dr lakshmi saleem 7thpsaap conference - cosmetic surgery clinic hyderabad

8/14/2019 Dr Lakshmi Saleem 7thPSAAP Conference - Cosmetic Surgery Clinic Hyderabad

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Salaja HoSpitalPrajasakthi Nagar, Vijayawada 500 010Phones: 0866-2474774 / 2476500 / 040-23403736

7th

PSAAPCONFERENCE

www.salaja.comwww.bodycontouring.in

LearnanySurgeryaLonewith

CreativityboLdneSSandkindneSS

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LASAwith

CBK


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Ekalavya is a character in the amous epic o India,Mahabharata. He is ocused and dedicated pupil o his guruDrona. He is taken as an example or hard work, perseverance

and sacrice. Though his guru denies to teach him the art o

archery, Ekalavya excels in it with concentrated and dedicated

practice o archery in ront o the statue o his guru. But when

his guru comes to know o his skills, he demands Ekalavyas

thumb as gurudakshina (ee) so that ekalavya cannot surpass

Arjuna, the avoured pupil o Drona. Hence Ekalavya is oten

quoted as an epitome o virtuous, unselsh and dedicated

pupil. Every one o us may not have the opportunity to learn

rom great gurus in our Plastic and Cosmetic surgery. Some o

us have the ortune o working with such gurus, some may have

access to literature written by them ew may have access to theprocedures in the orm o videos and I am sure some may only

hear directly or indirectly about certain procedures. I chose the

logo which says Sel learning or perection only to encourage

ourselves towards dedicated learning and pursuit o perection

like Ekalavya.

It may be easy to record the procedures and techniques

surgeries done, but it is dicult to quantiy the eorts or

the achievements. Following the oot steps o late Pro. C.

Balakrishnan I would like to pass on what I had learnt rom

him and the messages given by him or plastic surgeons beore

they are washed o by the tide o time. The most precious

lesson one can learn rom a senior colleague o his stature in

plastic and cosmetic surgery is the way to nd a solution to a

particular problem or a cosmetic need taking into consideration

the social, cultural and nancial background o the patient. One

should be able to visualize the three dimensional view o tissues

to be altered and rearranged with an ability to analyse the

Dr. Lakshmi SaleemMS, 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 o Pro. C. Balakrishnan, over the

years I have made protocols or each procedure based on the

requirements o most o our patients keeping the ethnic,

racial, nancial, and social backgrounds o 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 or mammoplasty which may not be

entirely or beautication as is the case in the western

countries. I have ollowed a simple algorithmic approach to

visualize the ultimate result and outcome o 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 yearsDr. Lakshmi Saleem MS, MCh.

Dr. M A Saleem, MS, FICSSalaja Hospital, Vijayawada

Rhinoplasty was perormed as the commonestCosmetic surgical procedure in 492 patients inour exclusive plastic surgery set-up over a 25-year

period. This is a study o Rhinoplasty perormed in

the South Indian population whose characteristics

are a combination o Caucasian and Arican noses.Simple and Standard techniques perormed are

described or the correction depending on the

appearances in Frontal, Basal and Lateral views.

Augmentation o the nasal bridge to increase the

height is perormed using bone grat rom ileac

crest. Excising the at and thick areolar tissues

narrows the bulbous nasal tip. Approximating the

lateral crura o alar cartilages by non-absorbable

suture helps in producing grooves on the fat

looking alar rim and also helps in narrowing thetip thus giving a better appearance. Nasal width

in the basal view is corrected by a wedge excision

o the alar rims at the lateral ends. Lengthening

o the columella was perormed either by adding

a L-shaped bone grat along with augmentation

o the bridge and also a V-Y plasty. Long term

ollow up results o bone grat are gratiying with

minimal resorbption, i any. The aim has always

been to do the entire correction in single stage.

Complication rate was negligible-less than 1% lacko satisaction 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 or specic problems o South Indian noses.

South Indians have a combination o Caucasian and

Arican 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-dened nasal tip without alar

grooves and projection

Thick skin in some individuals along with gross

accumulation o areolar and atty tissue and

attenuated alar cartilages account or the blunt and

bulbous tip. Flaring o the alae nasi and fattened

alar cartilages account or the increased width o

the nares. These problems are discussed with the

patient in detail with the aid o three basic views o

photographs Frontal, Basal and Lateral. Possible

corrections are suggested beore embarking on the

procedure or the ullest satisaction o the patient.

Simpler techniques are chosen to ulll the criteria.

Most o the patients preerred to have the entire

correction perormed in a single stage.

Material & Method

Salaja Hospital, Vijayawada is an exclusive Plastic

Surgery set-up in the region o South India where

cosmetic surgery is perormed along with otherplastic surgery procedures and burns management.

This unit is accessible to an approximate population

o over 60millions. Nearly almost all our patients are

South Indians.

The nasal index popularized by Topinard in 1890 or

anthropological determinations o the race, is the

ratio o the nasal width to the length multiplied

by 100. These measurements dene the rontal view

o the nose as triangle and the dimensions vary

according to the racial background. The spectrum


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o 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

o the ala to the cheek lies within longitudinal

lines drawn through the inner canthi. Nasal eatures

can be improved by bringing the elements o the

nose to lie within a triangle having a base closer

to the inner canthal lines. This is seen well in the

rontal view.

The inerior triangle is ormed by the tip and the

lateral attachments o the alae nasi to the cheekin the Basal view. It is most aesthetically pleasing

when this triangle is narrow based, slightly taller

than wide.

Flare can be dened as that portion o the ala,

extending lateral to the alar attachment to the

cheek. The inerior triangle can be altered by

increasing the height o the tip or by lessening the

fare o the alae.

Augmentation o the dorsum or raising the tipalters the nasal axis to best suit the patient 492

Rhinoplasties perormed between 1984 and 2007

are considered in this review.

