I'm Dr. Marie Gdalevitch, an orthopedic surgeon who conducts cosmetic limb-lengthening procedures in Montreal. AMA!

Purely hypothetically, as an experiment let's say...

Just how long could limbs be lengthened by? Arms and legs. What's the absolute maximum limit where the user could still operate and use them without injury or damage?

Dr. G: Bones can be lengthened alot in cases of bone loss but for cosmetic purposes 8cm is the max in the legs from a safety perspective in otherwise healthy people. In patients with certain types of dwarfism they can be lengthened more over their lifetime but not at one time

8cm... Okay that's not bad.

Now, if there were some less than scrupulous surgeons carrying out such a procedure, and the patient waived safety to just be as tall as possible. Maybe they were a huge fan of Avatar. Or basketball, but too short to make it.

How long can you go?

Dr G: proportions are important too, so there is a limit to how much you can lengthen without looking strange or affecting function. But if we are being technical, the bone can be lengthened past 8cm but not safely

Suppose I'm an eccentric billionaire and pay for everything to do it, absolve liability and overpay through the nose for uh, 18" height increase.

How badly is this gonna hurt. What's likely to fail?

Dr G: 18 inches of height is not possible in one lengthening

when patients go for a max height safely we go to 5 inches in legs

for patients who have an underlying diagnosis of dwarfism, we can lengthen them 3 x during their lives to gain 40cm in their legs and 10cm in their arms, but their body can accommodate that better than patients who dont have that diagnosis

My wife lost 1cm of length on one leg from a mediocre tib-fib fracture repair about 20 years ago. One of the bones didn't lose as much as the other, so her ankle is all kinds of wonky. Is this the kind of thing you can repair?

Dr G: This falls under deformity correction (in which we often use limb lengthening) and this can usually be fixed by recreating correct length between the two bones and covered by insurance or provincial health care.

Thanks for answering! We're in the US, but I have really good insurance, so we could probably get it covered by a US provider. Follow up question, which is my wife's primary concern: How long is the recovery period from this before regular load bearing activities can be resumed? She spent most of a year in a wheelchair when she broke her leg and had to relearn how to walk again, she's not very keen on repeating that experience. This was all before the advent of the knee-scooter, so I'm assuming there wouldn't be nearly as much or any wheelchair time past the hospital stay.

Dr G: Recovery can vary on the technique used to correct her problem. Your surgeon in the US can help clarify, but there are usually some weight bearing options

I actually live in Quebec and you've been telling me that the healthcare system will cover getting my one leg as long as the other? I've just been limping around and physio for the last few years! This is wild!

I also would like to know what recovery looks like though.

Dr G:

yes, this is covered. Having a limb length discrepancy is a huge functional problem and often affects all your other joints. Your welcome to come see us, there is no fee with your provincial health care card for a medical problem

Can you shorten legs?

Dr G: You can shorten legs. Recover is actually harder and longer than lengthening as the muscles have a really hard time adapting to the shortened length. You can shorten a femur by 5cm and tibias by 3cm

As it's a cosmetic procedure, whereby people are opting in for the surgery, are there any reasons you'd refuse to carry out the surgeries?

Dr G: I dont often refuse unless I dont think the surgery can help the patient, if for example patient has unrealistic goals or expectations. Patients who are depressed or suicidal are not great candidates until they are stable.

I'm curious about the depressed or suicidal bit. I've come to some basic conclusions in my head, but are you able to expand on this?

I'm not the good doctor here, but my assumption (and I'm happy to be told I'm wrong) would be that it won't be addressing the underlying issue/issues the patient would be having.

I don't believe it's entirely possible to treat depression or suicidal ideations with cosmetic surgery. And a person in that state of mind might believe it can and have unrealistic expectations, which can only serve to make their mental state worse.

Leading people in that frame of mind to believe it'll magically cure their clinical depression is unethical and just plain grossly wrong and negligent for a Doctor to do.

Again, happy to be corrected.

