7

th
PSAAP
CONFERENCE

LASA
with
CBK

Learn any
Surgery
alone with
Creativity
boldness and
kindness
Lakshmi Saleem’s tribute to
Late Prof. C. Balakrishnan

Salaja Hospital
Prajasakthi Nagar, Vijayawada 500 010
Phones: 0866-2474774 / 2476500 / 040-23403736
www.salaja.com
1
www.bodycontouring.in
 Ekalavya

E kalavya is a character in the famous epic of India,

Mahabharata. He is focused and dedicated pupil of his guru
Drona. He is taken as an example for hard work, perseverance
and sacrifice. Though his guru denies to teach him the art of
archery, Ekalavya excels in it with concentrated and dedicated
practice of archery in front of the statue of his guru. But when
his guru comes to know of his skills, he demands Ekalavya’s
thumb as gurudakshina (fee) so that ekalavya cannot surpass
Dr. Lakshmi Saleem Arjuna, the favoured pupil of Drona. Hence Ekalavya is often
       MS, MCh. quoted as an epitome of virtuous, unselfish and dedicated
Editor-cum-President
pupil. Every one of us may not have the opportunity to learn
from great gurus in our Plastic and Cosmetic surgery. Some of
us have the fortune of working with such gurus, some may have
access to literature written by them few may have access to the
procedures in the form of videos and I am sure some may only
hear directly or indirectly about certain procedures. I chose the
logo which says “Self learning for perfection” only to encourage
ourselves towards dedicated learning and pursuit of perfection
like Ekalavya.

It may be easy to record the procedures and techniques

surgeries done, but it is difficult to quantify the efforts for
the achievements. Following the foot steps of late Prof. C.
Balakrishnan I would like to pass on what I had learnt from
him and the messages given by him for plastic surgeons before
they are washed off by the tide of time. The most precious
lesson one can learn from a senior colleague of his stature in
plastic and cosmetic surgery is the way to find a solution to a
particular problem or a cosmetic need taking into consideration
the social, cultural and financial background of the patient. One
should be able to visualize the three dimensional view of tissues
to be altered and rearranged with an ability to analyse the

1
complex surgical problem with a thorough anatomical
knowledge and then choose a simple procedure with bold and
creative thinking tempered with common sense. Success in
cosmetic surgery can be achieved with meticulous planning,
patience in communicating the surgical outcome to the
patient, and accurate documentation (with good photographs).

Following the teachings of Prof. C. Balakrishnan, over the

years I have made protocols for each procedure based on the
requirements of most of our patients keeping the ethnic,
racial, financial, and social backgrounds of the patients
in mind. I share with my colleagues my experience in
mammoplasty and Rhinoplasty over the years in this note.

Being a woman plastic surgeon, I did come across many

women approaching for mammoplasty which may not be
entirely for beautification as is the case in the western
countries. I have followed a simple algorithmic approach to
visualize the ultimate result and outcome of each surgery
in three dimensional view. I share with my colleagues my
experiences in mammoplasty over the years in this Souvenir.

Perfection and perseverance like Ekalavya

Dr. Lakshmi Saleem MS, MCh.

Editor-cum-President
PSAAP-2008

2
 Algorithmic approach of aesthetic rhinoplasty:
basing on personal evaluation of 25 years
R hinoplasty was performed as the commonest
Cosmetic surgical procedure in 492 patients in
our exclusive plastic surgery set-up over a 25-year
period. This is a study of Rhinoplasty performed in
the South Indian population whose characteristics
are a combination of Caucasian and African noses.
Simple and Standard techniques performed are
described for the correction depending on the
appearances in Frontal, Basal and Lateral views.
Augmentation of the nasal bridge to increase the
height is performed using bone graft from ileac
crest. Excising the fat and thick areolar tissues
narrows the bulbous nasal tip. Approximating the
lateral crura of alar cartilages by non-absorbable
suture helps in producing grooves on the flat
looking alar rim and also helps in narrowing the
tip thus giving a better appearance. Nasal width
in the basal view is corrected by a wedge excision
of the alar rims at the lateral ends. Lengthening
of the columella was performed either by adding
a L-shaped bone graft along with augmentation
of the bridge and also a V-Y plasty. Long term
follow up results of bone graft are gratifying with
minimal resorbption, if any. The aim has always
been to do the entire correction in single stage.
Complication rate was negligible-less than 1% lack
of satisfaction among the Augmentation group and
less than 0.5% among all rhinoplasty procedures.
Introduction
There is not much data available in the rhinoplasty
literature regarding a conventional and accepted
approach for specific problems of South Indian noses.
South Indians have a combination of Caucasian and
African nasal characters. The common complaints
include:
3
Dr. Lakshmi Saleem MS, MCh.
Dr. M A Saleem, MS, FICS
Salaja Hospital, Vijayawada
• Depressed and wide nasal bridge, which lacks
anterior height
• Flared alae nasi with increased interalar distance
and wide nostrils
• Blunt and ill-defined nasal tip without alar
grooves and projection
Thick skin in some individuals along with gross
accumulation of areolar and fatty tissue and
attenuated alar cartilages account for the blunt and
bulbous tip. Flaring of the alae nasi and flattened
alar cartilages account for the increased width of
the nares. These problems are discussed with the
patient in detail with the aid of three basic views of
photographs – Frontal, Basal and Lateral. Possible
corrections are suggested before embarking on the
procedure for the fullest satisfaction of the patient.
Simpler techniques are chosen to fulfill the criteria.
Most of the patients preferred to have the entire
correction performed in a single stage.
Material & Method
Salaja Hospital, Vijayawada is an exclusive Plastic
Surgery set-up in the region of South India where
cosmetic surgery is performed along with other
plastic surgery procedures and burns management.
This unit is accessible to an approximate population
of over 60millions. Nearly almost all our patients are
South Indians.
The nasal index popularized by Topinard in 1890 for
anthropological determinations of the race, is the
ratio of the nasal width to the length multiplied
by 100. These measurements define the frontal view
of the nose as triangle and the dimensions vary
according to the racial background. The spectrum
of the south Indian noses lie somewhere between
Negroid and Caucasian noses.
Broadbent and Mathews describe ideal nasal
alignment to be such that the lateral attachment
of the ala to the cheek lies within longitudinal
lines drawn through the inner canthi. Nasal features
can be improved by bringing the elements of the
nose to lie within a triangle having a base closer
to the inner canthal lines. This is seen well in the
frontal view.
The inferior triangle is formed by the tip and the
lateral attachments of the alae nasi to the cheek
in the Basal view. It is most aesthetically pleasing
when this triangle is narrow based, slightly taller
than wide.
Flare can be defined as that portion of the ala,
extending lateral to the alar attachment to the
cheek. The inferior triangle can be altered by
increasing the height of the tip or by lessening the
flare of the alae.
Augmentation of the dorsum or raising the tip
alters the nasal axis to best suit the patient 492
Rhinoplasties performed between 1984 and 2007
are considered in this review.
Operative procedures
Three views of the nose are considered whenever a
Patient’s Complaint
Frontal View Basal view
Bone graft Wedge Alar base
resection
rearrangement reduction
Interalar reduction Crural fixation
4
Rhinoplasty is planned – Frontal view, Basal view
and Lateral view.
Frontal view: The appearance of nose in the frontal
view is considered to be pleasing if the triangle
is narrow based, slightly taller than wide, with
minimal alar flare. By augmenting the dorsum or
by reducing the tip, the nasal axis can be altered
to suit the patient. Aesthetically a pleasing nose
is 1/3 of one’s face in length or the length of one’s
own thumb and limits itself in width up to both the
medial canthal lines.
Depending on these factors, the surgical plan can be
summarized as follows. One can narrow the triangle
by dorsal augmentation with a bone graft (Ileac
crest). Very rarely nasal bone infracturing is done
to the same effect. Base can be altered by nasal
base reduction and inter alar reduction.
Basal view: Tip projection and definition can
be improved by suturing the lateral crura of alar
cartilages by non-absorbable mattress sutures with
4-0 proline. Alar base reduction also changes the
inferior triangle.
While planning the procedures the wide difference
in individual anatomy, relation of the nose & face
and variation in patients’ complaints and desires
are to be considered to get a complete patient and
surgeon satisfaction.
Lateral view
Tip Bone graft Alar Re-adjustment
reduction
Columellar
adjustment
List of operative techniques: Operative techniques
are decided depending on the appearances in the
frontal, basal and lateral views.
Operative techique
If only augmentation is planned, a right alar
incision is given on the mucosal aspect commencing
medially near the columella and extending laterally
for a few mms on the undersurface of lateral crus
of alar cartilage. If associated procedures are to
be performed for the tip, bilateral alar incisions
are given. Or a ‘V’ incision is given at the base
of columella extending to both sides and the
columella is lifted like an elephant trunk like in
open rhinoplasty. In either case, a plane is created
and the periosteum of the nasal bone is stripped
off making the recipient bed ready.
Bone graft of about 2 inches long is obtained from
the ileac crest. The graft is carved to the required
size and shape with the help of a bone nibbler and
a scalpel. Complimentary shaping of both recipient
site and inner surface of graft achieve stabilization.
The bone graft thus carved is firmly placed in the
subperiosteal plane on the dorsum of the nose.
No rigid fixation is done with pin or screw. The
incision is closed with 4-0 chromic catgut on the
mucosal side. In cases where extended skin incision
is given, the skin is closed with 5-0 proline.
Post-operative splinting is by couple of layers of
plaster of Paris or a ready-made nasal splint that
is retained for five days. Drain from the bone
graft donor site is removed after 24 hours and the
patient discharged.
In those patients who have an increased alar flare
and increased width, alar base resection is done as
a wedge at the junction where the ala meets the
cheek. Suturing is done with 4-0 vicryl and 5-0
proline.
Narrowing the tip, can be achieved by bringing the
alar cartilages together with a single 4-0 proline
mattress suture through alar incisions on both
5
sides. First bite is taken through the caudal edge
of lateral end of lateral crus of alar cartilage from
outside in. A tunnel is created with the curved
artery forceps connecting the two medial ends of
the alar incisions, passing through the membranous
septhum. The needle is transferred from right
nostril to the left through the tunnel and a similar
bite is taken of caudal edge of the lateral crus on
the left side (first from inside out and next from
outside in), to get a good hold on tip of the lateral
crus. The needle is brought back to right nostril
through the previously mentioned tunnel. Another
bite is taken through the rt side cartilage close to
the first one so that the knot comes on the outer
side. The suture is tightened as for the required
projection of the tip, recreating an alar groove. It
is to be remembered while tightening that often
there is only a fine line between a tip that remains
too bulbous and one that is pinched.
Results
A series of 492 rhinoplasties PERFORMED OVER
25 YEARS has been reviewed. Patients were
predominantly female and frequently in the age
group of 16 and 30 years. Average follow-up varied
from a few months to 10 years.
Of this series, only 291 patients had bone graft from
ileac crest. 155 patients had soft tissue correction
alone, with cartilage graft when needed.
Complications
Out of the 291 patients of bone graft, 2 patients
opted for the removal of the graft as they did not
like it.
4 patients required nasal splint for more than two
weeks to maintain the desired position of the
graft.
Conclusion
Rhinoplasty procedure performed in 492 patients
in a period of 25 years is reviewed. This study
included Rhinoplasty performed in the South Indian
population whose characters are a combination of
Caucasian and African noses. Standard but simpler
techniques are chosen. A clinical approach of the
patients’ complaints and the appearances in Frontal,
Basal and Lateral views guided the technique to
be followed. Augmentation of the nasal bridge to
increase the anterior height is performed using
bone graft from ileac crest. Excision of the fat and
thick areolar tissues in the bulbous tip helped to
narrow the nasal tip. Approximating the medial
nasal alar cartilages in the midline by non-
absorbable suture helps in producing grooves on
the alar rim and also helps in narrowing the tip
Presented at British Associate of Plastic Surgeons, Winter Meeting – December 2007
6
thus giving a better appearance. Nasal width in
the basal view is corrected by a wedge excision of
the alar rims at the lateral ends. Lengthening of
the columella was performed by adding a L-shaped
bone graft along with augmentation of the bridge
whenever required and also a V-Y plasty. Long term
follow up results of bone graft are gratifying with
minimal resorbption, if any. The aim has always
been to do the entire correction in single stage to
facilitate the patients’ compliance and satisfaction.
Complication rate was negligible-less than 1% lack
of satisfaction among the Augmentation group
and less than 0.5% among all the rhinoplasty
procedures performed.
 Ptosis surgery
Dr. Devendra K Gupta MS, MCh.
Derendra Hospital, Bareilly (UP)

