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Archive for the ‘calf implants’ Category

Case Study: Calf Implants in Bilateral Clubfeet

Saturday, August 3rd, 2013

 

Background: Calf augmentation using either a synthetic implant or fat injections is a well known surgical procedure to increase the prominence of the calf muscle. While many people think of the typical calf augmentation patient as a body builder or an athlete, aesthetic enhancement of normal calf muscles is only one reason to have the procedure. The other reason calf implants are done is for congenital deformities or obvious developmental asymmetries. Such deformities can include club foot, spina bifida and even polio.

Clubfoot is a well recognized lower leg deformity which is reported to be the most common birth defect. Medically known as congenital talipes equinovarus, the involved foot looks like it has been turned inward at the ankle. It occurs half the time in both feet at birth and more frequently in males. The calf (gastrocnemius) muscle is always smaller on the affected foot. Besides the issue of less functional use, studies have shown that the smaller size of the gastrocnemius muscle is due to wasting of the calf muscle from a reduction in the number of muscle fibers rather than their size.

When occurring on one side, clubfeet patients have a much smaller muscle than on the normal leg. When occurring in both feet, the calfs (as well as the entire leg) can be extremely thin. The calf muscle is so atrophic that there is a straight line from the inner knee straight down to the ankle without the usual calf muscle bulge seen in the frontal view. This is a source of embarrassment for many patients and will often prevent them from wearing shorts or otherwise exposing their calfs in public.

Case Study: This 23 year-old male was born with bilateral clubfeet and had been through many years of physical therapy, splints and achilles release surgery. He had thin upper thighs and very thin calfs that tapered inward from below the knee to the ankle. His skin was very tight around his calfs. While he ideally could have aesthetically benefited by both medial and lateral calf implants for both legs, the tightness of his tissues made that consideration too risky for fear of a compartment syndrome after surgery.

Under general anesthesia in the prone position, 3.5 cms long incisions were made in skin creases behind the knees at the inner half. Dissection was carried down to the muscle fascia where, in a stairstep fashion, fascial incisions were made well below the level of the skin incisions. An instrument dissected out a subfascial plane over the medial gastrocnemius muscle where solid soft silicone elastomer calf implants (15cm long x 5 cm wide, 135cc volume) were placed. the fascia and skin were closed in separate layers. He was dressed with tapes for his incisions and ace wraps for his calfs. The procedure was completed in one hour.

He rested his legs for the first few days, keeping his legs elevated. His recovery occurred over the next 3 weeks during which the calf muscles became used to having an implant sitting on top of it and the overlying skin stretched a bit. Returning to normal walking gradually occurred although a bit slower in the club foot patient who already had comfortable walking issues beforehand. His results showed a visible enlargement in his inner calf size that was proportionate to his thighs.

Calf implants in the clubfoot patient provide an immediate improvement in calf size. Fat injections are often not an option if they do not have any significant amount of fat to harvest in thinner patients. It is tempting to use larger sizes of calf implant or even two implants per leg but the tightness of the surrounding skin makes this a more risky approach in the patient with an atrophic overall calf. A larger size or an additional implant can be placed at a later date if desired.

Case Highlights:

1) For the clubfoot patient, calf augmentation with implants can provide a immediate and visible change in atrophic calf size.

2) Calf implants are placed on top of the muscle under the fascia in the inner calf muscle to get the most visible effect.

3) Calf implant augmentation is a very straightforward procedure that is accompanied by a longer recovery than the simplicity of the operation would suggest due to lower extremity dependency and function.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Implant Augmentation in Calf Asymmetry in Clubfoot

Saturday, June 22nd, 2013

 

Background:  Augmentation of deficient calf muscles is done for a variety of reasons. These include naturally small calfs, in bodybuilders who want their calfs to match the muscular look of the rest of their body and for congenital leg defects in which calf muscle development is small and ill-defined either on one leg or both legs.

One of the most common congenital lower leg defects that affects the calf muscles is that of clubfoot. Clubfoot is a well known birth defect, also called talipes equinovarus, as it occurs in about one in every 1,000 births. In about half of those so affected, it will occur on both sides. It is a birth defect that is far more common in males than females. The appearance of the foot so affected is unmistakeable with the foot turned inward on its side. The involved foot, calf and overall leg length is smaller and shorter.  If clubfoot is limited to one side, the calf asymmetry compared to that of the normal side is very apparent. Circumferential calf measurements are often 2 to 5 cms smaller than that of the unaffected leg.

