888

1.82

343433333332323232313131303030302929292828282727272726262625252525242424232323222222222121212020201919191918181817171717161616151515141414141313131212121211111110101099998887

1.84

333333323232323131313030302929292928282827272727262626252525252424242323232322222221212121202020191919181818181717171616161615151514141414131313121212121111111010101099988887

1.86

33323232313131313030302929292928282827272727262626252525252424242323232322222222212121202020201919191818181817171716161616151515141414141313131212121211111110101010999888877

1.88

3232313131303030302929292928282827272727262626252525252424242423232322222222212121202020201919191918181817171717161616161515151414141413131312121212111111111010109999888777

1.90

313131303030302929292828282827272727262626252525252424242423232323222222212121212020202019191918181818171717171616161515151514141414131313121212121111111110101099998888777

1.92

313030302929292928282828272727272626262625252524242424232323232222222221212120202020191919191818181817171716161616151515151414141413131312121212111111111010101099998887777

1.94

18,217,1317,1117,917,717,517,21716,1216,1016,816,516,316,115,1315,1115,815,615,415,21514,1114,914,714,514,21413,1213,1013,813,513,313,112,1312,1112,912,612,412,21211,1111,911,711,511,31110,1210,1210,810,610,310,1 9,13 9,11 9,9 9,6 9,4 9,2 9 8,12 8,9 8,7 8,5 8,3 8 7,12 7,10 7,8 7,6 7,3 7,1 6,13 6,11 6,9 6,6 6,4 6,2 6 5,12 5,9 5,7 5,5 5,3 5,1 4,12 4,10 4,8 4,6 4,4 4,1 3,13

62626161605959585857575656555554545352525151505049494848474646454544444343424241414039393838373736363535343433323231313030292928282726262525242423232222212120191918181717161615151414

1.36

60605959585857575656555554545353525151505049494848474746464545444443434241414040393938383737363635353434333332323130302929282827272626252524242323222221202019191818171716161515141413

1.38

59585857575656555554545353525251515049494848474746464545444443434242414140403939383837373636353534343333323231313030292928282727262625242423232222212120201919181817171616151514141313

1.40

Ht (Mts)

UN

DER

WEI

GH

T

HEA

LTH

Y

OV

ERW

EIG

HT

C

LIN

ICA

LLY

OB

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M

OR

BID

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BES

E

4'5" 6" 7" 8" 9" 10" 11" 5' 1" 2" 3" 4" 5" 6" 7" 8" 9" 10" 11" 6' 1" 2" 3" 4"

Wei

gh

t (K

gs)

Weig

ht (S

t & L

bs)

Body_Mass_Index_F.indd 1 11/20/2006 12:41:51 PM

24

The following diet and health program was developed for the employees and the dependants

of General Motors Inc.

The program was developed in conjunction with the grant from the US Department of Agriculture and the Food and Drug Administration. It was first tried at the Johns Hopkins Research Centre and was approved for distribution by the Board of Directors of General Motors Corporation at a general meeting on August 15, 1995.

General Motors Corporation wholly endorsed this program and is making it available to all employees and families. This program will be available at all General Motors Food service facilities.

It is the management’s intention to facilitate a welfare and fitness program for everyone.

This program is designed for a target weight loss of 5-6 Kgs. per week. It will also improve your attitude and emotions because of its systematic cleansing effects. The effectiveness of this seven day plan is that the foods eaten burn more calories than they give to the body in caloric value. This plan can be used as often as you like to without any fear of complications. It is designed to flush your system of impurities and give you a feeling of well being. After seven days you will begin to feel lighter by atleast 10 pounds. You will have an abundance of energy and an improved disposition.

During the first seven days you must drink 10 glasses of water each day.

Day one

All fruits except bananas. Your first day will consists of all fruits you want. It is suggested you consume lots of watermelon and cantaloupe.

Day two

All vegetables. You are encouraged to eat until you are stuffed with all the new and cooked vegetables of your choice. There is no limit on the account or type. Avoid oil and coconut while cooking vegetables. Have large boiled potato for breakfast.

Day three

Any mixture of fruits and vegetables of your choice. Any amount, any quantity. No bananas yet and no potatoes today.

Day four

Bananas and milk. Today you will eat as many as eight bananas and drink three glasses of milk. You can also have I bowl of vegetables soup.

Day five

Today is a feast day. You will eat 1 cup of rice. You also have to eat six whole tomatoes and drink 12 glasses of water today to cleanse your system of the excess uric acid you will be producing.

Day six

Today is another all vegetables day. You must eat 1 cup of rice today and eat all the vegetables you want cooked and uncooked to your hearts content.

Day seven

Today your food intake will consist of 1 cup rice, fruit juice and the vegetables you care to consume. Tomorrow morning you will be five to eight kgs. Lighter than I week ago. If you desire further weight loss, repeat the program again. Repeat the program as often as you like, however, it is suggested that you rest for three days before every repetition.