Operative procedures

Three views o the nose are considered whenever a

Rhinoplasty is planned Frontal view, Basal view

and Lateral view.

Frontal view: The appearance o nose in the rontal

view is considered to be pleasing i the triangle

is narrow based, slightly taller than wide, with

minimal alar fare. 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 o ones ace in length or the length o ones

own thumb and limits itsel in width up to both the

medial canthal lines.

Depending on these actors, the surgical plan can besummarized as ollows. One can narrow the triangle

by dorsal augmentation with a bone grat (Ileac

crest). Very rarely nasal bone inracturing is done

to the same eect. Base can be altered by nasal

base reduction and inter alar reduction.

Basal view: Tip projection and denition can

be improved by suturing the lateral crura o alar

cartilages by non-absorbable mattress sutures with

4-0 proline. Alar base reduction also changes theinerior triangle.

While planning the procedures the wide dierence

in individual anatomy, relation o the nose & ace

and variation in patients complaints and desires

are to be considered to get a complete patient and

surgeon satisaction.

Patients 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 o operative techniques: Operative techniques

are decided depending on the appearances in the

rontal, basal and lateral views.

Operative techique

I only augmentation is planned, a right alar

incision is given on the mucosal aspect commencing

medially near the columella and extending laterally

or a ew mms on the undersurace o lateral crus

o alar cartilage. I associated procedures are to

be perormed or the tip, bilateral alar incisions

are given. Or a V incision is given at the base

o columella extending to both sides and the

columella is lited like an elephant trunk like in

open rhinoplasty. In either case, a plane is created

and the periosteum o the nasal bone is stripped

o making the recipient bed ready.

Bone grat o about 2 inches long is obtained rom

the ileac crest. The grat is carved to the required

size and shape with the help o a bone nibbler and

a scalpel. Complimentary shaping o both recipient

site and inner surace o grat achieve stabilization.The bone grat thus carved is rmly placed in the

subperiosteal plane on the dorsum o the nose.

No rigid xation 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 o layers o

plaster o Paris or a ready-made nasal splint that

is retained or ve days. Drain rom the bone

grat donor site is removed ater 24 hours and the

patient discharged.

In those patients who have an increased alar fare

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

o lateral end o lateral crus o alar cartilage rom

outside in. A tunnel is created with the curvedartery orceps connecting the two medial ends o

the alar incisions, passing through the membranous

septhum. The needle is transerred rom right

nostril to the let through the tunnel and a similar

bite is taken o caudal edge o the lateral crus on

the let side (rst rom inside out and next rom

outside in), to get a good hold on tip o 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 rst one so that the knot comes on the outer

side. The suture is tightened as or the required

projection o the tip, recreating an alar groove. It

is to be remembered while tightening that oten

there is only a ne line between a tip that remains

too bulbous and one that is pinched.

Results

A series o 492 rhinoplasties PERFORMED OVER25 YEARS has been reviewed. Patients were

predominantly emale and requently in the age

group o 16 and 30 years. Average ollow-up varied

rom a ew months to 10 years.

O this series, only 291 patients had bone grat rom

ileac crest. 155 patients had sot tissue correction

alone, with cartilage grat when needed.

Complications

Out o the 291 patients o bone grat, 2 patients

opted or the removal o the grat as they did not

like it.

4 patients required nasal splint or more than two

weeks to maintain the desired position o the

grat.

Conclusion

Rhinoplasty procedure perormed in 492 patientsin a period o 25 years is reviewed. This study


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included Rhinoplasty perormed in the South Indian

population whose characters are a combination o

Caucasian and Arican noses. Standard but simplertechniques are chosen. A clinical approach o the

patients complaints and the appearances in Frontal,

Basal and Lateral views guided the technique to

be ollowed. Augmentation o the nasal bridge to

increase the anterior height is perormed using

bone grat rom ileac crest. Excision o the at 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 onthe 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 o

the alar rims at the lateral ends. Lengthening othe columella was perormed by adding a L-shaped

bone grat along with augmentation o the bridge

whenever required and also a V-Y plasty. Long term

ollow up results o bone grat are gratiying with

minimal resorbption, i any. The aim has always

been to do the entire correction in single stage to

acilitate the patients compliance and satisaction.

Complication rate was negligible-less than 1% lack

o satisaction among the Augmentation group

and less than 0.5% among all the rhinoplastyprocedures perormed.

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


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Anaesthesia

Local anaesthesia is preerable to general

anaesthesia i the patient will tolerate it since the

voluntary movement o the levator muscle aids in

the identication o lid structures and a better

operative assessment o lid level is possible.

Method

Mark the skin crease.1.

Evert the lid and inject 1 or 2 cc o local2.

anaesthetic immediately under the conjunctiva

just above the upper border o the tarsal plate.

Give a subcutaneous injection in the region o3.

the skin crease.

Note

a. Adrenalin in the local anaesthetic helps to reduce

bleeding but stimulates Mulllers muscle.

b. A rontal nerve block is not usually necessary

and runs a risk o aecting the unction o 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 unction. The result required depends

on the circumstances, i.e. the diagnosis, Bells

phenomenon etc. The optimum result in a patientwith simple congenital ptosis is or the eyelid levels

to be the same in the primary position o 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 o the

ollowing amount o aponeurosis and levator muscle

should lit the eyelid to an acceptable level:

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



These measurements are approximate. They include

both aponeurosis and levator muscle and are taken

rom just below the upper border o the tarsal

plate. The extent o the resection is modied by the

degree o ptosis, thus 2 mm o ptosis will warrant

>10mm

Degree of ptosis

Aponeurosis Surgery

>2mm

Fasanella Servat


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a lesser resection than 4 mm o ptosis i the levator

unction is the same. I the superior rectus muscle

is weak the resection should be increased by about4 mm. The adequacy o the resection can be conrmed

at operation. Under general anaesthesia the eyelid

should stay at approximately the level which is

achieved at operation i the levator unction is about

7 mm. I the levator unction is better than this the

lid will tend to rise post-operativcly and to all i the

levator unction is worse. Under local anaesthesia the

lid should be set 1-2 mm higher to compensate or

the paralysis o the orbicularis muscle.