Anaesthesia Levator resection

Local anaesthesia is preferable to general
anaesthesia if the patient will tolerate it since the
voluntary movement of the levator muscle aids in
the identification of lid structures and a better
operative assessment of lid level is possible.
Method
1. Mark the skin crease.
2. Evert the lid and inject 1 or 2 cc of local
anaesthetic immediately under the conjunctiva
just above the upper border of the tarsal plate.
3. Give a subcutaneous injection in the region of
the skin crease.
Note
a. Adrenalin in the local anaesthetic helps to reduce
bleeding but stimulates Mulller’s muscle.
b. A frontal nerve block is not usually necessary
and runs a risk of affecting the function of the
levator muscle.
The eyelid elevation which can be obtained by
shortening the levator complex depends primarily
on the levator function. The result required depends
on the circumstances, i.e. the diagnosis, Bell’s
phenomenon etc. The optimum result in a patient
with simple congenital ptosis is for the eyelid levels
to be the same in the primary position of gaze, but
lower level may be acceptable in a patient with a
partial third nerve palsy, a dry eye, or progressive
external ophthalmoplegia etc. A resection of the
following amount of aponeurosis and levator muscle
should lift the eyelid to an acceptable level:
Levator function 8-10 mm: 14-18 mm resection.
Levator function 6-7 mm: 18-22 mm resection.
Levator function 4-5 mm: 22-26 mm resection.
These measurements are approximate. They include
both aponeurosis and levator muscle and are taken
from just below the upper border of the tarsal
plate. The extent of the resection is modified by the
degree of ptosis, thus 2 mm of ptosis will warrant

