Special Problems in
Reoperative Body Contouring
JOSEPH F. CAPELLA
CHAPTER 89
R
eoperative procedures are an important component of a body-contouring prac-
tice. There are many factors leading to the need for revisional surgery; most
are the result of an unexpected outcome, but some can be related to the plastic sur-
geon‘s choice of primary procedure. In an effort to accommodate a patient’s busy
lifestyle, both the patient and plastic surgeon may be driven toward procedures with
the shortest recovery period or the shortest scar. Less-invasive procedures are often
innovative and are often reported to produce results similar to more invasive proce-
dures—but frequently have limited supportive data. It is essential that all plastic sur-
geons, particularly those early in their careers, have a clear understanding of the pro-
cedures and clinical scenarios that are most likely to result in patient dissatisfaction
and the need for revision.
In this chapter I have selected several body-contouring cases from different regions
of the body that resulted in the need for revisional surgery but might have been
avoided with a different primary procedure.
Abdomen, Thighs, and Buttocks
Lower Body–Contour Deformities After Liposuction
Contour deformities following liposuction of the lower body in a postpartum or
postbariatric patient are among the most frequent complaints leading to reoperative
surgery, in my experience. Almost all women have some weight gain during preg-
nancy, some more than others, leading to an extended period of soft tissue expan-
sion of the abdomen and to some degree the hips, thighs, and abdomen. After de-
livery, much if not all of the weight is lost and soft tissues retract in varying degrees,
depending on multiple factors, including age, number of pregnancies, the amount of
weight gained and lost, and the woman’s sun exposure, complexion, and tobacco
consumption. A postbariatric patient undergoes a similar but more exaggerated ex-
perience. However, the result for the two groups is similar: excess soft tissue, and tis-
sues with poor elastic qualities. As has been described by others, an appropriate
amount of fat in the soft tissues of the body is an essential element of a youthful ap-
pearance. In a postpartum or postbariatric patient, excess fat may be a component
of the contour deformity; however, excess soft tissue and limited elasticity are likely
to play a larger role. Liposuction alone for these patients will often result in an in-
crease in contour irregularities.
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Part XII Body Contouring
This 36-year-old woman underwent a 32 kg (70-pound) weight change with preg-
nancy. Her postpartum contour concerns were addressed on two occasions by an-
other physician with liposuction of the abdomen, thighs, and buttocks. She came to
me dissatisfied with her extensive contour deformities and loose skin. I performed a
circumferential lower abdominal, thigh, and buttock lift. She is shown 30 months
postoperatively.
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Chapter 89 Special Problems in Reoperative Body Contouring
The treatment of postliposuction contour deformities is challenging. An excisional
procedure will conceal the fatty deficits by tightening the soft tissue. Injection of fat
may be useful for small areas of fat deficiency but is unlikely to be practical over
larger areas of the body and when soft tissue excess is the primary problem. My pref-
erence is to wait at least 6 months before attempting to address postliposuction de-
formities with excisional procedures. A history of excessive liposuction, particularly
to the anterior abdominal wall, may compromise blood supply to these tissues.
Overall, I have found excisional procedures to be very useful, particularly with re-
gard to deformities closer to the waistline.
Postbariatric Lower Body–Contour Deformities
After Abdominoplasty Alone
Following weight loss, patients often present to a plastic surgeon with multiple com-
plaints involving the abdomen, thighs, and buttocks. For both men and women, the
abdomen is usually of greatest concern. The thighs and buttocks may be of concern,
but the degree of soft tissue excess in these areas is often not completely appreciated
by the patient unless he or she is examined in front of a mirror while upward trac-
tion is applied to the soft tissues of the lower body.
Postbariatric patients are often advised to undergo abdominoplasty alone or with
liposuction to the hips and thighs. These traditional procedures usually only partially
address the deformities that result from weight loss and in some instances may pro-
duce an unnatural-looking body contour. Abdominoplasty and liposuction can ac-
centuate the soft tissue excess of the hips, thighs, and buttocks and often produce
standing cones of tissue.
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Part XII Body Contouring
This 50-year-old man lost 59 kg (130 pounds) following gastric bypass surgery and
underwent an abdominoplasty. He came to me with concerns about laxity along the
lower abdomen and mons pubis and excess skin and fat along the hips and buttocks.
