Wednesday, March 28, 2007

YU Medical Ethics: Nose Job or No Job? Plastic and Cosmetic Surgery in Halacha

THESE NOTES ARE UNOFFICIAL AND UNEDITED. ANY AND ALL MISTAKES ARE MY FAULT.

Tonight, March 28, 2007, the YU Medical Ethics Society hosted a lecture on plastic and reconstructive surgery.

Introduction:

Hi everyone- welcome to the event on Plastic and Reconstructive Surgery. Tonight we have Dr. Gary Berger and Rabbi Dr. Richard Weiss [they then proceed to give us a lengthy list of all their qualifications and credentials, which can be seen here. Suffice it to say that they're wonderful people and very-well qualified.]

Our first speaker is Dr. Gary Berger.

Dr. Gary Berger:

Good evening.

First I want to thank Yonah Bardos, Chani Schonbrun, etc. This is a bit of a milestone for me as I'm a former YU guy. When I was at Stern before, there were only two buildings, and I wasn't allowed in either of them. [Laughter] Actually, the truth is that the last time I spoke publicly at YU was in Lamport auditorium on the Main Campus nineteen years ago at a Yom Haatzmaut celebration. I introduced the performance of a relatively unknown comedian named Jerry Seinfeld [Laughter] Now, we all know what Jerry’s been up to over the last two decades, but I’m going to tell you a little about how I ended up here.

First let me tell you a little bit about who I am. I come from a very YU family. My father, from the Bronx, went to MTA and Yeshiva College and married my mother from Brooklyn, who went to Central and TI. They compromised and moved to Queens, where I grew up going to shul, one Young Israel over from the one where Rabbi Weiss is now the Morah D’Asrah. At shul, I sat across from Kenny Brander; I grew up at MTA and one of my classmates at YU was Eddie Reichman, so I have a YU background. I met my wife at YU (a Stern ski trip as sophomores.)

I trained at Montefiore and Beth Israel- did general surgery. General surgery is a specialty of medicine where you take care of colon cancer, appendicitis, breast cancer-modified radical mastectomy- all best tissue and skin from one side of a woman's body (if it is only one side) and the woman was left rather deformed, with her front as flat as her back, and a scar- so I did this all the time- it wasn't pleasant for the patient.

15 years ago I was performing one of these, except in this case the woman had a reconstructive plastic surgeon who would reconstruct a breast for her after the mastectomy. His aides/ assistants were not there, so he asked me to stick around to help him and I agreed. He took an ellipse of skin, the skin and fat off of her, but he left attached to the rectus muscle (this is the muscle you would see if anyone here has a six-pack), so he took it up to where the breast had been and reconstructed it. The woman woke up with a brand-new breast and a tummy tuck.

I've always been a creative/ artistic person (involved in building set for YU plays, etc) so this appealed to me as a surgical specialty- I returned to Einstein; I have a private practice and I've been there all day today performing surgeries.

So that leaves us with a question- what is plastic surgery?

Now, those of you here who have seen "Extreme Makeover," so plastic surgery is like that, except perhaps not so extreme. "Nip/Tuck" and "Dr. 91210" are not plastic surgery.

Now, in every lecture I've ever attended on plastic surgery, the professor begins the same way, and so that is the way that I am going to begin. Plastic surgery is named from the Greek word plasticos meaning "to form" or "to create." It has absolutely nothing to do with the material used- it is not plastic.

Now, the first plastic surgeon was a man named Gaston Tagliacozzi. Tagliacozzi lived in the 1500s; he was a surgeon who reconstructed the noses of people whose noses were cut off by the Church as punishment for adultery. So what did he do? He attached their arms to their faces. And it worked! But the Church considered this blasphemous, so his body was exhumed after death.

Now, the tagline of this lecture is "plastic and cosmetic surgery in halacha." With all due respect, that really doesn't make any sense. Really, it's plastic and reconstructive surgery.

Cosmetic means something normal and you want to improve upon it, while reconstructive is where something is abnormal and you want to reconstruct it. The line between plastic and reconstructive surgery is often blurred.

SPECIALITIES WITHIN PLASTIC SURGERY

Burn Surgery: Major burns, reconstructive aspect

Cranial-Facial Surgeons: Cleft lip/ Cleft pallate, misshapen skulls- babies have 5-10 plastic surgeries. Actually, my friend, _____, recently when he helped detach those babies who were born attached at the head (New Yorkers know what I'm talking about.) Not a week goes by when I'm not called by the Emergency Room or nervous parents who want a plastic surgeon to sew up their kid (who hurt himself in his chin or face, etc.)

