Sun, May 16, 2004

      Operation's somewhat of a stretch
      Growth in leg-lengthening surgery for cosmetic purposes dividing doctors

      By JENN GEAREY, Ottawa Sun

      It is said that good things come in small packages but when it comes to being small in stature, some people are going to painful lengths to make themselves taller. Cosmetic leg lengthening is a surgical procedure gaining in popularity. Traditionally, it's been performed on children to correct disproportional leg lengths or to repair a leg after an accident. It's also been an option for people with dwarfism.

      But now some people are seeking the operation for esthetic reasons, and paying close to $100,000 for a couple of extra inches.

      Ottawa native Dr. Dror Paley, co-establisher and co-director of the Lifebridge International Center for Limb Lengthening in Baltimore, Md., has been performing leg lengthening surgeries for more than 18 years. He says only about 5% of his patients have the surgery for cosmetic reasons and there are rules about who can have it done.

      "Our cutoff, which is fairly arbitrary, is 5-foot-7 for males and 5-foot-2 for females," says Paley. "One really has to question why we have a limit. There's no more danger to someone 5-foot-9. It's more of an ethical question.


      "Most of the people who want this done are suffering from a psychological condition which we call 'height neurosis' or 'height dysphoria.' You can have height dysphoria being 5-foot-11 so it's not related to your actual height, it's a psychological condition and it's one of the few psychological conditions you can correct with surgery. The issue is that it's a big surgery and it's a risky surgery and in our hands it's very successful, but in the hands of most people it's fairly dangerous."

      Many leg lengthening patients are private about their operation and often go to extraordinary lengths to ensure no one finds out.

      "They invent incredible stories to avoid people knowing they're going through it," says Paley. "One guy told people he was going on a ski trip and then he had an accident and both of his legs were broken and had to be fixed. Somehow, when he got out of the wheelchair, he was three inches taller!"

      Typically, patients are men in their 20s, 30s and 40s who are intelligent and well-adjusted but feel their short stature adversely affects their life.

      "There's a tremendous amount of intrigue about it," says Dr. Robert Rozbruch, director of the Institute for Limb Lengthening and Reconstruction at the Hospital for Special Surgery in New York. "I've had many inquiries from patients from Canada ... I get about 20 to 30 e-mails a month from people about cosmetic limb lengthening.


      "The deterrent right now is not the pain or the time, it's the dollars. If it were something that was less expensive, or something covered by the insurance companies, we'd be doing five times as many of these."

      But not all orthopedic surgeons trained to do the operation agree with performing it for cosmetic reasons.

      "Basically, you're taking a healthy, normal leg and doing surgery on it for cosmetic reasons and some of the risks of cosmetic lengthening are the potential for infection in bone, and nerve and blood vessel damage," says Dr. Robert Feibel, an orthopedic surgeon at the Ottawa Hospital, who has been performing leg lengthening for medical, non-cosmetic reasons since 1993.

      "While I did my training in Italy there was a patient who was being treated who had both of his femora lengthened," says Feibel. "One side was lengthened 10 cm and on the other side the mechanism failed and he only lengthened 1 cm."

      With an average height gain of only two to three inches, doctors like Feibel question whether the cosmetic procedure is really worth a patient's pain and suffering.

      The current method used in the majority of leg lengthening patients -- and used in the U.S. for more than 15 years -- is called the "Ilizarov" method. And according to doctors and patients, the severe pain suffered during recovery doesn't compare to the dull pain typically associated with cosmetic surgery.

      With the Ilizarov leg lengthening method, a psychological evaluation is usually first conducted to ensure the patient can endure the lengthy recovery ahead -- up to a year in a wheelchair.

      If the patient is psychologically suitable, in a two-hour surgical procedure the tibia and fibula bones in both legs are broken. On the legs, small holes are drilled through the patient's skin and an external fixator device that consists of metal rods is attached to each half of each severed bone using pins and wires.