Anterior approach levator resection (g.1)

Principle

The levator muscle is approached through a skin

incision. The septum is divided and when the

pre-aponeurotic at is retracted the whole levator

complex can be examined directly or any deects.

The muscle is shortened and sutured directly to the

tarsus. Any excess skin can be excised and the skin

crease reormed with interrupted sutures which pick

up the underlying levator muscle.

Indications

A ptosis with 4 mm or more o levator unction;

skin excision; lid exploration; maximum levator

resection; preservation o tarsus and conjunctiva;

lash ptosis; entropion; skin crease deect.

Method

1. Mark the skin to match the crease on the

uninvolved side and make an incision throughthe skin with a blade (Fig.1 a).

2. Pick up the skin on either side o the incision in the

centre o the lid with two pairs o toothed orceps

and make a cut through the orbicularis muscle with

a pair o scissor aimed towards the tarsal plate.

3. Undermine the orbicularis medially and laterally

and cut it with scissors along the line o the skin

incision.

4. Clean the anterior tarsal surace sucientlyto suture the aponeurosis or levator muscle to

it. Stop 2 mm rom the lid margin to prevent

damage to the lash roots (Fig.1 b).

5. Dissect the pre-septal orbicularis muscle rom

the lower part o the orbital septum. The septum

can be identied by:

a. its attachment to the orbital rim which can be

elt as a rm band when traction is exerted on it.

b. orbital at can sometimes be seen behind it.

c. pressure over the lower lid may help to make the

orbital at more obvious.

6. Open the orbital septum to expose the pre-

aponeurotic at pad beneath which is theaponeurosis (Fig.1 c). This can be seen to move

when the patient looks up, i the operation is

under local anaesthesia.

7. Dissect the aponeurosis rom the tarsus (Fig.1 d) and

Mullers muscle rom the conjunctiva (Fig.1 e).

8. Cut the medial and lateral attachments (horns)

o 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 ).

9. Try to preserve Whitnalls 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 unction as an alternative to a brow

suspension. This does create a relatively static

lid with a marked degree o asymmetry on down

gaze in unilateral cases.

10.Pass a double-armed 6 O polyglycolic acid/vicryl suture into the anterior tarsal surace at

the intended apex o the lid curve.

Measure the aponeurosis and levator to be resected

and pass each needle o the suture through the

centre o the levator muscle just above the site o

the planned resection. Tie the suture with a slip

knot and cut the muscle (Fig.1 h).

11.Check the height and curve o the lid and adjust

the suture i necessary. Cut the suture and use

each arm to suture the muscle to the tarsus oneither side o the central rst suture (Fig.1 i).


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12.Thin the lower skin fap by excising a strip o

orbicularis muscle.

13.Excise any excess skin rom the upper skin fap.

14.Close the skin and reorm the crease with 6 O

absorbable sutures which pass ront the edge

o the lower skin fap, into the levator muscle,

and out through the edge o the upper skin fap

(Fig.1 j).

Note: Absorbable sutures are preerable since

skin crease sutures may be dicult to remove

completely and the scar is buried in the

crease.

15.Use a Frost suture.

Aponeurosis surgery

Aponeurosis surgery is indicated or patients with an

aponeurotic deect and good levator unction (i.e.

better than 10 mm). The approach is very similar to

that or a levator resection but the surgery is not so

extensive, the horns o the levator complex arc not

cut, and a Frost suture is rarely necessary to protect

the cornea. Local anaesthesia should be used i 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 o the orbicularis muscle unction

and oedema, but since the levator unction is goodthe lid will subsequently rise.


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The pathophysiology o breast hypertrophy is dueto an abnormal end organ response to circulatingestrogens and it is due to the hypersensitivity o the

some women during puberty and pregnancy. Breast

enlargement consists o brous tissue and at while

the glandular elements remain quite small. Sometimes

a amilial pattern can be traced back as members

o the same amily are aected. Breast hypertrophy

produces considerable unctional disability and

aects the quality o lie due to disproportionate

body disposition. Signicant improvement o the

individual sel esteem and sel condence are noted

in all the patients and symptomatic improvement in

the postural disability, neck and shoulder pain relie

were also noted. The aims o breast reduction is to

reduce, recontour reshape to suit the womans needs

and desires.

Selection o the procedure depends on the type o

breast, surgeons comort 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 nal nipple position depends on

the breast tissue that is let behind. With 30 years

o experience and understanding o the problem ew

Selection of procedure

for reduction mammoplastyDr. Lakshmi Saleem MS, MCh.Salaja Hospital, Vijayawada

simple guidelines are taken into consideration and

the problem is classied as ollows:

Grade 1: Teenage girls with increased areola and

ptosis requiring reduction o less than 200 grms.

Grade 2: Young women, who may need reduction up

to 500 grms.

Grade 3: Women who may need excision o up to

1000 grms

Grade 4: Women who may need massive reduction

o more than 1000 grms.

With 30 years o experience o reduction mammoplasty

various techniques, a simple procedure has been

recognized which is easy to execute with the long

lasting aesthetic eect. Classically it incorporates

the superiomedial pedicle with a vertical scar, and

excision o the gland with the skin rom the inerior

quadrant with extension onto the medial and lateral

segments, depending on the requirements o the

excison. This procedure has been ound to be

technically easy, sae, quick to perorm with minimal

complications and saety. It can be undertaken or

major resections o more than 1000 gms also.


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Markings or surgery

The patient is made to stand erect with the hands

tucked behind. Keeping the BMI in mind, thedesired size is discussed with the patient, and the

mid-sternal line is marked rst. ollowed by drawing

o the breast meridian.The nipple postion is noted.

