After a five-hour wait, the appointment is over in five minutes.

But Caitlin doesn’t care about the lost afternoon; she’s elated. What she doesn’t want to dwell on right now is that in less than a year — if she were to follow a typical lengthening schedule — another surgery would affix new devices to her upper arms. The truth is, with the end of her first procedure finally in sight, Caitlin doesn’t know if she can go through it all over again.

***

In the early 1950s, at a small hospital in a remote region of western Siberia, a Russian orthopedist named Gavril Ilizarov developed a groundbreaking surgical technique to treat the badly fractured bones of injured Russian soldiers. The Ilizarov method of limb reconstruction is based on the idea that new bone growth can be stimulated by “distraction,” or pulling the ends of a broken bone apart, while stabilizing the limbs with an external frame. It is only within the last 20 years, however, that limb-lengthening has become available to symmetrically lengthen the arms and legs of patients with dwarfism. Though the procedure has become safer and more effective over time, it is not without its risks — such as infection, stiffening of the joints or muscles, and nerve damage. Because few, if any, patients have reached middle age or older, the possibilities for long-term problems from the surgery aren’t certain.

The doctor who performed Caitlin’s first surgery, Paley, was the first North American surgeon to study with Ilizarov. Paley, who was born in Israel and raised in Canada, brought limb-lengthening to the United States in the mid-1980s and put it into practice as chief of the pediatric orthopedic surgery residency program at University of Maryland Medical Center in Baltimore. Along with two other orthopedic surgeons, Paley co-founded the International Center for Limb Lengthening at Sinai Hospital in 2001. Roughly 100 dwarfs undergo limb-lengthening at Sinai every year.

Though bilateral lengthening can be performed on adults, for children with dwarfism, particularly achondroplasia — the most common form of dwarfism — the optimal time to begin lengthening is around age 8, Paley says. The legs are lengthened first, generally by about four inches. The bones must fully heal before the next surgery, which takes place around age 12 or 13, adding another five or six inches of length to the legs. One year later, the upper arms are generally lengthened by roughly three inches, to keep the patient’s overall stature proportional. Some patients opt for a third and final procedure to lengthen the legs again by an additional four to six inches, at age 15 or 16. Each procedure — which includes all surgeries and physical therapy — costs from $200,000 to $300,000, and the expense is largely covered by most insurance plans. The medical claims for Caitlin’s procedure totaled almost $300,000; her family paid about $9,000 out of pocket.

A height increase of up to 16 inches is, Paley says, “a tremendously life-altering functional improvement.” But not everyone views the additional height with the same sense of appreciation. As the number of dwarf patients seeking limb-lengthening has grown, so has the controversy surrounding the physical, emotional and social impact of the procedure. Many members of the dwarf community believe that limb-lengthening sends the wrong message: that in order to fit in, be professionally successful or simply lead a “normal” life, it is necessary to conform to the larger population’s standards of height.

This perspective is fueled in part by a painful history of exploitation and social isolation. The cultural identity of dwarfs has evolved significantly since the early 19th century, when “midgets” — considered a derogatory term — were primarily considered social outcasts, circus performers or curiosities for public display. But even now, with dwarfs living and working successfully throughout society, there are still lingering stereotypes and reminders of how dwarfism has been linked with degrading humor. Consider “Mini-Me” from the popular Austin Powers movies, “Wee Man” from MTV’s “Jackass,” or the practice of dwarf-tossing, wherein dwarfs dress in padded Velcro suits and helmets and allow themselves to be tossed in bars or clubs for laughs. A French dwarf named Manuel Wackenheim famously argued that dwarf-tossing is a personal choice and a legitimate source of income, but the United Nations’ human rights committee determined otherwise, supporting a French ban on the activity in 2002.

