Cosmetic Leg Lengthening

Lengthening strategy and technique

Lengthening for stature in normally proportioned people with short stature but without dysplasia (dwarfism) requires a different strategy than does lengthening in patients with disproportion and dysplasia (dwarfism). Most patients with constitutional short stature or low normal stature require only modest increases in stature compared with the extreme amount of lengthening required by patients with dwarfism.

When assessing distribution of height in the population, we consider the normal Bell curve. We divide people by distribution around the mean (average). Normal height is considered ± 3 standard deviations (SD) from the mean. Stature below 3 SD from the mean in persons without a medical condition such as dwarfism or growth hormone deficiency is considered constitutional short stature. The lower limit of so-called normal stature for Caucasian men is 5’5″ (166 cm) and for women is 5’0″ (153 cm). (These info. were taken from a published article by dr. J. Herzenbreg.

Patients with constitutional short stature or low normal stature are not treated until they have completely grown (Age 14 for girls and 16 for boys ). They usually do not have deformities of the bones.

For leg bones ( Tibia and Fibula, we prefer the lengthening using ring fixator ( Ilizarov or Taylor Spatial frame by aid of computer software ). This is because when using ring fixator in our technique of maximum stability, this has shown the highest success rate without problems or complications in more than 3000 patients we have operated on since 1996 until 2012. Also, it is the safest method according to the scientific publications. As many new methods are available until the moment, but all are not fully developed yet and the scientific researches mentioned some complications with them.

For femoral lengthening, we prefer fully implantable nail as Precice Stryde nail with remote controller as we offer it for the lowest cost in the world and we do it in Cyprus in two of the best hospitals there including the American medical center in Nicosia: AMC

However, if you cannot afford the cost of doing it, there is still available the technique of LON or lengthening over nail that is available in our center in Cairo.

The usual goal of lengthening for stature of most patients with low normal stature is 2.5 to 3.5 in (6 to 9 cm). More than this amount of lengthening cannot be achieved safely in one pair of bones during one lengthening procedure. For more lengthening, one needs to repeat the process in a second pair of bones. This is safer and keeps the body proportions  (shape of your body).

It is not nice to have for example a long leg and a short thigh in relation to them! If you need to lengthen for example 15 centimeters, so it is better to do two operations for tibial (leg below knee) and Femoral (Thigh) lengthening rather than doing one operation for lengthening any of them. It is also not advised to do both operations at the same time by any way of fixation either externally or internally as for sure it affect your joints negatively and it is our aim to keep your joints and functions very well after the end of the lengthening procedure.

Dr. Elbatrawy is different from other doctors who like to promise much for their patients (for example lengthening 10 centimeters or more in one operation)! This is very possible to do, but definitely leaves permanent damage to the patients soft tissue ( muscles and ligaments ), so Dr. Elbatrawy who is looking for a healthy future for his patients refuses to lengthen more than a certain limit that should be calculated accurately for every patient after evaluation of his or her joints and body.

The usual strategy is to lengthen both tibiae (includes the fibula) 2.5 to 3.5 inches or 6 to 9 centimeters from a single site of lengthening.

Dr. Elbatrawy prefer using a single site of lengthening to decrease the pain that could results from lengthening of two bone sites at the same time. As this stretch the soft tissue for up to 2 millimeters per day. It is proved in many congresses that the complications and pain associated with a single site of lengthening are much less than with two sites of lengthening at the same time. Using his special technique of lengthening of Dr. Elbatrawy proved to have almost no complications and is safer than any other technique anywhere in the world.

If a second lengthening procedure is desired after legs (Tibiae), then both femoral bones could be lengthened. Most patients do not choose to have the femora done because of the added time commitment and the doubling of the expense. Furthermore, doing too much lengthening in the lower limbs in normally proportioned people could lead to disproportion. Up to 3.5 inches of lengthening produces no obvious disproportion.

Recovery duration

One can assume that it will take approximately 1 month for every inch (2.6 cm) of lengthening. Lengthening does not begin until 1 week to 10 days after the operation.

Therefore, 2 to 3.5 inches of lengthening takes 2 to 3 months. Then we have to wait until the newly formed bones are fully consolidated before external frame removal. This can take few months (the duration depends upon many factors including how many centimeters we lengthened?). Usually for 6 centimeters, it takes approximately about 6 months. In some patients it took 5 months and in others took up to 7 months. When using Dr. Elbatrawy new technique of maximum stability, Weight bearing is permitted very early after the procedure. At the end of lengthening and consolidation, the external fixators are removed from outside without need for further surgery to be done.

