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[Kintaeryos]

any segment where LL is done is never as good as without LL

OK, I'll take that, thanks for your perspective.

[TheDream]

The biomechamics of doing 6cm on femurs or 7 on femurs and 3 on tibias will have minimal change. In both cases they will be much worse than before LL and in the second one you have tibias broken  and lengthened with many risks and of course any segment where LL is done is never as good as without LL.
So for a non significant difference in biomechanics you face many risks, you lose money, time and both your segments will have a huge traumatic surgery like LL for no reason at all becsuse you would have been ok with only one surgery in femurs and the biomechanics would have been almost the same (many people do 6-7cm in femurs only and are fine).

If you still can't understand my points there is no reason to continue.

This is true.

The only counter argument would be the change in tibia to femur ratio which we know from research has a mean of 0.80 in humans with a standard deviation of 0.02 (i.e. it’s VERY rare to be even slightly off this ratio). Then some people have hypothesized that going away from this ratio by doing one segment of LL could lead to problems like joint degeneration and arthritis.

But then the question is would doing both segments LL to keep the 0.80 tibia to femur ratio actually do more good than bad? Or would the impact of the second surgery actually be more risky and cause more problems than simply having a different tibia to femur ratio.

I think this is an important and central question to LL that unfortunately we dont really have a clear answer to.

[Kintaeryos]

This is true.

The only counter argument would be the change in tibia to femur ratio which we know from research has a mean of 0.80 in humans with a standard deviation of 0.02 (i.e. it’s VERY rare to be even slightly off this ratio). Then some people have hypothesized that going away from this ratio by doing one segment of LL could lead to problems like joint degeneration and arthritis.

But then the question is would doing both segments LL to keep the 0.80 tibia to femur ratio actually do more good than bad? Or would the impact of the second surgery actually be more risky and cause more problems than simply having a different tibia to femur ratio.

I think this is an important and central question to LL that unfortunately we dont really have a clear answer to.

Exactly, this is what Sky is the Limit and I are trying to find out. Are the increased risks and stress on the body from doing LL on both segments to keep the tibia/femur ratio 0.8 worse than doing single LL but deviating from the tibia/femur ratio? Is doing double LL worse than having a non-typical tibia/femur ratio? Sounds like something Cyborg4Life could research and ask doctors for his channel. Most LL doctors should be able to answer it.

Edit: as luck would have it, Cyborg4Life just posted that he'll be doing an interview with Dr. Paley about Precise Max including a Q&A with questions by us. Perfect, I'll submit this one.

[LG1816]

This is why these sorts of conversations just go around in circles. If the researchers can't come to any firm conclusions about the Tib/Fib ratio in relation to the development of arthritis, we certainly can't. No one here is in any position to weigh up the cost-benefit here, and no surgeon has enough data to concretely say one way or another.

[Kintaeryos]

This is why these sorts of conversations just go around in circles. If the researchers can't come to any firm conclusions about the Tib/Fib ratio in relation to the development of arthritis, we certainly can't. No one here is in any position to weigh up the cost-benefit here, and no surgeon has enough data to concretely say one way or another.

Yeah, maybe Dr. Paley will have something to say about it. I just submitted these two questions for Cyborg's Q&A with him:

"A common topic of discussion when it comes to LL is the tibia-to-femur ratio, which for most men tends to be 0.80 with relatively little deviation. Some people claim that deviation from this ratio due to lengthening only one segment can cause various problems, including not just uncanny aesthetics and leg appearance but also altered biomechanics and other physical problems in the future (e.g. arthritis). However, it is also claimed that quadrilateral LL is more dangerous than single-segment LL.
Therefore, assuming time and money are not an issue, is it safer to do quadrilateral LL with per-segment increases such that the tibia-to-femur ratio is preserved, or are the risks of quadrilateral lengthening to end up with a normal tibia-to-femur ratio greater than the risks of doing single LL and ending up with an altered tibia-to-femur ratio? If it matters, I'm thinking of doing 7 cm: either femurs-only, or double, e.g. 4.5 cm for the femurs and 2.5 cm for the tibias (or whatever combination would preserve my ratio as decided by the doctor). Thank you."

