I wrote up a big summary of key points from our consult, which I'll elaborate on in an FAQ-style post. But first I should mention that I was very interested in doing quadrilateral lengthening. There's 2 types, one is simultaneous (meaning you have both surgeries on the same day) and then there's staggered (have tibiae surgery first, and then femurs done 3 weeks later, what Sweatpants is doing). My consult jumped straight into quadrilateral lengthening with Paley. I'll get into lots of other interesting things I've learned too after our quadrilateral discussion.
What are the costs of quadrilateral lengthening for simultaneous vs. staggered?
The pricing for simultaneous is $150,000 and the cost for staggered is $170,000. Keep in mind, the increased price is not going into my (Dr. Paley's) pocket. It's entirely to the hospital for its OR time costs.
Do you recommend simultaneous quadrilateral lengthening?
No. I don't know if it's because I'm getting older, but I've been taking a lot less risks lately laughs. (he continues to elaborate on this point, but I'm breaking everything up for organization)
What are the risks associated with simultaneous quadrilateral lengthening?
There's a lot. You have a very increased chance of fat embolism, definite need for a blood transfusion, and an increased risk to your life. We've only done 1 case of simultaneous limb quadrilateral lengthening and thank god he didn't have any serious issues. The way I look at it is this- you're young, healthy, and fit. Most likely you wouldn't have any severe complications, but the price differential is really not that hefty ($20,000) and risk to your life is not worth any amount of money. You're going to be in a lot of pain and suffering too. It's a lot of trauma for a body to endure, and I don't want you to have to go through that kind of pain.
We recently had a case of fat embolism with one of our patients. It was scary, and he came out with only an increased heart rate for 2 days, but it could have been worse. These are things that you cannot predict will or won't happen.
Misc. on quadrilateral lengthening.
Chances are, with quadrilateral limb lengthening, you will not be able to lengthen as much as you'd like. The reason is the intense strain your soft tissue is going under simultaneously, and for this reason, you will only be able to lengthen at max 10 cm. The man who did simultaneous surgery only went up to 8 cm because he was very concerned about his proportions.
Lengthening is initially done .75 mm/day on the tibiae initially and 1 mm/day on the femurs. Because you're 21, you'll be allowed to begin lengthening the day after surgery. If you were over 30, you would be required to wait at least 1 week before you were allowed to lengthen. Keep in mind, these lengthening rates are very subject to change, and we will be monitoring your rate of progress to see which segments need adjustments based on the complications you're incurring. ROM is key, and if your ROM is affected, we'll have to act accordingly by reducing your lengthening (for some patients, we have stopped lengthening entirely).
For staggered surgeries, you will want someone with you the first 2 weeks of both surgeries. That means for 2 weeks after your first surgery and for at least 2 weeks after your second surgery.
Have you had any complications with your PRECICE/PRECICE 2 nails?
Yes, we've had two PRECICE (first generation) nails break. Ironically, it was at the end of their lengthening period too. One of them said he wasn't even aware that he was lengthening anymore since he didn't have any pain, and as a result performed over-strenuous physical activity which resulted in a broken nail.
Have you heard about the PRECICE 2 lengthening complications in South Korea and have you this yourself?
No, we haven't had any of our PRECICE 2 nails break or stop lengthening knocks on wood out of already over 40 nail insertions. We had 2 cases of the first generation PRECICE nails that didn't lengthen, but that was out of over 100 nail insertions. We check to make sure that the nail lengthens properly when we insert the nail and lengthen your leg 1 mm.
What drugs will I be on after surgery?
Pain medication and blood thinners. You will be required to stay on a blood thinner the day after surgery until when I say you can stop. This will most likely be 1-2 months after you're done lengthening, so you will be on blood thinners for a while. You have an increased risk of blood clots (which can result in heart attacks) while undergoing LL and we make sure to take all necessary precautions for your livelihood.
What's physio like?
One hour a day, 6 days a week. We notice the guys who do the most physical therapy breeze by leg lengthening. That means taking the exercises you learn here, and continuing to do them for hours back at your home. One guy even brought his own physical therapist and he really breezed by here, lengthening his femurs 8 cm. We think it's because his PT was so hot though, kept him motivated. everyone laughs, fellow nods his head in agreement
What is weight-bearing on the PRECICE 2 like?