Most patients begin weight bearing 2nd day after the surgery. Physical therapy continues, mostly to keep full ankle motion and foot push-off strength. Daily exercises are recommended after the procedure for the ankle motion. This is to keep the ankle always dorsiflex up to 90 degrees (minimum).

In many centers of limb lengthening all over the world including USA, they usually do not allow the patient to walk or bear weight after the operation. And the patient has to use a wheel chair for at least 4 months after the operation. Then start very hard physiotherapy program to regain the lost muscles power ! As Dr. Elbatrawy did 3 fellowships in the best centers for limb lengthening in the world including USA, Italy and Russia and he learns there for years a lot from Dr. Catagni in Italy, Dr. Herzenberg and Dr. Paley in USA as well as in Ilizarov institute in Kurgan in Russia, He has developed his own technique in applying the ring fixators which increased the stability of the frames and minimized the common complications with external fixation as pin tract infection to be almost 0 % and the pain associated with lengthening. In this way, he allows his patients to weight bear and walk from the second day after the operation. As his patient start to walk early, so he or she does not lose his leg muscles power and there is no need to do any special hard physiotherapy program later on.

In case of lengthening less than 6 centimeters, then no other procedure is required to complete the lengthening successfully. In case the patient wishes to lengthen more (up to 9 centimeters then a possibility to need a further minor procedure as tendo achelis lengthening (the tendon behind your ankle joint ) could be a possibility.
Be taller in Cairo in 3 months only and travel back home!
Are you a suitable or a good candidate for cosmetic lengthening?
If you fulfill the following criteria then you are a candidate for lengthening:

1. Age: from 14 to 60.
2. Non smoker or stopped smoking for the last 6 months before starting the procedure. We do tests to detect that has smoking proved to affect negatively the new bone formation and the speed of healing and consolidation (can take longer time with smokers).
3. Not overweight.
4. Have no systemic disease as: Rheumatoid arthritis or Diabetes Mellitus, HIV positive, systemic lupus or any other systemic disease that can affect the lengthening procedure success.
5. Psychologically free: A meeting with a psychologist for evaluation could be arranged before the procedure to prove your eligibility for the procedure from the psychological point of view. From our previous experience with cosmetic lengthening patients, we found that it is important in some patients to study their fitness and eligibility psychologically for the lengthening procedure.

Lengthening Cost for external device (safest and most economic )

We can prepare an estimated cost for the evaluation, surgery, anesthesia, radiography (x-ray), hospital, and physical therapy costs. This estimate must be paid in advance before surgery begins.
For foreign patients who come to Egypt alone to do the procedure, we take care of them from day 1. No worry about accommodation or taking care of you after the operation, we can help for all of that and arrange ! Just contact us.
As a rough estimate, total medical costs can amount to be low as 12,000 Euro or equivalent in US $ or Egyptian pounds per pair of bones lengthened. This includes the operation, hospitalization and all follow-up visits

Hospital & accommodation

The first 4 to 5 days after the operation, the patient stays in the hospital. This includes 3 meals per day.
The hospital is a very modern and well equipped medical center lies in Cairo close to the international airport. The patient stay is in a private room, air conditioned room with TV, toilet and shower.
Dr. Elbatrawy admits his patients in 3 different medical centers. Saudi German hospital in Cairo: SGHC The other two hospitals are: Elnozha international hospital and Kattamia clinics hospital: KCH All of them are ISO certified.