Levator Function

Normal 15-18mm

>10mm <10mm

Degree of ptosis Levator Function

<2mm >2mm >4mm <4mm

Fasanella Servat Aponeurosis Surgery Levator Resection Brow Suspension

7
a lesser resection than 4 mm of ptosis if the levator
function is the same. If the superior rectus muscle
is weak the resection should be increased by about
4 mm. The adequacy of the resection can be confirmed
at operation. Under general anaesthesia the eyelid
should stay at approximately the level which is
achieved at operation if the levator function is about
7 mm. If the levator function is better than this the
lid will tend to rise post-operativcly and to fall if the
levator function is worse. Under local anaesthesia the
lid should be set 1-2 mm higher to compensate for
the paralysis of the orbicularis muscle.
Anterior approach levator resection (fig.1)
Principle
The levator muscle is approached through a skin
incision. The septum is divided and when the
pre-aponeurotic fat is retracted the whole levator
complex can be examined directly for any defects.
The muscle is shortened and sutured directly to the
tarsus. Any excess skin can be excised and the skin
crease reformed with interrupted sutures which pick
up the underlying levator muscle.
Indications
A ptosis with 4 mm or more of levator function;
skin excision; lid – exploration; maximum levator
resection; preservation of tarsus and conjunctiva;
lash ptosis; entropion; skin crease defect.
Method lid with a marked degree of asymmetry on down
1. Mark the skin to match the crease on the
uninvolved side and make an incision through
the skin with a blade (Fig.1 a).
2. Pick up the skin on either side of the incision in the
centre of the lid with two pairs of toothed forceps
and make a cut through the orbicularis muscle with
a pair of scissor aimed towards the tarsal plate.
3. Undermine the orbicularis medially and laterally
and cut it with scissors along the line of the skin
incision.
4. Clean the anterior tarsal surface sufficiently
to suture the aponeurosis or levator muscle to
8
it. Stop 2 mm from the lid margin to prevent
damage to the lash roots (Fig.1 b).
5. Dissect the pre-septal orbicularis muscle from
the lower part of the orbital septum. The septum
can be identified by:
a. its attachment to the orbital rim which can be
felt as a firm band when traction is exerted on it.
b. orbital fat can sometimes be seen behind it.
c. pressure over the lower lid may help to make the
orbital fat more obvious.
6. Open the orbital septum to expose the pre-
aponeurotic fat pad beneath which is the
aponeurosis (Fig.1 c). This can be seen to move
when the patient looks up, if the operation is
under local anaesthesia.
7. Dissect the aponeurosis from the tarsus (Fig.1 d) and
Muller’s muscle from the conjunctiva (Fig.1 e).
8. Cut the medial and lateral attachments (horns)
of the levator complex under direct vision. Curve
the scissors centrally towards the levator muscle
to avoid the trochlea medially and the lacrimal
gland laterally (Fig.1 f).
9. Try to preserve Whitnall’s ligament and advance
the levator muscle under it (Fig.1 g).
Note: The ligament can be sutured directly to the
tarsus to act as an internal sling in cases with
poor levator function as an alternative to a brow
suspension. This does create a relatively static
gaze in unilateral cases.
10.Pass a double-armed 6 ‘O’ polyglycolic acid/
vicryl suture into the anterior tarsal surface at
the intended apex of the lid curve.
Measure the aponeurosis and levator to be resected
and pass each needle of the suture through the
centre of the levator muscle just above the site of
the planned resection. Tie the suture with a slip
knot and cut the muscle (Fig.1 h).
11.Check the height and curve of the lid and adjust
the suture if necessary. Cut the suture and use
each arm to suture the muscle to the tarsus on
either side of the central first suture (Fig.1 i).
12.Thin the lower skin flap by excising a strip of
orbicularis muscle.
13.Excise any excess skin from the upper skin flap.
14.Close the skin and reform the crease with 6 ‘O’
absorbable sutures which pass front the edge
of the lower skin flap, into the levator muscle,
and out through the edge of the upper skin flap
(Fig.1 j).
Note: Absorbable sutures are preferable since
skin crease sutures may be difficult to remove
completely and the scar is buried in the
crease.
15.Use a Frost suture.
9
Aponeurosis surgery
Aponeurosis surgery is indicated for patients with an
aponeurotic defect and good levator function (i.e.
better than 10 mm). The approach is very similar to
that for a levator resection but the surgery is not so
extensive, the horns of the levator complex arc not
cut, and a Frost suture is rarely necessary to protect
the cornea. Local anaesthesia should be used if at
all possible and the lid set at operation to the same
level or a little higher than the other side. In the
immediate post-operative phase the lid will be low
due to recovery of the orbicularis muscle function
and oedema, but since the levator function is good
the lid will subsequently rise.
 Selection of procedure
for reduction mammoplasty
T he pathophysiology of breast hypertrophy is due
to an abnormal end organ response to circulating
estrogens and it is due to the hypersensitivity of the
some women during puberty and pregnancy. Breast
enlargement consists of fibrous tissue and fat while
the glandular elements remain quite small. Sometimes
a familial pattern can be traced back as members
of the same family are affected. Breast hypertrophy
produces considerable functional disability and
affects the quality of life due to disproportionate
body disposition. Significant improvement of the
individual self esteem and self confidence are noted
in all the patients and symptomatic improvement in
the postural disability, neck and shoulder pain relief
were also noted. The aims of breast reduction is to
reduce, recontour reshape to suit the woman’s needs
and desires.
Selection of the procedure depends on the type of
breast, surgeon’s comfort with the surgical skill,
scars and a long lasting aesthetic result. Important
points to consider are how much tissue need to be
removed and the final nipple position depends on
the breast tissue that is left behind. With 30 years
of experience and understanding of the problem few
10
Dr. Lakshmi Saleem MS, MCh.
Salaja Hospital, Vijayawada
simple guidelines are taken into consideration and
the problem is classified as follows:
Grade  1: Teenage girls with increased areola and
ptosis requiring reduction of less than 200 grms.
Grade  2: Young women, who may need reduction up
to 500 grms.
Grade  3: Women who may need excision of up to
1000 grms
Grade  4: Women who may need massive reduction
of more than 1000 grms.
With 30 years of experience of reduction mammoplasty
various techniques, a simple procedure has been
recognized which is easy to execute with the long
lasting aesthetic effect. Classically it incorporates
the superiomedial pedicle with a vertical scar, and
excision of the gland with the skin from the inferior
quadrant with extension onto the medial and lateral
segments, depending on the requirements of the
excison. This procedure has been found to be
technically easy, safe, quick to perform with minimal
complications and safety. It can be undertaken for
major resections of more than 1000 gms also.
Markings for surgery
The patient is made to stand erect with the hands
tucked behind. Keeping the BMI in mind, the
desired size is discussed with the patient, and the
mid-sternal line is marked first. followed by drawing
of the breast meridian.The nipple postion is noted.
The distance measured from the midsternal notch
to the nipple position is also noted. The desired
new nipple position is marked from the midsternal
notch. The areola is marked with the diameter of
3.5 to 4 cm with a nipple marker depending on the
need. The new nipple is marked with distance of 19
to 22 cm depending on height of patient keeping
the diameter 0.5 cm more than the previous
marking. An ellipse is drawn taking the top of the
new areola as the highest point The lowest point
of the ellipse is kept 1cm above the inframammary
crease. The maximum width of the ellipse is equal
to the diameter of the existing areola.
Procedure
1. Infiltration of the breast tissue with saline
adrenaline, avoiding the injection in the
upper, medial quadrant and the area that
needs de-epethelisation
2. Areola is incised and de-epethelisation
started going away from areola.
3. The lower “V” cut is deepend keeping the skin
intact.
4. The medial and lateral flaps raised with 0.5
cm thickness, upto the medial most and
lateral extent of Breast tissue.
Presented at British Associate of Plastic Surgeons, Summer Meeting-2008
11
5. The lower part of V is raised from below
upwards, exposing the pectoral fascia upto
0.5 cm below the de-epethelised sub areolar
region.
6. The medial and lateral segments of breast
tissue which need to be excised is included
with the V segment as one en-bloc of tissue.
7. The whole block of tissue is excised from the
upper part of breast protecting the nipple,
areolar complex.
8. Both the lateral and medial flaps are brought
together with skin hooks and any excess
skin is excised as an ellipse from the lateral
segment.
9. The aeolar complex is shifted up to the new
position and if there is difficulty in moving it
up relaxing incision given on the lateral part
of de-epethelised segment.
10. After areola is fixed with 3-0 monocryl and
lower breast tissue is brought together with
3-0 monocryl subdermal sutures.
11. After fixing the drains, the areola is sutured
with 6-0 vicryl and the lower incision is
sutured with subcuticular 3-0 monocryl.
12. With this technique, the vascularily of nipple was
never compromised and the only complication
that was seen was delay in healing at the lower
most part of incision, when excison was more
tran 800 gm.
 Repair of mid to distal penile hypospadias
by the tubularised incised plate urethroplasty
H ypospadias is a congenital defect resulting from
incomplete tubularisation of the urethral plate.
The meatus may be found any where along the penile
shaft and down on to the perineum. Hypospadias
with an incidence of 0.8 – 8.2 per 1000 live male
births is a common clinical problem. In the majority
of cases (80%) abnormal meatus is situated in the
glanular, coronal and subcoronal levels or in the
proximal part of the shaft.
The goal of hypospadias repair is a functional penis
with a normal cosmetic appearance. Established
procedures to correct the distal hypospadias are
the Thiersch-Duplay, Mathieu, Mustarde, meatal
advancement and glanuloplasty (MAGPI) and
tubularized incised plate (TIP) urethroplasty. Of
the various procedures Tip urethroplasty (Snodgrass
repair) most reliably creates a normal appearing
penis. At many centres it is now the preferred method
of repair since it creates a vertical slit like normal
appearing meatus, unlike a horizontally oriented
and rounded meatus (‘Fish mouth’) produced by the
meatal based (Mathieu) and onlay island flap repairs.
In addition this procedure allows construction of
neourethra from the existing urethral plate without
additional skin flaps. The technique is versatile and
suitable for almost all distal lesions.
Method
The penis is degloved with a U shaped incision
extending along the edges of the urethral plate to
healthy skin 2 mm proximal to the meatus.The lateral
borders of the distal urethral plate are separated
from the glans by parallel longitudinal incisions.
The glanular wings are further mobilized laterally for
subsequent tension free closure. The urethral plate
is then incised in midline from the hypospadiac
meatus distally. Incised plate is then tubularised
over a 6-8F stent using continuous subcuticular
12
Dr. Devendra K Gupta MS, MCh.
Derendra Hospital, Bareilly (UP)
6-0 chromic catgut suture. Neourethra is then
covered with a vascularized dartos flap harvested
from subcutaneous tissue of dorsal penile skin and
preputial skin. The granular wings, mucosal collar
and ventral shaft skin are closed in the midline. The
stent provides urinary drainage for 10 days.
With its simplicity, versality, excellent cosmetic and
functional results and a low complication rate, TIP
urethroplasty is the procedure of choice for most of
the distal defects. Since most of the patients with
midshaft and penoscrotal defects have a supple
urethral plate, a midline incision consistently
widens the plate and enables tubularisation. This
makes TIP plasty a versatile technique in repairing
the proximal hypospadias as well.
Contraindications to TIP plasty are severe chordee
requiring plate excision for straightening the penis
and unhealthy urethral plate that appears thin or is
insufficiently widened after incision. Complications
are rare. Fistula can be avoided by interposition of
a vascularised dartos flap between the neourethra
and overlying glans and shaft skin closures. Closure
of the first layer is done in a running subcuticular
fashion with efforts made to invert the epithelium
completely.
Bracka’s Versatile Two Stage
Hypospadias Repair
Aesthetic quality of the hypospadias repair with
natural looking glans and slit shaped terminal
meatus after multiple failed hypospadias repairs
remains a formidable challenge in reconstructive
surgery.
I Bracka’s (1995) two stage hypospadias repair
offers versatility, reliability and refinement and can
be used for almost any hypo­spadias deformity be
it primary repair in child or salvage surgery in an
adult.
Timing of surgery
1. At 18 months: Offers psychological advantage to
child. Better anaesthesia required
2. Before school at 4 years: We use most of the time
the second option for surgical correction. Tissues
are better developed
Operative steps
Stage 1
Anaesthesia: Caudal epidural anaesthesia. Advantages
are smooth recovery, postop analgesia and less risk
of postoperative bleeding and haematoma. Then the
assessment is done-of position and size of abnormal
meatus, the presence of chordee, the quality and
width of urethral plate and the configuration
of glans penis. 4/0 silk stay stitch is applied to
the glans and presence and degree of chordee is
assessed. Meatal assessment is done using urethral
dilators. Tourniquet is applied after dilatation. If
required, meatotomy is done to split the thin layer
of urethra to the spongiosum covered urethra. The
suturing of urethral mucosa to skin is done after
meatotomy using 6/0 chromic catgut. Two more
stay 5/0 sutures are applied on either side of the
midline over the distal aspect of the glans which
will be used as traction during glans split and later
as first tie-over suture.
Release of chordee is done from the proposed
neo-meatus to the ventral aspect of the abnormal
meatus. From the sub coronal part of the vertical
incision, lateral incisions on either side are done to
correct the chordee. This is done by a combination
13
of incision and excision of tissues using scalpel and
fine scissors. The chordee correction is achieved
in this manner in the majority of cases. In cases
of residual chordee further correction is done by
extending the sub coronal incisions to circumcoronal
incision and stripping the penis. A full thickness
preputial graft was taken and accurately tailored
into the defect using 6/0 chromic catgut. A firm
“tie-over” dressing was placed for 7 davs and a
urethal catheter for 7-10 days.
Stage 2 after at least 6 months to allow for graft
maturity and neovascularity. Neourethra was
fashioned from the supple grafted skin bed. The
meatus was reconstructed first by joining the
ventral point, the rest of the urethra was then
tubed around K-90 or K-91/NEL-CATH (Romsons)
catheter with a combination of interrupted and
continuous extraluminal inverting 6/0 chromic
catgut sutures. The repair is protected and
reinforced using an intermediate vascularised
fascial layer dissected from the dorsal aspect
following circumcoronal incision and stripping of
penis. This vascular layer helps the healing process
and avoids suture lines in contact with each other
and thus reduces the risk of fistula formation. The
successful reconstruction depends on proper
planning, gentle handling of tissues with fine
instrumentation, usage of fine suture materials,
inverting sutures of neo-urethra and usage of
intermediate vascular layer of tissues
The glans and skin repaired and dressing was done.
Catheter was removed on the 10th day.
The urinary catheter is fixed on the lower abdomen
with a “mesenteric type” of tape fixation so that the
catheter is directed upwards away from the ventral
suture line.
 Obesity Management
– a plastic surgeon’s perspective!
O ver two decades of my practice in Plastic and
Cosmetic surgery, I have come across quite a
number of people who have come to me seeking help
for being obese. They belonged to both genders and
also of different ages. In the early days it was not only
difficult to convince people to follow a disciplined
life pattern and take proper diet but it was a tough
task to dissuade them from seeking surgical option.