General motors weight loss diet

25

You have your system under control now and it will thank you for all the purging and cleansing you just gave it. Even more than a diet program it is good to follow this diet once in a while to clean your digestive system and remove toxic substances that have a accumulated in the system.

Additional comments

The most important element of the program is the 10 tall glasses of water a day. You can also flavour the water will some lemon to make the drink easier. While on the program, take only black coffee and never more than one teaspoon of oil. Preferably do not use oil because the high calorific content. No fruit juices before day seven.

Here is what happens to you body while you are on this program and how and why it works.

Day 1: You are preparing your system for the upcoming program. Your only source of nutrition is fresh fruits. Fruits are nature’s perfect food. They provide everything you can possibly want to sustain life except total balance and variety.

Day 2: Starts with a fix complex carbohydrates in the form of a boiled potato. This is taken in the form of a boiled potato and taken in the morning to provide energy and balance. The rest of the day too consists of vegetables which are virtually calorie free and provide essential nutrients and fibre.

Day 3: Eliminates the potato because you get your carbohydrates from fruits. Your system is now prepared to start burning excess pounds. You will have cravings, which should start to diminish by day four.

Day 4: Bananas and milk. You are in for a surprise. You probably will not be able to eat all the bananas allowed. But they are there for the potassium you have lost and the sodium you may have missed the last three days. You will notice a definite loss of desire for sweets and you will be surprised at how easy this day will go.

Day 5: Rice and tomatoes. The rice is for the carbohydrates and the tomatoes are for the digestion and the fibre. Lots of water purifies your system.

You should notice colourless urine today. Do not feel you have to eat one cup rice, you may eat less. But you may eat six tomatoes.

Day 6: It is similar to five. Vitamins and fibre from the vegetables and carbohydrates from the rice. By now your system is in a total weight loss inclination. There should be a noticeable difference in the way you look today compared to day one.

Day 7: You may celebrate with champagne. You may also have white wine instead of champagne, but in all practical programs, and in all surveys done to measure the success of the program, General Motors employees have always preferred champagne to white wine.

More than one cup of coffee with milk is especially forbidden. Milk and oil add empty calories to your diet. Avid coffee lovers can console themselves with black coffee. However, after the first week, it will help your digestion and set your stomach. The key thing to remember is that if you are hungry at any time, then you are not following the diet correctly. Almost all people give up the diet when they are hungry because of dieting. The secret of this program is that you should never be hungry. If it is a vegetable day, eat so much vegetables so that you are never hungry. If it is a fruits day, eat so much fruits that you are never hungry. You may be bored of eating vegetables all day, but you should not be hungry. You can take any amount of General Motors wonder soup on any day.

General motors wonder soup

The following soup is intended as a supplement to your diet. It can be taken any time of the day in virtually unlimited quantities. You are encouraged to drink large quantities of this soup.

23 oz water

06 large onions

02 green peppers

03 whole tomatoes

1 cabbage

1 bunch celery – add herbs and seasoning as desired.

26

This program is highly recommended for women and men above 40 for whom excess weight is especially dangerous. Excess weight for women aggravates arthritis problems and leads to rapid joint decay. Pain and joint deterioration can be lessened by weight loss as weight loss removes the stress on the knee joint. Excess weight is the most critical factor in keeping good health and excess weight is responsible for the most problems including coronary diseases, heart problems, arthritis and cancer among other serious life threatening diseases. Most serious health problems can be avoided by the single function of maintaining an ideal weight. Daily mild

exercise of 20 minutes is also essential. Do not tire yourself out, but being regular in your exercise and maintaining an ideal weight goes a long way in ensuring a happy, healthy and long life.

This article is published on this website assuming that all the material herein are in the public domain, as the intention of this article is a noble one – to make humans healthy. It’s published here with noble intentions. If you find that this article is copyrighted and is not supposed to be published without permission, please let me know by dropping an email to me at jaju@it.iitb.ac.in (spammers, please ignore.)

27

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taking you to a NEW LEVEL OF TOTAL WELL BEING. It guides you to take care of

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to shape after delivery.

Our Services

– Counseling

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– Yoga Therapy /Meditation

– Kerala Auyurvedic

Salaja HospitalPrajasakthi Nagar, Vijayawada 500 010

Phones: 0866-2474774 / 2476500 / 040-23403736www.salaja.com www.bodycontouring.in

28

6-3-871/A, Green Lands Road, Begumpet, Hyderabad - 500 016.

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With best compliments

3

Let us all FIGHT TOGETHER

to Nip the

OBESITY “instead” of

Banding Carving

Sucking &Body sculpturing

Lasa helps you to alter the

Life Style for betterment

www.lasa.in

www.bodycontouring.in