"Relating to my previous question of single-segment versus quadrilateral lengthening: it is widely claimed that the risk of LL is determined by the per-segment increase, with each segment having its own safety limit. The general numbers often mentioned are 8 cm for the femurs and 5 cm for the tibias. Does that then mean that if a patient wants for example 7 cm of extra height, and time and money are not an issue, it's safer to divide that increase along the two segments, ending up with per-segment increases further below the safety limits compared to doing the whole increase on the femur, where it would only be 1 cm below? Or do the overall risks of quadrilateral lengthening nullify the decrease in risk from lengthening further below each segment's safety limits? Thank you."

[finertoga]

I mean the man did say he’s from a Nordic country. If he’s from the Netherlands where average is like 6’0 for all ages and 6’1” for the younger gen, I can see where he’s coming from. This would be the equivalent of a 5’8”-5’9” guy getting CLL, which is on the upper end of the patient spectrum. So I think he’s reasonable in wanting to get this done (if he is from Netherlands or similar). If you guys see photos of the Dutch or read anecdotes by people they say there’s a ton of people in the 6’3”-6’5” range. I’ve even read about a 6’2” guy who visited the country and said for the first time he felt somewhat short.

Sky is the Limit what country are you from?

[Kintaeryos]

If he’s from the Netherlands where average is like 6’0 for all ages and 6’1” for the younger gen

tbf 5'11.5 for all men and 6'0 for younger gen men, and both numbers are self-reported (https://longreads.cbs.nl/the-netherlands-in-numbers-2021/how-tall-are-dutch-people/) but yeah they're still very tall compared to the global average. But indeed lot of people here getting annoyed with guys in normal height ranges wanting to do LL are coming from a perspective very centric to their country's, not aware of how tall some other countries can be.

[finertoga]

tbf 5'11.5 for all men and 6'0 for younger gen men, and both numbers are self-reported (https://longreads.cbs.nl/the-netherlands-in-numbers-2021/how-tall-are-dutch-people/) but yeah they're still very tall compared to the global average. But indeed lot of people here getting annoyed with guys in normal height ranges wanting to do LL are coming from a perspective very centric to their country's, not aware of how tall some other countries can be.

Yes this seems like a very US-centric forum, which is understandable considering that height is exceedingly important in American society. But people need to understand that height is relative so a 5’8” man could literally be tall in Indonesia one day, then fly to Northern Europe and become short over night.


So a 6’0” guy in the US wanting CLL is justifiably insane, but not so much for other regions of Europe.

[Sky is the Limit]

The biomechamics of doing 6cm on femurs or 7 on femurs and 3 on tibias will have minimal change. In both cases they will be much worse than before LL and in the second one you have tibias broken  and lengthened with many risks and of course any segment where LL is done is never as good as without LL.
So for a non significant difference in biomechanics you face many risks, you lose money, time and both your segments will have a huge traumatic surgery like LL for no reason at all becsuse you would have been ok with only one surgery in femurs and the biomechanics would have been almost the same (many people do 6-7cm in femurs only and are fine).

If you still can't understand my points there is no reason to continue.

It all seems to boil down to you assuming that undergoing LL twice somehow doubles the "lingering" negative effects that LL may have on your legs. But what are these negative effects that you are insinuating? You never mention exactly what these negative effects are that everybody undergoing LL seeminlgy are receptible to regardless of how little or how much they choose to lengthen.

One has to take into consideration what it actually is that is causing any possible pain or is leaving any permanent negative effects. Any possible long-term effects from LL is usually linked with the extensive stretching of the soft tissue and nerves. Because it can't be the bones themselves, since bones simply heal and a broken bone that has healed usually don't leave any permanent damage or lingering pain, if the cut has been "good," that is, if the bone has been clean cut and not splintered into several pieces. However, damaged soft tissue is another story. Soft tissue don't heal as good as bones. Most people who have had a broken bone are not left in any permanent pain. I am not saying that stretching the soft tissue will leave any permanent pain, but if one chooses to stretch them by too much, it certainly increases the risk of any possible permanent damage.