The distance measured rom the midsternal notch

to the nipple position is also noted. The desired

new nipple position is marked rom the midsternal

notch. The areola is marked with the diameter o

3.5 to 4 cm with a nipple marker depending on the

need. The new nipple is marked with distance o 19

to 22 cm depending on height o patient keepingthe diameter 0.5 cm more than the previous

marking. An ellipse is drawn taking the top o the

new areola as the highest point The lowest point

o the ellipse is kept 1cm above the inramammary

crease. The maximum width o the ellipse is equal

to the diameter o the existing areola.

Procedure

1. Inltration o 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 rom areola.

3. The lower V cut is deepend keeping the skin

intact.

4. The medial and lateral faps raised with 0.5

cm thickness, upto the medial most and

lateral extent o Breast tissue.

5. The lower part o V is raised rom below

upwards, exposing the pectoral ascia upto

0.5 cm below the de-epethelised sub areolarregion.

6. The medial and lateral segments o breast

tissue which need to be excised is included

with the V segment as one en-bloc o tissue.

7. The whole block o tissue is excised rom the

upper part o breast protecting the nipple,

areolar complex.

8. Both the lateral and medial faps are brought

together with skin hooks and any excess

skin is excised as an ellipse rom the lateral

segment.

9. The aeolar complex is shited up to the new

position and i there is diculty in moving it

up relaxing incision given on the lateral part

o de-epethelised segment.

10. Ater areola is xed with 3-0 monocryl and

lower breast tissue is brought together with

3-0 monocryl subdermal sutures.

11. Ater xing 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 o nipple was

never compromised and the only complication

that was seen was delay in healing at the lower

most part o 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 deect resulting romincomplete tubularisation o the urethral plate.The meatus may be ound any where along the penile

shat and down on to the perineum. Hypospadias

with an incidence o 0.8 8.2 per 1000 live male

births is a common clinical problem. In the majority

o cases (80%) abnormal meatus is situated in the

glanular, coronal and subcoronal levels or in the

proximal part o the shat.

The goal o hypospadias repair is a unctional 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. O

the various procedures Tip urethroplasty (Snodgrass

repair) most reliably creates a normal appearing

penis. At many centres it is now the preerred method

o 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 fap repairs.

In addition this procedure allows construction o

neourethra rom the existing urethral plate without

additional skin faps. The technique is versatile and

suitable or almost all distal lesions.

Method

The penis is degloved with a U shaped incision

extending along the edges o the urethral plate to

healthy skin 2 mm proximal to the meatus.The lateral

borders o the distal urethral plate are separated

rom the glans by parallel longitudinal incisions.

The glanular wings are urther mobilized laterally or

subsequent tension ree closure. The urethral plate

is then incised in midline rom 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 fap harvested

rom subcutaneous tissue o dorsal penile skin and

preputial skin. The granular wings, mucosal collar

and ventral shat skin are closed in the midline. The

stent provides urinary drainage or 10 days.

With its simplicity, versality, excellent cosmetic and

unctional results and a low complication rate, TIP

urethroplasty is the procedure o choice or most o

the distal deects. Since most o the patients with

midshat and penoscrotal deects 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 or straightening the penis

and unhealthy urethral plate that appears thin or is

insuciently widened ater incision. Complications

are rare. Fistula can be avoided by interposition o

a vascularised dartos fap between the neourethra

and overlying glans and shat skin closures. Closure

o the rst layer is done in a running subcuticular

ashion with eorts made to invert the epithelium

completely.

Brackas Versatile Two Stage

Hypospadias RepairAesthetic quality o the hypospadias repair with

natural looking glans and slit shaped terminal

meatus ater multiple ailed hypospadias repairs

remains a ormidable challenge in reconstructive

surgery.

I Brackas (1995) two stage hypospadias repairoers versatility, reliability and renement and can

Repair of mid to distal penile hypospadias

by the tubularised incised plate urethroplastyDr. Devendra K Gupta MS, MCh.Derendra Hospital, Bareilly (UP)


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be used or almost any hypospadias deormity be

it primary repair in child or salvage surgery in an

adult.

Timing o surgery

1. At 18 months: Oers psychological advantage to

child. Better anaesthesia required

2. Beore school at 4 years: We use most o the time

the second option or surgical correction. Tissues

are better developed

Operative steps

Stage 1

Anaesthesia: Caudal epidural anaesthesia. Advantages

are smooth recovery, postop analgesia and less risk

o postoperative bleeding and haematoma. Then the

assessment is done-o position and size o abnormal

meatus, the presence o chordee, the quality and

width o urethral plate and the conguration

o glans penis. 4/0 silk stay stitch is applied to

the glans and presence and degree o chordee is

assessed. Meatal assessment is done using urethral

dilators. Tourniquet is applied ater dilatation. Irequired, meatotomy is done to split the thin layer

o urethra to the spongiosum covered urethra. The

suturing o urethral mucosa to skin is done ater

meatotomy using 6/0 chromic catgut. Two more

stay 5/0 sutures are applied on either side o the

midline over the distal aspect o the glans which

will be used as traction during glans split and later

as rst tie-over suture.

Release o chordee is done rom the proposed

neo-meatus to the ventral aspect o the abnormalmeatus. From the sub coronal part o the vertical

incision, lateral incisions on either side are done to

correct the chordee. This is done by a combination

o incision and excision o tissues using scalpel and

ne scissors. The chordee correction is achieved

in this manner in the majority o cases. In caseso residual chordee urther correction is done by

extending the sub coronal incisions to circumcoronal

incision and stripping the penis. A ull thickness

preputial grat was taken and accurately tailored

into the deect using 6/0 chromic catgut. A rm

tie-over dressing was placed or 7 davs and a

urethal catheter or 7-10 days.