That’s not what the doctor is saying. He is saying that it would be unwise to operate on someone electively that is not mentally and emotionally well. One of the biggest reasons for this is that patient cooperation and adherence to post-operative guidelines and advice is significantly lower in patients that are in the aforementioned group. This would increase the likelihood of complications which can be life-changing and in certain cases simply exacerbate the patient’s poor mental health status.

Dr G (she/her): I agree with above comment on needing to find underlying cause of depression or other mental health issues and treating it appropriately. Cosmetic surgery cannot fix that. I also agree that we do not operate on patients who are actively suffering from a mental health crisis for reasons you stated (this is true for elective medically necessary surgery). For cosmetic surgery, we want to be sure that patients don't believe that the surgery will fix all their underlying issues and is not a replacement for therapy or other medical treatments for their mental health problems.

Dr G: yes, you are correct

Are there any ethical considerations you take into account? If so, what are they?

Hi ! It's Anne-Marie, reporter on this story. Could you expand on what you mean by ethical consideration?

Well, at the risk of stating the obvious, any surgery comes with some risks. When you have a patient who's 5'9", which is normal height, is it ethical to expose him to the risks of surgery just to satisfy his vanity?

Dr G: All surgery does come with risks but that is for the patient to decide on what risks they want to take. A patient who is 5'6 may feel perfectly ok with their height, whereas a patient who is 5'9 can feel short. It is more about how they feel in relation to their height, than the actual number

Hi Dr. Gdalevitch, thank you for this AMA. I have several questions, if you don't mind.

1) Are any women undergoing this procedure? Would there be differences in how it was performed on women vs. on men?

2) Would you say that those desiring to undergo this procedure are suffering from a form of body dysmorphic disorder? If so, would it be fair to say that (at least in some cases) there are parallels to gender-confirmation surgery?

3) Should this procedure be covered by insurance, at least in some instances?

Edit: inserted 'disorder' in point (2)

Dr. G: 1. yes woman are doing this as well, but less than 10% of my patients are women

1. I would say they mostly have heigh dysphoria (unhappy with their height) but for some it might feel like gender-confirming surgery in the sense that it is a life-changing procedure with regards to how they feel about themselves and their self confidence

2. This procedure is covered for patients who have dwarfism (a medical condition) unfortunately in a socialized medial system we dont yet have ressources to distinguish between different cosmetic procedures and this procedure is still considered cosmetic

A very basic (and maybe dumb question), do your legs go back to 100% flexibility and mobility? If that made sense. That after the surgery, eventually, everything will be just as same as before except I’m taller?

Dr G: The goal with this surgery is exactly that. The muscles, and tendons and ligaments and bone all adapt to the new length. Patients who do their rehab typically get back to their normal flexibility, but it can take almost 9-12months after the surgery for the muscles to get back to their "new" normal length

Thank you for getting back! Is there an ‘optimal’ age to do this surgery? I’m 20. Has there been recent advancements in this surgery? I remember inquiring about this years ago but I was pretty much told ‘it barely works and you’ll be in pain forever’. This appears almost…mainstream.

Dr G: Younger patients recover faster physically, but the maturity to undergo this procedure is also important. We have patients who do this from 18-60, but a large amount are in their 20's and 30's

The surgery has evolved with the advent of the intramedullary lengthening nails which makes it safer, more cosmetic and a lot less painful

How much does it cost?

Dr G: 90,000$ can for femurs, 95,000$ for tibias

The site shows only leg-lengthening. Is that the only limbs one gets lengthened during these procedures? Do you have any head-obscured Work-Safe images we can see of someone who has had this procedure done? I am wondering if they end up looking disproportional afterwards.

Also, what about nerves, blood vessels, etc - the images in the article only really imply bone-inserts for lengthening, but what about all the other important bits and bobs that run up and down our legs?

Do you do arms too?

