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(Follicular Unit Technique) & FUE (Follicular Unit (Follicular Unit Technique) A Surgical Solution to Baldness

Hair restoration has become one of the most popular techniques in male plastic surgery. Earlier used punch grafts were associated with a lot of unsatisfactory results giving a corn in a field appearance. A new era began in 1986, when Dr Carlos Uebel in the state of Rio Grande do Sul (Brazil) started the use of micro- and minigraft “megasessions.” It is considered a safe procedure which, allied to a natural hairline, is today a much valued option for surgeons and patients. Male pattern baldness (MPB) can start at the age of 16 years, caused by a coincidence of three main factors: hereditary, androgenic hormone and age. In today’s times, stress in the forms of smoking, late night jobs, long hours of work, irregular sleep cycles are contributing to the increased incidence in young men and women. Women are not immune from baldness, and indeed hair transplant is very successful in them also. In female patients hair fall appears more in the menopause period, but we also see androgenetic female baldness and thinning at earlier ages.

What is the Microfollicular Hair Transplant technique? In this technique, a strip of hair bearing skin is taken from the back of the head (which is the area of baldness. This area is relatively unaffected by the male hormones which are responsible for baldness. The hair bearing strip is cut down to single follicles under magnification. Slits are made by a microsurgical blade, while the follicular unit insertion is done with a micro forceps. This procedure can take 3-4 hours. Usually these two procedures are done side by by side, so the whole process can be expected to last 4-6 hours. For the front of the head about 1500-1800 hair follicle units are required. For a complete coverage, about 6000 units may be required. It is preferable to make a second replacement after 6-8 months.
Hair is like a plant â€" we need to keep a certain distance between each graft to enable them to grow with better vitality. In the frontal hairline we insert only single hair irregularly. To achieve a greater density, repeat sessions may be required.
The entire procedure is done under local anesthesia using a mixture of agents which are fast acting as well as have a prolonged duration of action. This allows a comfortable procedure, even while the patient is awake, and actively participates in the planning of the hair line. We have had patients driving back themselves to their homes after the procedure, of course with an attendant.

Hairline Design In young patients it is important to project the definitive frontal hairline.The frontal hairline is projected irregularly, maintaining the temporal recesses, and a non-straight line is important to achieve a natural and non-detectable result. The forehead middle point is normally 8 cm distant from the root of the nose varyingfrom 7 to 9 cm depending on the facial structure.

Post operative course The tiny hair that is transplanted in the graft normally falls out within the first few weeks. This is normal. The hair will then grow normally from the hair root and will be noticeable by approximately 3 months and carry on growing as fast and as long as your normal hair, usually about 1cm a month. Some crusting will occur around the grafts. These must not be scratched as the grafts may be pulled out. These crusts will quickly dissolve once hair wetting is started. The grafted area of scalp will appear slightly pinker than usual for a few days but this soon passes. It takes almost 6-7 months to appreciate good hair growth in men and about 9-10 month in women.

Follicular Unit Extraction This has been described as a Scarless Hair Transplant Procedure. Small punches of 1-1.5 mm are used to cut hair directly from the scalp and then implanted into the bald area. various donor areas such as the back of the head, chest hair, hair of the temple region, beard region can be used. This procedure is more time taking and generally limited to 800-1000 follicular units at a time. FUE is reserved for those who do not want a scar on the back of the head, or in those where sufficient scalp hair is not available.as the finest.

Body contouring - Liposuction and whole body figure correction

Liposuction
is the most common plastic surgery procedure all over the world. It is a permanent removal of fat cells by the use of a suction device. It is a safe procedure, with minimal down time. It has been shrouded in small controversies, and bad results, but this has been due to the procedure being done by untrained personnel, and other medicos who are not Cosmetic Surgeons.
Do not be led away by claims that the surgeon can remove 10 kgs or 12 kgs of fat and make you superthin. Please remember that the safe limits of liposuction are between 3-5% of the total body weight.

Procedure
The procedure involves infiltration of fluid into the areas to be liposuctioned. This has multiple benefits. It helps to loosen the fat, reduces the bleeding dramatically, and allows pain control after surgery as well. Usually Dr Amit Gupta infiltrates fluid in a ratio of less than 1:1 with the amount of fat that he plans to aspirate. The major benefit is that, what is aspirated is pure fat, and not water mixed with fat. This gives an exact estimate of the amount of fat taken out. We surgeons have a bad habit of including the amount of fluid aspirated into the total volume taken out also, so that we can boast of having done large liposuctions. What is important is not the amount taken out, but how much of actual fat there is.

