​The hymen is a diaphragm-like structure located at the external opening of the vagina. The aperture(s) in the hymen helps in the drainage of the menstrual blood. The hymen varies in appearance. Some individuals may have multiple apertures instead of a single aperture in the center. It can be either a thin or a relatively thick structure. 
The hymen gets disrupted following sexual intercourse. Following disruption, the hymenal remnants at the external vaginal opening are known as hymenal carunculae. The hymen can also get injured following clinical examination, strenuous physical exercise or disease. hence its appearance is not a definitive indicator of the virginity of a woman or a girl. The presence of an intact hymen in a bride is considered very important in some cultures. This probably arises from a correlation between an intact hymen and virginity. 
It is possible to repair a laceration of the hymen. This procedure is also known as hymenoplasty. Some also know this cosmetic surgery as 'revirginization'. It is a small procedure which does not require an overnight stay in the hospital. We usually perform this procedure under general anesthesia. The remnants of the hymen are carefully brought together in layers using fine absorbable stitches. Follow up is done after a few days as an outpatient. 
Patients should avoid strenuous activity for a few weeks following the procedure. The labial folds should not be stretched apart for a month following hymenoplasty. We recommend at least six weeks for the tissues to heal. There are no restrictions on any activity after this period. 
Hymenoplasty is a relatively new technique among other female genital cosmetic procedures. It may help some individuals cope with the stress arising as a result of the cultural taboos of our society. 

Lipomas are small soft swellings commonly found beneath the skin. Lipomas are usually painless. In most cases, they are accidentally detected while touching the area. In some individuals, they can be large and obvious from a distance. Some of us tend to get multiple lipoma over the body and face. This condition is known as lipomatosis. This may run in certain families. Lipomas are removed either to ascertain the diagnosis or because they are considered unsightly. Lipoma removal is usually an outpatient procedure. Patients can go back home after the surgery. 

The traditional technique of removal of a lipoma is with open surgery. An incision placed on the skin is used to dissect the lipoma away from the surrounding tissues. The disadvantage of this technique is the resulting lengthy scar. There is a newer technique which can minimize the length of the scars. This is achieved by means of liposuction. During liposuction, the fat in the lipoma is aspirated with a small tube (cannula) attached to a suction producing device. The tiny cannula is inserted with the help of a small incision. The residual lipoma which remains after liposuction can be removed with the help of a small incision. This technique has significant cosmetic benefits because it leads to a short scar. Thus all scar-related consequences such as hypertrophy, color and texture changes of the overlying skin are minimized. Patients are later reviewed in the clinic. It is usual to have some induration at the operated site. This gradually subsides over the next few weeks. The recovery following this procedure is similar if not faster when compared to the traditional technique for removal of lipomas.

Liposuction for the removal of lipoma is a good option for those who want to get it removed with the help of very small incisions. It is especially recommended for individuals with multiple lipoma as the resulting length of the scars are less compared to the traditional open technique. 

Gynecomastia correction is commonly performed for improvement in the aesthetics. It is done as an outpatient or short stay procedure. Which means that patients do not have to spend a long time at the hospital. 

Anesthesia: Depending on the severity of gynecomastia and patient preferences, the corrective surgery is carried out under local anesthesia or general anesthesia. In case of small enlargements carried out under local anesthesia patients are sent home the same day. In case of cases treated with general anesthesia, we opt to retain the patient overnight at the hospital. 

Returning home: Patients can go home the next day after the change of dressing. Patients are usually comfortable after the surgery and most report only minor discomfort and do not require multiple analgesics. Patients can shower next day onwards and are advised to apply a small pad over the suture line. Pressure garments have to be worn constantly for a month. 

Follow-up: We see patients in our outpatient set up after a few days to check on the healing. During this visit, most of the swelling has started to subside. Some of our patients resume light work after a few days. Sutures (stitches) placed on the areola (pigmented skin around the nipples) are removed at one week. 

Resuming work and exercise: After a week light exercise like running and walking can be resumed. We see our patients again at the end of a month. By this time, the improved contours of the chest are well made out. After a month there are no restrictions on any activity. We ask for a review at three months and one year after surgery. 

Most of the patients have an uneventful recovery. Some patients may get prolonged swelling due to postoperative collections. These are usually treated conservatively and settle after a period of time. The collection usually does not make any difference in the final outcome of the procedure. Gynecomastia surgery is associated with a high satisfaction rate and patients report an increase in self-confidence after the procedure. 

