Cosmetic Surgery & Procedures - Medico-legal implications :Current Scenario Prof OP Murty , MBBS,MD Professor , Forensic Medicine and Toxicology , All India Institute of Medical Sciences ,New Delhi 110029 Guest Lecture delivered on 02/02/2018 at 39th Indian Academy of Forensic Medicine Conference ,Pondicherry

ISAPS News Volume No2 International Society of Aesthetic Plastic Surgery Over 20 Million Cosmetic Procedures World Wide ! Beauty at any cost Ideals of beauty Ve Google Inc. Vienera Molaskaya , Paris

Motivations for Cosmetic Surgery External: appearance matters; avoidance of ethnic prejudice; fear of age discrimination; bullying by spouse/parent/boss/peers Internal: desire to avoid unpleasant feelings low self esteem , depression, shame, or anxiety; to alter a specific feature they dislike; desire for a more youthful, healthy look that matters , fertility (women); interest in developing a strong, powerful look that may facilitate career progress Requirement – handsome boy / beautiful girl !!!!!

Cosmetic Demand Adolescent – Body image , fat control, facial look so nose reshaping , augmentation of breast , liposuction, acne and hair procedures Young Adult female – look, facial look , lips , nose breast and hip augmentation, liposuction , shaping of buttocks and thighs etc. The Jade Lady Membrane Man-Made Hymen, marketed in China; Blood-colored fluid released during sex After delivery – liposuction , abdominoplasty , vaginal stitching and reshaping Commercial body image industry – looks and curvature Old age – enlarged and flabby portions

Hate Injuries cosmetic requirement Vitriolage – throwing acid Recent Amendment in law 326 A, 326 B IPC Cutting of penis – re-grafting 320IPC Cuttings of nose and ears 320 IPC Branding scars / burns simple/Grievous Tattooing by gangs Cutting of nose, ears in wars in India (Sushtra 6000 BC figure above )

Formulas of beauty Parameters change according to ….. Formulas of beauty were studied by different people. F.e. Leonardo da Vinci. According to his measuring – Distance from nose to chin = from eyelids to hair line Between eyes = length of eye Mouth not more than lines from interior border of iris Length of hand = height of face Measuring of Venire statue made by Orden in 1683.

Cosmetic female operations .. Joselein Wildeintein Eyelids lifting Liposuction Abdominoplasty Vaginal tightening after delivery Labiaplasty Other genital modifications as suggested in next slide. Face lift Hair removal Nose shaping Lips Breast Augmentation Hips augmentation Thighs shaping Botox injection Hyaluronic injections Katie piper

Cosmetic Surgery Approximate Average Rates.. Rhinoplasty – Reduce or increase , shape change of nose 6000USD Breast Augmentation – Enhance the size of the breats by silicone or saline implants 5000-10,000 USD Liposuction – Taking out unwanted fat 10000USD Chin and cheek implants -4000-5000 USD Blephropasty – eyelids lift 5000USD Brow lift - Forehead lift 3000-5000USD Abdominoplasty – 6000-10,000 USD Labia plasty – labia Minora and majora reshaping 5000-10,000 USD Breast reduction – 5000 USD Vaginography and tightening -

Demand in increasing Liao LM, et al. BMJ,2007;334:1090-1092 Labiaplasty 80% increase (404in 2006;1118 in 2008) Labia reduction 65% increase Vagina tightening 35% increase Clitoral hood reduction Vaginoplasties ( Pardo et al , 2006) Hymen repair G -spot on ant wall of vagina , 2.5 cm from entrance , nodule augmentation

Cosmetic Surgery of Female Genitalia Labioplasty –Labia minor and majora -Reduction or Augmentation Vaginal tightening procedures Hymenoplasty Clitoroplasty – hood reduction, clitoroplexy, size reduction Perineoplasty – reconstrution of vaginal introitus Pubic - lifting , liposuction G- spot augmentation on ant wall of vagina along urethra – bunch of erectile tissue which increase during act Julie MLCL Dobbeleir, Koenraad Van Landuyt , Stan J Monstrey . Aesthetic Surgery of the Female Genitalia. Seminars in Plastic Surgery, 2011;25(2): 130-141.

Breast/Hip Augmentation Enhances Size by silicone or saline implants In breast these are behind pectoral muscle Cost varies 4000-10000USD International Business Times , NY 5TH August, 2004- Grammy awards function Dangerous Curves High heels, thigh sharper , thongs , butt padding, skinny jeans ……permanent silicone bodies

Abdominoplasty Removes extra fat , skin from lower and middle abdomen Incision above pubic area from hip to hip bones in front Scarring , infections , takes 6m-1year to properly set Example Ref Figure 12 : Julie MLCL Dobbelier , Koenaard VL, Stanjay Monstrey. Aesthetic Sugery of Female Genitalia . Seminars in plastic Surgery , 2011; Volume 25 (2): 130-141. Figure 12 abdominoplasty

Breast implanting Localization of implant Over breast muscle Under breast muscle Silicone gel implants Saline implants Oils ….. Illegal