You're not providing any real arguments whatsoever regarding why there is no difference in biomechanics in the outcome regardless of whether one undergo a single, but huge LL, or two separate, but smaller LL:s. Take squatting for example. Wouldn't you agree that the mechanics get totally different with a much longer femur compared to the tibia?

It certainly does affect the fold-ability and proportions. Look for example at this video about squatting and fold-ability, especially from 3:10 onward:

I have already decided that I will do a quadrilateral lengthening. I know that I would look more aesthetic with equally longer femurs and tibias in relation to their original ratio than I would with one segment being considerably longer (6-8 cm) than the other one. It would also feel weird and look odd with a really long femur that is not backed up by an equally longer tibia.

Considering all this, I am strongly convinced it is perfectly fine to do a quadrilateral LL by lengthening both segments way within the safety limits - 5,5 cm for femurs and 3,5 cm for tibias - instead of undergoing a huge stretch by 9 cm in only one segment. The "feeling" (which is probably something that you are insinuating on, but not saying openly) in the legs won't be as dramatic as a whole if the segments are lengthened only by a small fraction of their original lengths. By making a huge lengthening in only one segment you are stretching the soft tissue to the limits (depending on how much you lengthen), which in turn will more likely cause problems in the long run than compared to only stretching the tissue within the safe limits. The safety limit for tibias is for example somewhere around 4 cm.

The first logical thought that came to my mind when I started to consider undergoing LL was that I will lengthen both legs in proportion to their original length to each other and not only one leg. I seriously am astounded that people choose to only lengthen one segment. It think the biggest reason why some choose to only lengthen one segment is a matter of cost, not what is actually best for them in the long run, both in regard to aesthetics and functionality.

[Sky is the Limit]

I mean the man did say he’s from a Nordic country. If he’s from the Netherlands where average is like 6’0 for all ages and 6’1” for the younger gen, I can see where he’s coming from. This would be the equivalent of a 5’8”-5’9” guy getting CLL, which is on the upper end of the patient spectrum. So I think he’s reasonable in wanting to get this done (if he is from Netherlands or similar). If you guys see photos of the Dutch or read anecdotes by people they say there’s a ton of people in the 6’3”-6’5” range. I’ve even read about a 6’2” guy who visited the country and said for the first time he felt somewhat short.

Sky is the Limit what country are you from?

I am from Scandinavia, also called the Nordic countries. The Netherlands is not semantically considered as a Nordic country, but a country in Northern Europe.

There are some small differences between the Scandinavian countries when it comes to average height, but being 6'3" would usually not be considered to be very tall or too tall amongst most people in Scandinavia. I would say that the cutting line between being tall and too tall goes somewhere around 6'4" in Scandinavia. For me, with my current height, I don't perceive a person that is 6'3" to be too tall.

[slowed & reverb]

It all seems to boil down to you assuming that undergoing LL twice somehow doubles the "lingering" negative effects that LL may have on your legs. But what are these negative effects that you are insinuating? You never mention exactly what these negative effects are that everybody undergoing LL seeminlgy are receptible to regardless of how little or how much they choose to lengthen.

One has to take into consideration what it actually is that is causing any possible pain or is leaving any permanent negative effects. Any possible long-term effects from LL is usually linked with the extensive stretching of the soft tissue and nerves. Because it can't be the bones themselves, since bones simply heal and a healed broken bone usually don't leave any permanent damage or lingering pain, if the cut has been "good," that is, if the bone has been clean cut and not splintered into several pieces. However, damaged soft tissue is another story. Soft tissue don't heal as good as bones. Most people who have had a broken bone are not left in any permanent pain. I am not saying that stretching the soft tissue will leave any permanent pain, but if one chooses to stretch them by too much, it certainly increases the risk of any possible permanent damage.

You're not providing any real arguments whatsoever regarding why there is no difference in biomechanics in the outcome regardless of whether one undergo a single, but huge LL, or two separate, but smaller LL:s. Take squatting for example. Wouldn't you agree that the mechanics get totally different with a much longer femur compared to the tibia?