Microsurgeons: They take care of tiny little arteries or veins, use stitches that are finer than your hair. Someone's finger is cut off in an accident? They put it back together. So also hand surgeons. Reconstructive surgery: If someone is in a car accident or has flesh missing, we can take a muscle right off someone's back and then reattach it. Literally remove the skin and fat from the body, leave the rectus muscle alone, leave the six-pack alone, bring the breast up- the advantage to this is a faster recovery and _____.

Now, cosmetic surgery is to enhance, improve, fix, regenerate..

Are Orthodox Jews allowed to do this? I hope so, considering the number of noses I've done...and other things that people probably don't want you to know about.

Plastic surgery is considered "head to toe" surgery- no other surgery sub-specialty does that- liposuction, stretch marks or hanging flesh after pregnancy- we can flatten their stomachs for them. Or then there is the field of bariatric surgery, lapbands, bypass- all that skin is now hanging down to their knees; at first they weighed 400 pounds, now they weigh 170 pounds so they come in with this skin hanging down. So then there is a question- is that cosmetic or reconstructive, removing that hanging skin?

Or there's the chest- a lot of guys come in with a symptom called Gynecomastia- feminizing breasts, a chest that might look like a woman's. Now, it used to be that insurance would cover that, but now it's hard to get that covered because insurance companies consider that to be cosmetic...but is it? There's a couple different ways to go about surgery for this- either a small incision and liposuction or _____.

Now, you're all women, so I'm sure you know that breasts can be made larger. But what about the girl who is an A-cup on one side and a C-cup on the other? Is that cosmetic or reconstructive surgery? She's really suffering, has social and emotional problems because of how she looks.

Or the woman who is 42 triple H- she wants a breast reduction to alleviate the pain in her neck/ back; she walks in stooped over/ down. Those are the happiest patients, by the way, breast reduction patients, because they wake up the next morning and the problem is gone; we've alleviated the problem right away.

Now there's a question by breast cancer- there can be multiple surgeries involved. So say one has a partial/ complete mastectomy. Then the patient might need chemotherapy or radiation (which is where they go after the cancer that might be left over in the chest). So the question is if chemo/ radiation are needed, can breast reconstructions be done? Sometimes surgeries are more complicated, and if it could possibly delay the chemo/radiation, then is that okay?

In terms of reconstruction, you can put in a tissue expander, which is like a balloon, and inflate that balloon through the skin, then take the expander out and put in permanent breast implants- you use someone's own tissues- take someone's skin from the back/ fat and move it to the front. This gets more and more complicated- adding 5-6 hours of extra surgery.

So even forgetting about halakha, is this someone who needs chemo right away or if there is a problem can they have chemotherapy in a month? I have that conversation all the time with their doctors/ oncologists before proceeding.

Now, the problem applies by microsurgery as well. 6-12 hour operation to do this, to completely remove something and then fit it back with manmade connections- but then, what if the manmade connections fail? Then go back to the beginning, and it can turn into a 24 hour surgery.

Now, none of these surgeries need to be done at the time of the mastectomy. That breast which we're creating has no function- it is purely aesthetic, made of stomach fat. What I will tell you is that the federal government said that no matter what you need to do with the healthy breast of the patient who has breast cancer- you can do whatever you want to the non-cancerous side to make the person as symmetric as possible.

Now let's get to HEAD AND NECK.

[He lists a whole lot of types of surgeries] eye-lifts, brow-lifts, hair-transplants, face-lifts, etc.

But what happens with the patient whose eyelids droop so much that she literally cannot see out of one eye? Is that cosmetic or reconstructive surgery? I just had a patient like that today.

What about the five-year-old whose ears are so misshapen that kids call her Dumbo? And that's the right age for that surgery; it's best if the child has it before starting first grade. Is that cosmetic or reconstructive surgery?

What about the person who is paralyzed on one side of the face- we'd like to give them half a face-lift to make them more symmetric.

If someone has a problem with a deviated septum and hence has a problem breathing when it comes to the nose, then I don't think anyone has a problem fixing it. But what if someone broke their nose, it healed, and it healed awkwardly. So then they go to fix it up at a later date, and then people say, "While you're there anyway, I never liked that bump on my nose, and I hate how it looks in profile, could you just shave that off, etc"- so that begs the question- Nose Job or No Job?

