Rhinoplasty (Nose Job Surgery)

Rhinoplasty is one of the commonest cosmetic plastic surgical procedures. It is a nose-reshaping surgery to correct any deformities or to enhance the aesthetics for cosmetic purposes. Rhinoplasty can be done under local or general anaesthesia. The main complaints by patients who are unhappy with their noses are:

- nose bridge hump

- crooked nose bridge

- bulbous nose tip

- long nose tips

- broad & flat nose bridge

- flared nostrils

- post-traumatic injuries to the nose

- birth defects


Our noses can be seen as made up of 3 main components:

1. Nostrils - the two arches of our nose. Some people have bigger & some have narrower arch. Changing the shape of these can change the way the nose looks.

2. Nasal bone & cartilage - these are a collection of cartilages which form the 'nose bridge'. This is where our spectacles/sunglasses rest on. Some people have flatter & wider cartilages and some have higher & narrower ones.

3. Columella - this is the piece of tissue in between our two nostrils. A shorter columella will make the nose look flat while a longer one will make it look higher.


Which part of the nose to be enhanced depends mainly on what the patient wants. Of course, the patients' expectations will have to be reasonable. Rhinoplasty will enhance the patients' looks but will not achieve perfection. The patients should not expect rhinoplasty to transform them into someone else.


It is vital to consult a properly qualified and board certified Plastic Surgeon for rhinoplasty. Other surgeons who do rhinoplasties are ENT & Maxillofacial surgeons.

Obesity Surgery

Obesity is defined as a Body Mass Index (BMI) more than 30. Normal BMI is between 18.5 to 25. Patients who have a BMI between 25 to 30 are said to be overweight.

Obesity is associated with many severe medical problems such as hypertension, heart attack, arrhythmias, obstructive sleep apnoea, metabolic syndrome, osteoarthritis, gastroesophageal reflux disease, urinary incontinence, polycystic ovarian syndrome, deep vein thrombosis, depression, low self esteem and increased risk of cancers.
The treatment for obesity includes:

- Lifestyle modifications which includes diet, exercise & behaviour modifications

- Medications. Egs: Sibutramine (appetite suppressant) & Orlistat (reduces fat absorption)

- Surgery:

1. Liposuction - A hollow stainless steel tube (cannula) with the assistance of a powerful vacuum is inserted into the patient’s abdominal skin to suck out the fatty tissue around his/her abdomen. Post liposuction, the patient might get some bruises from the liposuction site which will go away. This is a fast procedure which can be done under general or local anaesthesia. Complications include disfiguring skin irregularities and injury to abdominal organs if not done properly. Liposuction is usually done by qualified Plastic Surgeons only

2. Tummy Tuck (abdominoplasty) - This is a major operation done under general anaesthesia. The Plastic Surgeon will surgically remove a thick layer of fat from the lower abdomen, stretch down the skin from the upper abdomen and then create a new umbilicus for the patient. Post surgery, the patient will need at least 1 week to recover and the abdomen will look flat & trim post-surgery. However, there will be a long surgical scar at the lower waist which can be hidden under the patient’s pants.

3. Bariartric Surgery (Weight Loss Surgery) - a few methods are used but generally divided into "Restrictive" and "Malabsorptive". "Restrictive" surgery reduces the size of your stomach so the end result is you will eat less and then lose weight. The main types are “Gastric Banding”, "Balloon Gastroplasty" or "Sleeve Gastrectomy". "Malabsorptive" surgery is more complicated. Its function is to reduce the amount of intestine available to absorb fat. However, the gold standard is a combination of "restrictive" & "malabsorptive" surgery. Post-surgery, the patient will need at least 5 days to recover depending on the type of surgery. The indications for Bariartric Surgery are:

- Morbid Obesity; which is defined as BMI >40
- Obesity with severe medical conditions
- Failure to lose weight with non-surgical methods
- Medically compliant patient- Patient is medically fit to undergo the surgical procedure

INFLUENZA A H1N1 - The facts #2

High risk groups:

· Less than 5 years old
· More than 65 years old
· Pregnant
· Obese with chronic illnesses such as asthma, chronic lung disease, heart disease, diabetes or kidney disease
· On long term aspirin therapy
· On drugs that will suppress your immune system eg. steroids, oral chemotherapeutic drugs, azathioprine, cyclophosphamide
· Undergoing cancer treatment


Treatment of H1N1:

Vaccines

Vaccines are usually given to prevent infections. Influenza vaccines are made from either pieces of the killed influenza virus or weakened versions of the live virus that will not lead to disease. When vaccinated, the body’s immune system makes antibodies which will fight off infection if exposure to the virus occurs. However, the influenza virus has the ability to mutate. The latest strain is H1N1. So we will have to wait for the specific vaccine to be available.