It certainly does affect the fold-ability and proportions. Look for example at this video about squatting and fold-ability, especially from 3:10 onward:

I have already decided that I will do a quadrilateral lengthening. I know that I would look more aesthetic with equally longer femurs and tibias in relation to their original ratio than I would with one segment being considerably longer (6-8 cm) than the other one. It would also feel weird and look odd with a really long femur that is not backed up by an equally longer tibia.

Considering all this, I am strongly convinced it is perfectly fine to do a quadrilateral LL by lengthening both segments way within the safety limits - 5,5 cm for femurs and 3,5 cm for tibias - instead of undergoing a huge stretch by 9 cm in only one segment. The "feeling" (which is probably something that you are insinuating on, but not saying openly) in the legs won't be as dramatic as a whole if the segments are lengthened only by a small fraction of their original lengths. By making a huge lengthening in only one segment you are stretching the soft tissue to the limits (depending on how much you lengthen), which in turn will more likely cause problems in the long than compared to only stretching the tissue within the safe limits. The safety limit for tibias is for example somewhere around 4 cm.

The first logical thought that came to my mind when I started to consider undergoing LL was that I will lengthen both legs in proportion to their original length to each other and not only one leg. I seriously am astounded that people choose to only lengthen one segment. It think the biggest reason why some choose to only lengthen one segment is a matter of cost, not what is actually best for them in the long run, both in regard to aesthetics and functionality.

THIS!👆 i got the same point of view, people say tibias have hogher chance of complication, but complication can be reduced to minimum by a skilled surgeon so the argument itself is eh.

[Kintaeryos]

Yeah, maybe Dr. Paley will have something to say about it. I just submitted these two questions for Cyborg's Q&A with him:

"A common topic of discussion when it comes to LL is the tibia-to-femur ratio, which for most men tends to be 0.80 with relatively little deviation. Some people claim that deviation from this ratio due to lengthening only one segment can cause various problems, including not just uncanny aesthetics and leg appearance but also altered biomechanics and other physical problems in the future (e.g. arthritis). However, it is also claimed that quadrilateral LL is more dangerous than single-segment LL.
Therefore, assuming time and money are not an issue, is it safer to do quadrilateral LL with per-segment increases such that the tibia-to-femur ratio is preserved, or are the risks of quadrilateral lengthening to end up with a normal tibia-to-femur ratio greater than the risks of doing single LL and ending up with an altered tibia-to-femur ratio? If it matters, I'm thinking of doing 7 cm: either femurs-only, or double, e.g. 4.5 cm for the femurs and 2.5 cm for the tibias (or whatever combination would preserve my ratio as decided by the doctor). Thank you."

"Relating to my previous question of single-segment versus quadrilateral lengthening: it is widely claimed that the risk of LL is determined by the per-segment increase, with each segment having its own safety limit. The general numbers often mentioned are 8 cm for the femurs and 5 cm for the tibias. Does that then mean that if a patient wants for example 7 cm of extra height, and time and money are not an issue, it's safer to divide that increase along the two segments, ending up with per-segment increases further below the safety limits compared to doing the whole increase on the femur, where it would only be 1 cm below? Or do the overall risks of quadrilateral lengthening nullify the decrease in risk from lengthening further below each segment's safety limits? Thank you."

OK, Paley answered the first one, he said there's no evidence of altering the tibia-to-femur ratio with bilateral LL leading to arthritis or other negative health effects long-term. The only study that indicates such a thing is one conducted on cadavers of people with arthritis, and the findings were that they were naturally born with an abnormal t/f ratio and that was correlated with arthritis. He also said he performed his first cosmetic LL in 1988 and in the 35 years since then he has seen no evidence of patients who underwent bilateral LL developing arthritis. The only real factor is the cosmetic one.

Unfortunately due to time constraints or other reasons Cyborg didn't ask the second one. Maybe at another Q&A.

[LG1816]

OK, Paley answered the first one, he said there's no evidence of altering the tibia-to-femur ratio with bilateral LL leading to arthritis or other negative health effects long-term. The only study that indicates such a thing is one conducted on cadavers of people with arthritis, and the findings were that they were naturally born with an abnormal t/f ratio and that was correlated with arthritis. He also said he performed his first cosmetic LL in 1988 and in the 35 years since then he has seen no evidence of patients who underwent bilateral LL developing arthritis. The only real factor is the cosmetic one.