The official position of Little People of America, which has more than 5,000 members, has evolved along with the developments in the field of limb-lengthening over the last 15 years. Originally skeptical, on the grounds that the procedure was risky, experimental and potentially harmful, the current standpoint of the organization stresses that it is a matter of personal choice — but also notes that the surgery is generally performed for “adaptive” or “cosmetic” reasons.

“When we try to change our height, we are changing who we are in order to better navigate the social and physical barriers that we face,” says Gary Arnold, vice president of public relations for LPA. “But in my opinion, the answer is not to change our bodies. The answer is to impact the world in which we live.”

Arnold reiterates that prospective patients should be old enough to participate in, and fully understand, the complex decision-making process. But that position creates a logical dilemma. The procedure is ideally first performed on someone too young to give informed consent. How is this ethical collision resolved? In Caitlin’s case, it was resolved by tacit compromise; when she became a teenager, Caitlin made her own choice, informed by the 13 years she had lived as a dwarf. In many other cases, including that of Rachael Whitehead, a 14-year-old Canadian patient at Sinai with achondroplasia, the initial decision was made by someone else.

When Rachael walks into a room on crutches, it is difficult to picture her as a young woman with an original projected height of only four feet. After four rounds of surgeries, with three inches of length added to her upper arms and 15 inches added to her legs, Rachael now stands 5-foot-2 and is nearing the end of her final lengthening procedure.

Rachael’s mother, Esther Whitehead, decided to have Rachael go through the first surgery, adding four inches to her height, at age 7. Whitehead believed that after one round of lengthening, Rachael would know enough of the experience to determine whether she wanted to do it again.

Sitting with her daughter in the common room of the Hackerman-Patz House, a campus home-away-from-home for patients who travel long distances to have their limbs lengthened at Sinai, Whitehead says that after Rachael’s first surgery, she was still about the same height as an average male dwarf. As to whether she was certain that Rachael wanted the procedure as a child, Whitehead says firmly: “Children frequently change their minds. We felt this was the best option.”

When Rachael started asking questions about her height as a little girl, Whitehead took her to Little People of America gatherings, so she could begin to get a sense of what life might be like if she remained short-statured in adulthood.

“I wanted her to see that dwarfism isn’t cute forever,” Whitehead says.

Rachael chose to continue the surgeries. She wanted the added height, she says, because she believed it was the only way to live a normal life. Without surgery, she says, “your adulthood would be ruined, and that’s a lot longer than your childhood. This way, you can live your life and not be stared at.”

***

The living room is filled with brightly colored streamers and balloons, and a pink cake box sits on the counter in the kitchen. Caitlin, who is celebrating her 14th birthday today, is dressed in a striped shirt, sparkling black headband and a loose cotton skirt. She is only two weeks away from the surgery to remove her fixators. She remains vague about whether she plans to continue lengthening — arms or legs — but the possibility seems increasingly doubtful as she nears the final stage of her first procedure.

When the first cars appear at the crest of the hill and wind down the long driveway, Caitlin — who can now stand and walk for brief periods using a walker — rises to greet her guests outside. Caitlin’s movements are jerky, her stance forced unnaturally wide by the devices anchored inside each lower leg.

“You okay, Cait?” Jennifer asks quietly, opening the door for her daughter.

“I’m fine,” Caitlin replies sharply, and she stiffly quickens her pace.

“Okay,” Jennifer sighs. “I won’t be the helicopter mother.”

Still, as she talks with other parents, Jennifer keeps her eyes trained on her daughter. While they wait for the rest of the girls to arrive, Caitlin and four of her friends gather in a circle at the foot of the driveway, kicking a soccer ball and giggling about boys, cellphones, beauty products. Caitlin looks her age beside these girls, who are also 13 or 14 but appear older, dressed in baby tees and fitted jeans with cellphones and lip gloss tubes bulging in the back pockets. They pass the ball to Caitlin almost every other turn — gentle kicks that Caitlin can catch against the toe of her shoe. One of the girls accidentally sends the ball rolling into Caitlin’s walker.