Calf augmentation is most commonly done by synthetic implants. Commercially available calf implants offer immediate and permanent changes in calf size and are made of a very soft durometer solid (spongy) silicone material.  They are shaped like long fat cigars in various lengths, widths and volumes. These implants are placed in a subfascial location on top of the calf muscles. Complications can include infection and inadequate positioning whose risks are very low. The biggest issue with calf implants is the recovery, particularly if both calfs are treated.

Case Study: This 16 year-old female was born with a right clubfoot deformity. Her leg leg and foot were unaffected. She had been treated by serial casting as an infant and had a fairly normal gait. She was bothered by the difference in her calf sizes which was very visible in shorts. The difference in circumferential calf size measurement was 3.7 cms at the mid-calf area.

Under general anesthesia and in the prone position, a 3 cm incision above the medial gastocnemius muscle head was made in the popliteal skin crease of the right leg. Dissection was carried down to the gastrocnemius fascia which was horizontally incised. An instrument was used to develop the subfascial pocket over the muscle. A small silicone calf implant, measuring 16cms in length by 5.5cms in width (70cc volume) was inserted. The fascia and skin was closed with dissolveable sutures and taped. No other dressing was used.

Her recovery included some calf pain, swelling and inability to comfortably fully flex the ankle for a few weeks. By six weeks after surgery she had returned to all normal activities. Her calf asymmetry was improved, although not perfect, with a change to only a 1.5 cm difference in circumferential mid-calf measurement from that of the left normal side.

Gastrocnemius muscle augmentation using implants can provide an effective improvement in calf asymmetry due to clubfoot. The congenital shortness of tissue around the calf makes for tight skin. This limits the size of the calf implant that can be placed and dual muscle augmentation (medial and lateral heads) is not usually advised.

Case Highlights:

1) Calf augmentation by synthetic implants is the most reliable method of permanent volume enhancement

2) Congenital clubfoot deformity is associated with other lower leg issues of which small calf muscle development also occurs.

3) Calf augmentation (reconstruction) in club foot with synthetic implants must take into consideration the tightness and shortage of circumferential skin when selecting implant size.

Dr. Barry Eppley

Indianapolis, Indiana

Calf Augmentation with Fat Injections

Friday, June 21st, 2013

 

The shape of the lower third of the leg is highlighted by the appearance of the calfs. Whether they are big, small or somewhere in between, they are the dominant shape between the knee and ankle. The shape of the calfs is largely controlled by the size of the paired medial and lateral heads of the gastrocnemius muscle. Usually the inner or medial head of the gastrocnemius is bigger than the outer or lateral head although the medial head is most commonly seen and used to judge the muscular characteristics of the calfs.

Unlike many other body parts, the calfs have not been as easy to augment or increase in size. It can be one of the toughest muscles in the body to build up by exercise. While silicone calf implants are the quickest and most assured method of calf augmentation, it does require some significant recovery like the placement of any body implant. With the rise and popularity of fat injections, the calfs have not been left out as a place to be treated with this natural method of aesthetic enhancement.

In the July 2013 issue of the Journal of Plastic, Reconstructive and Aesthetic Surgery, an article was published entitled ‘Calf Lipo-Reshaping’. In this paper, the authors looked at five (5) patients over two years who had been treated by fat injections for calf augmentation.  An average of around 120cc as injected into each calf. Their follow-up was between six and eighteen months after the procedure and included circumferential measurements and magnetic resonance imaging (MRI) in two patients at the end of their follow-up. Their results showed that an average increase of just over 2.5 cms in circumferential enlargement occurred. Viable fat could be localized by MRI.

This is not the first article that has been published on the success of fat injections for modest to moderate amounts of calf augmentation. While lipoaugmentation is a viable alternative to the use of solid silicone implants, it is not a technique that is useful for many patients who seek a noticeable increase in the size of their calfs. One has to have enough fat to harvest for an adequate amount of fat to be injected and some patients with small legs/skinny calfs do not have enough donor material. There is also the question of how much fat will survive. This and other published studies to date, however, show that the calfs exhibit good fat retention and are not a more difficult place for its survival than most other body areas.