Stage 2 ater at least 6 months to allow or grat

maturity and neovascularity. Neourethra was

ashioned rom the supple grated skin bed. Themeatus was reconstructed rst by joining the

ventral point, the rest o the urethra was then

tubed around K-90 or K-91/NEL-CATH (Romsons)

catheter with a combination o interrupted and

continuous extraluminal inverting 6/0 chromic

catgut sutures. The repair is protected and

reinorced using an intermediate vascularised

ascial layer dissected rom the dorsal aspect

ollowing circumcoronal incision and stripping o

penis. This vascular layer helps the healing process

and avoids suture lines in contact with each other

and thus reduces the risk o stula ormation. The

successul reconstruction depends on proper

planning, gentle handling o tissues with ne

instrumentation, usage o ne suture materials,

inverting sutures o neo-urethra and usage o

intermediate vascular layer o tissues

The glans and skin repaired and dressing was done.

Catheter was removed on the 10th day.

The urinary catheter is xed on the lower abdomenwith a mesenteric type o tape xation so that the

catheter is directed upwards away rom the ventral

suture line.


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14

Obesity Management

a plastic surgeons perspective!Dr. Lakshmi Saleem MS, MCh.Consultant Plastic & Cosmetic Surgeon

Over two decades o my practice in Plastic andCosmetic surgery, I have come across quite anumber o people who have come to me seeking help

or being obese. They belonged to both genders and

also o dierent ages. In the early days it was not only

dicult to convince people to ollow a disciplinedlie pattern and take proper diet but it was a tough

task to dissuade them rom seeking surgical option.

Some were genuinely odd in their gure having

either bulky arms or heavy thighs, some had heavy

breasts and some were disproportionately large in

the upper or the lower parts o the body. Some

boys had heavy breasts resembling emale 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 or surgery? How can you

assure them that even i some at is removed rom

the parts o their body, what is the guaranty that it

does not re-accumulate due to their indulgence in

either over-eating or lazy lie pattern.?

Here comes the honesty on our part to decide and

classiy who alls in the category called obese.

What is obesity?

When the body weight o a person is more than 25%

o the expected weight in the case o a man and is

more than 32% in the case o a woman, that person

is considered obese. Another denition is that any

person with 40 Kg more than the expected weight is

considered obese or any individual.

But the best way to measure is by the specic

term called Body Mass Index. This is nothing but a

calculation at any age and or 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 i BMI is 20 25

Overweight i BMI is 26 30

Obese i BMI is 30 35i BMI is Morbidly obese 35 40

or above

Obesity and over weight have been recognized to be

global problems aecting over a billion adults and

17.6 million children under 5 years o 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 rom Arthritis

to Diabetes, Cardiovascular problems to rank Heart

ailures, Neurovascular problems to Alzheimers,Chronic depression to Dementia, Chronic skin

diseases to Cancers.

What causes obesity?

Apart rom the various hormonal causes like

Hypothyroidism, Hypercorticosteroidism, hormonal

changes due to pregnancy or menopause, the primary

actor that leads to obesity is imbalance between

calorie in take to that o calorie consumption

superadded by a sedentary type o lie style with no

physical activity. Heredity and depression o course

play some role as the causative actors.

How to prvent obesity?

Like in the case o many health problems, prevention

has the best role to eradicate obesity. Childhood

obesity has an alarming increase across the globe

and cause or concern as this predisposes to

adulthood obesity.

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


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15

and nutritious diet or their children. The school

environment should provide proper physical activity

to the children. They should be made aware o theproblems o energy rich salty oods, sot drinks

containing large quantities o sugar and large

quantity o dairy products and ice creams. They

should be taught to restrict such oods. Children

must also be made aware o the ill eects o

sedentary lie styles. The role o yoga or meditation

or such disciplining activities are denitely among

the much needed.

How to cure obesity

In spite o the best eorts to prevent obesity, i

it still is a problem, the steps to cure obesity are

again giving emphasis on lie style changes and

altering environmental actors. Dietary modication

like low calorie, high ber diet associated with

enhancing physical activity is mandatory. Chronic

stress or chronic depression may both lead to

obesity and hence such o the actors 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 thatemphasis is laid to sel motivation. A sel motivated

obese person is on the right track to cure him / her

sel o obesity.

Who needs surgery to cure obesity?

The choice o surgery depends on the severity o

the problem o obesity. Arbitrarily it can be said

that having tried all the physical, dietetic and

psychological methods to curing the problem

o obesity, the choice o surgery alls into twocategories.

One is just the removal o at or the excess o tissue,

which is usually preerred in only those that all

in the group o overweight up to a BMI o 30. The

procedures that can be carried out in this method

are Liposuction or Lipectomy.

Two is or those who all into the category o

severely obese or who suer morbid obesity with a

BMI o 40 or more needing Bariatric surgery where

the ood intake is either restricted or malabsorption

is created. However people with BMI o 30 35

associated with one or two co-morbid condition

may also need bariatric surgery.

The role o a cosmetic surgeon in taking care o

an over weight or obese individual cannot be

overemphasized. One should insist on an overweight

person with a BMI o 26 35 to reduce his/her

weight by about 5 Kg by proper diet, exercise and

change in lie style. This gives the plastic surgeon

to assess the genuineness in commitment on the

part o the individual how much the obese person

is going to ollow the instructions and how eective

the cosmetic surgical method be useul to such anindividual in the long run.

Even ater the Bariatric surgery there is a role or

a Cosmetic surgeon in contouring the body or the

residual or consequential eects.

Liposuction and lipectomy

Liposuction is one o the surgical options or the

obesity i the person is well motivated and willing

to maintain the weight. By doing the liposuction o

the certain areas, like inner thighs and the sides othe chest, it enables the obese person to go or walks

and exercises with out much diculty. Certain areas

where there is localized obesity like the arms, side

o fanks and thighs or buttocks need liposuction.

Some times the liposuction itsel can stimulate the

basal metabolic rate so much that the person can

start losing weight with a greater speed. It was

observed that liposuction itsel can make an overall

reduction o 10 to 15 Kgs.