Some were genuinely odd in their figure having
either bulky arms or heavy thighs, some had heavy
breasts and some were disproportionately large in
the upper or the lower parts of the body. Some
boys had heavy breasts resembling female pattern,
some girls even just around puberty had such heavy
breasts that embarrassed them both physically and
psychologically. Where do we draw a line to decide
who are the candidates for surgery? How can you
assure them that even if some fat is removed from
the parts of their body, what is the guaranty that it
does not re-accumulate due to their indulgence in
either over-eating or lazy life pattern.?
Here comes the honesty on our part to decide and
classify who falls in the category called ‘obese’.
What is obesity?
When the body weight of a person is more than 25%
of the expected weight in the case of a man and is
more than 32% in the case of a woman, that person
is considered obese. Another definition is that any
person with 40 Kg more than the expected weight is
considered obese for any individual.
But the best way to measure is by the specific
term called Body Mass Index. This is nothing but a
calculation at any age and for any gender wherein
the body weight (in Kg) is divided by height (in
Meters squared).
14
Dr. Lakshmi Saleem MS, MCh.
Consultant Plastic & Cosmetic Surgeon
B M I = Weight (kg) / Height (m2)
Accordingly a person is determined to be:
Healthy if BMI is 20 – 25
Overweight if BMI is 26 – 30
Obese if BMI is 30 – 35
if BMI is Morbidly obese 35 – 40
or above
Obesity and over weight have been recognized to be
global problems affecting over a billion adults and
17.6 million children under 5 years of age. Obesity is
presently considered as a chronic illness, in addition
to be a cosmetic problem. It is associated with
many other chronic diseases ranging from Arthritis
to Diabetes, Cardiovascular problems to frank Heart
failures, Neurovascular problems to Alzheimer’s,
Chronic depression to Dementia, Chronic skin
diseases to Cancers.
What causes obesity?
Apart from the various hormonal causes like
Hypothyroidism, Hypercorticosteroidism, hormonal
changes due to pregnancy or menopause, the primary
factor that leads to obesity is imbalance between
calorie in take to that of calorie consumption
superadded by a sedentary type of life style with no
physical activity. Heredity and depression of course
play some role as the causative factors.
How to prvent obesity?
Like in the case of many health problems, prevention
has the best role to eradicate obesity. Childhood
obesity has an alarming increase across the globe
and cause for concern as this predisposes to
adulthood obesity.
The teaching and training should start at home
wherein the parents are taught about balanced
and nutritious diet for their children. The school
environment should provide proper physical activity
to the children. They should be made aware of the
problems of energy rich salty foods, soft drinks
containing large quantities of sugar and large
quantity of dairy products and ice creams. They
should be taught to restrict such foods. Children
must also be made aware of the ill effects of
sedentary life styles. The role of yoga or meditation
or such disciplining activities are definitely among
the much needed.
How to cure obesity
In spite of the best efforts to prevent obesity, if
it still is a problem, the steps to cure obesity are
again giving emphasis on life style changes and
altering environmental factors. Dietary modification
like low calorie, high fiber diet associated with
enhancing physical activity is mandatory. Chronic
stress or chronic depression may both lead to
obesity and hence such of the factors that lead
to these psychological changes should be brought
under control. These can best be achieved by either
Yoga or Meditation. It is all the more important that
emphasis is laid to self motivation. A self motivated
obese person is on the right track to cure him / her
self of obesity.
Who needs surgery to cure obesity?
The choice of surgery depends on the severity of
the problem of obesity. Arbitrarily it can be said
that having tried all the physical, dietetic and
psychological methods to curing the problem
of obesity, the choice of surgery falls into two
categories.
One is just the removal of fat or the excess of tissue,
which is usually preferred in only those that fall
in the group of overweight up to a BMI of 30. The
procedures that can be carried out in this method
are Liposuction or Lipectomy.
Two is for those who fall into the category of
severely obese or who suffer morbid obesity with a
BMI of 40 or more needing Bariatric surgery where
the food intake is either restricted or malabsorption
15
is created. However people with BMI of 30 – 35
associated with one or two co-morbid condition
may also need bariatric surgery.
The role of a cosmetic surgeon in taking care of
an over weight or obese individual cannot be
overemphasized. One should insist on an overweight
person with a BMI of 26 – 35 to reduce his/her
weight by about 5 Kg by proper diet, exercise and
change in life style. This gives the plastic surgeon
to assess the genuineness in commitment on the
part of the individual how much the obese person
is going to follow the instructions and how effective
the cosmetic surgical method be useful to such an
individual in the long run.
Even after the Bariatric surgery there is a role for
a Cosmetic surgeon in contouring the body for the
residual or consequential effects.
Liposuction and lipectomy
Liposuction is one of the surgical options for the
obesity if the person is well motivated and willing
to maintain the weight. By doing the liposuction of
the certain areas, like inner thighs and the sides of
the chest, it enables the obese person to go for walks
and exercises with out much difficulty. Certain areas
where there is localized obesity like the arms, side
of flanks and thighs or buttocks need liposuction.
Some times the liposuction itself can stimulate the
basal metabolic rate so much that the person can
start losing weight with a greater speed. It was
observed that liposuction itself can make an overall
reduction of 10 to 15 Kgs.
Abdominal girth increase or looseness due to post
partum obesity does need to be addressed with
plastic surgery in the form of Abdominoplasty or
tummy tuck procedure. The same might be the case
in those obese people who underwent bariatric
surgery and lost weight but developed loose skin
folds and so on.
Gynaecomastia
Abnormal male breast development is seen in
some of the obese individuals and they invariably
present with these localized deposits of fat. These
can be classified as grades 1 to 3 depending on the
severity. Liposuction alone may be enough to treat
the mild deformities with out much of central core
of breast tissue being removed in Gr 1 cases. In
Gr 2 cases, liposuction along with surgical excision
may be needed. In Gr 3, the obese person may need
mastopexy to correct the excessive sagging of the
skin after excision of the gland.
Bilateral breast reduction
Breast hypertrophy (overgrowth) in women produces
considerable functional disability and affects the
quality of life due to disproportionate body, leading
to pain in the breasts, secondary back, shoulder
or neck pain. Skin below the breasts may be seen
to be macerated with or without infection. This
problem compounds the overall obesity of the
individual. Reduction mammoplasty wherein the
breast size is reduced to a reasonable level and also
liposuction of other obese parts of body can be
combined with it. The aim of reduction of breast is
to reduce and re-contour to suit the woman’s needs
and desire and to make the individual comfortable.
Significant improvement of the individual self-
esteem, self-confidence is noted in every patient
who had undergone breast mammoplasty and
postural disability is reduced greatly. The gain in
confidence levels is encouragingly very high in
younger individuals where they can fit into right
sized garments and be more presentable.
Body contouring after massive weight loss
following the bariatric surgery
In morbid obesity, contour deformities of the
abdomen are common after bariatric surgery and
radical weight loss. Traditional techniques fail to
improve the shape as there are lateral hip rolls
16
and flanks leaving the patient with a lot of lateral
redundancies and dog-ears. A modified vertical
abdominoplasty, combining with the transverse
approach, a single stage procedure for resection are
needed without undermining the tissues.
Neo-umbilicoplasty (reforming umbilicus in the new
position) is to be planned with care. If associated
hernia is present, this also can be dealt with in
the same sitting. Lower body lift and thigh lift can
be attempted together, but in spite of the tight
approximation of the sub-cutaneous facial system,
the saddle deformity and mid thigh laxity cannot be
corrected well.
In conclusion we can say that the following are the
steps to face the problem of obesity:
• Evaluation of the cause of obesity
• Assessing the extent of obesity in terms of BMI
and also marking if the obesity is localized.
• Dietary regulation and shift to low calorie and
high fiber diets and avoiding indulgence in
improper diets.
• Regular and constant exercises.
• Change of life style with regularity and discipline
in the diet and physical activities.
• Liposuction or lipectomy in the people with over
weight or obese individuals of less than 30 BMI.
• Suggesting Abdominoplasty for those who have
trunkal obesity.
• Suggesting and guiding the individuals with BMI
of 40 or 35 with co-morbid conditions to undergo
bariatric surgery.
• Taking care of the residual or consequential
effects of bariatric surgery.
 Management of Obesity
Obesity is a chronic disease and is also associated
most of the times with medical illnesses like
diabetes, hypertension, hyperlipidemia, chronic
arthritis and so on. The prevalence of obesity
cannot be questioned and its worldwide increase
at an alarming rate is noticed in both developed
and developing countries. In US the studies show
an incidence of overweight of 66%, obesity of
32% and morbid obesity of around 5%. In Europe
obesity prevalence ranges from 20% in men and
25% in women. Although well established statistics
are not available in India, one of the surveys by
All-India Institute of Medical Sciences showed that
76% of women in the capital, New Delhi, suffer from
abdominal obesity. NFHS analysis showed that 12%
men and 16% women suffer from obesity in India.
Excess body weight is the sixth most important risk
factor contributing to the health burden of the world.
There seems to be a positive correlation between
economic development and obesity: as a country
becomes richer, many people in that country become
fatter making them seek medical help. Prosperous
people tend to live sedentary lives. This seems to be
the case in India also. If you are rich, you can pick up
a phone and order a pizza; you have a car, you don’t
need to walk to many places. Many children no longer
take lunch-boxes to school. They drink colas and other
soft drinks and eat burgers. There is no awareness
among parents that this is a problem. With obesity
come related problems, from diabetes to heart failure.
An estimated 25 million Indians have diabetes, and
this is forecast to grow to 57 million by 2025.
Morbid obesity has acquired epidemic proportions in
the country with 5 per cent of the population suffering
from it. Problem is high among schoolchildren as
indicated from a study in Hyderabad. Obesity seen
and known from those seeking medical help is only
the tip of an iceberg; the incidence of obesity in the
17
Dr. M A Saleem MS, FICS
Consultant & Head of Department
General Surgery, Surgical Gastroenterology
and Laparoscopic Surgery
Care Hospital, Banjara Hills, Hyderabad
country is much higher and the is growing faster,
according to medical experts.
Obesity amplifies the risks of type 2 diabetes,
hypertension, cardiovascular disease, dyslipidemia,
arthritis, and several cancers and is estimated to
reduce average life expectancy. In the United States
alone, it is estimated that obesity-related health
problems account for about 300,000 deaths per year.
The medical expenses and cost of lost productivity
due to obesity in the USA are estimated to be greater
than $100 billion per year.
Patients with obesity seek medical attention either
for cosmetic reasons or for cure of associated
medical conditions. The surgical treatment of obesity
till recently revolved primarily around cosmetic
procedures like liposuction or abdominoplasty.
However, these methods were purely cosmetic in
that they did not address the basic pathophysiology
behind the development of overweight in the first
place. Consequently, they were associated with
recurrences and suboptimal results.
Increasing magnitude of this problem prompted
extensive research into the pathophysiology
of the development of obesity. This lead to a
better understanding of the disease process and
subsequently to the development of comprehensive
modalities for its treatment.
Definition
Various parameters have been evaluated to objectively
assess the amount of excess body adipose tissue
stores. Presently, obesity is defined and classified
based on the Body Mass Index (BMI).
BMI is calculated as:
Weight (in kg) / Height (m2) OR
Weight (in lbs) x 704 / Height (in2)
People with BMI between 25 and 30 kg/m2 are activity not only contributes to an increased energy
considered overweight, and those with a BMI greater expenditure and fat loss, but also protects against the
than 30 kg/m2 are considered obese. Obese persons loss of lean body mass. It improves cardiorespiratory
are at a higher risk for adverse health consequences fitness, reduces obesity-related cardiometabolic
than those who are overweight. The prevalence of health risks, and evokes sensation of well-being.
obesity-related diseases such as diabetes begins to Physical activity of a moderate intensity, 30 min in
increase at BMI values beyond 25. duration, performed 5 days a week is recommended.
To optimize weight loss, exercise should be increased
Classification by Body Mass Index to 60 min for 5 days a week.
Weight Classification Obesity BMI Risk of When obesity is a result of a lack of daily habitual
Class (kg/m2) Disease
physical activity, activities such as walking, cycling,
Underweight <18.5 Increased and stair climbing should be encouraged. Engagement
Normal 18.5-24.9 Normal of physical activity in weight management is
Overweight 25.0-29.9 Increased positively related to the level of education and
Obesity (mild) I 30.0-34.9 High on the other hand, inversely associated with the
Obesity (moderate) II 35.0-39.9 Very High occurrence of serious comorbidities, with age and
Obesity (severe/morbid) III ≥40.0 Extremely with degree of overweight.
High
Psychological factors influence both weight loss
Another factor that modifies the risk of obesity-related
and more importantly, long-term weight loss
complications is weight gain during adulthood. In
maintenance. Behavioral modification of lifestyle
both men and women, weight gain of 5 kg or more
should be included in the weight management
since the ages of 18 to 20 years increases the risk
strategies. Behavioral management includes
of developing diabetes, hypertension, and coronary
several techniques such as self monitoring, stress
heart disease and the risk of disease increases with
management, stimulus control, reinforcement
the amount of weight gained.
techniques, problem solving, rewarding changes in
Treatment modalities behavior, cognitive restructuring, social support,
and relapse prevention training.
Treatment of obesity now includes a multi-pronged
approach involving: Behavioral therapy can be provided in clinical and
commercial settings or as self help programs. Group
• life-style modification counseling results in comparable long-term weight
• dietary alterations loss but initial individual counseling is sometimes
preferred for severely obese subjects. Data on
• medical treatment and the efficacy of behavioral programs carried out in
• surgical procedures controlled settings show that weight losses average
nearly 9% in trials lasting 20 weeks. The major
A comprehensive approach to an individual patient limitation of these programs is the high likelihood
involves choosing the optimal combination of that individuals will regain weight once the behavioral
modalities based on the response to the treatment. treatment is ended. Behavioral modification of
lifestyle, especially self-control over daily energy
Life-style modification & Physical activity balance, plays a crucial role in long-term success
Physical activity should be an integral part of the of weight management. Self-monitoring of weight,
comprehensive obesity management and should be dietary intake and daily physical activity on a regular
individually tailored to the degree of obesity, age, and basis is an important determinant of weight loss
presence of comorbidities in each subject. Physical maintenance. Consistent eating patterns, including