The procedure is done with small incisions over selected areas of the body, after first discussing with the patient, and planning the site of the incision. These incisions generally are not visible and heal very well. They are only about ½ cm in length. There may not be a need to admit the patient in the hospital, so that the patient can go home the same day.

Precautions
After a liposuction, there is a need to wear specially designed pressure garment for upto 6 weeks. Any anticoagulant use such as aspirin should be stopped 1 week prior to surgery; smoking should also be stopped 2 weeks before to 2 weeks after surgery for best results

Newer technology
Power liposuction, vibro-liposuction, VASER, and laser liposuction are some of the newer innovations in this field. In Power and Vibro Liposuction the mechanical effort to carry out liposuction is reduced by the use of special machines, which produce a to and fro rapid motion, thus reducing mechanical fatigue and making the procedure faster. However these are significantly more expensive than conventional liposuction. Laser lipo allows very good redraping action on the skin; however its role in actual fat reduction is a bit controversial. Thus this has not found use in general practice.


Come and meet our doctors for further information.

Introduction
Breast Augmentation with silicone implants is an extrememly satisfying procedure for breast enlargement. It has been shown that silicne implants are safe or the body, does not cause any intereerence in lactation or cause any other problem at all. Since the availability of the best implants by MENTOR & ALLERGAN in various projections and profiles, we can almost customise the breast shape and size that the lady desires. We do stress to our patients to only go for implants manuactured by MENTOR or ALLERGAN since they are batch marked and offer warranties

Planning of the silicone implant breast enlargement surgery
The chest diameter and the breast dimensions are marked. This gives us an idea of the cup size, and the base diameter. The base diameter decides the maximum volume and projection of the implant that can be used. For a patient who required a larger projection for a given base diameter we select high profile implants. All this planning takes place in the preoperative period and depends on the aspirations of the patient. We get the patient to try on a few sample sizes of the implant to give her a feel of the procedure, allowing her to estimate the best volume for her.

Surgical Incisions and Procedure
Incisions like inframammary, periareolar, axillary, and transumbilical have been used. We prefer to use the inframammary and the transaxillary approaches.Positioning of the implant is either in the subglandular, subpectoral or subfascial (described by Dr Ruth Graf, and preferred by the author).Transaxillary approach allows a virtual scarless breast enlargement with endoscopic control.
Transaxillary technique of subpectoral augmentation has been available for many years, critics have observed difficulty in attaining precise positioning of the implant in the lower pole of the breast. Major advantages have been the absence of any scar on the breast surface, an avoidance of breast ductal transection, and a low probability of sensory nerve injury

Scarless Breast Augmentation/ Endoscopic Trans-axillary breast augmentation Endoscopic assistance has enhanced the transaxillary approach by allowing a more accurate placement of the breast implant.Described as scarless breast augmentation, here a pocket within the breast is made through an incision in the axilla. The implant is then placed through this incision itself,leaving the breast free of scars.

Silicone Gel Implants
Silicone, a polymer of dimethylsiloxane, is present throughout nature. Currently fourth-generation silicone implants (texturised implants)are used by the author. These implants do not rupture, have very low capsular contracture and do not leak. In some parts of Europe and Latin America, Polyurethane coated implants are being used. These implants are extremely soft, feel very natural, and have a long life. We are sure, that once these implants are available in India, they will become the most widely used

**** Come meet our doctors for more information.

MAMMOPLASTY (Female Breast Reduction)
Large breasts are often a source of embarrassment along with problems of ill-fitting clothes, inability to wear modern, designer clothing as well as back pain, bra strap marks on the shoulder, sweating and fungal infection below the breast line, and a general decreased self esteem.
Large breasts may be from teenage itself or more commonly after childbirth and lactation. The treatment for these problems is surgical reduction known as reduction mammoplasty or breast reduction.

Procedure Breast reduction involves an actual removal of excess breast tissue & skin,with internal breast tissue reaarangement to create a more shapely breast. Commonly this involves two different techniques:
The first is a Wise pattern (inverted ‘T’ scar pattern); the other is Vertical Short Scar Pattern. The latter technique is now well established, has a smaller scar, but can take upto 3 months to give the final breast shape

The ‘T’ scar technique
This involves a scar on the breast in the shape of an inverted T. The final shape is immediately visible after surgery, with little changes in the long term period.
The disadvantages of this procedure is long scar ( though the scar is hidden below the breast, so is visible only on lying down.

