Liposuction is among the more popular procedures done by a plastic surgeon. Liposuction is carried out as a single procedure or in combination with other surgical procedures. Some individuals refer to it as the 'keyhole' surgery for gynecomastia. 
Liposuction has certain advantages over open or conventional surgery. These include small incisions, faster recovery, and less postoperative discomfort. Liposuction can be carried out both under general or local anesthesia. Doing liposuction under local anesthesia has certain benefits. 


So, what are these benefits?
The important ones include,  

• Safety. When done with adequate precautions liposuction is usually a safe procedure. Thin tubes called cannulas are inserted under the skin into the fatty layer during liposuction. The cannulas help in the removal of fat from the treated areas. One of the risks of liposuction comes from the injury to structures in the adjacent areas. It is easier to detect the presence of a cannula in a different surgical plane in an awake patient (local anesthesia). This is due to the absence of muscle relaxation and sensitivity to pain in areas that are not infiltrated with the anesthetic solution. As a result, the local anesthesia increases the safety margin of the procedure. 
• Recovery. The recovery from general anesthesia may be associated with postoperative nausea or vomiting. There can be variations in systemic parameters like blood pressure and heart rate. These can are avoided when liposuction is carried out in an awake individual. This leads to a more straightforward recovery. 
• Postoperative stay. Due to the faster recovery with local anesthesia alone patients can be discharged soon after the procedure. This makes liposuction under local anesthesia suitable as an outpatient procedure. 

Are there any differences in technique with liposuction under local anesthesia? 
There are a few differences. 
Firstly, the patient is awake, and the monitoring of the patient is simple. When done in an awake patient, it takes longer to complete the procedure. There are a few reasons for this. The initial infiltration of the anesthetic solution in the treatment areas is done in multiple steps and takes longer to complete. Also, we prefer the use of smaller cannulas for infiltration and fat aspiration (suction). We usually use cannulas of sizes 3 mm or below in an awake individual. Due to the smaller cannulas, the aspiration of fat takes more time to complete. Liposuction in the awake individual is more gentle. 


Who is the right candidate for liposuction under local anesthesia? 
Almost all candidates for the procedure under general anesthesia are also good candidates for the procedure to be carried out under local anesthesia. However, if the patient is very anxious or has a fear of needles they may not be a good candidate for local anesthesia alone. Such individuals would be better suited for general anesthesia.


To summarize liposuction, in awake patients has a better safety profile. It has the added benefits of a faster recovery, and this also makes it suitable as an outpatient procedure. 
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Patients with gynecomastia have increased gland in addition to the fat. Fat is found both within the glandular tissue and immediately underneath the skin. Fat in both these places contributes to the deformity. In an overweight individual, the proportion of fat is more than that of a person with ideal body weight. During the surgical correction, fat is removed with the help of liposuction. Small cannulas are introduced under the skin and fat is removed with the help of suction combined with repeated movements of the cannula. Removal of fat leads to an improvement in the contour.

Prolonged and severe gynecomastia is also associated with excess skin. In most individuals removal of the breast tissue leads to the recoil of the skin during the months following surgery. However, in certain individuals, this recoil may not be complete. We may have to perform additional skin excisional procedures to improve the contour in such cases.

Individuals with excess weight should try to reduce weight by non-surgical methods. This involves dietary and lifestyle modifications. There are many advantages to doing so. It leads to better postoperative outcomes with more pleasing results. This is in addition to the other health and psychological benefits. Operating in a near-ideal bodyweight individual also means a simpler and shorter surgery. There is a lesser chance of wound-related adverse events such as infection and prolonged healing. BMI or body mass index is commonly used to assess the weight in comparison to the height of the individual. We usually discourage operations on individuals with a BMI greater than 30.

Being overweight increases the deformity associated with gynecomastia. However, it is possible to give a good outcome with surgical correction in conjunction with the appropriate lifestyle and dietary changes.

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These are uncertain times. There is a lot of uncertainty regarding health and finances. Each one of us is affected as a result of Covid19.