In addition, he thought that his lower abdominal scar was too high. This man’s con-
tour deformities are typical of those following abdominoplasty in a massive-weight-
loss patient. I addressed his concerns by performing a lower body lift; that is, a trans-
verse thigh and buttock lift and a medial thigh lift with a vertical component. He is
shown approximately 3 months after surgery.
Circumferential techniques are far more effective procedures for addressing the de-
formities of a massive-weight-loss patient; a more balanced aesthetic result can be
achieved, and the standing cones of tissue can be avoided. In addition, the infraum-
bilical portion of the abdomen can usually be made tighter than with abdomino-
plasty alone, because there is no limitation in scar length.
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Chapter 89 Special Problems in Reoperative Body Contouring
The Medial Thigh Lift Approach:
Thigh–Perineal Crease Alone Versus Thigh–Perineal
Crease Plus a Vertical Component
The medial thighs can be of great concern for both postpartum and postbariatric
individuals. These patients will often come in for a consultation, stand in front of a
mirror, and elevate their medial thighs toward the groin crease, requesting that this
be replicated by a surgical procedure. Many plastic surgeons approach medial thigh–
lifting techniques with great hesitation. The undesirable outcomes associated with
these procedures are well known: labial distortion resulting from excessive tension,
descent of scars from the thigh–perineal crease, descent of the pigmented tissues of
the groin onto the proximal thigh, and limited or no improvement of the medial thigh
contour. Nevertheless, patients are eager to have some kind of intervention. Elevat-
ing and securing the sagging medial thigh tissues to an immobile structure such as
Colles’ fascia appears to be an effective approach to this problem.
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Part XII Body Contouring
This 33-year-old woman lost 78 kg (172 pounds) after a gastric bypass procedure.
I initially performed a body-lift procedure on her (simultaneous abdominoplasty and
thigh and buttock lift). She was satisfied with the results but had remaining concerns
about her medial thighs. I described the thigh-perineal approach to performing a
medial thigh lift but explained that a more aggressive approach involving a scar along
her medial thigh extending to her knee would result in a better outcome. She was
adamantly opposed to this lengthy scar, and at that point in my career, I was recep-
tive to whatever choice was taken by the patient regarding the medial thighs.
I performed a medial thigh lift limited to the thigh perineal crease. The results are
self-evident (left). The scars have descended, the labia have been distorted, and aes-
thetically there appears to be no improvement in her result.
The same patient is shown 2 years after a body lift and 6 months after a medial thigh
lift with a vertical component (right). In addition to producing an improved aesthetic
result, the deformity at the thigh–perineal crease has been corrected by the addition
of the vertical component.
This case illustrated very clearly to me the factors contributing to the medial thigh
deformity in individuals after significant weight loss. There are three elements from
outside the medial thighs that affect the medial thighs: descent of the mons pubis to-
ward the medial thighs, descent of the buttocks toward the medial thighs, and in-
feromedial rotation and descent of the thighs toward the medial thighs. These three
consequences of significant weight loss are very effectively addressed by circumfer-
ential body-lifting procedures. However, circumferential excess at the thighs is not
addressed by body-lift procedures or medial thigh-lift techniques limited to the thigh–
perineal crease. Medial thigh lifts with a vertical component very effectively address
this remaining excess and produce a far better aesthetic result.
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Chapter 89 Special Problems in Reoperative Body Contouring
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Part XII Body Contouring
In a weight-loss patient who has undergone a circumferential body-lifting procedure,
the addition of a medial thigh lift limited to the thigh–perineal crease is usually of
limited benefit. Removing excess tissue in only a vertical vector along the medial
thighs and securing the thigh flap to an immobile structure (Colles fascia) will likely
produce a suboptimal aesthetic outcome. In an individual who has undergone sig-
nificant weight loss, the combination of inelastic qualities of soft tissues and the nor-
mal and necessary thigh abduction of everyday activities will eventually result in ei-
ther the descent of the thigh-perineal scar and labial distortion, or recurrence of soft
tissue excess along the medial thighs.
Arms
The arms are visible in everyday activities, and their appearance is important to in-
dividuals of all ages. Unfortunately, the consequences of many variables, including
weight loss, sun exposure, and tobacco consumption, greatly affect the contours of the
arms. The ready visibility of the arms makes patients and plastic surgeons particu-
larly averse to scars in this region.