Should one have synthetic implants or fat injections for calf augmentation? This question is not that one is better than the other. Numerous factors come into play as to which one is best in any patient. But fat injection grafting has a legitimate role for calf enlargement, particularly those who are having other body contouring procedures and willing to accept a modest increase in calf size.

Dr. Barry Eppley

Indianapolis, Indiana

The Uniqueness of Male Plastic Surgery – Body Procedures

Thursday, June 13th, 2013

 

When it comes to plastic surgery, just like many other areas in life, men are different than women. Not only are their faces and bodies not the same, but their attitudes and expectations about plastic surgery are also different. Having treated a fair number of men over the years in my Indianapolis plastic surgery practice, I have made a number of observations on these gender differences.

It is true that the number of men, particularly younger men, are making up an increasing percentage of the total plastic surgery population. While the number of men having actual surgery or in-office injectable and skin care treatments will always be substantially less than women, men are noteworthy in that their procedures are either unique or require modifications. Numerous cosmetic procedures are not only uniquely different in men, but some of them are exclusive to men.

Enhancement of the male chest is an increasingly popular male plastic surgery procedure.  Chest issues are very different from that of the female breast. While women have surgery for small, poorly shaped or asymmetric breasts, men consider surgery because their chest appearance is not masculine enough due to gynecomastia, prominent nipples or lack of pectoral muscle size and definition. Gynecomastia reduction surgery is vastly different than female breast reduction surgery. Lack of visible scarring in a man takes on primary importance and the use of liposuction tissue extraction subsequently takes on greater importance. Prominent nipples, which occurs far more frequently in men than women, can have a very negative psychological effect for some men. Having them be obscure in a tight shirt is a common goal of all ages of men and this nipple reduction procedure can be accomplished as an office procedure under local anesthesia

Male chest enlargement is done by soft solid silicone implants that have to stay within the  lower and lateral borders of the pectoralis muscle. Female breast augmentation is done with non-solid filler materials in a shell (bag) that must be often be placed beyond the lower border of the muscle to get the proper shaping effect.

When it comes to body implants, the shape objectives between men and women are different. Men undergo have body enhancements, such as the chest, arms or calfs) to create increased muscle size and definition. Women have body implants of the breasts and buttock to create more shapely soft tissue curves which are non-muscular in structure.

The distribution of fat in men is uniquely different from women. Men have liposuction exclusively in the stomach and love handle areas. While women have liposuction in the same areas they have a broader expanse of potential fat collections which leads to aspirated fat removal also being done in the extremities as well as the trunk areas of the back, hips and buttocks.

Excess and loose body skin occurs more selectively in men than women. Because of pregnancies and weight loss thereafter, women frequently require tummy tucks. Men only need such excisional body contouring surgeries after extreme amounts of weight loss. (greater than 75 to 100 lbs) Those skin removal needs are almost exclusively limited to the abdomen (tummy tucks) and chest and almost never in the extremities.

Plastic surgery for men has its own unique requirements both in the type of surgeries and the demeanor of the patients. One should not assume that every plastic surgeon or plastic surgery practice is equally adept about meeting the needs of the male patient. Just like breast reconstruction for women or body contouring after massive weight loss, the male patient presents unique challenges for a satisfying surgical outcome.

Dr. Barry Eppley

Indianapolis, Indiana

Contemporary Body Implant Augmentation Surgery

Sunday, May 26th, 2013

 

Muscular enhancement of certain body parts can be done through the use of synthetic implants. Everyone knows about breast implant augmentation although this is not a true muscular enhancement but a breast tissue enlargement. Historically the most recognized body implants were for the chest, buttocks and calfs. The number of such implants combined pale in comparison to the number of breast implants that are placed but that makes them no less useful.