      Lengthening of the legs begins about a week after surgery and continues over the next three months. New bone growth is achieved as a result of the patient turning a variety of screws in their legs which gradually increases the distance between the bones and allows new bone growth to occur in the space between.

      On average, the patient gains 1 mm of height per day and is required to do up to two hours of physical therapy every 24 hours. Although physical therapy is extremely painful, not performing it can extend full recovery by years. Doctors say that most leg lengthening patients require a narcotic to deal with the intense pain, although this kind of medication often also slows the healing process.


      Six-foot-tall Jordan Taylor, 19, a Carleton Place high school student, didn't need the leg lengthening procedure to enhance his height. But in 1996, after a car accident broke the growth plate in one of his legs, it didn't grow as long as it should have. Two weeks ago, Taylor opted for the leg lengthening surgical procedure with Feibel.

      "The biggest problem with this surgery is that you have open wounds the whole time so they're prone to infection," says Taylor. "It's only two weeks in and I already have one."

      But Taylor says that's to be expected -- and so is some pain that will accompany tightening the screws in his legs every three hours, which begins this week for him.

      "Since I'm tightening the bolts in such small increments I shouldn't have much pain, but the physiotherapist at the hospital said I'd better be on pain medication when I start turning them," says Taylor.

      In five to nine months, when a patient like Taylor achieves newly grown bone that's strong enough to bear their body weight, they will no longer need a wheelchair. The last step will be to perform an operation to remove the external fixator device on the leg.

      For most patients the leg lengthening procedure ends here but, in cosmetic cases, some people opt for a second operation to gain even more height. This time the femur bones of the thighs are broken and lengthened using the same procedure, giving the patient an additional three inches. Many doctors oppose this, as an additional six inches in the legs -- three on the lower legs and three on the upper -- will likely make the person appear significantly disproportional.

      But new methods of leg lengthening surgery are now emerging, facilitating the lengthening by omitting the need for any external devices, cutting the recovery time and catching the eye of many orthopedic surgeons.

      "There's a metal rod that's telescopic that attaches to the bone inside the leg and the patient literally just shakes their leg and the shaking of the leg moves the rod, which translates into lengthening," says Paley about ISKD, a new method currently in trials.

      Leg lengthening doctors strongly advise that potential patients be extremely vigilant with whom they choose to perform any leg lengthening operation, as inexperienced doctors could cost the patient their legs for life.

      "People should have the right to have surgical procedures to alter their bodies, but you're making an assumption that the surgery is done reliably and safely," says Paley.


      "At this point, very few surgeons can carry this out in a reliable, safe manner and achieve the kind of results that we get. Lengthening itself has a lot of potential complications and how to treat or prevent the potential complications of lengthening is where the main knowledge is required, which is what most people don't have."

      Although cosmetic leg lengthening is performed in a variety of countries other than the U.S., including China, Egypt, France, Germany, Greece, India, Italy, Jordan, Iran, Russia and the Ukraine, U.S. surgeons warn: Buyer beware.

      "They're doing it in foreign countries, but I've seen some mess-ups. I've had a patient who was operated on in Greece because he got a really good price, but it was done by people who really didn't know what they were doing," says Rozbruch.

      Although an orthopedic surgeon practising in Canada has yet to offer cosmetic leg lengthening, Feibel hasn't dismissed the idea for the future. "With conventional Ilizarov surgery, I don't think it's the right thing to do right now," says Feibel. "But certainly the internal fixation lengthening (like the ISKD method) will change the approach to cosmetic lengthening and there may be some surgeons who may begin doing it.

      "I've seen two patients in the past who have come to me about cosmetic lengthening, but after reviewing the risks with them they've elected not to do it," says Feibel. "The most important thing to remember is that we don't have long-term data to show this is a safe treatment. 'Caution' is the word for any cosmetic lengthening -- we really need to see what the 10- and 15-year followup is like."