Antivirals [Tamiflu (Oseltamivir), Relenza (Zanamivir)]

Antivirals are drugs that can treat people who have already been infected by a virus. Currently, two anti-virals are available which are Tamiflu and Relenza. These drugs are able to stop the virus from replicating in the body and has to be taken within two days after symptoms appear. However, it is not indicated for everybody with flu as the disease is mostly self-limiting. People who are in the high-risk group should be given the anti-virals if they have flu-like illness.
Tamiflu is a neuraminidase inhibitor. It is effective against both type A and B strains of flu.There is no generic version of Tamiflu available. 10 capsules (minimum amount) can cost around RM80 – RM100. Tamiflu helps to reduce your time with flu symptoms by about 1.3 days.

Dosage of Tamiflu:
Oseltamivir is marketed by Roche under the trade name Tamiflu, as capsules (containing oseltamivir phosphate 98.5 mg equivalent to oseltamivir 75 mg). Adults take 75mg twice a day for 5 days.

Side Effects:
The most common side effects of Tamiflu are nausea, vomiting, diarrhea, and conjunctivitis (pinkeye). Sometimes people report getting headaches after taking Tamiflu. There are concerns that oseltamivir may cause dangerous psychological, neuropsychiatric side effects including self harm in some users. These dangerous side effects occur more commonly in children than in adults.


Prevention

The main route of transmission of the new influenza A(H1N1) virus seems to be similar to seasonal influenza, via droplets that are expelled by speaking, sneezing or coughing. You can prevent getting infected by avoiding close contact with people who show influenza-like symptoms (trying to maintain a distance of about 1 metre if possible) and taking the following measures:
- avoid touching your mouth and nose;
- clean hands thoroughly with soap and water, or cleanse them with an alcohol-based hand rub on a regular basis (especially if touching the mouth and nose, or surfaces that are potentially contaminated);
- avoid close contact with people who might be ill;
- reduce the time spent in crowded settings if possible;
- improve airflow in your living space by opening windows;
- practise good health habits including adequate sleep, eating nutritious food, and keeping physically active.


The status of H1N1 now:

The WHO considers the overall severity of the influenza pandemic to be moderate. This assessment is based on scientific evidence available to WHO, as well as input from its Member States on the pandemic's impact on their health systems, and their social and economic functioning.

The moderate assessment reflects that:
- Most people recover from infection without the need for hospitalization or medical care.
- Overall, national levels of severe illness from influenza A(H1N1) appear similar to levels seen during local seasonal influenza periods, although high levels of disease have occurred in some local areas and institutions.
- Overall, hospitals and health care systems in most countries have been able to cope with the numbers of people seeking care, although some facilities and systems have been stressed in some localities.

WHO is concerned about current patterns of serious cases and deaths that are occurring primarily among young persons, including the previously healthy and those with pre-existing medical conditions or pregnancy.
Large outbreaks of disease have not yet been reported in many countries, and the full clinical spectrum of disease is not yet known.

For more info:
Malaysia: http://h1n1.moh.gov.my/
USA: http://flu.gov/
WHO: http://www.who.int/csr/disease/swineflu/en/index.html

INFLUENZA A (H1N1) – The Facts

What is it?

H1N1 (previously known as “swine flu”) is a new influenza virus causing illness in people. This new virus was first detected in people in Mexico in April 2009. Now many other countries around the world have reported people sick with this new virus. This virus is spreading from person-to-person, probably in much the same way that regular seasonal influenza viruses spread. This is a new influenza A(H1N1) virus that has never before circulated among humans. This virus is not related to previous or current human seasonal influenza viruses.

History

Over the years, different variations of flu viruses have emerged. At this time, there are four main influenza type A virus subtypes that have been isolated in pigs: H1N1, H1N2, H3N2, and H3N1. However, most of the recently isolated influenza viruses from pigs have been H1N1 viruses.

Signs & symptoms

The symptoms of H1N1 flu in people are similar to the symptoms of regular human flu and include fever, cough, sore throat, body aches, headache, chills and fatigue. Some people have reported diarrhea and vomiting associated with H1N1 infection. Severe illness (pneumonia and respiratory failure) and deaths have been reported with H1N1 (swine) flu infection in people. Like seasonal flu, H1N1 (swine) flu may cause a worsening of underlying chronic medical conditions. You will not be able to tell the difference between seasonal flu and influenza A(H1N1) without medical help. Only your medical practitioner and local health authority can confirm a case of influenza A(H1N1) with a throat swab.