Arm Contour Deformities After Liposuction
As in the rest of the body, poor skin elasticity and excess soft tissue in the arms is
likely to lead to a poor outcome after liposuction. From my own experience and from
examining patients from other practices, postpartum and postbariatric patients usu-
ally do not benefit from arm liposuction alone. The deformities from these proce-
dures may not be immediately recognizable but may appear later with aging and en-
vironmental exposure. The effects of skin retraction from liposuction procedures
alone are limited.
This 21-year-old woman lost 82 kg (180 pounds) after gastric bypass surgery. She
subsequently underwent laser-assisted liposuction of the arms. She presented to my
practice with concerns about her arm contour deformities and sagging skin. I per-
formed a brachioplasty that included concomitant liposuction and excision of soft
tissue. She is shown 6 months postoperatively and is very pleased with her results,
although she has gained significant weight since her surgery.
In many areas of the body, I have found the combination of liposuction and soft tis-
sue excision to be very effective. Liposuction facilitates greater soft tissue excision
and provides a readily identifiable plane of dissection.
Short-Scar Versus Traditional Brachioplasty Procedures
The rapid increase in the number of bariatric procedures in the United States and
abroad has made brachioplasty a commonly performed surgery for many plastic sur-
geons. Although before 2000 the procedure was rarely performed by any plastic sur-
geons, more than 14,000 brachioplasties were performed in the United States in
2009. Excisional procedures are generally accepted as the treatment of choice for in-
dividuals who have lost weight, but multiple variations of brachioplasty have been de-
scribed to minimize or eliminate the scar along the arm (see Chapter 82).
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Chapter 89 Special Problems in Reoperative Body Contouring
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Part XII Body Contouring
This 57-year-old postpartum woman had lost 20 kg (45 pounds) 10 years earlier
through lifestyle changes. Eight months before she came to me, she had undergone
liposuction of the arms, and 4 months before she presented, she had a brachioplasty
with the scar limited to the proximal arm and axilla. She was disappointed with the
results and thought that her best potential arm contour had not been achieved. I per-
formed a traditional brachioplasty with extension of the arm scar to the medial epi-
condyle. She is shown 3 months postoperatively.
In the obese state, fat is stored in characteristic areas for both men and women. The
soft tissues in these areas expand to accommodate fat. The longer the duration of
obesity and the greater the weight reached by the patient, the poorer the tissue elas-
ticity will be and the more excess soft tissue will be present. In both men and women,
fat along the upper extremity is stored primarily at the axilla and proximal arm. The
resulting deformity from weight loss requires that excess tissue be removed along a
horizontal vector at the arm. The length of the arm scar required to address the arm
contour deformity is determined by the degree of deformity present and the quality
of the result desired by the patient.
Concluding Thoughts
The effects of aging, the environment, pregnancy, excessive weight, and weight loss
will diminish the elasticity and quality of the soft tissue of the body, which in turn
leads to contour deformities. Despite significant advances in plastic surgery, the body-
contouring techniques available to us consist primarily of the removal and place-
ment of soft tissue and prostheses. No substantial gains have been made in the way
of improving soft tissue quality and elasticity. Thus it is unlikely in the near future
that the lengthy scars often needed for effective body contouring can be avoided.
Much of our clinical effort in this regard should be directed scar quality and per-
ceptibility and educating our patients about the appropriate procedures available to
achieve their goals.
Clinical Caveats
The need for revisional surgery is sometimes affected by the selection of the pri-
mary procedure.
Liposuction can produce contour deformities in individuals with excess soft tis-
sue and poor skin elasticity.
Contour deformities secondary to liposuction can be treated in varying degrees by
soft tissue excisional procedures.
Abdominoplasty and liposuction alone are unlikely to produce an optimal result
in the weight loss patient.
Medial thigh–lift procedures limited to the thigh–perineal crease have limited util-
ity and can be associated with significant complications in a weight-loss patient.
Circumferential body lifting procedures are often an integral component of cor-
recting the medial thigh–lift deformity in a weight-loss patient.
Careful patient selection is critical to effectively implementing short-scar tech-
niques in brachioplasty.
Lengthy scars are likely to be an important part of some body-contouring proce-
dures until substantial advances are made in the science of improving the elastic-
ity of soft tissue.
