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| EXPERT OPINION |
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| Year : 2017 | Volume
: 3
| Issue : 2 | Page : 75-77 |
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The cosmetic dream and future of lengthening procedures
Jean-Marc Guichet
Department of Orthopaedics, Princess Grace Hospital, 30 Devonshire Street, W1G 6PX London, UK and Columbus Clinic Centre, Via Michelangelo Buonarroti, 48, 20145 Milan, Italy
| Date of Web Publication | 22-Aug-2017 |
Correspondence Address:
Jean-Marc Guichet
30 Devonshire Street, W1G 6PX London, UK
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jllr.jllr_23_17
How to cite this article:
Guichet JM. The cosmetic dream and future of lengthening procedures. J Limb Lengthen Reconstr 2017;3:75-7 |
Growing represents about 20% of our physical and psychological life. However, some patients after adolescence do not feel that they have fully grown. In young people with stature shorter than average, or those who are slightly higher than normal, some feeling about missing some further growth might remain in the mind.
The underlying problem is getting maturity and trying to overcome a “below the standard” human condition, which involves not only the body envelope but also the psychological side. This human quest is as old as time. Crossing the Atlantic, getting on the top of the Himalayas, or to the moon, is a dream. It is also a strong pulsing to justify our own condition of human being, soon about to die. It also aims to resolve the depreciation felt by the aggressiveness of others, trying to go up beyond limits of other human being, like Columbus.
Challenges are always sought for psychological aims, but often involve a strong physical suffering. These days, people are more self-centered. Logically, the discomfort felt by some people has a new outlet: “Why not doing something for myself?”
Feeling short is not only physical. There is a need to mature as an adult, as high as possible, through a physical challenge. This maturation is the one of adults, having a family, raising children, experiencing difficulties and pain, and acquiring wisdom, which stabilizes them inside and also with others.
The adult dream of a lengthening is the same as the one of a child who wants to grow physically, but also mentally.
Now, let us consider the dream of a patient – any patient – for the heavy surgery of cosmetic lengthening. He wants the surgery, but to awake with no pain, stand up in operating room, and leave it walking on his feet to be discharged from the hospital on the same day. She cannot understand why she should not regain full function, do sports, and resume work. Surgery should be easy.
Many of us feel that this may happen in the distant future. No, it is happening now and we did it.
Let us go back to the first steps of surgical lengthening. Since Ombrédanne[1] (using the three-dimensional [3D] frame of Quenu-Lambret) performed the first gradual lengthening in 1913 (gain of 3 cm with daily steps of 5 mm increments), techniques have improved. Ilizarov[2] was the first one to show that in one surgical lengthening procedure, it was possible to obtain very large gains with primary healing (distraction osteogenesis), without the need for bone grafting, and over a fixator controlling the alignment in 3D (1952). Judet[3] was the first one in 1975 to use an intramedullary rod transfixing the skin. Bliskunov et al, 1983[4] did with one embedded in the body. The first one to spread in 16 countries was the Albizzia, designed in 1986.[6] All these implants were mechanical. New technologies are introduced, including magnetic and electronic ones, for example, the PRECICE nail.[5] All are nonweightbearing except the successor of the Albizzia nail. Compared to external fixators, implants dramatically reduce risks for patients and will be the exclusive choice in the future.
Do we miss something? Yes of course, we focus on devices and we forget the patient and his/her dream. Staying in wheelchair for months is like getting a cast for months with a severe and long-lasting muscle wasting. Would we like to stay in wheelchair? No. So, why do it for our patients? We would prefer to resume walking and sports like stepper or bike right away. Let us just do it for our patients.
We understand that designing a device for the future – or even the present – requires setting the primary goal: an implant should be fully weightbearing and should allow sports and normal life. Whether the implant is mechanical or electronic is secondary. Function comes first. With such a device, the patient can return to full activities and thus enjoy his/her life getting closer to his/her dream.
The dream is forget the past quickly and start a new life without complications. For that, we, as surgeons, need to secure further technical parts: the “hidden world.” True success of lengthening is multifaceted and so we need to study all aspects of lengthening. We are surgeons, but we should also take care of patients and their life.
The chief aim is to enable a rapid recovery, quickly heal the bone and lessen the risk of fractures, avoid bone grafting, etc. These are statistically eliminated when the bone heals. Fusion is the landmark of elimination of complications.
The dream of fast fusion is simple. As surgeons, we should be able to control the healing speed. Generally surgeons, when they see X-rays in front of patients, may say: “you are healing fast… or you are healing slowly… we see little bone formation….” Usual healing time for lengthening nails is roughly 35 days/cm (45 days/cm for external fixators). However, why not decide the speed of healing we want and do what is right for it? Ideally, the bone should be fused on the last day of lengthening. Can we fuse the bone in 8 days/cm? Yes. We did it. We introduced several improvements to fasten healing (bone progenitor cells grafting at initial surgery, bone healing boosting substances, food intake control, etc.); physical activity can increase muscle flow by ten times, thus the bone blood flow and healing capacity. We can speed up the healing time by two to four times, resulting in fusion within a few days after the end of lengthening. Let us optimize the biology of bone healing. It is our duty for the dream.
We need to thoroughly evaluate patients initially by Isokinetic Cybex type testing. We provide a calibrated training program to secure fast muscle recovery and increase local vascular supply to the bone. We repeat tests after the program, just before surgery. Patients dream of quickly returning to normal activities. Let us make it come true by creating a specific training program for them!