Then the patient is transferred to a nice furnished apartment with all amenities he or she may need during the following period including: Satellite TV and wireless ADSL internet, a nice fully equipped kitchen and a care taker service during the day. We can arrange all of that to help foreign patients.
During staying in the apartment, the patient has to pay for the cost of his food as he or she like. Generally, food cost in Cairo is 25 % the same in any European or American city although the high quality of the restaurants and also the naturalists of it. Food will never cost more than 250 US $ per month.  Patient can order food from different kind of restaurants around either by phone or via the internet: www.otlob.com  A web site available to access all local restaurants nearby from you. All kind of restaurants are available: MacDonald’s, Burger King, Hardees, Pizza Hut, Papa Jhones, KFC and many nice local fast food available. In addition, the care taker or the nurse in the apartment can cook any kind of food the patient likes to eat free of charge (but you have to pay for its cost). Many super markets and malls are very near from you and you can just use the internet or the telephone to buy what you need. For example city stars mall is just 5 minutes walking distance from the place of accommodation and Dr. Elbatrawy clinic which is in the same buildings area as your accommodation. The web site of city stars mall is: http://www.citystars.com.eg
The cost also includes using original ( FDA approval or CE certified frames ) and pins. The pins we use are the most expensive and best pins available in the medical market: HA coated pins of Orthofix. Please, browse: www.orthofix.com to understand more about. This kind of pins decrease much the incidence of pin loosening or infection down to 0 % as proved in our studies and scientific publications. All kind of frames we use should be marked by CE and or FDA. This means that the company produce the frame are sailing them to hospitals in USA and Europe. We never use any material that is locally made or made anywhere and is not marked by CE or FDA approved.

Some other centers for limb lengthening locally and everywhere in the 3rd world are using low cost frames and or pins either locally made or not CE marked or FDA approved. This kind of cheap frames can affect the results. We do not like to provide a cheaper cost over the quality of the material or the service provided. The quality of our work and results as well as used devices could be compared only to the same standards as USA and West of Europe, not to any other place on the earth where they produce more expensive operation for a much cheaper materials. Even if the final results of some other centers are good, but patient cannot know what could happen in the future for his or her body who had a bad quality metal for a long time which could be absorbed to the blood and make future problems for patients kidneys or liver…etc
Our aim is to help our patient with a tight budget who cannot afford to do the operation in USA or Europe for the same or better quality operation and for a much lower and affordable cost.
There are no hidden fees at all as the patient pay only the previous cost for the operation.
Extras are: Refundable insurance when return the frame: 1200 Euro or 1500 $.
Extras if use another technique as LON, LTN or internal technique.
Internal technique cost much more because the cost of the implant is much higher. For example we buy one Precice nail from the agent for 15 thousands of Euro and one Fitbon for 13000 Euro….etc So the total cost of the operation can go up to 65 thousands of Euro or equivalent in US $ or Egyptian pounds. or 48000 Euro for Precice 2 nails bilateral operation in Cyprus including hospitalization.

Internal method is not preferred at all to an external one as there are advantages and disadvantages for every method and technique. It is proved that external method in good hands as Dr. Elbatrawy is very safe and economically efficient. While internal method has advantage of having less scars but also is limited for mobility during the first 3 months after the operation (the lengthening period) because any internal device is mechanically weaker implant than the strong external fixator that can tolerate the body weight and have no possibility for breakage or mechanical failure.

Recently, Precice Stryde can tolerate body weight and allow the patient to full weight bearing from day 1 after the operation.

How long you should stay in Cairo ?

Although it is preferred, but it is not necessary to stay in Cairo during the entire duration of the procedure till frame or implant removal.
Many of Dr. Elbatrawy patients did the operation in Cairo and travelled back to their homes just after a week after it. Then they do the follow up every 40 to 45 days either with Dr. Elbatrawy or with a local Orthopedic surgeon who is oriented with lengthening and under the supervision of Dr. Elbatrawy himself either during the follow up visit or via e.mail. Many patients from Europe and USA choose this option.
Also, many patients preferred to stay in Cairo for the lengthening period only (about 3 months) then they traveled back home. 3 to 4 months later Dr. Elbatrawy arranges their frame removal either in his clinic in Cairo or in their homes or by a local specialist. It is an easy procedure and does not need a surgical operating room. Frame removal is free of charge in Dr. Elbatrawy clinic.
All follow up visit in CICLLR including x-rays are free of charge for patients who paid the operation cost in full.

We guarantee excellent results, so we never calculate cost of any additional procedure needed to treat a complication! Simply because usually WE DO NOT HAVE. Although many complications were reported as non union or delayed union or infection or nerve injury….etc but it is too rare to happen practically and if happened, we treat and care of our patients till full cure.

No one doctor is immune from complication in his patient, we are honest with our patients and we take care of them till full cure.