The vertical short scar technique
The procedure involves a vertical scar without the horizontal component. As a result of which the skin excision is more in the region around the areola (upper part). This procedure has been popularized by Dr Ruth Graf (Brazil)(with whom the author has trained with). The puckered appearance of the scar usually settles down in about 3 months.

The advantages of this procedure is shorter scar
The disadvantages of this procedure is that there may be need to revise the surgery in almost 30% of patients, the skin shaping is as not as good, because lesser skin is removed from the lower half of the breast and there are chances of scar stretching in the region of the areola.
This technique is not for women who have undergone rapid weight loss, and thus have more of loose skin. The success of the surgery depends to a large extent on the elasticity of the skin, and thus it is better to do a T scar procedure in these patients.

The Pectoralis Sling Procedure
This procedure involves using breast tissue from the lower part of the breast as a flap to increase volume in the upper part of the breast to give a pleasing shape. A sling is made from the Pectoralis muscle to support this breast tissue. This procedure has been popularised by Dr Ruth Graf (Curitiba, Brazil)
Possible problems with breast reduction.
The patient will be required to stay in the hospital for 1 day after the surgery. The possible problems associated with the procedure are

*lactation ability is lost on most patients. Ability to feed is the exception in most cases
*Sensibility of breast tissue will take almost 6 months to recover
*Chances of asymmetry are there
* In large reductions, some tissue loss is possible, but this heals.
*There may be chances of seroma or a hematoma formation

Introduction
Many young (as well as older) men have the problem of having excess of tissue in the region of the breast. This is clinically known as gynecomastia. Occasionally this may occur after disorders such as liver or kidney disorders, some medicines such as steroids. This is commonly seen in young men, who are working out and take steroid supplements for muscle building. Gynecomastia is indeed embarrassing because men have to modify their clothing to loose style shirts. They also find it difficult to go for activities such as swimming; outdoor sports where there may be requirement to take off shirts.

Physiology of gynecomastia
There may be an absolute increase of fat tissue (adipose type) or breast tissue (glandular type) or a mixture of both. Gynecomastia is classified into mild, moderate or severe depending on the projection of the breast.

Treatment
Gynecomastia is a surgical problem. The treatment may involve liposuction, surgical excision or a combination of both. If the cause is mostly adipose, liposuction is beneficial. If predominantly there is increased glandular tissue, then liposuction is not effective, and a surgical excision needs to be carried out. Usually, however there is combined use of liposuction and surgical excision for best results.

Results
The results of gynecomastia correction are satisfactory. Following the surgery, the patient gets more confidence to wear better fitting clothes and undertake outdoor activities.If surgical excision is carried out, there is a scar around the areola, which takes time to become less visible. Liposuction for treatment is becoming very common as this avoids the scar and the appearance of an operated look.

MASTOPEXY (BREAST LIFT)


Breast lift is a perfect solution to correct loose sagging breasts which are usually a result of age factor , pregnancy, breast-feeding that cause them to sag. This procedure can be performed alone, or in conjunction with breast augmentation to add more volume to the breast.

The procedure begins with surgical removal of excess skin to reposition & lift the areola and tighten the breast tissue. The incision patterns may vary, depending on the degree of skin excess and amount of lifting required, as well as patient and surgeon's preference. Performed under general anaesthesia, breast lift is a safe procedure and recovery is immediate and swelling subsides in 2-4 weeks & breasts may take 1-3 months to fully refine.

Breast Ptosis (Sagging breasts) and Breast Lift (Mastopexy)

Sagging breasts is medically known as Breast Ptosis. The breast tissue in these patients is adequate, but the women notice that the breast position is lower than normal, and they find it difficult to wear dresses and body hugging dresses.

Physiology of Ptosis
Normally the Nipple areola complex is at the level of the 5th Intercostal space. In any situation when the nipple is lower than this is referred to as ptosis. It may be mild, moderate or severe depending on the deformity present.

Correction of Ptosis
Mild ptosis may be corrected by simply putting an implant, in a process known as augmentation mastopexy. In situations where the breast tissue is adequate, and the use of implant is not desired, various techniques are available. In milder cases, a peri-areolar approach is used, which leaves virtually no scar on the breast. In more severe cases, more radical procedures are required, but the scar usually fades very well in a couple of months. The author uses the Pectoral Sling approach.

RHINOPLASTY

A good nose enhances the features of a face and even a slight imperfection can take attention away from a beautiful face. Rhinoplasty or nose correction surgery is performed either via a small external incision, or by a scar less technique, involving internal incisions that reshapes and re contours the nose creating a balance among facial features.