Limb lengthening is like transformation of a worm to a butterfly, through the chrysalis process: it is demanding and painful. We do not want it to last too long. Thus, could we accelerate it for quick gains? Yes, we did it. In life, results are faster when we prepare well. Preparation for surgery is like preparing for climbing on the top of the Himalayas for an Olympic competition. It is necessary as it allows muscle cell division and thus far faster and smoother adaptation to the lengthening process. As a result, we can get faster gains. We learned that gains may obey a constant linear speed (1 mm/day), but reality is different. Currently, our lengthening nail gains 44–45 mm in the 1st month in Caucasians, preserving flexibility and healing. Exercises enable this speed of lengthening, which is necessary, as slower speeds on an “optimized” patient would result in premature consolidation. Provided the training is good, speeding up distraction does not bring further risks. In fact, we need to adjust speed and rehabilitation by observing all ingredients around the lengthening implant (muscles, bone formation, nerves, and vessels).
Patients do not like complications. For lengthening nails, the major one is fracture. Any single fracture in cosmetic lengthening may result in a complaint from the patient. The introduction in our armament of lengthening nails highlighted the risk of fractures of the implant (nonweightbearing or weightbearing nails with a long-standing nonhealing) or of the bone.
For suppressing fractures of the implant, material and design choices are essential. For suppressing bone fractures, material design (screws and their position in the nail) and evaluation of the bone strength are essential. Dual-energy X-ray absorptiometry evaluates cortical strength noninvasively. Surprisingly, some young adult patients seeking a cosmetic lengthening have the density of a 70–100-year-old population (−2 to − 3 DS). Lengthening tensions the femoral “arch” and thus increases bending loads on the bone. Long clinical-lever arms and strong weights may induce fractures before bone fusion when the load is too high or when the bone is too weak. Security from our perspective consists of providing the recommendations adjusted to their bone evaluation, and making the bone heal faster to suppress the risks of fracture.
Nobody wants pain. In electronic implants, pain is easier to control than in mechanical implants. However, some patients do not present strong pain with mechanical implants. The key is to control the patient's mind and its maturation before and during the lengthening process.
Patients often take medicine (pain killers, morphine, etc.) for securing themselves, thinking it will cover for pain. Many studies show that placebo works like medicine. Since with “nothing,” pain is decreased, thus medicine acts as a placebo, with known side effects. When someone is well conditioned and explained about the postoperative phase, and is psychologically stable, the pain is much lesser.
Our patients write all medicines they are taking (each single pill) on an Internet spreadsheet. Under “positive” influence or stimulation from us, some patients do not take painkillers or stop taking them quickly. Innate or induced psychological stability may be the most important cause in the success of lengthening and reduced pain. We need to use the placebo effect on patients, for example, putting patches of light morphine and telling the patient it works for the whole week: the power of suggestion is tremendous. I call it the “psychological induction.” For succeeding, you need to do like for young children when new negative sensations occur in their body (scar, pain, etc.): “explain, reinsure, cocoon.” In a lengthening procedure, cosmetic patients discover again their body from scratch, and interaction with the surgeon and his team is essential. Pain is the chrysalis process inside the mind.
The final benefit, the most important one, is the psychological implication of cosmetic lengthening. It actually transforms the patient. A patient told me after almost 7 cm of gain: “The real growth is not at the thigh, but it is there (pointing out his brain)!” Effectively, patients negatively feel some discriminative aggressions on them linked to their height. They also know that they cannot easily attract sex partners when they are in the crowd, shorter than others; they feel like “zapped.” They are missing some maturity and want to raise themselves to normal human potential. Or they want to push themselves beyond the ordinary limits of humanity and of social relationships. Perhaps like well-known explorers through their quest, to manage their life better and feel quieter in the human stream. Some people practice this maturation through other ways (mindfulness, etc.), but the physical challenge of a lengthening is also a good way to do it, as it involves the mind and body.
A cosmetic lengthening is an access to a higher human understanding and is the continuing dream of youth, searching maturation, physically and in the mind. Securing the dream of growth is important and needs studying all aspects around the procedure itself.
Success always results from hard work. This is what, in our “niche” field of lengthening, as members of our family of surgeons, we do to change the world.
What is the future of implants and techniques? An implant fully electronic with automatic increments of 1/10 (or less) of a bone cell length, not rupturing the regenerate but stimulating it gradually, allowing it to form already mature bone. Other features: full autonomy with no need for outside power, regulated with feedback measurements of resistance from the soft tissues and from the bone formation. We should modify the lengthening program remotely (Wi-Fi or satellite) from the other side of the world. Is it a utopia? No, a prototype exists.
However, any implant has no value if the implant has no strength. To be fully efficient, the implant should be strong and have full weightbearing to return right away to full sports capacity, not only gentle sports, but also competition sports. Can we do it? Yes, we are on the way!
Let us make the dream real. Let us enjoy this birth all together in our family of limb lengthening specialists and… dreamers!
| References | |  |
| 1. | Ombrédanne L. Allongement d'un femur sur un member trop court. Bull Mem Soc Chir 1913;38:1177-80.  |
| 2. | Ilizarov GA. The tension-stress effect on the genesis and growth of tissues. Part I. The influence of stability of fixation and soft-tissue preservation. Clin Orthop Relat Res 1989;238:49-81. |
| 3. | Judet R, Les allongements des membres par le distracteur. Premiers résultats (Limb Lengthening with the Distractor. First results). Act Chir. Orthop de l'Hôpital R. Poincaré (Masson PARIS), 1975;12:93-122. |
| 4. | Bliskunov AI. Intramedullary distraction of the femur. Preliminary report. Orthop Traumatol Protez 1983;10:59-62, 1983. |
| 5. | Paley D, Harris M, Debiparshad K, Prince D. Limb lengthening by implantable limb lengthening devices. Tech Orthop 2014;29:72-85. |
| 6. | Guichet JM. Gradual Lengthening Nail. Theoretical Basis-Experimental Study. Dissertation of Medicine, Faculté de Médecine, Dijon, France; 1988. |
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