Dr G: During leg lengthening, the other structures get lengthened at the same time (in fact the bone is the easiest part of the lengthening). The muscles, nerves, tendons etc.. need to stretch as well and are the ones that resist the lengthening the most.

proportions are something we discuss during consultation

usually most people have a longer arm span than leg span and can accomodate the lenghtening of the femurs

tibial lengthening dont change proportions as much (think of a woman on high heels)

Is limb lengthening still primarily based on the Ilizarov technique? I had my right tibia and femur and left tibia lengthened when I was in my tweens in the mid-90’s, and my surgeon was said to be following the Ilizarov technique. (BTW, I was born without fibulae!)

My adult height without the surgeries would have been 4’10”, but with them it’s 5’2” — still very short for a man, but better than it would have been otherwise.

Dr G: Ilizarov principles are still used as the is the father of distraction osteogenesis, but we have some newer equipment nowadays, including circular hexapod external fixators that are computer assisted and magnetic telescopic internal nails.

Hi, Dr. Gdalevitch, thank you for taking the time to do this. My question is: I'm assuming there is a period of rehabilitation after the surgery to get the surrounding musculature to accept and adapt to the new length of limb, what does this look like? Are the stretches similar to exercises one would do to improve general flexibility anyway or is there anything special that needs to happen to allow the muscles to adapt? Or does the body just take to it without much rehab required?

And as a follow up question: if there is a period of stretching involved, do patients have the ability to further increase their flexibility, or is there a certain level that they can't progress? Would someone who was maybe considered flexible before the surgery lose a portion of flexibility due to the muscles now being permanently stretched?

Dr G: The most important part of the surgery is the rehab.

Patients do daily physiotherapy after the surgery and this is the most important part of the procedure. Usually patients will be able to regain their underlying flexibility after the surgery

What does the rehab consist of? It is similar to what one would do after a lower limb fracture (isometric, progressive overload with isotonic exercises, then plyo)? What are some of the restrictions (weight-bearing, activity restrictions, etc) within the first few months post surgery? What are the long-term implications on athletic performance (tendon length/stiffness, muscle thickness, sprint/jump velocity, ability to absorb impact in contact sports)?

Dr G: rehab consists of stretching multiple times a day and using a walking aid for 6 months, with increasing weight bearing in the last 3 months. Once full weight bearing achieved and bone is healed, strengthening is increased. Weight bearing during lengthening is at 70-80lbs per leg. Long term implications for performance is that most patients get back to their pre-surgical capabilities.

How long is the recovery and do you know if these men still wear lifts after the procedure?

Dr. G: lengthening is 3 months, consolidation can take anywhere from 3-6months after lengthening and full recovery to all contact sports usually takes one year.

few men still wear lifts after the procedure, but it depends on their starting height

I have looked at this over the years, but been put off by the cost and the rehabilitation required. Do you see this becoming more mainstream and faster recovery times?

Dr G: for recovery, once a full weight bearing nail is on the market recovery will be a little easier, but not faster

Anne-Marie: Hi! It's Anne-Marie, reporter for this piece. One of the key reasons the men we spoke to in this story did so, was their hope that this surgery would become more mainstream. Their hope was that with more demand, would be a reduction in the costs for surgery and rehab,

What would guess is the (pre procedure) height of your average cosmetic patient?

Dr G: Usually between 5'2 and 5'7

Do my tax dollars pay for this purely cosmetic procedure (I’m Canadian)?

Dr G: This is cosmetic surgery. Tax dollars do not pay for cosmetic surgery in Canada

Pain management? During and after?

Luckily I'm 1.83, so I do aiight in this department. 😎

Dr G: pain is worst in the first 2 days after surgery (like most surgeries), after the first week, my patients are taking tylenol for pain relief. The lengthening process is not very painful but we do use a botox injection into muscles at time of the surgery to help relax the muscles for lengthening

Really? My cousin did this procedure, albeit years ago, and said it was a gruesome year of recovery.

Dr G: Techniques have evolved and using the intramedullary lengthening nails makes the procedure alot easier than what was done years ago with external fixation