It can also be performed as reconstructive nasal surgery, which means correcting birth defects and disfigurements that are result of injury. Rhinoplasty can also relieve nasal obstruction and improve one's breathing. Particular care is taken to involve the patient at all stages of planning to achieve satisfactory results.

This procedure is generally performed as a day procedure under general anaesthesia & results appear within 6-8 days weeks with continued refinement till 6-12 months.

BLEPHROPLASTY

Introduction

Eyes are the mirror to the world. Indeed and eyes speak so much about the face of a person. They give out the inner emotions of the person, even when the person is trying to be someone else. And unfortunately they convey the age of a person, even if that person does not feel that old. Very early age related changes are easily visible in both the upper as well as the lower eyelid. An ageing lower eyelid with its hanging fat bags gives the feeling that the person is actually older than he is. in addition the tear trough deformity that is often present (the hollow crease present below the eyes), further aggravates the situation.It is possible surgically to correct this to a large extent, in a process known as blepharoplasty or eyelid rejuvenation surgery.

Causation of the ageing eyelids The skin of the lids tends to sag as a result of ageing. Further the fat bags which are present over the eyeballs tend to come out of their natural position, and get more visible. In some persons, the eyebrow also tends to sag down, and it is important to hitch the eyebrows as well as correct the eyelid problem.

Treatment The surgery can be done under local anesthesia in most patients. This involves an injection containing local anesthesia in the skin of the eyelids. The skin incision is just under the eyelashes, and the scar is easily hidden in the lines of the lids, and no evidence remains of the surgery. There is also the approach where the incision is done through the conjunctiva, known as trans-conjunctival blepharoplasty. Then the excess skin over the eyelid and protruding fat bags are removed, to leave behind a younger looking eyelid, and the look is not present anymore. The fat bags can also be used to cover the tear trough, and reduce the hollowness that is present under the eyes. This procedure has been popularised by Dr Ruth Graf in Brazil, under whom the author has trained.

Possible problems The skin over the eyelids is very thin; hence there is easily some swelling that comes there. This can take between 3-6 weeks to disappear. Thus the patient must know, that he/ she will need to wear glasses if they have to go back to work in this period. Some conjunctival inflammation can be there, particularly with the trans-conjunctival approach. If the patient is hypertensive, it is mandatory that this is controlled well before surgery. If there is the use of aspirin or similar drugs, they need to be stopped at least 7 days before surgery; otherwise there is a greater chance of bleeding.

Abdominoplasty and mini abdominoplasty ( Tummy tuck and mini tuck)
Introduction
Loose hanging skin in the region of the abdomen is very resistant to any kind of exercise and is very embarrassing to the person, because it prevents wearing of proper clothes and is visible as a hanging flab of tissue. this is particularly more common in post pregnant states where the expanded abdominal skin fails to retract back to its normal contour. This tends to be less common in men.
The surgical procedure done in this condition is known as a tummy tuck or an "abdominoplasty". A tummy tuck involves removal of the excess hanging skin along with the underlying fat to give a flat and toned abdomen. This procedure tightens the abdominal muscles and gives a new, rejuvenated abdomen. The position of the umbilicus is also shifted to a more natural position.

The scar
A lot of patients are worried about the scar of the tummy tuck. It is reassuring to know that the scar can be placed according to the type of clothing that the patient prefers to wear, and it is not visible from under the clothing. Thus, if the patient wants to wear a particular type of bikini, we can site the scar accordingly. The scar can be shaped according to the type of jeans or dresses, which the patient may prefer. The scar is fine and tends to mature a lot over time.
How is tummy tuck done
Tummy tucks are done under general anesthesia. Marking for the incision and determination of the amount of tissue to be removed are done in the preoperative period. After the necessary amount of skin and fat has been removed the muscles are tightened. It is also possible to produce a shaping of the sides by tightening the muscles there.
What is mini tummy tuck
In a condition where there is not that much of lax skin and the position of the umbilicus is not too low, the surgery can be made less extensive and limited amount of skin can be removed and abdomen shaped. It is possible endoscopically to tighten the muscles of the upper abdomen to give a better shape and figure also
Post operative period
the patient needs to have restricted physical activity for about 3 weeks after surgery. Gradual walking and light exercises should be done. Sexual activity must be avoided for 3 weeks and after that care to be maintained for another 3 weeks. Child birth is to be avoided for a period of 2 years. We cousel the patient to undergo a tummy tuck once she has completed the family.
Why tummy tuck and not liposuction alone?
The loose hanging skin does not retract well, as there is damage to the elastin fibres due to stretching. liposuctioin can only remove fat, and does nothing to the skin. Thus in the event of excess skin, it is practical to consider a tummy tuck. Liposuction is combined to Shape the upper part of the tummy and give a “younger" look.
Lipoabdominoplasty Today most of the tummy tucks are combined with liposuction in a procedure known as lipoabdominoplasty. Conventionally the lower part of the abdomen has the extra skin, which is removed. To tighten the abdominal muscles, the central part of the upper abdomen is undermined. In the lateral upper abdomen, and the flanks, liposuction is done to give a beautiful shape and leaner appearance.
Endoscopy assisted Mini tummy tuck In a mini abdominoplasty, the upper abdomen is never undermined. However it has been seen that tightening the muscles in the lower tummy leads to a gradual bulge in the upper part of the abdomen over a few years. Therefore, some surgeons (including myself) like to tighten the muscles in the upper part of abdomen using endoscopic assistance.