We only allow our patients to bear 75 lbs of weight per leg on the 12.5 mm diameter nails. This means that you can never have your full weight on one leg. The fellow then proceeds to show me what walking with a walker looks like, and while I should have already known this, it surprised me because then I realized just what the extent of what your mobility is reduced to. Every second, he had to be mindful that his weight was on the walker when he lifted a foot to make a step. Any mistep and displacement of weight, and you could risk your entire lengthening procedure (and additional costs). Physio will train you thoroughly so you can become good at walking.
The 12.5 mm nail is generally used for your femurs. For your tibiae; however, we'd most likely end up using the 10.7 mm nail which only allows up to 50 lbs of weight-bearing. We then proceed to look at my x-rays, and I point out that my tibial canals are actually wider than my femoral canals, which interested him. Yes, you may be able to fit 12.5 mm diameter nails in your tibiae, but the decision is really made during surgery and best judged by how the nails fit in your canals.
Would I be confined to a wheelchair? (I weigh 140 lbs, and obviously a 50 lb weightbearing nail wouldn't support my weight)
No, but you would be expected to put a lot more weight on your walker. (I didn't really get too clear of an answer on this, so I want to follow up with an email to ask about it).
I had a consultation with another doctor who recommended that I insert the nails into my femurs retrograde (via the knees) as opposed to antegrade (via the hips) due to the narrowing of my femoral canals closer to the top part of my femurs. Would you agree with this?
No, I wouldn't. First of all, I would argue that it wouldn't make much of a difference because the narrowing occurs in the middle of your femurs, which would require us to ream your canals regardless of which way we insert it. Secondly, retrograde insertion would damage cartilage in your knees. That's something we'd want to avoid.
At this point, we move onto the physical examination of my body. Like I said in my last post, Paley evaluated my body 100x better than Rozbruch did, and Paley knew exactly what needed to be done in regards to my inflexibility and tightness. I don't want to crap on Rozbruch because he's a nice guy, but I don't think he's as well-suited for cosmetic leg lengthening. He was previously a fellow of Dr. Paley and has a lot less expertise in the cosmetic side of the field (mostly because the prices in the NYC hospital he operates out of are astronomical when uninsured). Rozbruch also spent a lot less time with me, and didn't have much experience to refer to when answering my questions. Paley also confirmed things that I had already learned from my orthopedist, which meant he wasn't fudging facts.
Wow, BD, you are incredibly tight. In many different areas. First of all, we would do an ITB release on you. We do this on practically all our patients, and it's a really easy and safe procedure. It's neither a muscle or ligament, it's just thick tissue that runs along the side of your thigh, which due to its tightness, will make your lengthening process extremely difficult. Once released, it can always be regenerated. The price of this release is included in the surgery. (I'd like to mention that I fully agree with his take on the necessity of ITB releases. One: because I notice patients that don't have an ITB release, have a much more difficult time with their recovery due to muscle tightness and two: because his patients have very good outcomes).
However, we have some other problems that need to be released as well. The biceps in your thighs, otherwise known as the Biceps femoris, will need a very small release as well. It will be a small incision right here, which will improve your flexibility as well. This is easily rebuilt as well, people commonly have their ACL rebuilt from using the muscle in this area. (to imagine where the incision would be, bend your right knee, grab your right thigh closest to your knee, and feel underneath it. Feel those two muscles? The muscle on the left will be where he makes a small incision. Also, your ITB release will occur near your knee as well, to imagine where just touch the outer part of your thigh closest to your knees. It's very tough and strong to the touch.) Unfortunately the biceps femoris release is not included in the surgery price. This will cost an additional $5,000.
And lastly, you will most likely need a Gastrocnemius soleus release surgery. The reason for this is because your dorsiflexion is very, very tight. About 10 degrees ROM. (Your dorsiflexion is where your feet bend upwards at your ankles, I have an unnaturally tight achilles tendon which has been confirmed by my orthopedist). For this release, we would need to perform a gastrocnemius soleus release surgery, which I do quite rarely. I don't like doing them as well because it can result in a weaker "push-off" in your calves, which is why sprinters would be negatively affected by this surgery. You will likely rebuild the strength though. The cost of this release is also an additional $5,000.
