Bone lengthening for aesthetic reasons for normal or short stature has been reported recently. The ethical principles and psychological factors have to be taken into consideration. Psychiatric evaluation is mandatory for all patients to exclude body dysmorphic disorder [
54]. It is mandatory to have detailed preoperative psychological analysis to rule out any psychiatric illness which might affect the patient’s ability to make a sensible decision. A single counselling session of limited time may not be enough to have fair appraisal of patient sanity. It would be wise to arrange several meetings between the patient and previously treated patients as part of the preoperative preparation programme to give them a real example of the difficulties to be expected before reaching their goal [
55].
The first method used for cosmetic limb lengthening was the Ilizarov method, with a high rate of self satisfaction and improved level of social activities (96.7% of patients) [
56]. Bilateral tibial lengthening, monofocal or bifocal, was the most common procedure, with a few cases having femoral lengthening as well. Trunk limb proportions may limit the magnitude of lengthening to 5–7 cm. In 2014, Novikov et al. published the largest series of cosmetic lower limb lengthening treated by Ilizarov apparatus at the Ilizarov institute, including 131 patients. The ages of patients ranged from 16 to 67 years, with a mean lengthening of 6.9 cm. At last follow-up there was one poor result (0.77%) with a rate of complications about 37% [
42]. The authors were able to manage most of the complications successfully without affecting the final results. However, the patients were kept in the hospital for the whole period of treatment, allowing close monitoring and early management, which is not available in other institutions [
55]. The time in the fixator was reduced by using the lengthening over nail technique with a rather moderate rate of complications [
57,
58]. Intramedullary limb lengthening has developed as an alternative to external fixation which is quite attractive to patients; it has a lower rate of complications and higher costs [
30]. Recently, there has been a considerable desire for cosmetic lengthening surgery around the world. In spite of the extensive experience of the treating surgeon, many soft tissue and bone problems are possibly expected. Safety of the patient has to be more important than gaining more length [
42]. For example, if a weak regeneration zone develops, which is not responsive to cycles of compression distraction, the surgeon has to reduce the expected area of lengthening by gradual compression to improve the regeneration and avoid nonunion. In our opinion we think that this procedure has to be undertaken by a surgeon with great experience in the field to handle the potential complications.