“Oh, my God, I’m so sorry,” she exclaims.

“It’s okay,” Caitlin says, blushing slightly. She plants her arms on her walker and lifts her feet off the ground to nudge the ball back into the circle. Behind her, Jennifer winces, but she doesn’t intervene.

A half-hour later, while the party waits for Caitlin’s stepfather, Mike, and her brother, Jackson, to arrive with pizza, Jennifer sets up Dance Dance Revolution — a Wii video game with interactive floor mats that allow players to move along to the dance instructions on the screen. Caitlin supervises from her seat on the edge of her bed.

“I can try it,” she says suddenly, assertively. It’s a sensitive subject, as Jennifer made it clear before the party that Caitlin would not be allowed to play the game — the mats are slick plastic, and a fall could be disastrous.

Jennifer turns to her. “No, you can’t, Caitlin,” she says. “We didn’t go through six months of this for you to slip and fall.”

The two look at each other steadily for a moment. Jennifer exhales through pursed lips. “Look, let someone else go first, and we’ll see how slippery it is,” she finally allows.

Caitlin holds the game’s remote control as two of her friends stand up to play the first round. Through the screen door, one more car appears at the top of the driveway — the last party straggler — and Jennifer steps outside to greet the new arrival. Caitlin waits for the screen door to slam shut behind her mother.

“Hey, I can do it now!” she says. She stands and moves to one of the mats. Holding tightly to her walker, she starts a new game and begins to move her feet in rhythm on the mat. Her friends smile nervously, but the interlude doesn’t last. Outside, the car pulls away, and the screen door opens again. Jennifer stands in the entrance, her eyes wide when she sees Caitlin on the mat.

“Caitlin!” Jennifer shouts, but her expression quickly softens as she watches her daughter move with careful deliberation to keep pace with the game.

“I won’t slip; I’ve got my walker,” Caitlin tells her. Jennifer relents, and Caitlin does one more round with her friends. When the game ends, she sits back down on the edge of the bed.

On the couch, a handful of her friends are discussing the actor Orlando Bloom while they examine each other’s cellphones. Two other teens are giggling on the mats as they follow along with the game. Amid the flurry of activity, Caitlin seems alone for a moment, lost in the images on the screen. Her fingers tap against the handles of her walker, and her feet move slightly to the front, to the side, back again, as she mimics the movement of her dancing friends.

***

In the pre-op area at Sinai, Caitlin sits in a hospital bed, drumming her fingers against the mattress. It’s the day she has been waiting for, and she is both excited and nervous. Wearing a T-shirt printed with the famous refrain from Dr. Seuss’s “Horton Hears a Who” — “A person’s a person, no matter how small” — Caitlin is flanked by her parents as a middle-age nurse reviews her chart.

“Any loose teeth or contact lenses?” the nurse asks. Caitlin says no.

“What about body piercings?” asks the nurse.

Caitlin squints and tilts her head, smiling mischievously.

Jennifer cries, “She’s kidding!”

Stewart’s gaze is locked on the pins protruding from his daughter’s legs. “She has 24 body piercings,” he says, wryly.

Shortly before 8 a.m., Caitlin is wheeled into the large, state-of-the-art operating room, designed to accommodate limb-lengthening and reconstruction surgeries. X-rays of Caitlin’s legs are mounted on one wall. A narrow table draped in blue cloth displays rows of meticulously arranged, gleaming surgical instruments. A nurse positions a mask over Caitlin’s nose and leans down slightly, near Caitlin’s ear. “It’s a dream,” she says softly. “When you wake up, you’ll be a new woman.”

Caitlin’s eyes flutter and close, and Jennifer is escorted from the room. Shawn Standard, who will be leading the surgery this time, takes his place at Caitlin’s side. Another doctor stands across the table, and both begin to unscrew the fixator frames. The clunky black devices are removed easily, and soon only the 24 metal pins are left protruding from Caitlin’s legs.