The number of body implant surgeries that are performed have continued to increase over the past decade. Greater awareness and acceptance of body augmentations has fueled demand as well as improvement in  implant materials and surgical techniques. Body implants, unlike breast implants, are made of a solid but very soft and compressible silicone elastomer material. This makes them capable of being inserted through small incisions and to have a feel that is similar to what they intended to enhance…muscle. Because they are a completely polymerized non-liquid material they will never rupture, degrade or need to be replaced.With these better materials has come an expansion of body implants to new and innovative areas of augmentation. These have included such areas as the arms, shoulders and even the hips to create muscle prominences and increased curves.

Muscle implants are used to surgically build-out an underdeveloped area of muscle in the body. These muscle deficiences can be caused by a birth defect, a traumatic injury, or an aesthetic desire for body shape improvement. Aesthetic desires for body implants (pectoral, calf, arm implants) comes from an inability to build up the muscle adequately from exercise. There are also recent fashion and body image trends for an increased gluteal size. (buttock implants) Birth defects can also drive the need for implants and include club foot and Spina Bifida for calf implants, chest wall deformities from Pectus and Poland’s syndrome for pectoral implants and Sprengel’s deformity for deltoid implants.

An overview of old and new body implants includes the following.

PECTORAL IMPLANTS Male chest enhancement is done by transaxillary implant placement under the pectoralis major muscle but staying within the outline of the muscle. (unlike breast implants) They are available in different oval and more square shape forms.

BUTTOCK IMPLANTS Intramuscular or subfascial pocket placement in regards to the gluteus maximus muscle is used for implant location. I prefer the intramuscular location to reduce the risk of potential complications even if it poses size limitations (< 400ccs implant volume) and a longer recovery.

CALF IMPLANTS Being the smallest of all body implants, they have a cigar-type shape that are available in different lengths, widths and thickness. They may be used to build up the inside of the leg (medial head gastrocnemius muscle) or combined with outside of the calf augmentation as well. (lateral head gastrocnemius muscle)

ARM IMPLANTS The top (biceps) and bottom (triceps) of the arm can be build up for those men that either can’t get enough muscle bulk by exercise alone or want to maintain a more muscular arm shape with less long-term exercise maintenance.

DELTOID IMPLANTS While there are no true shoulder implants, they can be made by either modifying existing body implants used for other areas or hand making the implants from performed silicone blocks.

HIP IMPLANTS Placing implants placed below the muscular fascia below the prominence of the greater trochanter of the hip can build out an otherwise straight leg line.

Body implant surgery is both safe and effective when done by a surgeon who has good experience with these  materials and has anatomical knowledge of the different and varied parts of the body where these implants go. While fat injection augmentation has a valuable role in the enhancement of certain body areas also, synthetic implants offer a permanent and assured solution to body augmentation that has the trade-off of an implanted material and a longer recovery.

Dr. Barry Eppley

Indianapolis, Indiana

Reshaping The Leg With Liposuction and Calf Implants

Monday, November 19th, 2012

 

The legs are often overlooked when it comes to modification by plastic surgery. There are numerous procedures that can be done that focus on the thigh, knees and ankles. But before considering what to do, one has to know what makes a leg attractive. Most people know when they see a good looking pair of legs but describing why they look so is more difficult.

Whether it be female or male, the first important feature is a leg that is well proportioned to the rest of the body. It can not be too thick or too thin compared to the body frame onto which it is attached. The shape of the leg may even be more important with emphasis on its inner aspect. A straight line from the top of the thigh down to the ankle is desired with curves inward at the knee, top of calf and the ankle. As the line of the thigh crosses the knee, there should not be an outward bulge. Once below the knee, the line should curve inward and then out again at the top of the calf. The line then descends gradually inward towards the ankle. It is the straight inner line combined with curves around the knee that define an attractive leg.

These leg attractiveness concepts are important for a variety of plastic surgery procedures but none more significant than liposuction. While liposuction can not make a large leg small, it can create better shape. The bulges of the outer and inner thighs can be reduced to make the silhouette of the upper leg more straight.  While this  is commonly done, the knees and ankles are often overlooked. Many patients tell me they didn’t even know that these areas could be treated.

Liposuction of the knee can be one of the most gratifying areas to treat and the amount of fat removed can be substantial.  The knee bulge can be eliminated and a straight line made that extends from the thighs across the knees. When suctioning the knees, it is important to create an indentation below the knee and at the top of the calf, creating an in and out line below the knee. This provides a separation of the knee and the calf.