Male breast enlargement or gynecomastia can be treated effectively with liposuction and direct removal of the gland. And a significant number of such patients can be treated under local anesthesia. With improvements in anesthesia techniques, it is possible to have a near pain free experience. There are certain advantages in undergoing the procedure under local anesthesia. These include:

1. Faster recovery:  Patients can return home soon after the procedure. The benefits also include the absence of general anesthesia associated effects like nausea and vomiting.
2. Improvement in safety: It is safer when the surgery is performed under local anesthesia. Liposuction under local anesthesia has been shown to result in far less number of adverse events when compared to general anesthesia.
3. Good pain relief in the postoperative period. Careful infiltration of local anesthetic solution is important for adequate pain relief during the procedure.This also has the added benefit of giving good pain relief for a long time after the surgery.

Some types of gynecomastia are particularly suitable for treatment under local anesthesia. These include:

1. Glandular enlargement confined to an area close to the nipple areola. These cases usually present with a bulge under the areola.
2. Milder forms of gynecomastia.  Even larger variants can be treated in a motivated patient these take longer to complete.

There are certain disadvantages when doing liposuction and excision under local anesthesia when compared to general anesthesia. Perhaps the most important would be the longer duration of the procedure. Local anesthesia should be allowed to act for a sufficient duration before liposuction is begun. Similarly, it is common to again inject the anesthetic solution and wait before resuming the procedure. The procedure takes longer to complete under local anesthesia. Individuals who are afraid of needles and do not want to be awake during the surgery may not be right candidates for the procedure.

To summarize, local anesthesia is a good option if you are adequately motivated and have one of the milder forms of gynecomastia. The advantages include faster recovery and improved safety profile of the procedure.




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Revision rhinoplasty is a secondary correction of a previously operated nose. It may be carried out for improvement in appearance and breathing (function). A significant number of patients who have undergone rhinoplasty present themselves for revision surgery. According to some reports, this is as high as twenty percent.

Why do undergo a secondary rhinoplasty?
The dissatisfaction with appearance could be as a result of unrealized expectations or due to the presence of a new deformity. It could be an unexpected result due to scarring associated with the previous surgery. A rhinoplasty is associated with swelling which can last approximately one year. The final shape of the nose is not apparent up to one year following a rhinoplasty. Because of this, it is prudent to wait for at least one year before carrying out a secondary correction.

Who is a good candidate for secondary rhinoplasty?
A good candidate should have realistic expectations about what can be achieved following a secondary correction. Depending on the existing anatomy there is usually a limit to the amount of improvement that can be achieved with corrective surgery.
Also, patients should be in good health. Smokers have significantly higher complications associated with healing when compared to nonsmokers.

When is a secondary rhinoplasty performed?
Secondary correction is done after allowing sufficient time for the tissues to settle. This usually takes around one year after the first surgery. In the case of corrections undertaken after a second or third surgery, we wait for more than eighteen months.

How is revision rhinoplasty different from the primary rhinoplasty?
Revision rhinoplasty involves manipulation of tissues which have been altered during a previous surgery. There will be scars as a result of the previous surgery. In many cases, some of these scars would be excised and in others, the scars may be left behind or used as a filler material.
Additional support to the nose may be obtained by the use of cartilage grafts from donor sites such as ear or ribs. It is likely that cartilage donor sites within the nose may be exhausted during the primary rhinoplasty.
In general, a secondary correction is more difficult and time-consuming when compared to primary correction.

How is the recovery following revision rhinoplasty?
The recovery following revision rhinoplasty is similar to that of a primary rhinoplasty. A nasal pack may be used for one or two days. Dressings are usually removed after two days. A splint is used in case the bones have been manipulated. Sutures come off within a week.
Patients are usually able to resume light work after a week. Most of the swelling disappears within a month. The nose settles into a final shape by approximately one year following surgery.

What are the benefits of undergoing a secondary rhinoplasty?
An improvement in appearance and function is associated with improvement in self-esteem and confidence. A positive outcome following rhinoplasty is a very rewarding experience for both the patient and the treating surgeon.

For more information on rhinoplasty, click here.  

Filler injections are most commonly used in cosmetic medicine to treat wrinkles and plump up lips. They are very popular because of the minimal downtime and reliable results. 

Our skin becomes thinner as we age. This leads to wrinkles and creases. Loss of volume is also seen in the fatty layer under the skin. This causes sagging of the various youthful highlights of the face. Apparent lengthening of the lower eyelids, the descent of the malar (cheek) mounds and appearance of jowls and prominent folds between the nose and cheek are some of the changes as a result of volume depletion of these deeper layers.  Fillers can counteract these changes by providing volume to the skin and the fatty layer below it.