Only in case the patient lengthened more than 6 centimeters and he or she needs for an additional minor operation to lengthen tendo achelis (to avoid ballerina foot problem ) as this could happen in about 30 % of patients lengthen more than 6 centimeters ( 2.5 inches ). Then the cost of this operation is only 3500 Euro including hospitalization for one day.

Payment methods

Payment is either in cash or using travel checks ( in your doctor name). Other possibility is to use Bank transfer ( Most of patients do that because it is the cheapest way ). As the system here in Egypt is different from USA or Europe, Your doctor is responsible financially about you in front of the hospital. There is no financial deal between the patient and the hospital, but between the patient and the doctor and then between the doctor and the hospital. This is very frustrating for doctors here as the doctor has to pay for the hospital, companies sailing devices and pins. He also has to pay for fees of others involved in the procedures as nurses, anesthesia doctor…etc. So, here the doctor is the responsible about everything financially regarding his patient.

You can also pay using your credit card: Visa or Master if the limit allow that in our center for a small charge as 2% more.

Follow up

The pain sensation is different from one person to another; however 90 % of patient has no actual pain after 3 days from the operation or during the lengthening procedure.
For the first 3 days after the operation, the pain management specialists like to give my patients a regular dose of Bethedine or Morphia for his or her comfort. The patient should not feel pain at any time after the surgery by using pain medication. Also, it is preferred to inject regular continuous dose of Marcain or Xylocain( anesthesia ) injecting into the epidural catheter when the patient has epidural local anesthesia during the operation. Specialist do that using a special electric automatic device called Syring Pump. This guarantees no pain after the operation. Regular anti – inflammatory pain medication as Voltaren, Brufen…etc are not allowed to be used after the surgery. This because its negative effect to the quality of the new bone formation. This is because the new bone formation is an inflammatory process and this medicine is anti – inflammatory!
The technique of application of the device itself plays an important role in decreasing the pain after the operation. From my experience working for years in the best centers for lengthening of bones all over the world, I can confirm that the lowest possible pain after the operation is among my patients. When the frame is very stable using my new technique of maximum stability that proved to be the best among different techniques of application of the frame, this means almost no pain after the operation. I can see patients in my clinic every week who applied frames in other hospitals by other doctors in a very old fashioned ways or non scientific ways and they are in terrible pain ! It is very clear for me that this is because they have unstable frames!

Our techniques ensure having the lowest rate of pain among all.
Although this surgery is considered cosmetic, we recognize that most people seeking this type of surgery are driven to do so for psychological reasons. This is clearly related to individual body image. Our psychological testing after lengthening compared with before lengthening has convinced us that in the majority of cases, stature lengthening alleviates or eliminates the neurosis the patient has before doing the operation. This neurosis is due to his or her wish to be taller. Having stated that, we have had to make an arbitrary cutoff of maximum height for which we feel comfortable offering this service. Please recognize that we are approached by individuals who are just as distressed by their perceived short stature independent of their measured height.

Other lengthening techniques

Internal technique:

Different methods for lengthening are available. As we mentioned we prefer external fixation method as Ilizarov ring fixator or TSF for legs and Orthofix LRS device for thighs. This is because of the highest rate of success (which reached to 100 % in our patients.
Any internal device inserted inside the bone to do the job of lengthening is considered a weak implant except the mew Precice Stryde nail This is because the diameter of the implant is not more than 10 or 11 millimeters in the best condition. This cannot tolerate the full body weight and makes it little risky to have a mechanical failure. So, the patient having internal method of lengthening should follow a special protocol for weight bearing after the operation even with Precice Stryde nail.
This is controversy to the patient having external fixation only which are allowed for full weight bearing after the operation!
Full weight bearing and early walking make things faster for rehabilitation than patients having internal method of lengthening. This is the opposite of what patients believe that internal method is easier or less painful than external one.
As any internal fixation of bone, there is a risk of infection. Even this risk is very little as 2 to 3 % only, but the patient should orient the possibility for that to happen. If this happened, it is not difficult to treat if it is detected early.
Some other complications were reported in scientific studies as Compartmental syndrome or vascular or nerve injury or thrombus……etc

So, in our patients we like to do what is called ventilation for the medulla during reaming process and we do the reaming slowly to allow ventilation and this decrease the incidence of this complication as no one of our patients developed this complication previously, however if it happen, we must take the patient to the operating room again and do what is called Fasciotomy by opening all the leg compartments. It happen in tibia more than in femoral bone. The incidence for it to happen is no more than 2-3 %.
Other reported complications in scientific studies as vascular or neural injuries are very rare to happen and if happened we must treat them as early as possible. There is no operation free of risks at all.

neuroparaxia or nerve shock could happen and it is reversible if happened and need no exploration to the nerve if happened in case we do not have a surgical incision at that site of the nerve.