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Chapter 89 Special Problems in Reoperative Body Contouring
Annotated Bibliography
Abramson DL. Minibrachioplasty: minimizing scars while maximizing results. Plast Recon-
str Surg 114:1631-1634; discussion 1635-1637, 2004.
A short-scar brachioplasty or minibrachioplasty technique is described that limits the
scar to the axilla and proximal arm. Eight patients were treated with the technique. Bra-
chioplasty techniques with scars limited to the proximal arm are likely to have limited
utility in weight-loss patient. Very careful patient selection is critical to properly imple-
ment short-scar techniques in brachioplasty.
Baroudi R. Reoperation after liposuction and body contouring surgery. In Grotting J, ed. Re-
operative Aesthetic & Reconstructive Surgery, 2nd ed. St Louis: Quality Medical Pub-
lishing, 2007.
The author reviews complications following a wide array of body-contouring proce-
dures. Causes of patient dissatisfaction after liposuction are discussed, such as insuffi-
cient or excess fat removal and skin irregularities and laxity resulting from poor skin
retraction. The effects of weight fluctuations after liposuction are illustrated. The use of
secondary liposuction, fat injection, and soft tissue excision to address contour irregu-
larities is described.
Capella JF. Body lift. Clin Plast Surg 35:27-51; discussion 93, 2008.
I review my first 425 body lifts (simultaneous abdominoplasty, thigh, and buttock lift).
The indications for the technique and the limitations and disadvantages of performing
abdominoplasty alone in postbariatric patients are discussed. Multiple cases are pro-
vided, exemplifying the varied presentation of this patient population. A detailed review
of complications after a body lift describes the association between body mass index
and pulmonary embolism.
Capella JF. Brachioplasty. Presented at the Baker Gordon Symposium, Miami, Feb 2005.
At this conference I discussed the reasons that medial thigh–lift procedures limited to
the thigh–perineal crease are unlikely to be effective in individuals after weight loss. The
variables contributing to the medial thigh deformity were reviewed, including ptosis of
the mons pubis, inferomedial descent of the thighs, buttock ptosis, and horizontal or
circumferential excess thigh soft tissue. Use of a circumferential body lift and medial
thigh lift with a thigh–perineal crease and medial longitudinal component to address
the medial thigh deformity was reviewed.
Suggested Reading
Richards ME. Minimal incision brachioplasty: a first-choice option in arm reduction sur-
gery. Aesthet Surg J 21:301-310, 2001.
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Part XII Body Contouring
FINAL THOUGHTS
PART XIII
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Reflections on the
Art of Aesthetic Surgery
FOAD NAHAI
CHAPTER 90
A
esthetic surgery is an art, a visual art. Despite efforts to quantify results and
set standards to measure outcomes, our evaluations remain subjective. Beauty
is interpreted subjectively by patients and surgeons: the patient’s idea of beauty may
not be the same as the surgeon’s. There are also significant ethnic and cultural dif-
ferences that define our concept of what features are considered attractive. High-
arched eyebrows, the ideal in some cultures, may seem exaggerated or overdone in
others. The ideal breast size varies considerably from culture to culture and from one
geographic area to another. Whereas a plump or full figure is admired in some re-
gions, in the United States the media promote a slender figure as the ideal. A suc-
cessful aesthetic surgeon who is mindful of these differences actively elicits the pa-
tient’s concept of beauty and expectations for a result.
Aesthetic surgery adapts to the times; it is a part of our culture, reflecting current
fashions, trends, and fads. Occasionally these trends become exaggerated and di-
vorced from normal standards of appearance and beauty. This can be seen in frozen,
expressionless foreheads overtreated with Botox, or excesses in lip augmentation
where these delicate structures are inflated beyond proportion, or augmented breasts
with exaggerated upper pole fullness, a characteristic seen so frequently that some
people accept this as normal. It is our responsibility to educate our patients and the
public so that they understand the difference between a normal enhanced appear-
ance and one that has been unnaturally altered.
Aesthetic surgery is also, first and foremost, a surgical discipline, and in that respect
no different from any other surgical specialty. It cannot be taught overnight or prac-
ticed effectively without a strong surgical background. Aesthetic surgery does not ex-
ist in a vacuum. This is a discipline based on sound knowledge of anatomy and phys-
iology combined with an understanding of the psychosocial aspects of altering the
face and body. Principles of surgery, specifically physiologic responses to surgical
trauma, wound healing, and the prevention and management of complications, ap-
ply as much to aesthetic surgery as to any other surgical specialty. Years of experi-
ence in basic surgical technique, training in reconstructive surgery, and exposure to
detailed anatomy in the laboratory are prerequisites for practicing aesthetic surgery.
