Question 1

What are the cost implications of these surgeries?

Dr. Pradeep Kumar Singh · Accepted Answer

We are much cheaper than the Western world, but costs vary. Microvascular reconstructions, with a hospital stay of around 4 to 5 days, range from about USD 6,000 to USD 9,000 or 10,000, depending on whether the patient needs a single procedure or several within a defined period. Purely cosmetic procedures range from USD 2,000 to 4,000 or 5,000, sometimes 7,000. We also run a 'mommy makeover' package of breast reduction, liposuction and tummy tuck at a fixed price of USD 7,000.

Question 2

What are the success rates for these procedures?

Dr. Pradeep Kumar Singh · Accepted Answer

Over the last two years, our success rate for microsurgical procedures has been about 99%: only two procedures did not turn out as we expected. For cosmetic procedures it depends on the patient's expectations. If those expectations are reasonable, patients can expect a success rate of around 90 to 95%.

Question 3

In real time, how should our doctor colleagues in Africa triage a case, based on which parameters should they identify that this looks fit for reconstructive surgery versus purely aesthetic, and at what point should they send the case note to you?

Dr. Pradeep Kumar Singh · Accepted Answer

Plastic surgery was originally developed for reconstruction, so any wound that hasn't healed in three weeks, whether traumatic, burn, or post-cancer resection, needs plastic surgery intervention and can be referred directly. Any congenital defect, a hand anomaly, cleft, or other soft tissue deformity, should also be sent directly. Cancerous skin lesions, where excision and reconstruction go together, are handled by plastic surgery too. And any leg oedema that doesn't resolve with elevation and conservative management is a specific trigger for lymphoedema referral. These are the practical trigger points to know.

Question 4

Can doctors like us be given access to courses and training through Jivo? Does your hospital run courses or fellowships in plastic surgery?

Dr. Pradeep Kumar Singh · Accepted Answer

We are in the process of developing fellowships in our department, mainly in microsurgery and maxillofacial surgery, and information should be available in two to three months. We are also starting an online plastic surgery course: we are developing an app that will carry all the information and study material, which doctors can subscribe to.

Question 5

What is the golden time for an amputated part of the body to be reconstructed with a good outcome, and does it differ from one body part to another?

Dr. Pradeep Kumar Singh · Accepted Answer

Yes, it differs by body part. When we talk about replantation we mean the limbs: hand, leg or foot. For the arm the golden period is 4 hours, so with an amputation through the arm you should start the reconstruction within 4 hours. For the forearm it is 6 hours, and for fingers you can wait even 8 to 10 hours. These figures refer to warm ischaemia time, where the amputated part was not properly preserved. Early in my practice I attempted proximal replantation at 10 or 12 hours, but the post-operative period was very shaky, and I learned my lesson: proximal replantation should be attempted within 4 hours, at most 6, and not beyond.

Question 6

In a cross-border setting, replantation within the golden window is often not feasible, and surgery happens without the best outcome. Can such patients still benefit meaningfully if they reach India two or six months later?

Dr. Pradeep Kumar Singh · Accepted Answer

Yes, we can help. If a finger was amputated and not reconstructed, we can do a toe transfer to the hand, which gives a good amount of functional benefit. A few centres, not ours, have started cadaveric hand transplant, and we plan to start a hand transplant programme in our department in about a year to a year and a half. For now, for fingers we do toe transfers, and we also offer cosmetic rehabilitation with prostheses, including permanent osseointegrated prostheses for fingers and hands. Bionic, myoelectric hands are another option for these patients.

Question 7

What anticipated complications are associated with these procedures, and what is their nature?

Dr. Pradeep Kumar Singh · Accepted Answer

As with any surgery there are some complications, roughly 4 to 5% in each case, and for patients in whom we anticipate post-operative complications we weigh costs against benefits. We have developed protocols in our department to minimise them. Their nature depends on the patient. In aesthetic procedures, some patients are very prone to keloid scarring and may develop keloids. Patients with comorbidities such as diabetes, hypertension or thyroid disease are more likely to have wound dehiscence and infection. Wound problems, infection, haematoma and seroma are the common ones, which I would call side effects of these procedures rather than complications.

Question 8

What pre-surgical evaluations do you carry out for brachial plexus injuries?

Dr. Pradeep Kumar Singh · Accepted Answer

For all these patients we do three things. First, a clinical examination, to map out the deformities the patient has after the brachial plexus injury and plan the procedure on that basis. Second, nerve conduction studies and EMG, to see how many donor nerves or donor muscles are available for transfer. Third, MRI, which is essential, to map the brachial plexus. We manage birth brachial plexus injuries as well as adult traumatic and oncological brachial plexus injuries.

Question 9

Do you repair Klumpke's palsy from birth trauma if it persists and compromises physical dexterity later in life?

Dr. Pradeep Kumar Singh · Accepted Answer

Yes. We recently operated on a two-year-old child with a birth brachial plexus injury, and we manage Klumpke's palsy regularly. It is a birth palsy: sometimes the obstetrician pulls the arm during delivery, causing a stretching injury of the brachial plexus. We manage all these patients.

Question 10

What is the lowest age limit for aesthetic surgery?

Dr. Pradeep Kumar Singh · Accepted Answer

We usually do aesthetic procedures once growth of that part is complete. For the face or nose, growth is usually complete by 15 years, so a 15-year-old's face is as good as an adult's, and the minimum age for a facial procedure is 15, perhaps 16. For other parts of the body, 17 or 18 is the optimum age, because by then patients are mature enough to think about their body image and understand the implications of aesthetic surgery. In our centre we do facial cosmetic procedures for 15-year-olds as well as adults.

Question 11

Is the minimum age for aesthetic surgery governed by any regulation, given that in India many things are restricted to 18?

Dr. Pradeep Kumar Singh · Accepted Answer

No, there is no such regulation; it is a purely medical decision. For a minor of 15, parental consent is enough.

Question 12

Can you repair a congenital mandibular deformity?

Dr. Pradeep Kumar Singh · Accepted Answer

Yes. We do all orthognathic surgery for mandibular and maxillary deformities, and we manage all these conditions.

Question 13

What is the merit of direct doctor-to-doctor referral pathways, in an industry where agents often misguide patients?

Dr. Pradeep Kumar Singh · Accepted Answer

When doctors interact directly with the referring doctor, both understand the medical implications and the best way forward for the patient. This industry is now full of agents who spread misinformation about medical care, so building a platform where doctors of different specialties in different parts of the world can interact directly is the best way forward. Over the last 10 years I have seen a great deal of improvement in India's health infrastructure: large corporate hospitals with the latest equipment available anywhere in the world, and Indian manufacturing capability that has grown by leaps and bounds. Compared with any European set-up, we have all the facilities needed to treat any patient, and, because this field depends on doctors, we have specialists qualified to perform any procedure done anywhere in the world. Doctors are also moving towards new technologies such as AI and robotic surgery.

Question 14

How competitive is entry into medicine in India?

Dr. Pradeep Kumar Singh · Accepted Answer

Every professional programme in India is very competitive, and only the top of the spectrum gets in. Two parallel systems run in the country, government and private. Initially only the government system existed, and getting into it was extremely hard: we spent two to three years preparing to enter. The private system is now catching up and doing very good work, but the government system, which very few can enter, is still considered the best. Getting into medicine, engineering or any professional field is a tough task that only the top students achieve.

Live Discussion with Dr. Pradeep Kumar Singh