Emergency warning signs in children that need urgent medical attention include:
- Fast breathing or trouble breathing
- Bluish or gray skin color
- Not drinking enough fluids
- Severe or persistent vomiting
- Not waking up or not interacting
- Being so irritable that the child does not want to be held
- Flu-like symptoms improve but then return with fever and worse cough

Emergency warning signs in adults that need urgent medical attention include:
- Difficulty breathing or shortness of breath
- Pain or pressure in the chest or abdomen
- Sudden dizziness
- Confusion
- Severe or persistent vomiting
- Flu-like symptoms improve but then return with fever and worse cough
- Continuous fever for more than three days

Guidelines if you are feeling unwell:
If you feel unwell, have high fever, cough or sore throat:

- stay at home and keep away from work, school or crowds;
- rest and take plenty of fluids;
- cover your nose and mouth when coughing and sneezing and, if using tissues, make sure you dispose of them carefully. Clean your hands immediately after with soap and water or cleanse them with an alcohol-based hand rub;
- if you do not have a tissue close by when you cough or sneeze, cover your mouth as much as possible with the crook of your elbow;
- use a mask to help you contain the spread of droplets when you are around others, but be sure to do so correctly;
- inform family and friends about your illness and try to avoid contact with other people;
- If possible, contact a health professional before traveling to a health facility to discuss whether a medical examination is necessary.
- Do not go to work. You should stay home and away from work through the duration of your symptoms. This is a precaution that can protect your colleagues and others.
- Avoid travelling

For more info:
Malaysia: http://h1n1.moh.gov.my
USA: http://flu.gov/
WHO: http://www.who.int/csr/disease/swineflu/en/index.html

Next: Treatment, prevention & WHO guidance on clinical management of H1N1

Thyroidectomy (Surgery to remove Thyroid Gland)

Thyroidectomy is the medical term for the surgical procedure to remove the thyroid gland. The indications for thyroidectomy are:
- thyroid cancer
- thyrotoxicosis (symptoms of excess of thyroid hormones; refer to earlier topic)
- huge goitre with compressive symptoms (eg. difficulty breathing, difficulty in swallowing)
- cosmesis & patient's request (unsightly neck swelling)

The surgery is performed under general anaesthesia and hospital admission is necessary. Prior to surgery, the patient's thyroid function should be assessed. Patients who are hyperthyroid should be treated with anti-thyroid medications (carbimazole or propylthiouracil) to reduce the levels of thyroid hormones. This is because patients who are hyperthyroid will have an increased risk of a 'thyroid storm'. A thyroid storm is an uncommon but serious complication of thyroid surgery which is precipitated by an acute exacerbation of thyrotoxicosis.

The patient should also undergo an indirect laryngoscopy to assess the patient's vocal cords for any abnormalities. This is because the nerves supplying the vocal cords (recurrent laryngeal nerve) are situated just adjacent to the thyroid gland and any injury will affect the vocal cords. If the goitre is suspicious for cancer, a fine needle aspiration cytology (FNAC) should be carried before surgery to confirm the diagnosis of a cancer. For huge goitres, a chest x-ray or a CT-scan should be done to check for any extension of the thyroid gland inferiorly under the sternum. This would make the surgery more extensive and longer.

After all the pre-operative assesment is done, the patient is admitted for anaesthetic assessment and surgery. During surgery an incision is made just above the collar bones. It is usually around 5-8cm in length depending on the size of the goitre.
There are two options for surgery for thyroid swellings. A hemi-thyroidectomy is performed if the patient has only a single thyroid nodule on one side or small early thyroid cancers (<1cm)>. A total thyroidectomy is performed in patients with a multi-nodular goitre involving both thyroid lobes, thyroid cancers, Graves' disease & thyrotoxicosis. Duration of surgery for a total thyroidectomy ranges from between 1-4 hours depending on the extent of disease and the size of the thyroid gland. Sometimes it might take longer if lymph node dissection is required in cancer patients.

The complications of thyroidectomy can be divided into early and late complications.