And now we have Dr. Richard Weiss.

Rabbi Dr. Richard Weiss:

Thank you Dr. Berger; that's really an excellent review of cosmetic/ reconstructive surgery- that lightens my task.

Incidentally, Kenny Brander and I were actually classmates in elementary school in Detroit- this goes back farther back than I want to go back right now, etc. [Then he mentioned something in connection to a show he used to watch called the "Six Million Dollar Mine" ; I didn't catch it.]

I want to thank the CJF, TAC, Yonah Bardos, Chani Schonbrun, Elisheva Levine- thank you for inviting me, thank you to my good friend Rabbi Dr. Reichman- I enjoy teaching at Stern College; I have a full time job as a Rabbi, but this is very important to me.

So I wanted to begin with an anecdote to ease things from your [Dr. Gary Berger's] presentation to mine:

    A surgeon goes up to heaven, he has a stethoscope wrapped around his neck (of course the internists would ask, "What does he need a stethoscope for?" When I was in Medical School, the surgeons made fun of the interns, the interns made fun of the surgeons, and they all made fun of the psychiatrists. [Laughter])

    So this surgeon is in heaven, and he's standing in line to get to the Caf, and he cuts to the front of the line and speaks to the angel in charge, saying, "I was a very prominent cardiothoracic surgeon; I think I should get in first." But the angel says that they are all equal in heaven and he has to wait his turn in line.

    So he goes back toward the end of the line, and then he notices another surgeon. This surgeon also moves to the front of the line, but everyone steps back and lets him through. The cardiothoracic surgeon goes back to the angel and complains, saying, "I thought you said we were all equal; why'd you let him in first?" And the angel replies, "Him? That's no doctor; that's God. He just likes to play doctor."


So we like to play God- I want to give an overview here-

In Jewish medical halakha and in general, one always starts by talking about clinical facts- in addition, then has to in any situation, particularly end of life but also cosmetic/ reconstruction surgery, must be sensitive to the wishes of the patient.

In General Bioethics, the patient is the focal point, but in halakha, one has responsibilities to the patient but also has responsibilities to halakha/ God.

Some issues overlap- we're going to focus on the patient, but some are relevant to the physician as well- what is permitted for the patient certainly reflects on what is permitted for the patient.

Introducing a book you may be familiar with- it is the basis of Jewish Bioethics. It is called Jewish Medical Ethics by Immanuel Jakobovitz. Lord Rabbi Dr. Immanuel Jakobovitz was born in Ireland, served in New York, at the Fifth Avenue Synagogue (where incidentally I served as Assistant Rabbi many years later), was the Chief Rabbi of the British Commonwealth, was knighted by the Queen- hence the Lord. I had the privilege of hearing him in person and meeting with him one time- one time he wasn't feeling so well, so they asked whether there were any doctors present, so we went up to him. He and his wife- very lovely couple.

You must own this if you are interested in Jewish Bioethics, not just historical text- it is not outdated; first of all he updated some sections in the 1970s, but even those that he did not update are relevant, still well-written; this is a fundamental book. I want to read to you one page with regard to this:

    [my paraphrase] Moral questioning aroused by popular ideas of cosmetic/ plastic alteration/surgery has found some rabbinical echoes. [He then talks about various ideas/ problems with regard to plastic surgery. ]

    1. Theological implication of "improving God's wishes" or "flying in the face of providence" (Rabbi Weiss smiles, says, "That's a nice phrase, flying in the face of providence")

    2. The possible risks to life (endangering oneself by opting for these surgeries)

    3. Mutilation of someone else/ Mutilation of self, which is an issurei d'oraisa (biblical prohibition)

    4. Ethical center of human vanity, especially among males


It's the first three that are most important for our discussion tonight.

I'd like to read to you some discussions- there's a very fine journal the college owns called No'am. It's a very sophisticated journal put out in Israel- I want to read two short sections. It's compiled by Rabbi Yitzchak Yehuda Hershkowitz.