“It takes hours to put these things on,” Standard says of the pins and frames, “and it takes about 15 minutes to take them off.”

One by one, the pins are unscrewed and pulled free of Caitlin’s thighs and calves, clinking as they are dropped into a bucket on the table. By 9 a.m., less than half an hour after Standard entered the room, all of the pins are out.

Outside the OR, two hours pass before Stewart and Jennifer receive an update on Caitlin’s progress. The news is mixed: Despite Paley’s earlier prediction, Standard has decided to err on the side of caution and place titanium rods in both of Caitlin’s femurs, to stabilize the bones and help maintain alignment in the event of a fall or fracture. Jennifer rubs her temple. “Caitlin’s not going to be happy,” she says. This also means another surgery, as the rods are generally removed within six months to a year.

The two settle into chairs in the waiting room and talk about the years of deliberations that led Caitlin to surgery.

“When she decided,” Stewart says, “I said that it would be the end of her childhood.”

“I think her childhood ended a couple years ago,” Jennifer counters, “when she started to really realize and face the fact that she was different.”

Standard emerges from the OR to speak with Jennifer and Stewart at 12:30 p.m. “She did really well,” he says immediately. He adds that if Caitlin has her arms lengthened in the spring, he’d plan to remove the rods in her legs at the same time.

After Standard leaves, Stewart looks at Jennifer. “So the rods will come out when she does her arms,” he says. Jennifer shakes her head. Though Caitlin has not definitely decided, and she still has another couple of months before she would need to schedule a surgery for the upcoming spring, Jennifer says that right now, Caitlin doesn’t think she’s going to have more surgery.

This development comes as a surprise to Stewart. “I thought that was a done deal,” he says.

Jennifer leans back in her chair. “Caitlin can function with her arms. For Caitlin, she just wants to be able to function.”

“Yeah,” Stewart adds, “but she also wants to be as close to normal as possible.” He pauses. “Well, it’s her decision.”

“It always has been,” Jennifer says.

***

Caitlin didn’t know any other dwarfs as a child. All of her friends and family members were average height, and Caitlin never participated in meetings or activities within the dwarf population — something that both she and Jennifer view with a tinge of regret. Before she met other patients like herself at Sinai, Caitlin’s sole connection to little people was through movies and TV. She has developed a sense of the dwarf community by watching The Learning Channel’s “Little People, Big World,” a reality show that follows a family of both little and average-height individuals.

Dahlia Kronish, a 30-year-old ordained rabbi and high school teacher, lives that reality. Kronish — like Caitlin — is the only dwarf in her family. And like Caitlin, Kronish was presented with the option of pursuing limb-lengthening when she was a teenager. But Kronish had grown up with a strong connection to the dwarf community, through Little People of America and through a similar organization that her parents founded after the family moved to Jerusalem, when Kronish was 18 months old.

Nestled on a sofa in her New York City apartment last February, Kronish explains that she was 16 when she first met with a surgeon in Israel who described the lengthening procedure, still in an early stage of development. When the surgeon detailed how they would break and drill pins into Kronish’s bones, her mother fainted.

Kronish saw another surgeon a year later before telling her parents that she didn’t want to have her limbs lengthened. Her family, she says, supported her choice.

“I had learned to cope with being stared at and receiving different treatment,” she says. “Even if I wished — which I often did and still sometimes do — that it would have been better or easier if I wasn’t this way, I still wasn’t interested in a whole new identity at age 16.”

Kronish’s cheerful apartment on the Upper West Side is a testament to the identity she chose to embrace. There are stepstools in the kitchen so that she can reach her countertops and sink. The shelves above the counter are bare or sparsely occupied by items she seldom uses; dishes are stored in a low cabinet. A bookshelf in the living room displays a framed photo of Kronish laughing with her fiance, Josh Maudlin, who is also a dwarf. She avoids the subway, where the crowds are overwhelming and the steps are an exhausting strain. Instead, she drives a car with removable extensions to reach the pedals and pillows to push her forward in the seat so her hands can grasp the steering wheel.