Unfortunately due to time constraints or other reasons Cyborg didn't ask the second one. Maybe at another Q&A.

And his answer is really a microcosm of what we see on this forum on a daily basis -- a muddy amalgamation of anecdotal evidence and layperson's interpretation of research, then dispelled by someone who actually knows what they're talking about.

Of course, the forum's greatest asset is its anecdotal content -- the individual experiences (diaries) of people who have gone through this are invaluable. What's completely unhelpful, though, is when the continual appeals to understand the ins and outs of this procedure are met with the same anecdotal discourse and nothing more than an un-informed opinion touted as fact.

[CLLvet]

OK, Paley answered the first one, he said there's no evidence of altering the tibia-to-femur ratio with bilateral LL leading to arthritis or other negative health effects long-term. The only study that indicates such a thing is one conducted on cadavers of people with arthritis, and the findings were that they were naturally born with an abnormal t/f ratio and that was correlated with arthritis. He also said he performed his first cosmetic LL in 1988 and in the 35 years since then he has seen no evidence of patients who underwent bilateral LL developing arthritis. The only real factor is the cosmetic one.

Unfortunately due to time constraints or other reasons Cyborg didn't ask the second one. Maybe at another Q&A.

For what it's worth, I actually had a follow up consult yesterday with Giotikas and asked him this question regarding whether altering the 0.8 femur/tibia ratio leads to arthritis and/or loss of biomechanical functioning. Giotikas essentially gave the same response as Paley.

I am summarizing what he said, but here it is- Giotikas said

"there have never been any studies (Giotikas had seen) to suggest that altering the ratio leads to arthritis or biomechanical problems down the line. He has operated a lot of deformity correction cases (i.e. non cosmetic) and there were never any instances where altering the proportions was the cause for functioning reductions either.

The key to avoiding those types of problems is preserving the mechanical axis of the leg, which a skilled LL surgeon should know how to do. According to his experience and knowledge of studies, there is no clear benefit (to functionality in the legs/ body) from preserving the proportions.

Proportion (femur to tibia ratio) is an individualized decision. Doing both femurs and tibias gives you a more proportional result, but it also comes with 2 surgeries. This carries double the risk of complications and nearly double the time and double the cost. "

//////////////////// BREAK (My thoughts on this matter)

So I guess (and now these are my thoughts, not Giotikas), it makes very little sense to do quadrilaterals because you think it will give you better biomechanical functioning. I would argue the opposite as the LL surgery (on whatever segment you end up choosing) in and of itself will LOWER THE FUNCTIONING OF THAT SEGMENT you do, no matter how good your outcome is. If you get a femur surgery, you will NEVER be able to move your femurs as fast as you did previously, and thus you will never fully regain your prior sprinting speed. If you do quadrilaterals and now add tibias to the mix, that exacerbates the functionality issue even more. Now you have reduced the functionality of both segments simply because both segments underwent LL. So if your goal is preserving biomechanical functionality, it seems to me that doing the surgery on both segments (even if you only lengthen a small amount in each, say 5 cm femurs, 3 cm tibias) would reduce the functioning of your body far more due to the compound effects of having 2 LL surgeries. It would do more damage than if you maxed out your femurs (say 8 cm) and then never touched your tibias whatsoever. 

But again, I am not a surgeon and that last thought is my 2 cents on this (complicated/ confusing topic), so please take it with a grain of salt and form your own conclusions. Or better yet, bring this matter up with your prospective surgeons when you schedule your consultations. 

This leads me to my conclusion. I see 2 reasons to consider doing quadrilateral LL right from the start-

1). proportion is so important to you (from an aesthetic standpoint) that you simply will be horrified looking at yourself in the mirror after a femur LL because your femurs are now out of proportion with your tibias. You think this is a major problem or could become one for you.  I can't make that decision for you, but I will share a personal anecdote below of why I think this reason is not the best reason to do quads.