In case our patient disappear or travel after the operation without notice, then we are not responsible about the outcome of the operation.

The patient pay the cost of the operation to us to do it, not pay the cost of it to get a results. although of that, we confirm that our results are excellent in all of our patients as we take care of them till full cure.

Combined technique:

LON: Lengthening Over Nail:

It means External and internal in which we apply an external device as Orthofix LRS or Ring fixator from outside the bone and an intra medullary regular interlocking nail (much cheaper in price and stronger than previous types of nails used for lengthening ) at the same time. We use the external device only till end of lengthening stage which is about 2 to 3 months then continue the fixation by the internal interlocking nail. The advantage of this technique that it save time as the external fixator is removed just after 2 to 3 months ( the lengthening stage ) while the internal nail support the lengthened bone till it become hard enough for the remaining period of consolidation which take about 3 to 4 months more in most of cases.
The disadvantage of this technique that two implants are used ( external and internal ) and so the rate of deep infection could be higher ( about 2-4 % ) while it is 0 % when using external method only. Also, it needs to do three operations: first to insert the nail and apply the external fixator and second is to remove the external fixator and lock the nail and a third one to remove the nail !

LTN: Or Lengthening Then Nailing:

It is a combined technique too as LON but the external fixator is used first till lengthening stage finished then in the second operation, it is removed and the internal interlocking nail is inserted. A third operation may be needed to remove the interlocking nail a year later after full consolidation.

Lengthening stages: 

1. Latent stage: for the first 10 days after the operation, the patient should not do distraction. This gives a chance for little maturation of the blood between both ends of bone at the level of the osteotomy or corticotomy site and also it gives a chance for healing of the wounds of the operation. During this stage the patient is allowed to walk and practice his or her life using a walker.
2. Lengthening stage: We prefer a distraction rate of ¾ mm. per day for the first 3 weeks then an x-rays is taken to see the quality of the newly formed bone. Usually the quality is very good then we proceed for a rate of 1 mm. per day and just 1 centimeters before reaching to the required level of lengthening, we prefer to slow the rate of lengthening to be ¾ then ½ then ¼ mm. per day till we stop lengthening or distraction completely.
3. Allignment adjustment: A long film x-rays is taken and adjusting of the alignment should be done at this stage before the newly formed bone is fully consolidated. This could be done using a special hinges applied to the device and it is a completely pain free procedure.
4. Consolidation stage: In which we give a chance to the newly formed bone to consolidate completely before we are able to remove the metal hardware either internal or external. Usually this stage takes a time that is 1.2 of the time of the lengthening. It means if we took about 3 months for lengthening of 7 to 8 centimeters, then it may need about 4 months till full consolidation of the newly formed bone. During this stage, the patient should leave the walker and use just a stick or nothing at all. Usually the patient is much more active in practicing his life during this stage. At end of this stage, the hardware could be removed.
5. Removal of hardware: In case the patient have an external frame, then it should be removed from outside after the bone is fully consolidated. This could be done without anesthesia in most cases, however, few patients prefer to have it with anesthesia. The cost of frame removal with anesthesia could be about 1000 $ only.

Tendo Achelis Lengthening:

Tendo Achelis is the thick tendon behind your ankle. When we lengthen the bone, the soft tissues including tendons are not lengthened in the same rate. I mean, it does not accept the rate of 1 mm. and so, it becomes under tension! In our experience, all patients who lengthened up to 6 centimeters needs no further operation and had no problems. While about 50 % of patients lengthened more than 6 centimeters needed for a further operation for Tendo Achelis Lengthening. This operation is a minor procedure and it could be done at the end of the lengthening stage. We do it in a very special technique that preserves the whole thickness of the tendo-achelis and it never affects its function later on. For sure, this is considered as an additional procedure and its cost is variable from 4 to 5 thousands of $ for both sides.
We always advise our patient to lengthen between 5 to 7 centimeters as we see that this is the best valuable amount of lengthening. It does not take a long time and has no problems later on in life.

×