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| EDITORIAL |
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| Year : 2017 | Volume
: 3
| Issue : 2 | Page : 73-74 |
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Cosmetic limb lengthening surgery: The elephant in the Room. Harm minimization not prohibition
Minoo Patel
Department of Surgery, Monash University; Epworth Healthcare, Department of Surgery, Monash University, Hon. Research Fellow, University of Melbourne, Melbourne, Australia
| Date of Web Publication | 22-Aug-2017 |
Correspondence Address:
Minoo Patel
Centre for Limb Reconstruction, Suite 5-7, The Epwoth Centre, 32 Erin Street, Richmond, VIC 3121
Australia
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jllr.jllr_22_17
How to cite this article:
Patel M. Cosmetic limb lengthening surgery: The elephant in the Room. Harm minimization not prohibition. J Limb Lengthen Reconstr 2017;3:73-4 |
This edition of the Journal features an article titled Cosmetic Lower Limb Lengthening by Novikov et al.
Cosmetic limb reconstruction surgery, mainly cosmetic or so-called stature lengthening is a contentious field of orthopedics.[1],[2],[3],[4] Like the odd relative that we either wish away or talk about only in hushed tones, stature lengthening is the true elephant in the room.
While some consider it unnecessary and dangerous, there is a considerable and growing demand for it around the world. Proponents of cosmetic limb lengthening counter that they are offering a service for which there is a considerable demand. The internet has many cosmetic limb lengthening groups, run by patients (or clients). The argument put forward by patients who want this surgery and surgeons who perform it, is that if patients can have breast augmentation or even gender reassignment, why not limb lengthening?
For many of us, cosmetic limb lengthening is a misuse of limb lengthening surgery.[1] We are, rightly, worried about the potential complications of limb reconstruction surgery.[5],[6],[7],[8] While there may be tones of self-righteousness underpinning this position, many of us are seeing an unacceptable increase in severe limb-threatening complications,[5] especially among medical tourists, returning to their home countries and cities. The burden of managing these complications then falls on the health systems of these countries.
International medical tourism has meant that in many places it is a booming but unregulated industry. Like with many new technologies, ethics and regulation have not kept pace with speed of change. The arrival of motorized distraction intramedullary nails has made cosmetic lengthening “easier” and thus more “acceptable” to patients. Yet there has been little to no debate about the ethics of cosmetic limb lengthening.
There are many centres around the world that openly advertise and target vulnerable patients. Many centres are poorly regulated. Patients have unacceptably high rates of complications which are often left unresolved. This problem has been growing in recent years.
At the 2nd combined ASAMI-BR and ILLRS meeting in Brisbane last year we finally managed to have an open discussion of this contentious issue.[9],[10] While no formal consensus was reached there was broad agreement on the guidelines that need to be set for cosmetic limb lengthening.[11]
The genie is already out of the bottle, and there is no putting it back. Prohibition, does not, and will not work. What we need is an enlightened policy for harm minimization.[11]
While accepting that an organization such as ours, with a membership spread across many different countries, has little or no authority over individual surgeons, we can still promulgate guidelines and standards, which can empower the constituent national bodies within ASAMI and ILLRS to lobby their governments and medical regulators to enforce these guidelines.[11]
These are the proposed guidelines for ethical cosmetic limb lengthening surgery:
- Surgery must only be performed by experienced fellowship trained limb reconstruction surgeons.
- Surgery must only be performed in major hospitals with backup facilities.
- While initial consultations may be through remote means such as the internet, there must be at least one in-person consultation before surgery. There must be a detailed informed consent procedure.
- There must be a psychological assessment of the patient, and ongoing pastoral care of the patient.
- There must be a minimum cooling off period to allow the patient to call off the surgery, without any financial or other penalty.
- There must be clear avenues for complaint for the patient, including the right to redress in case of unacceptable outcomes and complications.
- The surgeon must have a commitment to manage the patients till the completion of their treatment, including rehabilitation and management of their complications.
- There must be no financial exploitation of patients. This includes a prohibition on nonrefundable deposits, and a commitment to manage complications for little or no extra cost, irrespective of the patient's ability to pay.
- National bodies have a duty to report or reprimand underperforming or exploitative colleagues, and those that indulge in unethical practice.
This is the beginning of the discussion that we must continue to have if we are to be true to our Hippocratic Oath: Primum non nocere; first do no harm.
| References | |  |
| 1. | Leopold SS, Sabharwal S. Editorial: Indications – On the fringes and in the mainstream. Clin Orthop Relat Res 2014;472:3247-9.  |
| 2. | Cattaneo R, Villa A, Catagni M, Tentori L. Limb lengthening in achondroplasia by ilizarov's method. Int Orthop 1988;12:173-9. |
| 3. | Aldegheri R, Dall'Oca C. Limb lengthening in short stature patients. J Pediatr Orthop B 2001;10:238-47. |
| 4. | Catagni MA, Lovisetti L, Guerreschi F, Combi A, Ottaviani G. Cosmetic bilateral leg lengthening: Experience of 54 cases. J Bone Joint Surg Br 2005;87:1402-5. |
| 5. | Watts J. China's cosmetic surgery craze. Leg-lengthening operations to fight height predjudice can leave patients crippled. Lancet 2004;363:958. |
| 6. | Novikov KI, Subramanyam KN, Muradisinov SO, Novikova OS, Kolesnikova ES. Cosmetic lower limb lengthening by ilizarov apparatus: What are the risks? Clin Orthop Relat Res 2014;472:3549-56. |
| 7. | Emara KM, Diab RA, El Ghazali S, Farouk A, El Kersh MA. Foot and ankle function after tibial overlengthening. J Foot Ankle Surg 2014;53:12-5. |
| 8. | Yun AG, Severino R, Reinker K. Attempted limb lengthenings beyond twenty percent of the initial bone length: Results and complications. J Pediatr Orthop 2000;20:151-9. |
| 9. | Patel MK. Complication of Cosmetic Limb Reconstruction Surgery. An Australian Perspective. 2 nd Combined ASAMI-BR & ILLRS Congress. Brisbane; 22-24 September, 2016. |
| 10. | Patel MK, Paley D, Lee DH, Baumgart R, Dahl M, Tetsworth K. Moderator Lengthening for Stature. Symposium, 2 nd Combined ASAMI-BR & ILLRS Congress. Brisbane; 22-24 September, 2016. |
| 11. | Patel MK. Lengthening for Stature. Consensus Statement. 2 nd Combined ASAMI-BR and ILLRS Congress. Brisbane; 22-24 September, 2016. |
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