So that would mean the cost of my surgery would be...
Yes, so your surgery for same-day procedure would be $160K and for staggered it would be $180K. (I was pretty much sweating bullets from that answer, that's a lot of money!! 
. I'll talk more about my finances after this post).
Out of order, misc. questions.
I notice some patients underwent hypertrophy in their calves after this surgery. Have you ever had this happen and why does it happen?
That's because of a procedure called Facsiotomy. It's done to relieve tension in the tibiae when performing the surgery. Think of it like cutting a piece of chicken meat- first you have the membrane that surrounds the chicken meat. Once you cut that membrane, the chicken starts expanding and falling out of it, as if it were being trapped in there. That's kind of what this procedure does, and causes your calves to look girthier. Eventually the membrane heals and prevent your calves from getting any thicker, but the girthiness will stay permanently. We have no problem doing this on guys (which made me excited, I really want to have thicker calves!) But we do not do this procedure on women ever, since they really do not want to have thicker calves (good news for you ladies out there!)
Here, I'm talking about when I first discovered LL and how I thought it was a pipedream when I first saw it in the movie Gattaca.
Paley scoffs and while smiling says yea, I know, I was the consulting doctor on that scene in the movie.
What!!!! Mind=blown. 
I sat there with a stupid grin on my face when I heard that. The man is seriously Hollywood.
I've read reported studies of over 70% persistent/permanent knee pain in patients after insertion of the IM nail into their tibias. Have you seen this with your patients?
No, I have never seen close to that figure with my patients. Probably less than 10% have this issue. Fellow nods and adds that he's only seen it in less than 10-15% of his patients from their case studies. What causes it? That's the thing, no one knows what causes it. My decreased rates for persistent knee pain could be coming from from the way I insert the nails into the tibiae, which is higher up the patellar starts talking with a lot of scientific terminology with his Fellow that I couldn't quite follow.
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And that's about the rundown on my consultation! I wish I could have recorded it, since an actual recording would do a lot more justice to what was said rather than just trying to remember everything. But you get the gist. That was the longest post I've written here, and I'm wiped out, so I'll come back later today and respond to everyone's questions (and PMs!) I hope this really helps for your future decision, and gives you better insight into what you should find out from your doctors. I know if I had the money and time to do it right now with Paley, I would do it 110%. He really knows his stuff, has decades of experience, and clearly upholds precaution, three of the most important factors when considering a doctor. I recommend that you still do your own consultation with him, because his answers vary from whom he's speaking to. His price for a consultation is $750 and also $350 for the x-rays taken. My flight was about $500 and for considering such an expensive surgery, getting to know your doctor and their facilities is well worth it.
Big D is Growing - PRECICE 2 Internal Femurs - Dr. Paley
Hey BD!
This is an awesome post that is extremely valuable.
Gives you a lot to think about. I think it is evident that Paley is certainly the best option out there. What I love is his vast experience, honesty and focus on safety. Most of us have been influenced by him in some way.
If you can afford it, go for it, but be careful about quad.
Good luck with your decision.
Wow, thanks for the abundance of interesting information! That's a lot of releases the doc wants to do on you. He's confident that you'll recover from all of them? The gastrocnemius soleus release seems like it would have the most long term effect. I thought after that release people who need them aren't ever quite the same. Interesting reading that Paley thinks you'll rebuild that strength. Maybe the effects of that release aren't permanent like some others have said?
Judging from your witnessing of Dr. Paley's depth of knowledge, if you did not have the funds to go to him do you think you would have a higher degree of confidence in a different surgeon who had a fellowship or took a course under him, as opposed to a surgeon who has not studied under Paley?
This is extremely informative.
Thanks a lot.
Quote from: mediocre on March 11, 2014, 01:30:20 AMI wonder how much is your allotted budget for your LL, if you don't mind. Dr. Paley is on my top list if money is not an issue.
Does he really give old forum members discount? How about us, LL Forum members? 
The budget question is a real complicated one for me! I know I can spend at least $100,000 on this surgery, but when we start getting in the upper 100s range (for quadrilateral), then I get very nervous. I want to be able to have enough money for when I have to do taxes at the end of the year. Also, I have to base being able to afford the quadrilateral surgery on whether or not my projected income can afford it. I'm going to email him later to see if he has any financing plans.