Early complications include:
- bleeding from the surgery wound
- voice change (due to swelling of the nerves)
- temporary low calcium levels (due to reduced function of parathyroid glands)
- wound infection

Late complications include:
- unsightly scar
- permanent low calcium levels (because the parathyroid glands were injured or removed during the surgery)
- permanent hoarseness of voice (injury to recurrent laryngeal nerve)
- vocal cord paralysis with difficulty breathing (injury to both recurrent laryngeal nerves)
- inability to produce a high pitched voice (injury to external branch of superior laryngeal nerve)
- permanent hypothyroidism (in total thyroidectomy, the body cannot produce any more thyroid hormones)

The parathyroid glands are located just behind the thyroid gland in the neck. Usually there are between 2 -6 parathyroid glands in everybody. Its main function is to maintain a normal level of calcium in our body. Due to its location near the thyroid gland, it has a risk of being injured or removed. However, the risk is approximately 1% only. Patients with permanent low calcium levels are treated with calcium supplement tablets.

The recurrent laryngeal nerve supplies our vocal cords. The nerve is located beside the thyroid gland on both sides. The risk of injury is approximately 1%. Injury to the nerve will cause hoarseness of voice (one sided injury) or breathing difficulty (both sided injury). Most patients will have a temporary hoarseness of voice due to swelling of the nerve during manipulation. This resolves spontaneously usually within 1 month.

The external branch of superior laryngeal nerve are located near the upper lobes of the thyroid gland on both sides. Injury to the nerve will lead to an inability to produce high-pitched voice.

Patients who have had a total thyroidectomy will need thyroid hormone supplements for life. This is because there is no more thyroid gland to produce thyroid hormones. This is usually prescribed in the form on levo-thyroxine (L-thyroxine) tablets.

Health Screening

Medical screening is the process of diagnosing a disease in an otherwise healthy individual before the symptoms occur. The benefits of early diagnosis are that a disease can be treated earlier before it becomes complicated and results in a better outcome. The disadvantages of screening are that there are a small percentage of false positives (diagnosing the disease when in actual fact the patient does not have it), false negatives (missing the diagnosis when the patient actually has the disease) and also the anxiety of being diagnosed with a disease.

There are many different packages for health screening in hospitals and private medical labs. This is what they call "executive health screenings". Some centres also have specially designed packages for women and older people. Usually, a doctor will be on hand for consultation and to get any medical history from you. He/She will then proceed to examine you. Then they will proceed with the investigations such as blood tests, urine tests, chest x-rays, ECGs, Echocardiogram and more.

For routine blood tests, what they check for are:

Full blood count - to check the levels of heamoglobin, platelets and white cells in your body. Basically, this will tell you if you have enough blood in your body (anaemia), any signs of infection and if you have sufficient platelets in your body for clotting.

Renal function test - to check for levels of salt in your body ie. Sodium, Potassium, Chloride. Also to check if your kidneys are functioning well (Serum Creatinine, Urea).

Liver function test - to check if your liver function is normal and if you have enough protein (albumin) in your body. Also can tell if you have jaundice or any liver enzyme/cellular abnormality.

Coagulation profile - to check if your blood clotting mechanism is functioning normally (INR/PT/APTT).

Fasting Blood Glucose – for diagnosis of diabetes mellitus.

Lipid profile – to look at levels of cholesterol (HDL – good /LDL – bad) and triglycerides.

Tumour markers - these are what labs promote the most. Not very sensitive and even if it is raised as it does not mean that the patient has cancer. It is used as a guide in diagnosis of certain cancers. The results should be correlated with clinical findings and with other investigations. Egs: AFP for liver cancer, CEA for colon cancer, CA125 for ovarian cancer, CA19-9 for pancreas cancer, PSA for prostate cancer, Thyroglobulin for thyroid cancer, CA153 for advanced breast and lung cancer.

Blood type and rhesus compatibility - basically telling you your blood type (A/B/O) and whether it is rhesus positive/negative.

ESR/CRP - marker for inflammation. Not very specific.

Uric acid - for diagnosis of gout

Serum Calcium - to check levels of calcium in the body.

Serum T3/T4/TSH - to check levels of thyroid hormones in the body. For diagnosis of hyper or hypothyroidism.

H.Pylori serology – to detect the presence of H.Pylori, a bacteria which causes gastritis and also a risk factor for stomach cancer.

Infectious Disease screen – to check for Hepatitis B, Hepatitis C and HIV.

Urinalysis - to check the urine for protein, bacteria, blood and cells.

ECG (EKG) – to check your heart beat (60 – 100 per minute is normal), heart rhythm (regular or irregular), check for any heart block, check for any angina or ischaemic heart disease.

Echocardiogram – to check if the heart is pumping normally, to look for any problems with the heart muscle, to look at the ventricular function, to look for any heart valvular abnormality.

Mammogram - to detect presence of suspicious breast lumps for diagnosis of breast cancer.