Various substances are employed as fillers. For example, hyaluronic acid, collagen, and hydroxyapatite based fillers. They differ in their indications, risks, and duration of action.
Hyaluronic acid fillers are perhaps the most commonly employed fillers. Hyaluronic acid is a naturally occurring substance found in the body.  Hence they are not associated with allergy following injections. Hyaluronic acid in addition to supporting the tissues also draws in water. This property also contributes to the volume enhancement. This, in turn, leads to a better appearance due to improvement in proportions of the treated areas.

Uses of filler injections 
They are most commonly used for: 

1. Treatment of fine wrinkles and lines
2. Treatment of marionette lines in lips
3. Off-label uses include lip augmentation and improvement of tear troughs and scars. Fillers are a convenient way to add volume to lips to give it a fuller appearance. 

Duration of action of hyaluronic acid fillers
Hyaluronic acid is metabolized in the body by hyaluronidase enzyme. The duration of action is approximately 8 to 12 months. It is possible to reverse the effect of a filler injection by injection hyaluronidase. 

Common side effects of hyaluronic acid fillers 
The most commonly include side effects include swelling, bruising and lumps. These are mostly temporary and last a few days. Cold compresses help in the resolution of these symptoms if they occur. Tyndall effect is a bluish discoloration as a result of superficial injection of the filler in areas with thin skin. Visual disturbances and vascular compromise are very rare complications seen with filler injections. 

Contraindications for filler injections
The following increases the risk of adverse events and constitute contraindications for filler injections: 

1. Unrealistic expectations
2. Bleeding disorders
3. Infection at the site 

How does one get a filler injection? 
A consultation helps the doctor to understand the expectations of the patient. A filler injection is an outpatient procedure. The area to be treated is numbed with a numbing cream or injections. The filler is injected into the area with syringes with very fine needles. There may be bruising at the treated area. Most of it is usually gone by one or two days. 

 The main benefits of filler injections are the minimal downtime and almost immediate results. Patients can get back to work or other activities soon after treatment. 

​Gynecomastia or male breast enlargement is a  common condition affecting men of all ages. It is a cause of much distress in those affected. Due to the embarrassment, it causes they may avoid situations which reveal the chest deformity. These include places like gyms, swimming pools and places of religious worship. 

Corrective surgery for gynecomastia is a short stay procedure. Surgical correction results in definitive and longstanding improvement of this condition. As the enlargement is comprised of both fatty and glandular they are both removed separately.  

Procedure: During the day of surgery patients have to present at the surgical center with an attendant. This could be a close friend or relative. Once the markings are performed, the surgery is done under general anesthesia. 
Liposuction is used to remove the fat from the enlarged breast tissue with a small pipe like instruments. The remaining gland is removed directly with the help of a small incision near the nipple. Dressings are placed over sutures and are held in place with the help of paper tapes. A compression garment is placed for reduction of the swelling. Sometimes a drain is placed to help evacuate any fluid which collects at the operated site.

First week: Patients are discharged after an overnight stay. They can resume light activities once they reach home. In case a drain has been used it is removed during the first operative visit. This is usually scheduled two days after discharge.  During this visit, fresh dressings are applied. After this patients can shower and apply a dressing over the suture line. Suture removal is done at one week. 

The second week onward: Pressure garment is advised till one month after surgery. 
Most of the swelling is gone at the end of one week. It is common to have symptoms of abnormal sensation near the scar. This usually resolves in a few weeks without any intervention. Patients can return to light work at the end of the first week. Unrestricted activities like sports can be resumed at the end of one month. 

Pain after procedure: Gynecomastia correction is usually not associated with significant pain. This is probably due to the liposuction with the administration of local anesthetic mixture. Pain if present is usually well managed with oral medications. 

Scars: As the incisions placed are very small the resulting scars are small and not readily noticeable. An incision placed within the pigmented part around the nipple (areola) settles very well and is nearly inconspicuous. 
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Most of the operated patients are much relieved to get rid of the excess breast tissue and have an increased level of self-confidence after the procedure. 

​Negative pressure wound therapy is an increasingly popular technique to treat difficult wounds. It involves the application of a negative pressure or vacuum to wound environment to expedite wound healing. 

Technique: An interface such as open pore sponge or gauze is placed on a clean wound bed. This is then sealed with a transparent film so that the wound exterior is separate from the external environment. A sterile tubing then connects the sponge to a vacuum producing device. Controlled negative pressures of 75 to 120 mm of Hg are applied to the wound. 