Though Covid19 is a recent disease and the first case was reported in December 2019, we have come to know a lot about this illness in this short period. However, there is a lot we are yet to know. An improved understanding would help us better deal with this at the level of an individual and that of the community. Though it leads to a mild illness in those affected, a small percentage can have a severe outcome. Because of this, and that the virus can spread rapidly, a lot of individuals can become simultaneously be affected by it. This leads to the possibility of our existing health care becoming overwhelmed. Hence, we take multiple steps to prevent the rapid spread of this virus. Some of the steps are easy and some are difficult.

One of the recommendations during this pandemic is to defer elective surgeries. Especially those in which the outcome may not significantly change if they are done at a later date. An example would be aesthetic or cosmetic surgery. Now, why should we postpone such types of surgeries? There are multiple reasons. One is that hospitals tend to be more exposed to individuals affected by Covid19. It is also known that many of the people with Covid19 can be mildly symptomatic and yet have the ability to transmit the infection. Another reason is that many individuals may come in close contact with a patient during the procedure and in the postoperative period. Many of the interventions may generate aerosols which can lead to a greater chance of transmission. We would also like to conserve our resources so that all our protective equipment and manpower can be used in case there is an escalation during a community spread.

All elective surgeries are not similar. In certain cases, it would be important to treat certain illnesses early since early intervention leads to better outcomes. An example would be cancer surgeries. It is also important for individuals with chronic illnesses to continue with medical care. An example would be dialysis in those with chronic kidney disease.
Cosmetic procedures are meant for improving appearance. Postponing such surgery is unlikely to influence the outcome.

Even during these times, there are a lot of things we can do to improve our health and appearance. We should exercise. Even if going out is not an option we would be able to exercise inside our homes and yards. Eating right is important. Eat only when we are hungry. Eating should not be a remedy for boredom.

As mentioned before these are uncertain times. But it is also certain that this uncertainty can't be permanent. Till then it is important to stay safe and wear masks (cloth would do) when we step outside.

Pushback otoplasty is done for improvement in the appearance of prominent ears. It is usually carried out under general anesthesia in children and local anesthesia in adults. During this procedure, ear cartilage is removed and reshaped so that it lies closer to the head. It is carried out either as a short stay or outpatient procedure. Pain is controlled with the help of oral medications.

After the procedure, a dressing is given in the form of a head wrap with a bandage. The ears are inspected on the first postoperative day for the presence of any collection. The bandages are retained for a week.

At the end of the week, the dressings are removed. Patients can shower once the dressings are out. For two weeks following the procedure, a headband is advised to be worn constantly. After this period, a headband should be worn during the night.

It is common to have swelling of ears following surgery. This gradually subsides over time. Most of the swelling disappears by the end of a month. Pushback otoplasty is a cosmetic procedure. It does not alter the hearing.  It helps individuals with prominent ears to obtain a better body image.

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Hair transplant is a surgical procedure for redistribution of hair from areas of relative abundance to those with deficiency. It is most often carried out for male pattern baldness (MPB). In MPB, the hair of the posterior (back) of the scalp is relatively spared when compared to the hair in front of the scalp. The word, 'relatively' is important since the hair in the posterior part of the scalp is not completely unaffected by the changes in MPB. However, this property of relative sparing of the posterior scalp hair in MPB continues even after grafting (transplant).

Hair shafts occur as small groups called follicular units. During a hair transplant, a follicular unit is removed from the donor area (usually the posterior scalp) and implanted at the recipient area (usually the front of the scalp). A follicular unit may contain one, two or three hair shafts. The number of follicular units transplanted in a procedure depends upon the donor and recipient areas. Male pattern baldness usually requires the transfer of a large number of grafts. This is in contrast to the small numbers required for hair loss associated with small scars.

As mentioned previously, the posterior (back) part of the scalp is usually used as a donor area for hair transplants. Less preferred donor areas include beard and body hair. In certain individuals, the posterior scalp hair may be inadequate as a source for donor grafts. This can be due to the progress of MPB. This is observed as reduced density (hair follicles per square cm) and thinning (miniaturization) of hair follicles. It can also be as a result of a previous harvest of hair follicles during a hair transplant. An individual with a poor donor area also tends to have an advanced stage of MPB.