2). You are certain that your lengthening goals are 9 cm or above and you would not be satisfied with anything less. Then I believe it IS worth considering quadrilaterals so that you do not dramatically exceed what are commonly the upper limits of femur lengthening (7-8 cm) and tibia lengthening (5-6 cm).

However, if you are simply trying to gain more height, aren't so worried about proportions, and think you would be satisfied with 8 cm AND do not care so much about the aesthetic proportion factor, I think maybe you should consider starting off with just a femur LL and see how you feel after that.

I can tell you that after my femur surgery, there was literally not a single person who (from what I could tell) ever looked at me and seemed to exhibit any sort of curiosity as to why my femurs seemed so much longer to my tibias. And of course nobody ever actually said anything.

I really feel that nobody (or at least very few people) are analyzing your legs and trying to figure out if your femurs/ tibias match a certain ratio or if your legs are symmetrical to your torso.

 After my surgery, I felt nobody seemed to care about my new proportions, not even women who saw me walking around unclothed and thus got a great look at my proportions while those body parts were very much "on display" 

[Robert Adam]

Does the quadrilateral, lengthen by 1mm / 0.75mm per day (femur/tibia)? or only 0.75 mm / 0.5 mm per day?

[Sky is the Limit]

Thanks for your input! Of course LL will always have some kind of effect on the functionality, but the question is by how much. There are numerous examples of people that have fully regained and retained their former athletic ability after undergoing quadrilateral leg lengthening. I believe that it is possible to minimize the loss of functionality as much as possible by keeping the amount of lengthening way within the safe limits.

So I guess (and now these are my thoughts, not Giotikas), it makes very little sense to do quadrilaterals because you think it will give you better biomechanical functioning. I would argue the opposite as the LL surgery (on whatever segment you end up choosing) in and of itself will LOWER THE FUNCTIONING OF THAT SEGMENT you do, no matter how good your outcome is. If you get a femur surgery, you will NEVER be able to move your femurs as fast as you did previously, and thus you will never fully regain your prior sprinting speed. If you do quadrilaterals and now add tibias to the mix, that exacerbates the functionality issue even more. Now you have reduced the functionality of both segments simply because both segments underwent LL. So if your goal is preserving biomechanical functionality, it seems to me that doing the surgery on both segments (even if you only lengthen a small amount in each, say 5 cm femurs, 3 cm tibias) would reduce the functioning of your body far more due to the compound effects of having 2 LL surgeries. It would do more damage than if you maxed out your femurs (say 8 cm) and then never touched your tibias whatsoever.

I think this is kind of a broad statement that leaves a lot of questions unasnwered.

You are essentially implying that the loss of functionality is somehow static and equal for everyone, when in fact it is highly dependent on a lot of different factors, one major one being the amount of lengthening.

There has to be degrees in loss of functionality which could be determined in relation to the amount one chooses to lengthen. If a patient's femur bones are cut, but lengthened with 0 mm, that is, not lengthened at all, there should not be any permanent effects in the functionality after the bones have healed. I draw this conclusion only based on the fact that the soft tissue have not been streched. If the bone is cut and lengthened by only 1 cm, there should not be any noticeable effect on functionality after healing and rigorous physiotherapy. If the bones have been lengthened by 2-3 cm, the difference in athletic ability should be non-existent, even if the soft tissue has been streched a little bit. The soft tissue can be streched up to a certain amount before the effect that it may have on the functionality of the legs starts to be noticeable. According to studies found, the recommended amount of lengthening the femur bone is 7 cm (Wagner H: Operative lengthening of the femur. Clin Orthop 136: 125–142, 1978).

The question here is. Would lengthening the femur by 8-9 cm affect the functionality so much that in total it is more harmful for your athletic ability and functionality compared to a situation where you divide the lengthening into two smaller ones for each segment?

The more length that is added after a certain point, the more it increases the risk of affecting the functionality of the legs in a negative way. Every increase in millimeter above a certain point (the safe limit) increases the loss of functionality more or less exponentially. This would mean that a lengthening of 9 cm will have a multifold negative effect on functionality in comparison to a situation where the same amount of lengthening is divided into two separate, but smaller, lengthenings in both segments, for example femur 5 cm and tibia 4 cm. The compound effect of two smaller lengthenings in terms of loss of functionality would not be as dramatic as it would be in the case where you lengthen your femur with more than 8 cm.