A more shapely ankle can also be created with small cannula liposuction.  The ‘cankle’ problem is the result of having no separation between the two. By removing fat from just above the angle on both its inner and outer aspects, the leg line can continue to move inward as it approaches the ankle. Liposuction can also be extended to the lower end of the calf to make it thinner also. Combining lower calf and upper ankle fat reduction helps make for greater definition of the bottom half of the lower leg.

Besides liposuction, there is another leg contouring procedure done below the knee….calf implants. Whether it is for calf asymmetry or calfs that are simply too thin, implants can be used to create the appearance of more muscle mass or bigger calfs. It is virtually impossible for ordinary people to build up the calf muscles through exercise. While the gastrocnemius muscle has two heads (inner and outer), most aesthetic augmentations are done on the medial or inner muscle head. This is because creating the outer bulge of the inner calf makes for a curvilinear shape below the knee. Calf implants, while creating a few centimeters of circumferential size increase, create their effects more by providing an increased calf outline and contour.

Greater leg attractiveness is desired for a variety of reasons which is almost an exclusive female concern. Being able to comfortably wear skirts and shorts is a primary objective. Through the artful use of liposuction, and occasionally calf implants, legs can be reshaped with a silhouette and lines that are more appealing.

Dr. Barry Eppley

Indianapolis, Indiana

Common Questions about Body Implant Surgery

Tuesday, January 26th, 2010

1. What is body implant surgery?

While everyone has heard of breast implants, few are aware that there are other locations for the placement of implants to enhance the contours of one’s body. All of these body implants are for the purposes of enhancing certain muscles. Think of body implants as muscle contouring surgery. These include traditional areas of the chest, buttocks, and calfs as well as newer implants for the arm (biceps and triceps), hip and deltoid areas. The majority of body implant patients are male.

Some may think that the use of these implants is cheating, as opposed to muscle growth through working out, but many of these procedures are used for reconstructive purposes as well. Some  patients may use them to help with genetic or injury-related body deformities caused by such conditions as pectus excavatum, spina bifida, and clubfoot. These cause deformities marked by muscle atrophy, underdevelopment or asymmetry.

2. Aren’t pectoral implants in men a lot like breast implants in women?

Yes and no. Pectoral implants, commonly referred to as breast implants for men or male chest implants, is done to  enhance the appearance, size and outlines of the pectoral muscles. Like breast implants, they are very effective at creating that change and are associated with no greater amount of risks or complications. From the standpoint of location under the existing pectoralis muscle, they are very similar to breast implants in that regard.

They do differ in that the end goals are not the same. Breast implants are trying to make a rounded or tear-drop mound that sits up and away from the chest wall and has some compressibility. Pectoral implants are only trying to push out the existing muscle and, as a result, need less volume to do so. A muscle also has more of a firm feel to it rather than displacement to the touch like a breast. Therefore,  pectoral implants are smaller in size and are composed of a soft but solid silicone elastomer. They are not fluid or gel-filled like breast implants.

3. What is the best way to achieve a larger and rounder buttocks?

There has been a significant increase in the number of buttock enlargement/enhancement requests. Fueled by increasing multiracial population growth and popular figures like Jennifer Lopez, more women are pursing an increased curvature to the buttocks through different forms of augmentation.

The debate in buttock augmentation is whether to do it through the use of an implant or with fat injections. There are surgeon advocates for both procedures and, when done well, satisfying results can be achieved either way. This is why it is important to look at each one’s advantages and disadvantages.

Buttock or gluteal implants have the advantages of a bigger and immediate result that will not change after surgery. Its downside is that it is a more invasive procedure, takes a lot longer to recover, and runs the risk of infection and implant displacement.

Fat injections have the advantage of a more ‘natural’ procedure that is not associated with any of the potential complications related to a foreign body. It also gives one the extra benefit of fat reduction from the donor site. Its disadvantages are that it can not usually achieve the same buttock size as that of an implant (at least in one fat grafting session) and the take of the fat graft is not completely predictable.