In spite of these challenges, it is possible to improve upon the appearance of those with a poor donor area. In such a situation we try to achieve improvement with the help of fewer grafts. Frontal forelock occupies the portion behind the central part of the forehead. Many individuals with advanced male pattern baldness tend to retain hair in this region. A relatively full forelock does not give an unnatural look in an individual with advanced hair loss. The forelock helps frame the face when an individual is observed from the front. It would be the part of the scalp that would be visible as a person steps out of an elevator. Increasing the density in the forelock region would require lesser grafts when compared to the rest of the scalp.

In patients without donor deficiency, other areas that are addressed include the hairline and mid-scalp. These occupy the area adjoining the forelock. The crown is given lesser importance when compared to the previously mentioned areas because of the lesser aesthetic significance and the requirement of a large number of grafts.

Salvaging the remaining hair follicles is also important in a person with MPB. MPB is usually a progressive condition and left untreated many can progress to more advanced stages of baldness. This is especially true in the case of younger individuals in whom the hair loss has not stabilized. Preservation of remaining hair follicles is achieved by means of medications. These medications include nutritional therapy, topical Minoxidil, and Finasteride. It is important for individuals to make an informed decision about the use of these medications. They should be taken for long periods for adequate results.

Male pattern baldness with poor donor areas offers some challenges for hair restoration. But often it is possible to improve upon the appearance with the help of medications and a limited hair transplant.

For more information on hair transplant please visit, https://www.amicusclinic.in/hair-transplant

Breast augmentation is an important part of sex reassignment surgery (SRS) in transwomen. It helps avoid the use of external padding to achieve a feminine appearance. It enables an individual to integrate better with the body image.

There are both similarities and differences in breast augmentation in SRS when compared to augmentation carried out in women to enhance the appearance of breasts. Breast augmentation is usually achieved with the help of silicone implants. The technique is largely similar to breast augmentations carried out in women for hypomastia. However, there are certain differences relating to the preoperative requirements, and outcomes.

As in other procedures carried out in SRS, breast augmentation requires the clearance and referral letter from a mental health professional. Most individuals are also on hormonal therapy under the guidance of a physician.  Hormonal treatment helps in breast development and the enlargement of the nipple and areola. Improvement in the size of breasts with hormonal treatment leads to better soft tissue coverage over the implants. This helps in optimizing outcomes. Breast augmentation is usually carried out after two years of hormonal treatment.

The contour of a male chest is different when compared to a female chest. The male chest tends to be wider and more muscular. Also, the soft tissue cover including skin tends to be less yielding in a natal male when compared to a natal female. The crease that separates the breast from the lower part of chest is known as the inframammary fold (IMF). The distance between the nipple to IMF is lesser in men when compared to women. Breast augmentation leads to an increase in this distance. The nipple and areola (pigmented skin surrounding the nipple) are more laterally (towards the sides) placed in men when compared to women. In women, the nipple-areola is more centrally located in the chest. These variations in the anatomy also influence our decision making relating to the implant selection and outcomes.

Ideally, the nipple and areola should be on the apex of the breast mound. The lateral position of the nipple relative to the chest in a natal male can lead to a lateral position of the nipple after the placement of a large diameter implant. This is factored into the decision making during implant selection. Traditional silicone implants are hemispherical. Profile or projection refers to the height when the implant is kept on a flat surface. A high profile implant also has the advantage of helping us to achieve the maximum projection for a given breast volume.  It is common to opt for a relatively lesser diameter and high profile (projection) implants.

The placement of the implant can be under the breast tissue (sub-glandular) or partly under the muscle (sub-pectoral). Both approaches have their relative advantages and disadvantages. The decision is taken after taking into account clinical examination findings and discussion with the individual. Breast augmentation is carried out as a short stay procedure. The recovery is similar to breast augmentation carried out in females for hypomastia. Most individuals return to work within a week of undergoing the procedure. The implant is initially found to have a prominent upper pole fullness. This settles into a more natural-looking appearance over the next few months.

Breast augmentation is a relatively simple procedure with significant benefits in suitable individuals. It is an important part of the gender confirmation procedures. It is associated with positive effects on body image, self-confidence.

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