Cosmetic Procedures Procedures involve skin puncture : dermal filter injections; botulinum toxin A injection ;autologus platelet –rich plasma; skin whitening injections; lipolysis injections; microneedle therapy ;tattooing ;body piercing Chemical/ mechanical exfoliation of skin : microderma abrasion; chemical peel; water microjet plus vaccum Procedures involving external application of energy: Laser (class 3b and 4) ; radiofrequency ; intense pulse light; extracorporal shock wave; lipolysis by ultrasound ; Cryolipolysis;plasma; high voltage pulsed current ; light emitting diode phototherapy; infrared light ; micro-current therapy; cryo-electrophoresis; pulsed magnetic field therapy; microwave application Other therapies : colon hydrotherapy; hyperbaric oxygen therapy; dental bleaching ; suction massage

Blephroplasty Remove of excess fat , skin and muscles from upper and lower eyelids Brow and / Forehead lift –corrects drooping brows and smoothes forehaed Cost 4000-6000 USD Example

Microderma abrasion To remove dead outer skin Sandblaster spray with pressure stream od aluminium oxide and salt crystals 5-10 sittings Cornea protection is required

Chemical peel To remove damaged outer layer of skin Carbolic acid ( Phenol) , trichloroacetic acid Alphahydroxy acids for light peel Disadvantages Permanent lightening and loss of tanning capacity Allergy Blisters and fever

Botulinum is a product of the bacteria Clostridium Botulism Botox cosmetic is an acetylcholine inhibitor and neuromuscular blocking agent used to improve appearance Given at 5 places on face , max 20 units , 4-5 units at one place by IM injections Symptoms are consistent with botulinum toxin effects.

Injectable used Hyaluronic acid Sodium hyaluronate Collagen Polyactic acid Polyacrylamide Cosmetic injection , anti wrinkle injections , lip injections ,for agelines , ehance pouting of the lips , facial wrinkles etc…. Cosmetic tourism Collagen Injections To provide full to lips , face , hands Stinging , burning sensation , swelling , allergic reaction, flu-like syndrome Infections

Men Neck lift Penis enlargement Face lift Penis lengthening Eyelid surgery Liposuction Breast reduction Hair transplant Laser hair removal Chemical peeling Ear reshaping Penis enlargement Penis lengthening Penis reconstruction Hidden penis Buried penis Scrotum reduction Peno-scrotal web Girth increase Gray J Alter , Christopher J Salgado, Harvey Chim .Aesthetc Surgery of the Male Genitalia.Seminars in Plastic Surgery, 2011;25(3):189-195.

Top for men Liposuction Rhinoplasty Otoplasty Eyelid surgery Face lift surgery Michel Jackson Penis ( Text Atlas of Penile Surgery) Micro- less than 2cm at birth , 2.5 cm at 1yr, 4.0cn at pre-pubertal age Less than 10 cm in adult Flaccid penile 5-13cm 9(Av9cm) Stretched penile size 7.5 to 17.5cm ( AV 12.5CM) Flaccid penile 8.5 -11.5 cm ( Av 10cm)

Beauty Parlor Syndrome Transitory symptoms during and after visit Headache , neck ache , slurred speech , visual disturbances , neck fractures , massage related issues , infections, dye reactions More in: advanced age , HT , DM , Obese , smoking , inactive lifestyle . Neck Massage – fracture Leg massage –PTE David SY Wong. Beauty Parlour deaths and the medical profession. Hong Kong Med J 2014;20:352-353.

Scenario At AIIMS………. Liposuction - 2 fatal female cases published - JFMT , IAFMT died due to fat embolism Laser burns during hair removal 1 unpublished- simple burns With mild scarring over legs Other Indian News paper reported cases – Chennai -1 Hair transplantation of one medical student at Chennai Majority cases go unreported …………………… ----------------------------------------------------------------------------------------------- World ( Liposuction ) complications 2008 – 72 cases Lehnhardt et al (23 necrotizing ,PTE) 2004 – 14 cases Hanke et al 2002- 36 cases Houseman et al 2000- 95 , Grazer and Jong et al 1999- 5 Rao et al 2017 -Gluteal fat grafting -22 deaths autopsy based diagnosis PTE( Mark Mofid, Steven T at al Aesthetic Journal Surgery)

Recent …. 2017 -Litigation in Plastic Surgery – 93 cases (Procedures :Cosmetic breast -32 ;liposuction-17;Body contouring-13; facial rejunvenation-11; non-invasive -5 ; breast -5 reconstruction ; rhinoplasty -3 ; lasers -2 ; burn-1 ,etc… Cause of action( n-93): misrepresentation 3& , loss of consortium3.2%, breach of standard care , failure to diagnose & failure to treat ( 30%); lack of consent 30%; Negligence 50%; surgical error 2% ; wrong procedure 1 % ; etc. Also read : MayroforuA, Giannoukas A, Michalodimitrakis E . Medical Litigation in cosmetic plastic surgery. Med Law 2004;23(3):479-88. Paul J Therattil , Stella Chung , Aditya sood, Mark S Granick. An analysis of Malpractice litigation and expert witnesses .www.eplasty.com , At 32nd Annual Meeting NE Society of plastic surgeons) Vol17