18
regularly eating of breakfast, also influence the
outcome of weight management. It is obvious that
special attention should be paid to patients who are
prone to failure in long term weight management.
More frequent dietary counseling contributes to a
better outcome of long-term weight management.
This counseling might be traditional-patient visits
or can be provided by phone, e-mail or Internet chat
applications. Psychological support is necessary for
patients with depression or dietary disinhibition.
Psychologist should train patients how to cope with
situations triggering dietary disinhibition (e.g.,
stress, anxiety, and depression).
Dietary modifications
A low-energy diet recommended for the treatment
of obesity should be of low fat (30% of daily energy
intake), high carbohydrate (55% of daily energy
intake), high protein (up to 25% of daily energy
intake) and high fiber (25 g/day). Recently, several
studies evaluated the role of low-carbohydrate
diets in weight management. These diets have been
advocated because they induce many favourable
effects such as a rapid weight loss, a decrease of
serum triglyceride levels, and a reduction of blood
pressure as well as a higher suppression of appetite
(partly due to ketogenesis, partly due to a higher
protein intake). However, several unfavorable effects
of low-carbohydrate diet administration also have
been demonstrated, such as an increased loss of lean
body mass, increased levels of LDL cholesterol and
uric acid and an increased urinary calcium excretion.
Long term studies are needed to evaluate the overall
changes in nutritional status. Increased content of
protein in a diet contributes to better weight loss
maintenance because proteins are more satienting
and thermogenic than carbohydrates and fats.
Drug Treatment
Anti-obesity drugs have been developed to
assist weight loss in combination with life-style
management to improve weight loss maintenance
and to reduce obesity-related health risks. Anti-
obesity drugs affect different targets in the central
nervous system or peripheral tissues and aim to
19
normalize regulatory or metabolic disturbances that
are involved in the pathogenesis of obesity.
Currently, only three anti-obesity drugs have been
successfully used in long-term weight management.
It is expected that lifelong treatment with anti-
obesity drugs will be required to specifically target
the particular abnormality. Current potential to treat
obesity by drugs is limited in comparison to the
drug treatment of other complex diseases such as
hypertension, diabetes, and dyslipidemia. The U.S.
FDA has approved the drug Orlistat for use in children
and adolescents. Orlistat, as an inhibitor of lipase,
reduces fat absorption in the intestine. Patients
treated with Orlistat and life-style modification
exhibited a greater weight loss and a significant
reduction in diabetes incidence compared with
those who underwent life-style modification and
received placebo.
Sibutramine, as a serotonin and norepinephrine
reuptake inhibitor, induces satiety and prevents
diet-induced decline in metabolic rate. Continued
use of sibutramine maintained weight loss almost
completely for this period of time.
Rimonabant administration leads to significant
weight reduction and improvement in cardiometabolic
risk profile in four randomized double-blind clinical
trials conducted in overweight or obese adults.
Recently, the anti-epileptic drug Topiramate was
discovered to have beneficial effects on weight control
and is being investigated as a weight loss drug.
Weight loss induced by currently available anti-obesity
drugs is only modest, reaching usually 5–8% of initial
body weight. Assignment of patients to a particular anti-
obesity drug should respect their licensed indications
and contra indications; i.e., Sibutramine should
not be administered to patients with uncontrolled
hypertension, Orlistat should not be administered to
patients with cholestasis and centrally acting drugs
should be indicated with caution in patients with
depression. Drugs should be administered to patients
who adequately responded to the initial phase of
treatment over a 1.5 to 3 month period.
Surgical Management
Life-style intervention programs with diet therapy,
behavior modification, exercise programs and
pharmacotherapy are widely used in various
combinations. Unfortunately, with extremely rare
exceptions, clinically significant weight loss is
generally very modest and transient, particularly in
patients with severe obesity. In a recently published
randomized study, in adults with mild to moderate
obesity (BMI 30–35 kg/m2), surgical treatment was
found to be significantly more effective than non-
surgical therapy in reducing weight, resolving the
metabolic syndrome and improving quality of life.
Till recently, surgical procedures conduced in obese
patients were usually cosmetic procedures like
liposuction/lipoplasty, aimed at reduction of body fat.
However, they do not prevent weight regain following
the surgical procedure. With better understanding of
the pathophysiology behind development of obesity,
various procedures are developed aimed at either
restricting the intake of food, promoting malabsorption
or both, thus ensuring long term weight reductions.
Bariatric surgery
Bariatric surgery is the most effective treatment for
morbid obesity in terms of weight loss, health risks and
improvement in quality of life. It should be considered
for patients with BMI >40 kg/m2 or with BMI between
35 and 40 kg/m2 with comorbidities. Obesity surgery
should be conducted in centers that are able to assess
patients before surgery and to offer a comprehensive
approach to diagnosis, assessment, treatment, and
long-term follow-up. Bariatric surgery could be carefully
considered in severely obese adolescents who have failed
to lose weight in a comprehensive weight management
programs carried out in a specialized center for at least
6 -12 months and for those who have achieved skeletal
and developmental maturity.
Centers performing bariatric surgery in adolescents
should have a good experience with such
treatment in adults and should be able to provide
a multidisciplinary team that possesses paediatric
skills related to surgery, dietetics and psychological
management. In elderly patients (>60 years), the
20
risk-to-benefit ratio should be considered on an
individual basis. It is necessary to emphasize that
the primary objective of surgery in elderly patients
is to improve quality of life as surgery per se is
unlikely to increase lifespan.
In bariatric surgery, restrictive procedures as well
as procedures limiting absorption of nutrients are
currently available. The magnitude of both weight loss
and weight loss maintenance is increasing with the
following procedures: gastric banding, vertical banded
gastroplasty, proximal gastric bypass, biliopancreatic
diversion with duodenal switch, and biliopancreatic
diversion. Although sufficient evidence-based data
to suggest how to assign a particular patient to a
particular bariatric procedure is slowly coming up,
for patients with BMI of 50 kg/m2, gastric bypass
or biliopancreatic diversion brings more benefits.
Pure restrictive procedures are not recommended for
patients with a significant hiatal hernia or severe
gastro oesophageal reflux disease. Gastric banding
cannot contribute to further substantial weight
loss in patients in whom a significantly diminished
food intake has been verified before the surgery.
On the other hand, it should be considered that a
laparoscopic adjustable gastric banding is the safest
bariatric procedure associated with only minor peri-
operative surgical risks.
Bariatric surgery has been proved as the most
effective way of treating Type-2 Diabetes in severely
obese patients. More than 10 years ago, it has been
demonstrated that 83% of patients with diagnosed
Type-2 Diabetes exhibited normal blood glucose and
normal glycosylated hemoglobin levels 7.6 years
after bariatric surgery. Further, 99% patients with
impaired glucose tolerance normalized a glucose
tolerance after bariatric surgery. The 10-year follow-
up in the Swedish Obese Subjects (SOS) study
demonstrated that a bariatric surgery is a viable
option for the treatment of severe obesity, resulting
in long-term weight loss, improvement in lifestyle,
and except for hypercholesterolemia, amelioration
of cardiometabolic risk factors.
After 10 years, in the SOS study the average
weight loss from baseline was 25% after gastric
bypass, 16% after vertical banded gastroplasty,
and 14% after gastric banding. The group that
had undergone surgical intervention had lower
incidence rates of diabetes, hypertriglyceridemia,
and hyperuricemia in comparison to the control
group. The most important recent finding of the
Swedish Obese Subjects study is a reduction of
overall mortality by 24.6% in the surgery group
versus control subjects.
The schematic representation of various bariatric
surgical procedures is given below. All the surgical
procedures are now being conducted laparoscopically,
thus decreasing the operative morbidity. However, best
results are obtained when the procedures are conducted
in a center with a multi-specialty team involving
bariatric surgeon, anesthetist, endocrinologist,
psychiatrist, dietician, physiotherapist, intensivist,
plastic surgeon and a good nursing team.