Abdominal girth increase or looseness due to post

partum obesity does need to be addressed with

plastic surgery in the orm o 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

olds and so on.

Gynaecomastia

Abnormal male breast development is seen in

some o the obese individuals and they invariably


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17

Management of Obesity

Dr. M A Saleem MS, FICSConsultant & Head of Department

General Surgery, Surgical Gastroenterologyand Laparoscopic SurgeryCare Hospital, Banjara Hills, Hyderabad

Obesity is a chronic disease and is also associated

most o the times with medical illnesses like

diabetes, hypertension, hyperlipidemia, chronic

arthritis and so on. The prevalence o 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 o overweight o 66%, obesity o

32% and morbid obesity o around 5%. In Europe

obesity prevalence ranges rom 20% in men and

25% in women. Although well established statistics

are not available in India, one o the surveys by

All-India Institute o Medical Sciences showed that

76% o women in the capital, New Delhi, suer rom

abdominal obesity. NFHS analysis showed that 12%

men and 16% women suer rom obesity in India.

Excess body weight is the sixth most important risk

actor contributing to the health burden o 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

atter making them seek medical help. Prosperous

people tend to live sedentary lives. This seems to be

the case in India also. I you are rich, you can pick up

a phone and order a pizza; you have a car, you dont

need to walk to many places. Many children no longer

take lunch-boxes to school. They drink colas and othersot drinks and eat burgers. There is no awareness

among parents that this is a problem. With obesity

come related problems, rom diabetes to heart ailure.

An estimated 25 million Indians have diabetes, and

this is orecast to grow to 57 million by 2025.

Morbid obesity has acquired epidemic proportions in

the country with 5 per cent o the population suering

rom it. Problem is high among schoolchildren as

indicated rom a study in Hyderabad. Obesity seen

and known rom those seeking medical help is onlythe tip o an iceberg; the incidence o obesity in the

country is much higher and the is growing aster,

according to medical experts.

Obesity amplies the risks o type 2 diabetes,

hypertension, cardiovascular disease, dyslipidemia,

arthritis, and several cancers and is estimated to

reduce average lie expectancy. In the United Statesalone, it is estimated that obesity-related health

problems account or about 300,000 deaths per year.

The medical expenses and cost o 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

or cosmetic reasons or or cure o associated

medical conditions. The surgical treatment o 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 o overweight in the rst

place. Consequently, they were associated with

recurrences and suboptimal results.

Increasing magnitude o this problem prompted

extensive research into the pathophysiology

o the development o obesity. This lead to a

better understanding o the disease process and

subsequently to the development o comprehensivemodalities or its treatment.

Defnition

Various parameters have been evaluated to objectively

assess the amount o excess body adipose tissue

stores. Presently, obesity is dened and classied

based on the Body Mass Index (BMI).

BMI is calculated as:

Weight (in kg) / Height (m2) OR

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


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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 personsare at a higher risk or adverse health consequences

than those who are overweight. The prevalence o

obesity-related diseases such as diabetes begins to

increase at BMI values beyond 25.

Classifcation by Body Mass Index

Weight Classication ObesityClass

BMI(kg/m2)

Risk oDisease

Underweight


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19

regularly eating o breakast, also infuence the

outcome o weight management. It is obvious that

special attention should be paid to patients who areprone to ailure in long term weight management.

More requent dietary counseling contributes to a

better outcome o 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 or

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 modifcations

A low-energy diet recommended or the treatment

o obesity should be o low at (30% o daily energy

intake), high carbohydrate (55% o daily energy

intake), high protein (up to 25% o daily energy

intake) and high ber (25 g/day). Recently, several

studies evaluated the role o low-carbohydrate

diets in weight management. These diets have been

advocated because they induce many avourable

eects such as a rapid weight loss, a decrease oserum triglyceride levels, and a reduction o blood

pressure as well as a higher suppression o appetite

(partly due to ketogenesis, partly due to a higher

protein intake). However, several unavorable eects

o low-carbohydrate diet administration also have

been demonstrated, such as an increased loss o lean

body mass, increased levels o 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 o

protein in a diet contributes to better weight loss

maintenance because proteins are more satienting

and thermogenic than carbohydrates and ats.

Drug Treatment

Anti-obesity drugs have been developed to

assist weight loss in combination with lie-style

management to improve weight loss maintenance

and to reduce obesity-related health risks. Anti-

obesity drugs aect dierent targets in the central

nervous system or peripheral tissues and aim to

normalize regulatory or metabolic disturbances that

are involved in the pathogenesis o obesity.

Currently, only three anti-obesity drugs have been

successully used in long-term weight management.

It is expected that lielong treatment with anti-

obesity drugs will be required to specically target

the particular abnormality. Current potential to treat

obesity by drugs is limited in comparison to the

drug treatment o other complex diseases such as

hypertension, diabetes, and dyslipidemia. The U.S.

FDA has approved the drug Orlistat or use in children

and adolescents. Orlistat, as an inhibitor o lipase,

reduces at absorption in the intestine. Patientstreated with Orlistat and lie-style modication

exhibited a greater weight loss and a signicant

reduction in diabetes incidence compared with

those who underwent lie-style modication and

received placebo.

Sibutramine, as a serotonin and norepinephrine

reuptake inhibitor, induces satiety and prevents

diet-induced decline in metabolic rate. Continued

use o sibutramine maintained weight loss almost

completely or this period o time.

Rimonabant administration leads to signicant

weight reduction and improvement in cardiometabolic

risk prole in our randomized double-blind clinical

trials conducted in overweight or obese adults.

Recently, the anti-epileptic drug Topiramate was

discovered to have benecial eects on weight control

and is being investigated as a weight loss drug.

Weight loss induced by currently available anti-obesitydrugs is only modest, reaching usually 58% o initial

body weight. Assignment o 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 o

treatment over a 1.5 to 3 month period.