Kronish, who served as president of the New York City LPA chapter for a year, has been thinking about how she’ll share a dance with her father at her wedding in June. She’s considering options — perhaps a raised platform she could stand on — but worries about looking awkward.

Kronish teaches rabbinical studies to students in ninth, 10th, and 12th grades at the Abraham Joshua Heschel School on the Upper West Side, and each year, she offers her students an opportunity to comment frankly about her height. She tells them about her choice not to pursue limb-lengthening and answers their questions.

This time, when she asks five of her high school seniors to share their thoughts about the impact of her size in the classroom, the students immediately recall a painful moment from the beginning of the 2007 school year.

Faculty and students gathered on the first day of school in September for a “welcome back” breakfast. To help spur excitement for the new academic year, the school hired a standup comedy troupe. For one skit, the troupe invited two students to join them before the group; the comedians would perform a scene and then pause, asking the students to suggest a word or phrase that they would then incorporate into the act. When the comedians turned to one of the two students, a senior known for his good-natured sense of humor, the student blurted out the phrase “midget-tossing.”

The room of 250 students and 50 faculty members grew very quiet, but the comedians promptly let loose with a string of jokes about “midget-tossing.” The student, realizing his own blunder, tried unsuccessfully to change his suggestion. After a few moments, Kronish stood up and walked out of the auditorium.

“I couldn’t handle it,” Kronish says later. “I was tearing up.” She refused to cry in front of her students.

The school principal, mortified, followed Kronish into the hallway along with two other faculty members. A few moments passed before Kronish composed herself and returned to the room to lead the gathering in the after-breakfast prayer.

“That was the hardest thing I’ve ever done,” she says.

When the class is dismissed, Kronish stands and follows her students out into the busy hallway, making her way to a teacher’s meeting. In the classroom, pasted above the blackboard, is a printed quote by author and Buddhist teacher Sylvia Boorstein:

“There are only two possible responses to every challenge — balanced acceptance or embittered resistance. Acceptance is freedom. Resistance is suffering. We all know this.”

***

In the food court of Bowie Town Center, Jennifer zips Jackson’s backpack and eyes her daughter, reminding Caitlin of the objective of today’s shopping trip: “You need pants.” Caitlin, armed with a small roll of cash tucked in a bright pink wallet, is eager to part ways and head off in search of her long-awaited new jeans. She’s been pining for real pants for months.

Stepping outside into the cold, overcast afternoon, onto the busy sidewalks of the outdoor mall, Caitlin immediately heads toward the stores on the other side of the street. It’s been two months since the surgery to remove her fixators and over a month since she stopped using a wheelchair, and her gait is somewhat stiff. She has physical therapy three times a week, which is still painful and exhausting. But now she is beginning to appreciate the results. “I’m not the shortest kid in my class anymore!” she announces. Time has begun to soften the hard reality of what she went through, and she’s not as quick to say that a second procedure is out of the question.

The first store on Caitlin’s list is Wet Seal, a prime destination for teenage girls. She opens the door to a blast of heat and punk rock music. The walls of the store are covered to the ceiling in tees with brightly colored sequins and sassy messages: “My Boyfriend Is Cuter Than Yours,” “I Don’t Like Your Girlfriend” and “Love, Peace and Party.” Caitlin heads toward several long shelves of jeans.

She’s not sure what size she is — she’s gotten taller and lost weight over the last eight months — so she grabs several pair, ranging from size 0 to size 3 (all designated “short”). On the way to the dressing room, she passes a rack of boots and shoes. She pauses in front of a pair of black, lacy, open-toed shoes with a skinny three-inch heel. “These are so cute,” she says.

In the dressing room, the size 0 turns out to be a bit too snug, and the flared bottom of the pant almost covers her entire foot; the 5 inches she’s gained since March make a big difference, but the pants are still slightly long. Caitlin changes into a pair of black jeans — size 1 short — and opens the door with a euphoric grin.