Esophagen By passed portion

Proximal Pouch of stomach
of Stomach

“Short” Intestinal
Roux Limb

Pylorus

Duodenum

Gastric Banding Roux-en-Y Gastric By-pass

Gastric
“Sleeve”

Pylorus

Excised
Stomach

Gasric sleeve Resection

21
See where
you stand
as per BMI
and follow
the diet

22

HOSP
 BODY MASS INDEX (BMI) READY RECKONER
Height (Ft & Ins)
4'5" 6" 7" 8" 9" 10" 11" 5' 1" 2" 3" 4" 5" 6" 7" 8" 9" 10" 11" 6' 1" 2" 3" 4"
115 62 60 59 57 55 54 53 51 50 48 47 46 45 44 43 42 41 40 39 38 37 36 35 35 34 33 33 32 31 31 18,2
114 62 60 58 57 55 53 52 51 49 48 47 46 45 43 42 41 40 39 39 38 37 36 35 34 34 33 32 32 31 30 17,13
113 61 59 58 56 54 53 52 50 49 48 46 45 44 43 42 41 40 39 38 37 36 36 35 34 33 33 32 31 31 30 17,11
112 61 59 57 56 54 53 51 50 48 47 46 45 44 43 42 41 40 39 38 37 36 35 35 34 33 32 32 31 30 30 17,9
111 60 58 57 55 54 52 51 49 48 47 46 44 43 42 41 40 39 38 38 37 36 35 34 34 33 32 31 31 30 29 17,7
110 59 58 56 55 53 52 50 49 48 46 45 44 43 42 41 40 39 38 37 36 36 35 34 33 32 32 31 30 30 29 17,5
109 59 57 56 54 53 51 50 48 47 46 45 44 43 42 41 40 39 38 37 36 35 34 34 33 32 32 31 30 30 29 17,2
108 58 57 55 54 52 51 49 48 47 46 44 43 42 41 40 39 38 37 37 36 35 34 33 33 32 31 31 30 29 29 17
107 58 56 55 53 52 50 49 48 46 45 44 43 42 41 40 39 38 37 36 35 35 34 33 32 32 31 30 30 29 28 16,12
106 57 56 54 53 51 50 48 47 46 45 44 42 41 40 39 38 38 37 36 35 34 33 33 32 31 31 30 29 29 28 16,10
105 57 55 54 52 51 49 48 47 45 44 43 42 41 40 39 38 37 36 35 35 34 33 32 32 31 30 30 29 28 28 16,8
104 56 55 53 52 50 49 47 46 45 44 43 42 41 40 39 38 37 36 35 34 34 33 32 31 31 30 29 29 28 28 16,5
103 56 54 53 51 50 48 47 46 45 43 42 41 40 39 38 37 36 36 35 34 33 33 32 31 30 30 29 29 28 27 16,3
102 55 54 52 51 49 48 47 45 44 43 42 41 40 39 38 37 36 35 34 34 33 32 31 31 30 29 29 28 28 27 16,1
101 55 53 52 50 49 47 46 45 44 43 42 40 39 38 38 37 36 35 34 33 33 32 31 30 30 29 29 28 27 27 15,13
MORBIDLY OBESE

100 54 53 51 50 48 47 46 44 43 42 41 40 39 38 37 36 35 35 34 33 32 32 31 30 30 29 28 28 27 27 15,11
99 54 52 51 49 48 46 45 44 43 42 41 40 39 38 37 36 35 34 33 33 32 31 31 30 29 29 28 27 27 26 15,8
98 53 51 50 49 47 46 45 44 42 41 40 39 38 37 36 36 35 34 33 32 32 31 30 30 29 28 28 27 27 26 15,6
97 52 51 49 48 47 46 44 43 42 41 40 39 38 37 36 35 34 34 33 32 31 31 30 29 29 28 27 27 26 26 15,4
96 52 50 49 48 46 45 44 43 42 40 39 38 38 37 36 35 34 33 32 32 31 30 30 29 28 28 27 27 26 26 15,2
95 51 50 48 47 46 45 43 42 41 40 39 38 37 36 35 34 34 33 32 31 31 30 29 29 28 27 27 26 26 25 15
94 51 49 48 47 45 44 43 42 41 40 39 38 37 36 35 34 33 33 32 31 30 30 29 28 28 27 27 26 25 25 14,11
93 50 49 47 46 45 44 42 41 40 39 38 37 36 35 35 34 33 32 31 31 30 29 29 28 27 27 26 26 25 25 14,9
92 50 48 47 46 44 43 42 41 40 39 38 37 36 35 34 33 33 32 31 30 30 29 28 28 27 27 26 25 25 24 14,7
91 49 48 46 45 44 43 42 40 39 38 37 36 36 35 34 33 32 31 31 30 29 29 28 27 27 26 26 25 25 24 14,5
90 49 47 46 45 43 42 41 40 39 38 37 36 35 34 33 33 32 31 30 30 29 28 28 27 27 26 25 25 24 24 14,2
89 48 47 45 44 43 42 41 40 38 38 37 36 35 34 33 32 32 31 30 29 29 28 27 27 26 26 25 25 24 24 14
88 48 46 45 44 42 41 40 39 38 37 36 35 34 34 33 32 31 30 30 29 28 28 27 27 26 25 25 24 24 23 13,12
87 47 46 44 43 42 41 40 39 37 37 36 35 34 33 32 32 31 30 29 29 28 27 27 26 26 25 25 24 24 23 13,10
86 46 45 44 43 41 40 39 38 37 36 35 34 34 33 32 31 30 30 29 28 28 27 27 26 25 25 24 24 23 23 13,8
85 46 45 43 42 41 40 39 38 36 36 35 34 33 32 32 31 30 29 29 28 27 27 26 26 25 25 24 24 23 23 13,5
84 45 44 43 42 41 39 38 37 36 35 35 34 33 32 31 30 30 29 28 28 27 27 26 25 25 24 24 23 23 22 13,3
83 45 44 42 41 40 39 38 37 35 35 34 33 32 32 31 30 29 29 28 27 27 26 26 25 25 24 23 23 23 22 13,1
82 44 43 42 41 40 38 37 36 35 35 34 33 32 31 30 30 29 28 28 27 26 26 25 25 24 24 23 23 22 22 12,13
81 44 43 41 40 39 38 37 36 35 34 33 32 32 31 30 29 29 28 27 27 26 26 25 24 24 23 23 22 22 22 12,11
80 43 42 41 40 39 38 37 36 34 34 33 32 31 30 30 29 28 28 27 26 26 25 25 24 24 23 23 22 22 21 12,9
79 43 41 40 39 38 37 36 35 34 33 32 32 31 30 29 29 28 27 27 26 26 25 24 24 23 23 22 22 21 21 12,6
78 42 41 40 39 38 37 36 35 33 33 32 31 30 30 29 28 28 27 26 26 25 25 24 24 23 23 22 22 21 21 12,4
77 42 40 39 38 37 36 35 34 33 32 32 31 30 29 29 28 27 27 26 25 25 24 24 23 23 22 22 21 21 20 12,2
76 41 40 39 38 37 36 35 34 32 32 31 30 30 29 28 28 27 26 26 25 25 24 23 23 22 22 22 21 21 20 12