For me this experience began in the anatomy lab, culminating in an honors degree
in anatomy, followed by years spent restoring form and function through anatomic
research and clinical applications. My current interest in aesthetic surgery was a nat-
ural extension of this reconstructive and anatomic training. What I have come to re-
alize is that whether we are restoring form and function or enhancing body or fa-
cial appearance, we are guided by the same aesthetic principles and goals. Expertise
and competence in aesthetic surgery is not gained through a weekend course, a few
days spent observing an expert, or an hour viewing a DVD.
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Part XIII Final Thoughts
I love this specialty because there are so many ways of solving problems, regardless
of whether we are rejuvenating the aging face, correcting changes in the shape and
size of the breast, or recontouring the body. Each of the approaches is right for the
right patient. Because the specifications will vary for each individual, depending on
the patient’s physical situation and desire for change, the surgeon should be skilled
in a number of different techniques, but not necessarily all, which can be applied or
modified accordingly. Clinical decision-making, which contributes to patient satis-
faction, must also take into account the patient’s motivation for seeking aesthetic
surgery, degree of concern over the perceived problem, and expectations. Choices
can only be made after listening to the patient and setting goals that are in balance
with his or her lifestyle. A patient seeking facial rejuvenation who has only a few
days for full recovery and whose lifestyle will not permit sun avoidance is obviously
not a candidate for a fully invasive face lift or laser resurfacing. In this situation, the
patient must either agree to temporarily alter that lifestyle and have the invasive pro-
cedures or be willing to accept a less than ideal result with injectables, other nonin-
vasive procedures, and skin care.
The pendulum swings; fads come and go. We should not precipitously embrace every
new technique, treatment, or technology that is advanced until each has been eval-
uated, its value, safety, and efficacy established, and the appropriate role or indica-
tions defined. Regrettably, many manufacturers are promoting their products directly
to the public before physicians have the opportunity to scientifically evaluate them
to verify their safety and efficacy. I am concerned that these companies no longer
view us as their customers, preferring to drive demand by targeting the public, who
lack the scientific background for judging these products and may be more gullible
and accepting of exaggerated claims. To ensure that our patients receive the best care
with the safest products, we need to find a way to get back into the mix and to re-
sume our proper role in monitoring this process.
Aesthetic surgery, as is true of all surgery, carries risks. When I discuss these with
my patients, I advise them to forget the word “cosmetic” and remember the word
“surgery.” I explain that all surgery, even in the best of hands, carries risks. The best
we can offer our patients is reduction of this risk by taking the necessary measures to
minimize complications and morbidity. The patient is responsible for selecting the
surgeon; the surgeon is responsible for the patient’s safety, comfort, and privacy.
Ensuring patient safety and minimizing risk begins with the initial consultation and
history-taking and continues with preoperative preparation, intraoperative mea-
sures, postoperative care, and follow-up. Patient selection is a key part of this process.
The medical history should elucidate factors that will affect outcomes in aesthetic
surgery, such as smoking, hypertension, other general medical conditions, medica-
tions, allergies, and history of psychological problems. If necessary, or if there is any
doubt about the patient’s health, the patient should be referred to his or her primary
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Chapter 90 Reflections on the Art of Aesthetic Surgery
care physician, counselor, or psychiatrist for a thorough evaluation before any op-
eration is undertaken.
The type and length of procedure and the combination of procedures have an im-
pact on patient safety. Where the operation is performed (the physician’s office, a
freestanding certified outpatient surgical facility, or the hospital) is also relevant.
These decisions are normally made by the surgeon with little if any input from the
patient. However, given concerns about expense, and with the advent of the fasci-
nation by the media and public with extreme makeovers, where multiple procedures
are performed simultaneously for a complete, rapid transformation, it is not unusual
today for patients to request or even demand multiple simultaneous procedures. Al-
though in some patients this may be safe, it is prudent for the surgeon to point out
the increased risks of these long, multiprocedure operations. Patient safety should
not under any circumstances be compromised by financial concerns or succumb to
the patient’s insistence that everything be done at once. Similarly, the choice of fa-
cility where the operation will be performed should be based on sound surgical judg-
ment rather than financial concerns.