As far as discounts, nope, that's just an old forum ploy. His prices are actually much higher than they were years ago, so whoever called that LL was going to become more expensive over time was right!
Quote from: Smallguy on March 11, 2014, 03:30:12 AMGood for you. Are you going to him for sure? Can't wait for that update 
Thanks Smallguy 
I think if I were to do LL with any doctor now, it would definitely be Dr. Paley.
Quote from: Polycrates. on March 11, 2014, 04:52:48 AMSo no go for Birkholtz? I agree with everyone else, if you have the money, go with Paley. I was banking on you being Birkholtz's first though.
Dr. Birkholtz is a fantastic doctor who is still my #2 choice for PRECICE 2. The only reason he isn't #1 is because he operates in a time zone much different than mine, and in a country that has less than great internet speeds. My job relies on me being in the states and having very good Internet. Also, not to downplay the successes of Dr. B, but he hasn't had as much experience in cosmetic lengthening as I'd like. Once he has a breakthrough and starts seeing more cosmetic lengtheners, I think his practice is going to be an absolute hit. I also think anyone considering PRECICE 2 who can't afford Dr. Paley and would have no problem moving to a foreign place should definitely have the surgery done with Dr. B. At least schedule a consult with him, and you'll see that you're in safe hands.
Quote from: mediocre on March 11, 2014, 05:24:07 AMI wonder how much would be the difference between Dr Paley and Dr Franz. If not that big, then definitely Paley.
It's pretty significant 
Paley charges $80,000 for bilateral femoral lengthening which only includes physio, while Birkholtz charges only $48,000 for bilateral femurs, physio and accommodation for 75 days included. That's an absolutely amazing price Birkholtz is charging because his profit margins are so thin. A pair of nails cost $30,000!
Quote from: Franz on March 11, 2014, 06:02:22 PMHey BD!
This is an awesome post that is extremely valuable.
Gives you a lot to think about. I think it is evident that Paley is certainly the best option out there. What I love is his vast experience, honesty and focus on safety. Most of us have been influenced by him in some way.
If you can afford it, go for it, but be careful about quad.
Good luck with your decision.
Dr. B,
I cannot express my gratitude to you enough. You've helped educate and inform so many people on this forum, including myself. Thank you! I really really hope your practice starts seeing a lot of guys from this forum visit you, since you offer such a tremendous opportunity at the best prices anyone will find anywhere for PRECICE 2.
Any LL doctors reading this, Dr. B is a class act. Watch and learn!
Quote from: Kilokahn on March 11, 2014, 06:05:43 PMWow, thanks for the abundance of interesting information! That's a lot of releases the doc wants to do on you. He's confident that you'll recover from all of them? The gastrocnemius soleus release seems like it would have the most long term effect. I thought after that release people who need them aren't ever quite the same. Interesting reading that Paley thinks you'll rebuild that strength. Maybe the effects of that release aren't permanent like some others have said?
Judging from your witnessing of Dr. Paley's depth of knowledge, if you did not have the funds to go to him do you think you would have a higher degree of confidence in a different surgeon who had a fellowship or took a course under him, as opposed to a surgeon who has not studied under Paley?
I agree, I'm nervous actually about how many releases I would need. I had a feeling too that it would come to this, because I'm a naturally tight individual, no matter how much I stretch. My dorsiflexion is a joke especially. He's confident that I'd recover from the ITB release and also the biceps femoris release. But, when talking about the gastrocnemius release, it seemed to me like he was unsure when talking about its potential for full recovery. I understand that it'd probably result in a permanent reduced strength in my calves. It's a risk I'm willing to take because I'm not a professional athlete and I can live with being weaker in my calves for height.
I'm not sure if I would go to one of his fellow to be honest. Dr. Donghoon Lee was one of his fellows, and is running a very successful clinic in South Korea, but he doesn't believe in ITB releases and his patients have been having bad results with the PRECICE 2. I still don't know if that's because of his decisions or the nails, but I do believe being a fellow underneath Dr. Paley does give the doctor a lot more credibility. But I'm not sure if it would make me more compelled to select them.