Weight (St & Lbs)

75 41 39 38 37 36 35 34 33 32 32 31 30 29 29 28 27 27 26 25 25 24 24 23 23 22 22 21 21 20 20 11,11
Weight (Kgs)

74 40 39 38 37 36 35 34 33 32 31 30 30 29 28 28 27 26 26 25 24 24 23 23 22 22 21 21 20 20 20 11,9
73 39 38 37 36 35 34 33 32 32 31 30 29 29 28 27 26 26 25 25 24 24 23 23 22 22 21 21 20 20 19 11,7
72 39 38 37 36 35 34 33 32 31 30 30 29 28 27 27 26 26 25 24 24 23 23 22 22 21 21 20 20 20 19 11,5
CLINICALLY OBESE

71 38 37 36 35 34 33 32 32 31 30 29 28 28 27 26 26 25 25 24 23 23 22 22 21 21 21 20 20 19 19 11,3
70 38 37 36 35 34 33 32 31 30 30 29 28 27 27 26 25 25 24 24 23 23 22 22 21 21 20 20 19 19 19 11
69 37 36 35 34 33 32 32 31 30 29 28 28 27 26 26 25 24 24 23 23 22 22 21 21 20 20 20 19 19 18 10,12
68 37 36 35 34 33 32 31 30 29 29 28 27 27 26 25 25 24 24 23 22 22 21 21 21 20 20 19 19 18 18 10,12
67 36 35 34 33 32 31 31 30 29 28 28 27 26 26 25 24 24 23 23 22 22 21 21 20 20 19 19 19 18 18 10,8
66 36 35 34 33 32 31 30 29 29 28 27 26 26 25 25 24 23 23 22 22 21 21 20 20 19 19 19 18 18 18 10,6
65 35 34 33 32 31 30 30 29 28 27 27 26 25 25 24 24 23 22 22 21 21 21 20 20 19 19 18 18 18 17 10,3
64 35 34 33 32 31 30 29 28 28 27 26 26 25 24 24 23 23 22 22 21 21 20 20 19 19 18 18 18 17 17 10,1
63 34 33 32 31 30 30 29 28 27 27 26 25 25 24 23 23 22 22 21 21 20 20 19 19 19 18 18 17 17 17 9,13
62 34 33 32 31 30 29 28 28 27 26 25 25 24 24 23 22 22 21 21 20 20 20 19 19 18 18 18 17 17 16 9,11
61 33 32 31 30 29 29 28 27 26 26 25 24 24 23 23 22 22 21 21 20 20 19 19 18 18 18 17 17 17 16 9,9
60 32 32 31 30 29 28 27 27 26 25 25 24 23 23 22 22 21 21 20 20 19 19 19 18 18 17 17 17 16 16 9,6
59 32 31 30 29 28 28 27 26 26 25 24 24 23 22 22 21 21 20 20 19 19 19 18 18 17 17 17 16 16 16 9,4
58 31 30 30 29 28 27 26 26 25 24 24 23 23 22 22 21 21 20 20 19 19 18 18 18 17 17 16 16 16 15 9,2
57 31 30 29 28 27 27 26 25 25 24 23 23 22 22 21 21 20 20 19 19 18 18 18 17 17 16 16 16 15 15 9
56 30 29 29 28 27 26 26 25 24 24 23 22 22 21 20 20 19 19 18 18 18 17 17 17 16 16 16 15 15 8,12
OVERWEIGHT

21
55 30 29 28 27 27 26 25 24 24 23 23 22 21 21 20 20 19 19 19 18 18 17 17 17 16 16 16 15 15 15 8,9
54 29 28 28 27 26 25 25 24 23 23 22 22 21 21 20 20 19 19 18 18 17 17 17 16 16 16 15 15 15 14 8,7
53 29 28 27 26 26 25 24 24 23 22 22 21 21 20 20 19 19 18 18 18 17 17 16 16 16 15 15 15 14 14 8,5
52 28 27 27 26 25 24 24 23 23 22 21 21 20 20 19 19 18 18 18 17 17 16 16 16 15 15 15 14 14 14 8,3
51 28 27 26 25 25 24 23 23 22 22 21 20 20 19 19 19 18 18 17 17 16 16 16 15 15 15 14 14 14 14 8
50 27 26 26 25 24 23 23 22 22 21 21 20 20 19 19 18 18 17 17 17 16 16 15 15 15 14 14 14 14 13 7,12
49 26 26 25 24 24 23 22 22 21 21 20 20 19 19 18 18 17 17 17 16 16 15 15 15 14 14 14 14 13 13 7,10
48 26 25 24 24 23 23 22 21 21 20 20 19 19 18 18 17 17 17 16 16 15 15 15 14 14 14 14 13 13 13 7,8
47 25 25 24 23 23 22 21 21 20 20 19 19 18 18 17 17 17 16 16 16 15 15 15 14 14 14 13 13 13 12 7,6
46 25 24 23 23 22 22 21 20 20 19 19 18 18 18 17 17 16 16 16 15 15 15 14 14 14 13 13 13 12 12 7,3
45 24 24 23 22 22 21 21 20 19 19 18 18 18 17 17 16 16 16 15 15 15 14 14 14 13 13 13 12 12 12 7,1
HEALTHY

44 24 23 22 22 21 21 20 20 19 19 18 18 17 17 16 16 16 15 15 15 14 14 14 13 13 13 12 12 12 12 6,13
43 23 23 22 21 21 20 20 19 19 18 18 17 17 16 16 16 15 15 15 14 14 14 13 13 13 12 12 12 12 11 6,11
42 23 22 21 21 20 20 19 19 18 18 17 17 16 16 16 15 15 15 14 14 14 13 13 13 12 12 12 12 11 11 6,9
41 22 22 21 20 20 19 19 18 18 17 17 16 16 16 15 15 15 14 14 14 13 13 13 12 12 12 12 11 11 11 6,6
40 22 21 20 20 19 19 18 18 17 17 16 16 16 15 15 15 14 14 14 13 13 13 12 12 12 12 11 11 11 11 6,4
39 21 20 20 19 19 18 18 17 17 16 16 16 15 15 15 14 14 13 13 13 13 12 12 12 12 11 11 11 11 10 6,2
38 21 20 19 19 18 18 17 17 16 16 16 15 15 14 14 14 13 13 13 13 12 12 12 11 11 11 11 11 10 10 6
37 20 19 19 18 18 17 17 16 16 16 15 15 14 14 14 13 13 13 13 12 12 12 11 11 11 11 10 10 10 10 5,12
36 19 19 18 18 17 17 16 16 16 15 15 14 14 14 13 13 13 12 12 12 12 11 11 11 11 10 10 10 10 10 5,9
UNDERWEIGHT

35 19 18 18 17 17 16 16 16 15 15 14 14 14 13 13 13 12 12 12 12 11 11 11 11 10 10 10 10 9 9 5,7
34 18 18 17 17 16 16 16 15 15 14 14 14 13 13 13 12 12 12 11 11 11 11 10 10 10 10 10 9 9 9 5,5
33 18 17 17 16 16 15 15 15 14 14 14 13 13 13 12 12 12 11 11 11 11 10 10 10 10 10 9 9 9 9 5,3
32 17 17 16 16 15 15 15 14 14 13 13 13 13 12 12 12 11 11 11 11 10 10 10 10 9 9 9 9 9 9 5,1
31 17 16 16 15 15 15 14 14 13 13 13 12 12 12 12 11 11 11 10 10 10 10 10 9 9 9 9 9 8 8 4,12
30 16 16 15 15 14 14 14 13 13 13 12 12 12 11 11 11 11 10 10 10 10 9 9 9 9 9 8 8 8 8 4,10
29 16 15 15 14 14 14 13 13 13 12 12 12 11 11 11 11 10 10 10 10 9 9 9 9 9 8 8 8 8 8 4,8
28 15 15 14 14 14 13 13 12 12 12 12 11 11 11 10 10 10 10 9 9 9 9 9 8 8 8 8 8 8 7 4,6
27 15 14 14 13 13 13 12 12 12 11 11 11 11 10 10 10 10 9 9 9 9 9 8 8 8 8 8 7 7 7 4,4
26 14 14 13 13 13 12 12 12 11 11 11 10 10 10 10 9 9 9 9 9 8 8 8 8 8 8 7 7 7 7 4,1
25 14 13 13 12 12 12 11 11 11 11 10 10 10 10 9 9 9 9 8 8 8 8 8 8 7 7 7 7 7 7 3,13