4. Can an implant make my calf bigger?

Calf augmentation creates fullness in the gastrocnemius muscle of the  lower leg by placing implants in subfascial pockets overlying the muscle. It can help those men and women who can’t achieve the size of the calf muscle they desire. The calf muscle is one of the more difficult muscles in the body to enlarge due to its very compact muscle fibers. This form of lower leg  sculpting can also correct muscle imbalance as a result of such congenital defects as disproportionate calf development, clubfoot, bowleggedness, and just plain skinny calfs. (aka ‘chicken legs’)

The calf muscle is a two-headed muscle in which one or two implants which may be used in each leg. A person may desire to have only the inner head of the muscle enlarged, the outer head, or both. They are inserted through a small incision in the skin crease behind the knee.

The biggest issue with calf implants is the recovery period. Because they are in the lower part of the legs, some significant swelling can occur. And it usually takes up to three weeks before one can walk more normally. Working out and other unrestricted activities will take at least a month or two following surgery.

Recent reports have seen the use of fat injections for calf augmentation. But this approach is just in its infancy and consistent long-term outcomes remain to be seen.

5. I have heard there are implants for the arms. Is this true?

Bicep and tricep implants will create muscular definition and perceived enlargement of the muscles in both the front and back of the upper arms. This procedure is done exclusively for those who can’t achieve the upper arm size they want even after significant efforts at muscular exercise. Generally, two implants are placed in each arm to give the greatest overall change.

6. Are there any new areas where body implants are being used?

The newest uses of body implants are for the hip and deltoid areas. Deltoid implants are used to rebuild or augment deficiencies of the deltoid muscle group caused by  congenital deformities (Sprengel’s deformity or scapular hypoplasia) or traumatic injuries. (motor vehicle accidents) Hip implants are exclusively done for cosmetic augmentation. For those women who feel that their hips are too narrow and want more of an hourglass figure, hip implants can give them more curvature.

7. What complications can occur with body implants?

Placing an implant always has the standard medical risks of infection, displacement, and chronic pain as well as the cosmetic risks of over- or undercorrection. Unlike the face, body implants are always placed in areas exposed to constant motion and stress and are much larger in size. As a result, they have a higher incidence of fluid collections and displacement.

Dr. Barry Eppley

Indianapolis, Indiana

Calf Implants for Lower Leg Enhancement

Monday, December 24th, 2007

Calf Implants and Augmentation

The use of calf implants to give the lower leg more shape is not as uncommon as you think. There are many different reasons why someone wants calf implants; from the bodybuilder who can’t get the calfs big enough compared to the rest of the thighs, a birth defect or surgically-induced problem where one calf is much smaller than the other (asymmetry), or someone that just has extremely thin calfs since they were born. (stick legs) Calf muscles are some of the hardest muscles to build up by exercise and are extremely resistent to getting bigger without a herculean effort at weight-lifting.

Calf implant surgery is based on two important concepts; the placement of calf implants to simulate the two calf muscles on both sides of the calf (although not every patient requires two implants per calf) and the use of rubbery (semisolid, not liquid) silicone implants that come in a variety of sizes and shapes. The location and size of the implants should be determined in the office in advance of surgery by measurements.

Calf implants are placed through an incision in the back of the knee and pockets into which the implants are placed developed within the calf muscles. After which, the implants are slipped into place. The surgery does not take long but you need to be prepared for some recovery after surgery. While the procedure is done as an outpatient, calf implant surgery can be quite painful and full recovery is going to require some time. Be prepared to do the following after calf implant surgery; plan to take two weeks off work, rest your legs and elevate your ankles for several days after surgery and use crutches to get around, plan to walk in heeled shoes for a while (walking flat footed initially is very uncomfortable), walk with knees slightly bent, don’t work out for 4 to 6 weeks after surgery, and avoid running for two to three months after surgery. The biggest complication of calf implant surgery is the implants shifting from their place or a fluid collection occurring around them (seroma). Both of these problems are caused by too much calf activity after surgery! Also, expect stiff and sore calves for a month or so after surgery.

Calf implants can definitely give a better shape and a more muscular appearance to the lower legs but you have to be prepared for the recovery period. Calf implants take the longest to recover from any other body implant surgery in my experience. (pectoral, biceps, triceps, buttocks)

Dr Barry Eppley

Indianapolis, Indianapolis


Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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