[It's in Hebrew, but he translates]

    QUESTION: A woman who has some kind of external blemish; is it permissible for her to perform

    (Rabbi Weiss interjects: It's an interesting formulation of the question- she isn't going to perform anything, after all she's not going to perform surgery on herself; that would be a very gifted student. It's implicit in the formulation of the question that the patient/doctor are seen as the same, that is, that whether she herself performs the surgery or is having it performed is irrelevant, either way)

    a surgery for the sake of beauty

    (Rabbi Weiss: And maybe we don't say she's endangering herself- there are issues related to anesthesia, for example. There are two types, general and local. General carries a higher risk of morbidity and mortality-so there's a question of whether she's permitted to engage in something that endangers herself- hopefully Dr. Berger can come back and discuss anesthesia risks. Today in 2007 they are relatively low- general anesthesia has risks of less than 1% for risks of serious complications, but it is still a risk.)

    -so is she permitted to do this for her own appearance and not out of necessity/ tzorech?

    (Rabbi Weiss: The idea is that you can enter danger if there's a tzorech or necessity. To remove a gallbladder, to alleviate pain and discomfort- those are absolute benefits. Now, is this surgery considered a definitive benefit?)

    Then this talks about men- men focused on appearance might be a violation of men wearing women's clothing- but let's leave men aside.


So he says that "yeish l'hatir"- "I think it's permissible" (Rabbi Weiss to Dr. Berger: See, I just saved your practice) because this is an everyday occurrence (hence it is not risks that are a problem halakhically- that's the idea presented) and people don't end up with serious complications (I think he means that the risks are relatively low) and this is something people commonly do and they accept that risk- important to clarify that.

With regard to men, he says minhag ha'medinah- the norm of the society.

Now I want to look at a little bit more of the expanded discussion- also in No'am, Rabbi ________.

So if someone wants a plastic surgery because of disfigurement that was caused by disease but that is not necessary for recovery from the illness, which means it is not cosmetic, but reconstructive surgery- is that okay? But then again, maybe it's still self-mutilation or the physician is not allowed to mutilate?

There's an important difference between general bioethics and Jewish bioethics, and this is AUTONOMY. General bioethics- allows for self-determination, the person is the center of healthcare decisions. In halakha, we believe in autonomy but also obligations to halakha, a person can't just wantonly do or decide things.

This surgery isn't done for cosmetics but to remove a psychosocial discomfort (busha- embarrassment). Now, that's not needless, not just for the purposes of enhancement; this is for the purposes of removing serious discomfort- also not considered mutilation. Mutilation is when one hurts oneself, but here you are not hurting but helping.

More elaborate discussion by Lord Jakobovits-

    Is it permissable for the person to create a situation of potential hazard/ mutilate himself/ is it appropriate to improve the creation, the form- concept suggesting is that God is the Tzayar, the ultimate plastic surgeon- so if I try to improve upon my face/ body am I not objecting/ contravening- is it permissable to do so? In a sense, is it not blasphemous, contradicting the decree of a king?


He makes a number of very fascinating points- he was truly ahead of his time; the father of Jewish medical ethics. Following him, Dr. Rosner, Dr. St___, Dr. Abraham, ______, young people as well, _____.

So he quotes the Ramah in Yoreh De'ah:

    It is prohibited for a person to endanger himself, but there are circumstances where a person can endanger himself. Birkhat Ha'Gomel is proof of that- gratitude to God for surviving dangerous situations- not accidental, necessarily- but traveling seas, deserts, for parnassah (making a living), for purposes of making a living one can enter into these dangerous situations. It is not imperative to find work locally rather than travel- you travel, and then you say Gomel afterwards.


So maybe you can make some argument again- by anesthesia- percentages being less than 1% for anesthesia, small but real percentages; they used to tell us in medical schol that 1 person in 50, 000 who has that complication has it 100%; it's not bashel b'shishim, you can't kasher it away.

So try to remove psychosocial discomfort the woman/ man feels, may be enough.

One may suggest (I don't know if there have been studies done on this/ whether they support this) that the woman may be better able to fight the cancer, in a better modd, less depressed if she has reconstructive surgery done.

Issue of chavalah-mutilation. He is less comfortable about this. He talks about various/ multiple issues, now says that it is permissable based on an idea of the Rambam.

Now Rabbi Moshe Feinstein (I'm shifting from reconstructive to purely cosmetic right now) - is a young woman allowed to improve his appearance through surgery that mutilates her body?

The questions seems generic; it doesn't seem to be specifically targeted- just in general. This is referring to a woman who was not comfortable with her appearance to the point where she felt it was impeding her socially, and perhaps by shidduchim.