“They fit!” she declares, running her hands down the outside of her thighs, over the places where rows of metal pins jutted from her flesh two short months earlier. “I know my size!” she says and studies her reflection in the dressing room mirror. “I have a size.”

***

This past summer brought a chance for a new beginning: Caitlin’s family bought their first home and moved to a shaded neighborhood in Alexandria. It’s a big change from the sprawling fields surrounding their rented house in Clinton, and a shorter commute for Jennifer, who is working long hours again as managing director of office services at the law firm Hogan & Hartson in Washington. Early into her freshman year at a new high school, Caitlin is still adjusting to the routine and making friends. She’s glad that she didn’t undergo surgery in the spring, which would have meant starting high school with fixators on her arms. So far, only one classmate has asked about the scars running along her thighs and calves. Caitlin said they were from a car accident.

“A lot of people don’t really understand,” Caitlin says. “I’m just so afraid that people might think that it’s a plastic surgery and wonder why I went through that just to be taller. I really don’t want people to think that about me.”

It’s an irony that is not lost on Jennifer. The skeptic who feared that Caitlin would choose to have surgery because of social pressure, Jennifer now worries that Caitlin may delay or decline it for the same reason.

At a follow-up appointment a few months ago, Paley urged Caitlin to consider additional lengthening, reminding her that the procedure would be most successful while she is young. But for now, she has no plans to go through the process again. It’s an uncommon choice, he says, so uncommon that Paley has little doubt that Caitlin will change her mind.

“She needs to get her normal life back, and then . . . she will decide to do it again,” Paley says. “They all do. The number of patients who have not gone through a second lengthening is very, very few.” With the pain of the process behind them, Paley contends, patients quickly come to value the end result and usually decide that it’s worth the temporary sacrifice.

But surgery, Caitlin realizes, didn’t change everything; it didn’t “fix” the fact that she feels different among her peers. She still sometimes finds herself on the sidelines among her friends, and she can’t always relate to their interests and priorities. Her experience — growing up with a unique set of social challenges and limitations, and her decision to test her emotional, physical and psychological limits to gain the functionality she wanted — has given her a sense of perspective beyond her years.

“My personality is different,” she says. “I don’t like drama; I don’t like talking about people. I don’t fit in that way.”

***

Since the family moved to their new neighborhood, filled with kids and bike trails, Caitlin’s stepfather had been determined to buy Caitlin a new bicycle. She didn’t want one. She tried riding a friend’s bike a few months ago, she told her parents, and it didn’t work out; after a few shaky attempts to pedal a bike that was too big for her, she gave up. Still, Mike was insistent: new start, new bike.

So a week before her 15th birthday, on a stormy afternoon, Caitlin and her family drove to Toys R Us. Caitlin was not thrilled about where they were shopping, even though the store had a larger selection of bikes with 24-inch tires; she thought most of them were ugly, with childish colors. She wore her sunglasses inside. Embarrassed and eager to leave as soon as possible, she chose a dark purple bicycle.

Mike assembled the bike at home as the storm outside began to quiet. When the rain finally stopped, Caitlin decided to give it a try. She stood on her toes and climbed onto the seat. It fit her perfectly.

In the beginning, she concentrated hard on maintaining her balance, pushing the pedals awkwardly as the bike wobbled across the wet pavement. But soon the movement felt like second nature; she stopped concentrating and began to simply ride. She picked up speed, circling back to pass her mother, who stood watching. The look on Caitlin’s face, Jennifer says, was profound happiness and relief.

Caitlin kept going, clutching the handlebars and pedaling furiously. Jennifer watched her go faster and faster, rounding the bend in the street and disappearing from her view.

Caitlin Gibson, legal administrator for The Post, is a writer who lives in Bethesda. She can be reached at gibsonc@washpost.com.