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20

Surgical Management

Lie-style intervention programs with diet therapy,

behavior modication, exercise programs andpharmacotherapy are widely used in various

combinations. Unortunately, with extremely rare

exceptions, clinically signicant 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 3035 kg/m2), surgical treatment was

ound to be signicantly more eective than non-

surgical therapy in reducing weight, resolving the

metabolic syndrome and improving quality o lie.Till recently, surgical procedures conduced in obese

patients were usually cosmetic procedures like

liposuction/lipoplasty, aimed at reduction o body at.

However, they do not prevent weight regain ollowing

the surgical procedure. With better understanding o

the pathophysiology behind development o obesity,

various procedures are developed aimed at either

restricting the intake o ood, promoting malabsorption

or both, thus ensuring long term weight reductions.

Bariatric surgery

Bariatric surgery is the most eective treatment or

morbid obesity in terms o weight loss, health risks and

improvement in quality o lie. It should be considered

or 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 beore surgery and to oer a comprehensive

approach to diagnosis, assessment, treatment, and

long-term ollow-up. Bariatric surgery could be careully

considered in severely obese adolescents who have ailedto lose weight in a comprehensive weight management

programs carried out in a specialized center or at least

6 -12 months and or those who have achieved skeletal

and developmental maturity.

Centers perorming 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-benet ratio should be considered on an

individual basis. It is necessary to emphasize that

the primary objective o surgery in elderly patientsis to improve quality o lie as surgery per se is

unlikely to increase liespan.

In bariatric surgery, restrictive procedures as well

as procedures limiting absorption o nutrients are

currently available. The magnitude o both weight loss

and weight loss maintenance is increasing with the

ollowing procedures: gastric banding, vertical banded

gastroplasty, proximal gastric bypass, biliopancreatic

diversion with duodenal switch, and biliopancreatic

diversion. Although sucient evidence-based datato suggest how to assign a particular patient to a

particular bariatric procedure is slowly coming up,

or patients with BMI o 50 kg/m2, gastric bypass

or biliopancreatic diversion brings more benets.

Pure restrictive procedures are not recommended or

patients with a signicant hiatal hernia or severe

gastro oesophageal refux disease. Gastric banding

cannot contribute to urther substantial weight

loss in patients in whom a signicantly diminished

ood intake has been veried beore the surgery.

On the other hand, it should be considered that alaparoscopic adjustable gastric banding is the saest

bariatric procedure associated with only minor peri-

operative surgical risks.

Bariatric surgery has been proved as the most

eective way o treating Type-2 Diabetes in severely

obese patients. More than 10 years ago, it has been

demonstrated that 83% o patients with diagnosed

Type-2 Diabetes exhibited normal blood glucose and

normal glycosylated hemoglobin levels 7.6 years

ater bariatric surgery. Further, 99% patients withimpaired glucose tolerance normalized a glucose

tolerance ater bariatric surgery. The 10-year ollow-

up in the Swedish Obese Subjects (SOS) study

demonstrated that a bariatric surgery is a viable

option or the treatment o severe obesity, resulting

in long-term weight loss, improvement in liestyle,

and except or hypercholesterolemia, amelioration

o cardiometabolic risk actors.

Ater 10 years, in the SOS study the average

weight loss rom baseline was 25% ater gastric


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21

bypass, 16% ater vertical banded gastroplasty,

and 14% ater gastric banding. The group that

had undergone surgical intervention had lowerincidence rates o diabetes, hypertriglyceridemia,

and hyperuricemia in comparison to the control

group. The most important recent nding o the

Swedish Obese Subjects study is a reduction o

overall mortality by 24.6% in the surgery group

versus control subjects.

Pylorus

ExcisedStomach

GastricSleeve

Pylorus

The schematic representation o 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 portiono stomach

Esophagen

Proximal Poucho Stomach

Short IntestinalRoux Limb

Duodenum

Roux-en-Y Gastric By-pass

Gasric sleeve Resection


24/32


25/32


26/32

24

The ollowing diet and health program wasdeveloped or the employees and the dependantso General Motors Inc.

The program was developed in conjunction with

the grant rom the US Department o Agriculture

and the Food and Drug Administration. It was rsttried at the Johns Hopkins Research Centre and was

approved or distribution by the Board o Directors

o 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 amilies. This program will be available at all

General Motors Food service acilities.

It is the managements intention to acilitate a

welare and tness program or everyone.

This program is designed or a target weight loss

o 5-6 Kgs. per week. It will also improve your

attitude and emotions because o its systematic

cleansing eects. The eectiveness o this seven

day plan is that the oods eaten burn more calories

than they give to the body in caloric value. This

plan can be used as oten as you like to without

any ear o complications. It is designed to fush

your system o impurities and give you a eeling

o well being. Ater seven days you will begin

to eel lighter by atleast 10 pounds. You will

have an abundance o energy and an improved

disposition.

During the rst seven days you must drink 10 glasses

o water each day.

Day one

All ruits except bananas. Your rst day will consists

o all ruits you want. It is suggested you consume

lots o watermelon and cantaloupe.

Day two

All vegetables. You are encouraged to eat until

you are stued with all the new and cooked

vegetables o your choice. There is no limit on

the account or type. Avoid oil and coconut while

cooking vegetables. Have large boiled potato orbreakast.

Day three

Any mixture o ruits and vegetables o your choice.

Any amount, any quantity. No bananas yet and no

potatoes today.

Day our

Bananas and milk. Today you will eat as many as

eight bananas and drink three glasses o milk. Youcan also have I bowl o vegetables soup.

Day fve

Today is a east day. You will eat 1 cup o rice. You

also have to eat six whole tomatoes and drink 12

glasses o water today to cleanse your system o the

excess uric acid you will be producing.

Day six

Today is another all vegetables day. You must eat1 cup o rice today and eat all the vegetables you

want cooked and uncooked to your hearts content.

