1. 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
Guest Lecture delivered on 02/02/2018 at 39th Indian Academy of Forensic Medicine Conference ,Pondicherry

2. 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

3. 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 !!!!!

4. 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

5. 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 )

6. 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.

7. 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

8. 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 ,000 USD
Liposuction – Taking out unwanted fat 10000USD
Chin and cheek implants USD
Blephropasty – eyelids lift 5000USD
Brow lift - Forehead lift USD
Abdominoplasty – ,000 USD
Labia plasty – labia Minora and majora reshaping ,000 USD
Breast reduction – 5000 USD
Vaginography and tightening -

9. 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

10. 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):

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

12. 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): Figure 12 abdominoplasty

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

14. 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

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

16. 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

17. 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

18. 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.

19. 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

20. 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):

21. 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 cm ( Av 10cm)

22. 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:

23. Scenario
At AIIMS……….
Liposuction 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
cases Houseman et al
, Grazer and Jong et al
Rao et al
2017 -Gluteal fat grafting -22 deaths autopsy based diagnosis PTE( Mark Mofid, Steven T at al Aesthetic Journal Surgery)

24. 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):
Paul J Therattil , Stella Chung , Aditya sood, Mark S Granick. An analysis of Malpractice litigation and expert witnesses . , At 32nd Annual Meeting NE Society of plastic surgeons) Vol17

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

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

27. 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):
-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:

28. 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

29. 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

30. Injuries attributable to cosmetic procedures by unlicensed persons
28 cases
Buttock injections
Face injections
Laser facial procedures 2
Liposuction
Burn
Ptosis
Scar
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.

31. 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

32. 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

33. 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

34. 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

35. 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):
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):
Paul J Therattil , Stella Chung , Aditya sood, Mark S Granick. An analysis of Malpractice litigation and expert witnesses . , 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):
Deccan Chronicle 2016 , 9th June Chennai

36. Thank you very much for your kind attention and opportunity