I want to read you something important from a medical textbook on this issue:

    [me paraphrasing] Cosmetic changes in appearance will not help to save a failing marriage, help someone get a new job or open up other large opportunities. Someone who believes that the surgery will offer them unrealistic opportunities should not be allowed to go forward with it.

    The ideal candidate is the adult or mature teenager who has realistic ideas of what the change will afford him/ her, is not being pressured by others, doesn't expect major changes in career opportunities, etc.


[Now goes back to R' Moshe- Rabbi Weiss offers an anecdote of how he was in Rabbi Schachter's shiur for many years and sometimes R' Shachter would look at the questions/ answers and try to come up with the answers/ see how they were derived and would come up with alternative approaches- he was trying to expres the greatness of R' Moshe Feinstein, whose answers you can't necessarily anticipate.]

Most important point based on the Rambam who writes that the "prohibition to mutilate oneself/ others is only when someone insults/ assaults someone else in derek nitzayon, a malicious, assaulting way."

So R' Moshe writes: Is this derek nitzayon? Doing it maliciously or in aggravated, insulting way? No! Here the surgeon is doing it to help her; therefore it is not forbidden based on that.

R' Moshe's conclusion- says that it's permissable for young women to have this mutilation as it is for her good and not mutilation as the Rambam saw it.

He also quotes the idea of 'v'ahavta l'reacha kamocha' (love your fellow as yourself)- according to Rashi/ Ramban- that this is out of l'tovaso (for his good)- out of love for myself, I would want my nose to be improved, so out of my love for someone else, I can improve someone's nose- out of concept that I would do it for myself- regarding cosmetic surgery-

Lord Jakobovitz quotes it with regard to reconstructive surgery, and certainly if it works for cosmetic surgery, then it works for reconstructive surgery.

Now, there are two teshuvos from the Tzitz Eliezer- R' Waldenberg- I had the privilege of meeting him nay years ago; I went to see him when my parents and I were in Israel for Pesach. He lived in a very, very modest apartment. So he set me down, offered me grapejuice, asked me if I own his sefarim (which I do not- though I use them all the time, here at Stern, for instance, there's about 20 of them, that's why I don't own them) so I wanted to leave him some money, some American dollars because he lived so modestly- and he didn't seem to understand what I wanted to do. So he said, there was a woman helping them to make the Pesach, give it to her-

So back to these teshuvos.

1. Reattachment Procedure- there was a kohen who had one finger severed. The question was, is it permissable to reattach the finger- until reattachment occurs, the kohen will be in a room with a limb that is m'tamei (impurifies him). The Tzitz Eliezer concludes that it is permissable- that is a form of reconstructive surgery.

2. In contrast to that, he has another teshuva (response) where he's particularly stringent and not so open about cosmetic surgery. He says that the idea that God imprinted upon each individual the form that is appropriate for him, person has no right to augment/ change his form.

There's a whole discussion in the Gemar about the license to heal of a rofei (physician)- what about God's will? Well, so the Gemara answers, I'm obligated to do what I can in order to be healed; this includes going to/ seeing a doctor.

Says R' Waldenberg, license to heal only applies in situations of illness. There is a pasuk (verse) of V'hasheivosa lo (and you shall return it to him) when a person has lost something, lost his health, then I am obligated to restore it. If person didn't lose something, didn't suffer from debilitating illness or car-accident, simply born a certain way and didn't lose something, then consider it to be prohibited- person shouldn't try to outsmart halakha- prohibited for patient and doctor to perform surgery (if wholly cosmetic.)

Lord Jakobovitz:

You find that there is a mandate in the Torah "v'kivshuha"- to conquer/ improve/ master the world (this is reminiscent of Rabbi Joseph B. Soloveitchik's idea). Use what God gave us- maybe also includes figure of human being- to enhance (but for psychosocial ideas, person must have a realistic idea of what will occur.)

I am hear to answer basic questions, not as a posek, but to present the basic issues.

So, to review:

1. RECONSTRUCTIVE SURGERY- Overwhelming support

Not considered endangerment

A. Risks low
B. Person allowed to engage in risks like these anyway (birchat ha'gomel)

2. CHAVALAH/ MUTILATION

A. For the Rambam's reason- that it's not mutilation unless you've actually attacked the person in an assault kind of way

B. Idea of improving God's world- we were commanded by God to conquer/ master the world

3. There's a machlokes between the Tzitz Eliezer and Rabbi Moshe Feinstein with regard to whether one is allowed to engage in surgery for purely cosmetic purposes (when one has not suffered a debilitating illness/ been in a car accident/ etc)

In terms of the issue of delaying chemotherapy- wanted to ask you differences, constructive surgery- clinically significant, etc? Question of risks- again, how many risks can a person take?