FACE LIFT (Rhytidoplasty)
The face is the social parameter of a person. We often judge a person by his or her initial appearance, and it is the face which tells the observer a lot about us, and unfortunately about our age also. The visible effects of ageing appear first on the face, and make the person look older than he or she feels.

Brief physiology of ageing : The face betrays the effects of gravity and the effect that the beating of the sun has on it. There is an effect both on the skin as well as on the underlying structures such as the SMAS ( the underlying soft tissue below the skin lying over the muscles of the face). The ultraviolet radiation has the ill effect of skin damage and gravity adds the effect of descent of tissues. It is therefore essential that any surgical treatment protocol involves tackling both the skin as well as the underlying SMAS layer. It is possible now to surgically peel off a few years off somebody’s face without giving her/ him too many visible scars

The Face Lift - what is it and how is it done Surgical face lift is a procedure that can be done under local (under injections + sedation) or general anesthesia. It involves an incision at the junction of skin of the face and the ear. (Nowadays short scar face lifts are done, where the scar is very small and over a period of time are rarely visible enough to draw attention). After the incision, the skin and the underlying SMAS is tightened and pulled in an antigravity fashion to oppose the effects of gravity. Once the symmetry is achieved on both the sides, the incisions are closed taking care not to disturb the hair line or disturb the appearance of the ear. In men the side burns can get effected and gets closer to the ear, therefore they are forewarned about the possible requirement of laser to allow hair removal. However it is not required in the vast majority of the population.

Results Following a face lift, you can expect a role back of almost a decade in your physical appearance. Combined with a PIXEL laser, it gives also a fresh and rejuvenated, soft skin to complement the effect of surgery. A good facelift, is symmetric, maintains the hair line, both in the region of the temple and in the back of head, as well as maintaining the symmetry of the ear. We can expect the effects of a surgical face lift to last for over a decade to almost 15 years if the procedure has tackled both the skin and the underlying SMAS. A number of surgeons do not tackle the SMAS for fear of injuring the underlying nerves, but no face lift is complete, without this, and at best skin only procedure, gives benefit for a few months. Revision of a face lift is also possible, and it is also possible to correct a prior poor face lift. Most common effect of a poor prior procedureis a disturbed hair line in the region of the temple, but such cases can be tackled with hair transplant in this area. The face lift can be combined with eyelid surgery (blepharoplasty) to give a young look to the eyelids also.

Complications of Face lift The most common complication is bleeding and haematoma formation in the post operative period. Therefore it is essential that no patient should be on aspirin therapy prior to procedure and blood pressure should be well under control before surgery.

Hospital stay The patient need only stay in the hospital for about 24-36 hours, after which he or she can go home, but under watchful supervision. There is a definite downtime, and time has to be taken off from work/ social responsibilities to allow the incisions to heal and all the post operative swelling to settle down.

MACS LIFT - Now in India at a Fraction of the Cost of that in Europe, contact our doctors for more information.

BUTTOCK IMPLANT
The Buttock lift is a new procedure which involves placement of an implant in the buttock region to provide that special look to the rear. It allows for treatment of a sagging buttock, while also to augment the appearance of the buttock. The procedures are performed endoscopically to reduce the size of the scar.

CALF AUGMENTATION
Augmentation of the calf region is done endoscopically with the placement of implant in the lower leg, to produce the athletic leg appearance. This procedure is another revolution previously unavailable in India.

AUTOLOGIUS FAT TRANSFER
Fat is used as a permanent filler to produce lip augmentation, to fill wrinkle lines along lips, nose, below the eyes and to augment the buttocks. Fat is harvested from the abdomen or thighs, processed with delicate care and injected into the required area to produce permanent results. Most of these procedures are performed under local anaesthesia allowing speedy recovery and early return to work.