Day seven

Today your ood intake will consist o 1 cup rice,

ruit juice and the vegetables you care to consume.

Tomorrow morning you will be ve to eight kgs.

Lighter than I week ago. I you desire urther weight

loss, repeat the program again. Repeat the program

as oten as you like, however, it is suggested thatyou rest or three days beore every repetition.

General motors weight loss diet


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25

You have your system under control now and it will

thank you or all the purging and cleansing you just

gave it. Even more than a diet program it is goodto ollow 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 o the program is the

10 tall glasses o water a day. You can also favour

the water will some lemon to make the drink easier.

While on the program, take only black coee and

never more than one teaspoon o oil. Preerably do

not use oil because the high caloric content. No

ruit juices beore 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 or the

upcoming program. Your only source o nutrition is

resh ruits. Fruits are natures perect ood. They

provide everything you can possibly want to sustain

lie except total balance and variety.

Day 2: Starts with a x complex carbohydrates in

the orm o a boiled potato. This is taken in the

orm o a boiled potato and taken in the morning

to provide energy and balance. The rest o the day

too consists o vegetables which are virtually calorie

ree and provide essential nutrients and bre.

Day 3: Eliminates the potato because you get

your carbohydrates rom ruits. Your system is now

prepared to start burning excess pounds. You will

have cravings, which should start to diminish by

day our.

Day 4: Bananas and milk. You are in or a surprise.

You probably will not be able to eat all the bananas

allowed. But they are there or the potassium you

have lost and the sodium you may have missed the

last three days. You will notice a denite loss o

desire or sweets and you will be surprised at how

easy this day will go.

Day 5: Rice and tomatoes. The rice is or the

carbohydrates and the tomatoes are or the digestionand the bre. Lots o water puries your system.

You should notice colourless urine today. Do not

eel you have to eat one cup rice, you may eat less.

But you may eat six tomatoes.

Day 6: It is similar to ve. Vitamins and bre rom

the vegetables and carbohydrates rom the rice. By

now your system is in a total weight loss inclination.

There should be a noticeable dierence in the way

you look today compared to day one.

Day 7: You may celebrate with champagne. You may

also have white wine instead o champagne, but in all

practical programs, and in all surveys done to measure

the success o the program, General Motors employees

have always preerred champagne to white wine.

More than one cup o coee with milk is especially

orbidden. Milk and oil add empty calories to your

diet. Avid coee lovers can console themselves

with black coee. However, ater the rst week, it

will help your digestion and set your stomach. The

key thing to remember is that i you are hungry

at any time, then you are not ollowing the diet

correctly. Almost all people give up the diet when

they are hungry because o dieting. The secret o

this program is that you should never be hungry.I it is a vegetable day, eat so much vegetables so

that you are never hungry. I it is a ruits day, eat so

much ruits that you are never hungry. You may be

bored o eating vegetables all day, but you should

not be hungry. You can take any amount o General

Motors wonder soup on any day.

General motors wonder soup

The ollowing soup is intended as a supplement to

your diet. It can be taken any time o the day invirtually unlimited quantities. You are encouraged

to drink large quantities o this soup.

23 oz water

06 large onions

02 green peppers

03 whole tomatoes

1 cabbage

1 bunch celery add herbs and seasoning asdesired.


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26

This program is highly recommended or women and

men above 40 or whom excess weight is especially

dangerous. Excess weight or women aggravatesarthritis 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

actor in keeping good health and excess weight is

responsible or the most problems including coronary

diseases, heart problems, arthritis and cancer among

other serious lie threatening diseases. Most serious

health problems can be avoided by the single

unction o maintaining an ideal weight. Daily mild

exercise o 20 minutes is also essential. Do not tire

yoursel out, but being regular in your exercise and

maintaining an ideal weight goes a long way inensuring a happy, healthy and long lie.

This article is published on this website assuming

that all the material herein are in the public domain,

as the intention o this article is a noble one to

make humans healthy. Its published here with noble

intentions. I you nd 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

[email protected] (spammers, please ignore.)


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27

Lasa is a health home, to help you to learn to alter the life style for betterment,

taking you to a NEW LEVEL OF TOTAL WELL BEING.It guides you to take care ofyourself by counseling of Diet, Weight Exercises, General life style Hobbies and Interests,

Spiritual preferences and Future Goals. Then a thorough medical evaluation is done

for health risks like Diabetes, Hypertension, Stroke, Cancer, Aids. A comprehensive

programme is planned for each individual depending on the likes and preferences of the

individual. Every effort is made to detoxify, rejuvenate and make one look fit, healthy

smart and young with a healthy glow. In house facilities for regularizing the diet with

cooking demonstration in the common kitchen is taught. A healthy way of life is taught

with yoga, meditation, kerala auyurvedic massages, and Gym. The same facilities are

offered as an outpatient providing crche for the young mothers who want to come back

to shape after delivery.

Our Services

Counseling

Cosmetic Surgery Classical Dance

Yoga Therapy /Meditation

Kerala Auyurvedic

Salaja HospitalPrajasakthi Nagar, Vijayawada 500 010

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


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

Phone: 040-66735555 (5 Lines)/23400057 & 58.

Fax: 040-66735535.

VIVEKANANDA HOSPITALA Unit of ADITYA HOSPITALS PVT. LTD.

A Multispeciality Hospital with fabulous track record of over a decade in theservice of mankind has grown to be one of the nest health care provider in

twin cities. It is known for its rich culture and patient friendly attitude.

We believe responsibility towards bringing the nest facilities of Healthcare

within the reach of needy as every individual has a desire and will to

lead a healthy life.

With best compliments


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3

Let us all

FIGHT TOGETHER

to Nip the

OBESITYinstead of

BandingCarving

Sucking &Body sculpturing

Lasa helps you toalter theLife Style

for betterment

www.lasa.in

www.bodycontouring.in


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dr lakshmi saleem 7thpsaap conference - cosmetic surgery clinic hyderabad

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