Hair Transplantation .. One Medical student in Chennai paid Rs.73,000/-for hair transplant – 10 hours surgery died ( Ref: Deccan Chronicle June 9, 2016)

Risks of Cosmetic Surgery Infection Bleeding Hematoma Seroma , Necrosis Swelling Delayed healing Bruising Irregularities Asymetry Nervous loss Disfiguring scarring

Top Surgeries for female Complications Beast augmentation Liposuction Eyelid surgery Face lift Neck Lift Abdominoplasty Abscess, granuloma , TE, FE, VisPer, Infection * Scarring , infection Infection , allergy Infection , scarring Fat em, inf , scarring -Frederick M Grazer , Rudolph H , De Jong . Fatal outcome from liposuction: Census survey of Cosmetic Surgeon . Plastic and reconstructive Surgery ,2000;105(1):436-446 -Paul Harboe Jaconsen , Lisbert R Holmich , et al. Mortality and Suicide Among Danish Women with cosmetic Breast Implants. Arch Int Med,2004;164;13/27:2450-2455.

Procedure wise complications Face- scarring - nerve damage, asymmetry, botox poisoning Nose – deformation Eyelids- dropping , scarring , infection Breast augmentation - infection, deformity, visible implant, loss of function , numbness , scarring Liposuction-uneven areas, contour disfigured ,fat-embolism, more deposition

Procedures complications Tummy tuck- seroma, bulging tissues( dog ears), infection, necrosis, DVT Thigh modification- seroma, infection, delayed healing, scarring Vaginography – infection , urinary incontinence Penis enlargement – deformation and scarring Penis implants – failure , infection

Injuries attributable to cosmetic procedures by unlicensed persons 28 cases Buttock injections 11 Face injections 7 Laser facial procedures 2 Liposuction 2 Burn 1 Ptosis 1 Scar 1 Results : Injuries -16; hospitalization -8; death -4 ; amputation Ref: Janathan E Mayer , David J Goldberg . Injuries attributable to cosmetic procedures performed by unlicensed individuals in United State . J Clin Aesthet Dermatol.2015;8(10):35-37.

Consent 1. Competence to understand and to decide Need for treatment 2. Voluntary decision making capacity 3. Disclosure of material information ( Pros and cons) 4.Recommendation of plan and execution 5.Comprehension of terms and finance plans 6. Decision in favour of plan considering above, and finally 7. Authorization of plan Need for treatment Modalities of treatment Finance matters ( fix and variables according to post operative condition ) –Rough estimate Duration of surgery Number of sittings Expected results Follow-up Instructions before and after

Service Providers Unlicensed and unregulated Saloons Beauty Parlors Derma clinics Massage Parlors Beauty products Unregulated and poorly -trained service providers Hygeine Safety First aid Resuscitative facilities Control Registration Substandard products

Consumer complaints & remedies Informed consent Avoid Guarantee Clear financial terms Clean equipped sterilize OT and instruments Reasonable patient outcome Post operative photographs Drawing documents Good follow up District forum – if less than 20 lacs State commission – up to one crore National commission- if more than one crore Criminal complaints – on death or Grievous hurt / simple injury

Drugs and Cosmetic Act , 2016 (Amended) Sec9 –Misbranded drugs Sec9A-Adulterated drugs Sec 9B-Spurious drugs Sec9C-Misbranded drugs Sec 17 C-Misbranded Cosmetics Sec17 D –Spurious Cosmetics Sec 17 E- Adulterated Cosmetics Sec27- Penalty for manufacture, sale etc. in contravention – if 320 IPC satisfied then 10 years or life plus 10 lacs as fine Sec 33J –Punishment for subsequent offences

References Indian Drugs and Cosmetic Act , 2016 Indian Penal Code International AssocIation of Aesthetic Surgery USA Bulletin YMCA bulletin Julie MLCL Dobbeleir, Koenraad Van Landuyt , Stan J Monstrey . Aesthetic Surgery of the Female Genitalia. Seminars in Plastic Surgery, 2011;25(2): 130-141. Janathan E Mayer , David J Goldberg . Injuries attributable to cosmetic procedures performed by unlicensed individuals in United State . J Clin Aesthet Dermatol.2015;8(10):35-37. MayroforuA, Giannoukas A, Michalodimitrakis E . Medical Litigation in cosmetic plastic surgery. Med Law 2004;23(3):479-88. Paul J Therattil , Stella Chung , Aditya sood, Mark S Granick. An analysis of Malpractice litigation and expert witnesses .www.eplasty.com , At 32nd Annual Meeting NE Society of plastic surgeons) Vol17 Julie MLCL Dobbelier , Koenaard VL, Stanjay Monstrey. Aesthetic Sugery of Female Genitalia . Seminars in plastic Surgery , 2011; Volume 25 (2): 130-141. Deccan Chronicle 2016 , 9th June Chennai

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