However, this is a debatable subject, and whichever strategy that would be most suitable in a specific situation way vary between people and is a thing that is best discussed with the surgeon that is going to perform the surgery.

[Sky is the Limit]

Based on the discussions here, I have contemplated two different strategies for my own leg lengthening journey and I will provide them here as a way to concretize my own thoughts and plans of going through with this surgery.

My goal is to have a height between 190 and 192 cm around the clock, ie. throughout the whole day and night. This means that I am okay with having a little higher morning height.

Strategy 1: The quadrilateral procedure from the get go (all in one go)

Doing 5 cm femur + 4 cm tibia seems like a perfect quadrilateral LL plan for me. Both segments will preserve the ratio of 0.8 with these amounts of lengthening. It seems that a ratio of 5 cm femur + 4 cm tibia would be a perfect fit for me, because it is exactly within the 0.8 f/t-ratio. I still have to make exact measurments of my bones with x-rays to determine how much I would lengthen them if I would follow this strategy. Preserving the ratio as intact as possible may not leave any room for regrets later on, because the lengthening process could not have been done more optimally in regard to keeping the ratio, and, by extension, the biomechanics and functionality, as intact as possible. I know for sure that I would feel more secured and confident about my choice if I know I have lengthened both segments in accordance to the standard ratio of 0.8.

The downside of going through a quadrilateral lengthening all in one go is that it is more stressing on the body, both the lengthening procedure and time to heal is a lot longer compared to lengthening only one segment, and the cost is higher (almost double).
 
Strategy 2: The prolonged quadrilateral lengthening procedure (femur first and tibia sometimes later on in life)

In this strategy, I would start of by only lengthening my femurs with around 7 cm in order to reach a morning height of 190 cm and call it a day, leaving the possibility open for further lengthening later on.

The only problem with this is that if I choose to only lengthen my femur by 7 cm, and then later on lengthen my tibias, I would have to lenghten my tibias by 5,6 cm (7 cm * 0,8) in order to preserve my femur/tibia-ratio as a 0.8, which would leave me at a morning height of 195,6 cm-196,1 cm (183 cm - 183,5 cm + 7 cm + 5,6 cm), which in turn would definitely be way too tall for me and my taste. If I chose to "feel the water" by starting of with only one segment with the intention to later on add more height by lengthening the tibias also, I would either have to lengthen my femurs by only 5 cm or choose to get a little more skewed tibia/femur-ratio due to only lengthening my tibias by up to 4 cm. I also think that lengthening the femur by only 5 cm is a tad small amount to lengthen the femurs considering how much you can safely lengthen them without receiving any serious complications. This is why I would rather choose to lengthen my femurs with at least 7 cm while I am at it.

Starting off with lengthening my femurs by around 7 cm (instead of going through a quadrilateral lengthening process from the get go) would allow me to keep the possibility open to later on reach a higher end-height by undergoing an additional lengthening of the tibias by up to 4 cm. This is, in one way, a future-proof way in the whole grand scheme of leg lengthening, in that it gives me room to reach an even higher height than would be the case if I chose to undergo a quadrilateral lengthening as described above in Strategy 1. It would also give me a direct benefit more quickly, with less struggle and less money spent. One should also take into account the possibility of some shrinking of the spine due to age. By leaving room to later on add more height by also lengthening the tibias, it would allow me to adjust my height goal in accordance to how I perceive my new height and it would also leave me with a fail-safe in case the height growth of the future generation will get completely out of hands.

The only downside with choosing this strategy is that it would leave me with a skewed femur/tibia-ratio (at least for a certain amount of years). It may also  leave me with the feeling that I have left the whole procedure half-done, at least until the moment I choose to lengthen my tibias also. However, it feels much more tempting to follow this strategy than the first one and makes me more excited about this whole procedure. The benefits of choosing this strategy is that it would be more cost effective than going through a quadrilateral lengthening from the get go and it would give me the desired height more quickly and with less taxing on the body.