Page 2 - Introduction
Distraction osteogenesis using the circular external fixator of Ilizarov [13–16] is an accepted and time-tested modality of limb lengthening in patients with limb length discrepancy [3, 5, 7, 9], short stature, particularly achondroplasia [2, 8, 17] and bone defects [1]. The same technique is being used to increase the height of somatically normal persons who report negative feelings regarding their short stature [2, 6, 11, 20] deriving from cosmetic, social, and occupational concerns.

Short stature can have serious psychologic and social implications [22] and the number of patients undergoing cosmetic limb lengthening has increased [23]. However, this technique is not without concerns and controversies [12, 23], particularly in, only one study has been published regarding benefits and safety of cosmetic limb lengthening [6].

We therefore reviewed a group of patients undergoing cosmetic lower extremity lengthening in terms of (1) soft tissue challenges, (2) bone-related complications, and (3) functional and subjective clinical outcomes. Patients and Methods
We retrospectively reviewed a consecutive series of 138 somatically normal patients with a negative feeling of short stature who underwent bilateral symmetric lower limb lengthening between January 1983 and December 2006. The indications for surgery were (1) the presence of a clear reason to undergo limb lengthening, (2) strong motivation, and (3) consented to undergo the procedure after complete awareness of the nature of surgery, possible complications, and the rehabilitation program. The contraindications to surgery were (1) the presence of psychologic disorders like dysmorphophobia, (2) associated endocrine disorders like hypothyroidism, (3) the presence of systemic illnesses related to growth and development like renal insufficiency, and (4) the presence of dysplastic syndromes like multiple epiphyseal dysplasia. After approval of our institutional review board, all patients who had a minimum followup of 1 year (mean, 6 years; range, 1–14 years) after removal of the fixator were included in the study. Seven patients were excluded as they did not have the required followup. Thus medical records, radiographs, and clinical photographs were available for 131 patients (95%; 65 males, 66 females).

The mean age of the patients at presentation was 25 years (range, 14–68 years), 28 years (range, 14–68 years) for males and 23 years (range, 14–45 years) for females (Table 1). The mean preoperative height was 159 cm (range, 130–174 cm), 162 cm (range, 143–174 cm) in males and 156 cm (range, 130–174 cm) in females. The reasons for limb lengthening were variable: students unable to keep up with their peers, requirements of individual sports such as volleyball, water polo, basketball, and tennis, vocation requirements, and issues with interpersonal relationships. Nine patients (six males, three females) had a mild varus deformity (5 degrees – 7 degrees) of the proximal tibia that needed simultaneous correction. One hundred twenty-four of the 131 patients (95%) had tibial lengthening alone, 66 (53%) had monofocal lengthening and 58 (47%) had bifocal lengthening. Ninety-two patients (74%) preferred bilateral surgery on the same day; 32 (26%) had the surgeries performed with a gap of 4 weeks. One patient (0.76%) preferred simultaneous bilateral lengthening of the femur. In the other six patients (4.58%), crossed contralateral lengthening of the femur and tibia was done with a gap of 4 weeks. All six patients who had crossed tibial and femoral lengthening had more than 10 cm lengthening. They were concerned about the thigh leg proportion and therefore this option was selected. One patient had bilateral distal femur lengthening per his preference since he had disproportionate lower limbs with a longer leg segment and shorter thigh segment.

We ascertained the height and trunk-limb proportions through standard anthropometric measurements. AP and lateral views of both lower limbs and a standing scanogram from the pelvis to the heel were done to assess length, deformity, limb length discrepancy, and any focal bone disorder. Consent for treatment was obtained after complete psychologic assessment by a psychologist and comprehensive counseling regarding the treatment and rehabilitation. Particular attention was given to rule out systemic illnesses, hormonal imbalances, dystrophic syndromes, and psychologic issues such as dysmorphophobia [21]. The patient and family were counseled on more than one occasion, and motivation to proceed with treatment was ensured.