It is the role of the surgeon working with the surgical team to coordinate patient
comfort and safety in the operating room. This includes proper functioning of all in-
struments and equipment, positioning and protection of pressure points, protection
of the cornea, appropriate placement of grounding plates, maintenance of patient
body temperature, and deep venous thrombosis prophylaxis, to mention only a few.
After the operation, the patient should be cared for in an appropriate setting. This
will range from their home to overnight or longer in a suitable overnight facility or
a hospital. This decision is based on the type of procedure and the patient’s general
medical condition. For multiple body-contouring procedures, I recommend hospi-
talization with at least one overnight stay. For facial aesthetic surgery, I prefer to take
care of them in our own freestanding certified surgical center with at least one
overnight stay in our facility. Breast augmentations and small volume liposuction are
outpatient procedures performed in our surgicenter; however, I do ask these patients
to stay within 20 minutes’ reach of our office for the first postoperative night. Al-
though immediate complications are very rare in this group, I do not think it is wise
to allow them to travel long distances, and I prefer to have them in close proximity
in the unlikely event of a complication.
Postoperative patient management after discharge from the facility should include
directions for the specific procedure and general information on the prevention and
management of postoperative nausea and vomiting, pain and discomfort, and tem-
perature changes. The patients are also instructed to look for any sudden or unusual
swelling or change in the operative site which may indicate hematoma. All patients
undergoing surgical facial rejuvenation remain in our facility overnight and are con-
tinuously monitored for elevation of blood pressure, nausea, and pain and discomfort.
3186
Part XIII Final Thoughts
Trends in aesthetic surgery are toward procedures that are less invasive, less expen-
sive, require less recovery, have less morbidity, and require less time. However, less
is not necessarily more; in fact, it may be less, except in younger individuals who are
seeking aesthetic surgery in ever-larger numbers. For some of these patients, skin
care, injectables, and noninvasive treatments can be as effective as a full face lift in
older individuals. These trends are growing rapidly as younger and younger patients
with minimal or moderate aging changes seek early rejuvenation and as older indi-
viduals increasingly request less-invasive procedures. Therefore it seems only logical
to predict that the demand for complex, extensive surgical procedures requiring pro-
longed recoveries has declined and will continue to decline. However, this prediction
does not hold true for all patients. There is an emerging new group of candidates for
aesthetic surgery, massive-weight-loss patients, whose only effective options are all
extensive, complex facial and body-contouring procedures.
Medical tourism is another trend that has grown in popularity, in some cases pos-
ing a potential threat to patient safety. Contrary to what we knew as medical tourism
in the past, where wealthy individuals from developing countries travelled to West-
ern Europe and North America in search of excellence, today the trajectory has been
reversed as patients travel to developing countries in search of bargains in health care
in general and in aesthetic surgery in particular. Clearly, there are many well-qualified,
skilled physicians and first-rate facilities in these developing countries, but the
fact remains that it is a risky business when patients choose caregivers based solely
on price considerations. Regrettably, there are numerous unscrupulous, untrained
practitioners who offer bargain prices to unwitting consumers; these practitioners
are frequently aided by tour organizers, vacation resorts, and even national govern-
ments who promote these services while downplaying the serious nature and risks
of surgery. Instead, they focus on the vacation and the tourist attractions available,
conveniently glossing over issues of recovery and the potential complications asso-
ciated with any surgical intervention. Although we cannot slow this trend, we can
provide some balance and help to educate the public and our patients about poten-
tial dangers. For those of us who treat patients who travel long distances to see us,
it is essential to make sure that these patients are well informed and that arrange-
ments are made for safe follow-up care on their return home.
Aesthetic surgery is evolving. Procedures are continually being revised and refined to
offer our patients the best care possible. As new techniques and technologies are in-
troduced, established techniques are reevaluated and even abandoned. This evolu-
tionary process is necessary; it should and will continue. It is my hope that this sec-
ond edition will mirror the ongoing evolution and contribute to the advancement of
our specialty. Ultimately, aesthetic surgery is an art form; it is creative, dynamic, and
for me, it represents completion of my personal lifelong fascination and passion with
the practice of plastic surgery.
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Credits
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