Negative pressures are applied in a continuous or intermittent mode. The NPWT dressings are removed and reapplied after a few days until the treatment endpoints are achieved. 

Mechanism of action: NPWT acts by, 

1. Increased blood flow 
2. Reduced oedema 
3. Increased angiogenesis and granulation
4. Mechanical deformation

When done using proper technique on appropriate wounds NPWT leads to lowering of bacterial loads and increased granulation tissue formation. NPWT is ideal in those situations when the patient is at a greater risk for conventional reconstructive procedures. 

Contraindications for NPWT: 
These include, 

1. Osteomyelitis
2. Infective wounds
3. Abnormal hemostasis 
4. Exposed large vessels in wound bed
5. Malignancy 

The benefits of NPWT include faster healing and reduction in the complexity of reconstruction. It is especially useful in situations when conventional methods are ineffective or risky. 

Surgical scar revision is a commonly requested procedure. The changes that can be achieved include:

1. Wide scars can be narrowed.
2. Long scars can be broken down into non-linear zig-zag pattern. This reduces the deformity. They become less readily observable.
3. Scars can be made to lie along natural lines and creases. Thus making them less obvious to an onlooker.
4. Contracture release. Contractures are deforming scars across mobile parts of the body. Contracture release leads to restoration of function of the affected body part.
5. Improvement of texture, color and contour mismatch.

These procedures are associated with improvement of body image and self esteem.

Deep wrinkles of the forehead are commonly seen in an aging face. They are usually seen in the area between the eyebrows. They tend to give a serious look to the affected individual. In the beginning, these wrinkles become apparent during facial expressions. Later on, they become fixed and are constantly present. Lowering of the eyebrows can be associated with the appearance of these wrinkles.

Because of their position, these wrinkles are immediately apparent to an onlooker. The wrinkles are as a result of the contraction of underlying muscles of the forehead. The skin becomes thin with age and as a result of the contraction of the underlying muscles, the overlying tissues gets folded in like an accordion. These wrinkles can be improved by both nonsurgical and surgical techniques.

Nonsurgical treatments:

This is comprised of injections with botulinum toxin and dermal fillers. The nonsurgical procedures are preferred by many as these are performed as outpatient procedures. They do not have a downtime and patients can get back to their routines soon after the procedure.

1. Botulinum toxin injection:

Botulinum toxin acts on the junction between the nerves and muscles to prevent transmission of impulses. This causes relaxation of the forehead muscles which are responsible for wrinkles. A small needle is used to inject to treat the targeted muscles. The full effect of the injections takes approximately one week. The effect lasts for around six months. For continuing action, these injections need to be repeated once the effect wears off.

2. Filler injections:

As the name suggests they 'fill up' areas. As we age we undergo volume loss of the soft tissues. This includes the skin and deeper tissues of the face. Fillers counteract these changes by addition of volume. There are various fillers which differ based on their constituent molecule, and duration of action. The most commonly used fillers are made of hyaluronic acid. They are injected into the skin with the help of fine needles. They soften the wrinkles by making the skin firmer. Filler injections can also be used at a deeper level adjacent to the bones.

Deep and static wrinkles of the forehead usually need treatment with a combination of fillers and botulinum toxin injections.

Surgical treatment:

Unlike nonsurgical treatments, surgical therapy is more invasive. A brow lift is a technique used for surgical rejuvenation of the forehead.

Brow lift:

A brow lift is also known as a forehead lift. It addresses age-related changes such as:
1. the wrinkles of the forehead,
2. the wrinkles between the eyebrows,
3. the lowering of the eyebrows. It results in a higher resting position of the eyebrows and,
4. improves the hooding of the eyelids as a result of the lower position of the eyebrows.

A good candidate for a brow lift would be one who is in good health, has reasonable expectations about the procedure and is a non-smoker.

A brow lift is performed under general anesthesia. The incision is placed usually behind the hairline. The tissues of the forehead are elevated to a higher position and excess skin is trimmed away. Brow lift requires an overnight stay in the hospital. A drain may be placed temporarily to prevent collection at the operated site. The sutures are removed at ten days. Patients can return to work at the end of a week. Most of the swelling following brow lift abate by the end of one month. The results of the brow lift, though invasive last much longer than the office-based procedures.

Deep wrinkles of the forehead can be managed effectively both by means of simple office based procedures and a surgical brow lift. They vary in their indications, downtime, and permanency of results.