1.36 1.38 1.40 1.42 1.44 1.46 1.48 1.50 1.52 1.54 1.56 1.58 1.60 1.62 1.64 1.66 1.68 1.70 1.72 1.74 1.76 1.78 1.80 1.82 1.84 1.86 1.88 1.90 1.92 1.94

Ht (Mts)

KEEP COOL, EAT HEALTHY FOOD, SLEEP WELL, EXERCISE REGULARLY

CLINIC
HOSPITAL
MAINTAIN GREEN ZONE SALAJA COSMETIC SURGERY CENTRE
 General motors weight loss diet
T he following diet and health program was
developed for the employees and the dependants
of General Motors Inc.
The program was developed in conjunction with
the grant from the US Department of Agriculture
and the Food and Drug Administration. It was first
tried at the Johns Hopkins Research Centre and was
approved for distribution by the Board of Directors
of General Motors Corporation at a general meeting
on August 15, 1995.
General Motors Corporation wholly endorsed this
program and is making it available to all employees
and families. This program will be available at all
General Motors Food service facilities.
It is the management’s intention to facilitate a
welfare and fitness program for everyone.
This program is designed for a target weight loss
of 5-6 Kgs. per week. It will also improve your
attitude and emotions because of its systematic
cleansing effects. The effectiveness of this seven
day plan is that the foods eaten burn more calories
than they give to the body in caloric value. This
plan can be used as often as you like to without
any fear of complications. It is designed to flush
your system of impurities and give you a feeling
of well being. After seven days you will begin
to feel lighter by atleast 10 pounds. You will
have an abundance of energy and an improved
disposition.
During the first seven days you must drink 10 glasses
of water each day.
Day one
All fruits except bananas. Your first day will consists
of all fruits you want. It is suggested you consume
lots of watermelon and cantaloupe.
24
Day two
All vegetables. You are encouraged to eat until
you are stuffed with all the new and cooked
vegetables of your choice. There is no limit on
the account or type. Avoid oil and coconut while
cooking vegetables. Have large boiled potato for
breakfast.
Day three
Any mixture of fruits and vegetables of your choice.
Any amount, any quantity. No bananas yet and no
potatoes today.
Day four
Bananas and milk. Today you will eat as many as
eight bananas and drink three glasses of milk. You
can also have I bowl of vegetables soup.
Day five
Today is a feast day. You will eat 1 cup of rice. You
also have to eat six whole tomatoes and drink 12
glasses of water today to cleanse your system of the
excess uric acid you will be producing.
Day six
Today is another all vegetables day. You must eat
1 cup of rice today and eat all the vegetables you
want cooked and uncooked to your hearts content.
Day seven
Today your food intake will consist of 1 cup rice,
fruit juice and the vegetables you care to consume.
Tomorrow morning you will be five to eight kgs.
Lighter than I week ago. If you desire further weight
loss, repeat the program again. Repeat the program
as often as you like, however, it is suggested that
you rest for three days before every repetition.
You have your system under control now and it will
thank you for all the purging and cleansing you just
gave it. Even more than a diet program it is good
to follow this diet once in a while to clean your
digestive system and remove toxic substances that
have a accumulated in the system.
Additional comments
The most important element of the program is the
10 tall glasses of water a day. You can also flavour
the water will some lemon to make the drink easier.
While on the program, take only black coffee and
never more than one teaspoon of oil. Preferably do
not use oil because the high calorific content. No
fruit juices before day seven.
Here is what happens to you body while you are on
this program and how and why it works.
Day  1: You are preparing your system for the
upcoming program. Your only source of nutrition is
fresh fruits. Fruits are nature’s perfect food. They
provide everything you can possibly want to sustain
life except total balance and variety.
Day  2: Starts with a fix complex carbohydrates in
the form of a boiled potato. This is taken in the
form of a boiled potato and taken in the morning
to provide energy and balance. The rest of the day
too consists of vegetables which are virtually calorie
free and provide essential nutrients and fibre.
Day  3: Eliminates the potato because you get
your carbohydrates from fruits. Your system is now
prepared to start burning excess pounds. You will
have cravings, which should start to diminish by
day four.
Day  4: Bananas and milk. You are in for a surprise.
You probably will not be able to eat all the bananas
allowed. But they are there for the potassium you
have lost and the sodium you may have missed the
last three days. You will notice a definite loss of
desire for sweets and you will be surprised at how
easy this day will go.
Day  5: Rice and tomatoes. The rice is for the
carbohydrates and the tomatoes are for the digestion
and the fibre. Lots of water purifies your system.
25
You should notice colourless urine today. Do not
feel you have to eat one cup rice, you may eat less.
But you may eat six tomatoes.
Day  6: It is similar to five. Vitamins and fibre from
the vegetables and carbohydrates from the rice. By
now your system is in a total weight loss inclination.
There should be a noticeable difference in the way
you look today compared to day one.
Day  7: You may celebrate with champagne. You may
also have white wine instead of champagne, but in all
practical programs, and in all surveys done to measure
the success of the program, General Motors employees
have always preferred champagne to white wine.
More than one cup of coffee with milk is especially
forbidden. Milk and oil add empty calories to your
diet. Avid coffee lovers can console themselves
with black coffee. However, after the first week, it
will help your digestion and set your stomach. The
key thing to remember is that if you are hungry
at any time, then you are not following the diet
correctly. Almost all people give up the diet when
they are hungry because of dieting. The secret of
this program is that you should never be hungry.
If it is a vegetable day, eat so much vegetables so
that you are never hungry. If it is a fruits day, eat so
much fruits that you are never hungry. You may be
bored of eating vegetables all day, but you should
not be hungry. You can take any amount of General
Motors wonder soup on any day.
General motors wonder soup
The following soup is intended as a supplement to
your diet. It can be taken any time of the day in
virtually unlimited quantities. You are encouraged
to drink large quantities of this soup.
23 oz water
06 large onions
02 green peppers
03 whole tomatoes
1 cabbage
1 bunch celery – add herbs and seasoning as
desired.
This program is highly recommended for women and
men above 40 for whom excess weight is especially
dangerous. Excess weight for women aggravates
arthritis problems and leads to rapid joint decay.
Pain and joint deterioration can be lessened by
weight loss as weight loss removes the stress on
the knee joint. Excess weight is the most critical
factor in keeping good health and excess weight is
responsible for the most problems including coronary
diseases, heart problems, arthritis and cancer among
other serious life threatening diseases. Most serious
health problems can be avoided by the single
function of maintaining an ideal weight. Daily mild
26
exercise of 20 minutes is also essential. Do not tire
yourself out, but being regular in your exercise and
maintaining an ideal weight goes a long way in
ensuring a happy, healthy and long life.
This article is published on this website assuming
that all the material herein are in the public domain,
as the intention of this article is a noble one – to
make humans healthy. It’s published here with noble
intentions. If you find that this article is copyrighted
and is not supposed to be published without permission,
please let me know by dropping an email to me at 
jaju@it.iitb.ac.in (spammers, please ignore.)
Lasa is a health home, to help you to learn to alter the life style for betterment,
taking you to a NEW LEVEL OF TOTAL WELL BEING. It guides you to take care of
yourself by counseling of Diet, Weight Exercises, General life style Hobbies and Interests,
Spiritual preferences and Future Goals. Then a thorough medical evaluation is done
for health risks like Diabetes, Hypertension, Stroke, Cancer, Aids. A comprehensive
programme is planned for each individual depending on the likes and preferences of the
individual. Every effort is made to detoxify, rejuvenate and make one look fit, healthy
smart and young with a healthy glow. In house facilities for regularizing the diet with
cooking demonstration in the common kitchen is taught. A healthy way of life is taught
with yoga, meditation, kerala auyurvedic massages, and Gym. The same facilities are
offered as an outpatient providing crèche for the young mothers who want to come back
to shape after delivery.

Our Services
– Counseling
– Cosmetic Surgery
– Classical Dance
– Yoga Therapy /Meditation
– Kerala Auyurvedic

Salaja Hospital
Prajasakthi Nagar, Vijayawada 500 010
Phones: 0866-2474774 / 2476500 / 040-23403736
www.salaja.com  www.bodycontouring.in

27
 With best compliments

VIVEKANANDA HOSPITAL A Unit of ADITYA HOSPITALS PVT. LTD.

A Multispeciality Hospital with fabulous track record of over a decade in the

service of mankind has grown to be one of the finest health care provider in
twin cities. It is known for its rich culture and patient friendly attitude.

We believe responsibility towards bringing the finest facilities of Healthcare

within the reach of needy as every individual has a desire and will to
lead a healthy life.

6-3-871/A, Green Lands Road, Begumpet, Hyderabad - 500 016.

Phone: 040-66735555 (5 Lines)/23400057 & 58.
Fax: 040-66735535.

28
 Let us all
FIGHT TOGETHER
to Nip the

OBESITY
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Banding
Carving
Sucking &
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Life St
yle
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for betterment

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