Quote from: mediocre on March 11, 2014, 07:19:20 PMThis is extremely informative.
Thanks a lot.
My pleasure. It really helps me to write all this stuff out!
Quote from: rickybobby on March 11, 2014, 09:09:32 PMBD,
excellent post!
Did paley mention if you did one surgery on your femurs and did 8cm would you have any knee pain in the future do to a large femur:tibia ratio.?
We went over my x-rays and my tibia/femur ratio is actually .84. This means I can afford to do more lengthening on my femurs to keep the ideal .8 tibia/femur ratio. They recommended 8 cm/5 cm if I were to do two separate lengthening (as opposed to quadrilateral).
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After a lot of discussion with my girlfriend, we realized I probably shouldn't go the quadrilateral route, instead play it safe and lengthen 7-8 cm on my femurs. Recover, consolidate, and then come back for 5 cm on my tibias. Who knows, I may even be happy with my height after 8 cm! And I come that much closer to my goal of being 5' 10" one day...
This reason is not only for safety, but also financial security. 160K-180K is a s**t-ton of money, so I'm better off being completely financially secure and doing just 1 LL surgery this year, and then a 2nd next year.
I was planning on consultation with Dr Paley, now I don't have to. Thanks again.
Seems like you're more likely to get it done with Dr Paley in May? I don't think I can afford him unless I score big in a poker tournament. All the best.
It looks like he does not believe that one can avoid those releases just by stretching pre-LL to improve flexibility.
This is very informative, thanks BD!!
Is the ITB and Biceps femoris release a standard procedure on all his patients? Or does he release other thigh muscles for femur lengthening?
Quote from: mediocre on March 12, 2014, 01:37:31 AMI was planning on consultation with Dr Paley, now I don't have to. Thanks again.
Seems like you're more likely to get it done with Dr Paley in May? I don't think I can afford him unless I score big in a poker tournament. All the best.
It looks like he does not believe that one can avoid those releases just by stretching pre-LL to improve flexibility.
No problem! I'm probably going to book my surgery with Dr. Paley very soon so I can get a May date. As long as nothing else comes in the way
I think it makes sense too that one cannot just stretch to avoid a release. When you look at this way, no one can stretch any amount that will make the current muscles we have able to easily withstand an extra 6-8 cm of length. The muscles would have be loose and droopy pre-lengthening for that to happen.
Quote from: TheRisingShorty on March 12, 2014, 03:37:24 AMThis is very informative, thanks BD!!
Is the ITB and Biceps femoris release a standard procedure on all his patients? Or does he release other thigh muscles for femur lengthening?
No problem The ITB release is standard, and biceps femoris release is almost as common as well.
Quote from: Franz on March 11, 2014, 06:02:22 PMHey BD!
This is an awesome post that is extremely valuable.
Gives you a lot to think about. I think it is evident that Paley is certainly the best option out there. What I love is his vast experience, honesty and focus on safety. Most of us have been influenced by him in some way.
If you can afford it, go for it, but be careful about quad.
Good luck with your decision.
Dear Dr Fanz,
These questions below are a bit hypothetical. I don't mean it literally, and I do not mean to be disrespectful to people involved in CLL but I am curious what your thoughts on it are.
1. What is the motivation for LL surgeons to ever perform CLL? It seems like not much of the money from the surgery actually goes to the doctor, and I wonder with the very long process and hours spent that perhaps it is not financially worth it compared to doing other operations?
2. Could they not improve their profitability just by rejecting every CLL patient or only charging for a consultation and then rejecting every candidate?
3. People on these forums report greatly improving their outlook on life/feeling better about themselves after becoming taller. Do doctors find this outcome to be smaller/more of a nuisance compared to fixing someone with an actual physical deformity? I look at hair transplant surgeons and I know the comparison is not perfect but they are in some ways mainly treating the mind, not a physical body part. And they believe, or at least say they do, that their work and mission helps people and is worthwhile.
And
4. Why 165cm upper limit? And do you think if the year was 1800 the limit would be more like 155 cm? Or if you were from the Netherlands it would be a higher limit like 170cm? I remember Dr Paley in one of his writings at first resisting to operate on a man from the netherlands because the man was still taller than the average male height.
I hope I asked these in respectful ways. I am just musing.
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