If I can ask you to discuss a little bit now- risks of surgery itself- hopefully there'll be time for questions at the end as well, otherwise Chag Kosher v'Sameach.

Dr. Gary Berger:

Glad most of this is good for me- keep me in business, aside from R' Waldenberg's opinion.

Delaying chemotherapy- absolutely a medical decision- sometimes meetings with twenty people trying to figure out what to do with the patient- usually a decision of the oncologist, not the plastic surgeon or the general surgeon.

And sometimes you're wrong!

Anesthethiologists gently talk to the patient- the statistics are good- there are actually three types of anesthesia:

1. Local
2. Sedation- falls alseep, then gives local
3. General

Always quote what we bench gomel about for years- times go on, risks become less and we stop benching gomel- going to Florida for vacation, going in metal flying machines over the seas, only going to get a suntan (which you shouldn't) but you do it, you're still allowed.

Now, statistically, general anesthesia is safer than going on an airplane.

Interestingly, general anesthesia is better than sedation; during general the machine literally breathes for you, they're in charge, have all the machines and pills and medicines and IV set up- so consider general anesthesia safer. Then again, every doctor I've operate on still wants sedation- it's a hard thing to give control of yourself and your breathing to another person.

As far as men go, statistically the norm for a lot of men to do this [have plastic surgery.]

Now, sometimes you read all these horror stories in the newspapers- people dying from plastic surgery- almost never a board-certified plastic surgeon with a board-certified anasthesiologist. There was a story a year ago about a doctor who had an operation at 11:00 at night, finished at 2 AM, then the patient wakes up, felt dizzy and died, so some people said, "Oh my god, plastic surgery is not safe," and I said, "Oh my god, why is he starting at 11:00 at night? Not good."

[looks at his jotted notes] I'd tell you more if I could read my handwriting. [laughter] Well, I graduated medical school. [laughter]

With me, I talk to the person, sit down with them for at least an hour- tell them everything that can go wrong- also, I ask the person why they want the surgery and if they "This is for my husband" then alarm bells go off in my head. I have turned people away- someone else can take them and their money, but there is a right way to do things and a wrong way to do things, so I do it the correct way. Most people, honestly 90% of the people looking for plastic surgery, they want to do it for themselves, not for other people.

Also, as a sidenote- I don't think v'ahavta l'raecha kamocha always works in medicine.

-

I'm skipping the first question.

QUESTION 2: The kohen whose finger was reattached- was he considered a ba'al mum once his finger was fixed?

ANSWER: I don't believe so- example of microsurgical procedure. Reattachment of single digits- what if doesn't function as well- doesn't invalidate kohen for functional defects, usually, not necessarily- usually for anatomical defects.

-

Conclusion:

Thanks TAC/ CJF/ MedEthics Board.

13 comments:

Anonymous said...

A very informative review.
Thank you.

jackie said...

Do you want to give lessons on how to write so quickly while listening to someone else speak?

I want to sign up.

Moshe said...

Thank you.
And please sign me up for a writing lesson, too.

Charlie Hall said...

Ditto on the speedwriting lessons. And thank you for this review!

Minor Minor quibble with Rabbi Dr. Weiss: Being knighted gives you the title "Sir" if you are a male British citizen, but doesn't make you a Lord. That is a much higher honor and is extremely rare.

PsychoToddler said...

I work with Plastic Surgeons all the time and they help people with some of the most horrific deformities you can imagine. Chronic open wounds with exposed muscle and bone...burns...etc. Kol Hakavod to anyone who can stomach that.

BTW Rabbi Weiss officiated at my Father's funeral and is one of the biggests mentchin you will ever find.

Erachet said...

Wow...very detailed. I'd like that writing lesson as well, please. My notes from school have a lot of question marks in them from not being able to keep up with the teacher. :D

Anonymous said...

Glad I got a chance to read the notes since I had lab during the night of the presentation.

Shelly Smith said...

Well said..!!
Shelly Smith..
-------------------------
Toronto Plastic Surgeon

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