Breast Lumps

Breast lumps are a common complaint among women. It constitutes about 60% of referrals to the breast specialist clinic. However, the good news is that up to 90% of breast lumps are non-cancerous. The common causes for breast lumps are: fibroadenomas, cysts, fibrocystic disease, lipomas, haematomas, abscesses and breast cancer.

Fibroadenomas are common in young women. It usually occurs in adolescence and up to early 30s. It is a benign (non-cancerous) condition and does not turn malignant (cancerous). A small fibroadenoma can be observed and treated conservatively while a palpable one can be surgically excised. The surgery is a minor one and takes less than 1 hour. It is usually done as a day case (no need for admission to hospital).

A breast cyst is a collection of fluid within the breast lobules. It usually occurs in premenopausal women. Clinically, smooth discrete lumps will be palpable. It is diagnosed by ultrasonography. The treatment of breast cyst is with simple aspiration of the cyst in the clinic.

Fibrocystic disease is the commonest cause of breast lumps. It consists of a spectrum of cysts, lobules and fibrous changes within the breast. Treatment is the same as for a fibroadenoma.

Lipomas are benign tumours which originate from fat cells. It presents as a soft, lobulated lump. Lipomas can also grow at other parts of our body as long as there are fat cells. The treatment of lipoma is surgical excision.

A haematoma is a collection of clotted blood. This is usually preceded by a history of trauma or occurs after a biopsy is taken from the breast.

An abscess is a localised collection of pus. This occurs more commonly in women who are diabetic or who are immunocompromised. It can also occur in an infected haematoma. A breast abscess can also form from an infection in the nipple. This condition usually occurs during breastfeeding (lactational mastitis). The treatment for breast abscess is antibiotics and aspiration of the abscess. If that does not work, a surgical drainage of the abscess would be necessary.

Breast cancers commonly occur in women aged 40 and above. The lifetime risk for a women to get breast cancer is 11%. Patients usually present with a breast lump, breast ulceration or incidentally detected on screening.

All patients with breast lumps should go through a triple assessment. This consists of:
- consultation and clinical examination by a doctor,
- radiological investigations (mammogram for women >40 years old and ultrasound for women <40),
- biopsy of the lump either with a Fine-Needle Aspiration Cytology (FNAC) or a core biopsy or with a surgical excision biopsy.

FNAC and core biopsies can be done in the clinic. A FNAC is a simple procedure where a needle is inserted into the breast lump and its cells are aspirated and sent for microscopic examination. The results will show if the lump is benign or malignant (cancerous).

A core biopsy is carried out with a bigger needle. It is called so because a core of tissue from the breast lump is taken out using the needle. This procedure is done in the clinic but local anaesthesia is usually given. There is a risk of bruising after the procedure. Core biopsies provide a piece (core) of tissue for histopathological examination. It can help determine if a lump is benign or malignant. It is also able to tell if the lump is an invasive cancer or early confined (in-situ) cancer. Hormonal receptor status of the lump can also be identified which will help in post-operative treatment of breast cancer.

Hyperthyroidism

Hyperthyroidism means an increase in the amount of circulating thyroid hormones (T3 & T4) in the body. This condition leads to thyrotoxicosis which represents the symptoms and signs which occurs due to increased thyroid hormones.
Hyperthyroidism can occur due to an autoimmune disease such as Graves' disease, a toxic hyperfunctioning goitre or solitary nodule, due to medications such as lithium, secondary to pituitary tumours in the brain, due to an inflammatory process (thyroiditis), ectopic thyroid tissue or rarely due to thyoid cancers.
The common symptoms of thyrotoxicosis are: sweating, palpitations, irritability, heat intolerance, weight loss, increased appetite, increased bowel movements, impaired fertility, reduced libido, hyperactivity and insomnia. Signs associated with thyrotoxicosis are an irregular, rapid pulse, tremor, warm moist skin, muscle weakness, enlargement of the male breast tissue and goitre.
Diagnosis of hyperthyroidism is made in the presence of the symptoms and signs of thyrotoxicosis with a confirmatory blood investigation for raised levels of serum T3 and T4. Then, the cause for the hyperthyroidism should be investigated. Usually an ultrasound of the neck is done to assess the goitre.
Patients with Graves' disease will also have specific signs for the disease such as protruded eyeballs (proptosis), swelling around the eyes (periorbital oedema), limited eyeball movement (extraocular muscle involvement), deterioration of vision and swelling of the lower limb skin (pretibial myxoedema). Blood investigations for anti-thyroid peroxidase and anti-thyroglobulin antibodies are diagnostic.
Treatment of hyperthyroidism is aimed at reducing the levels of thyroid hormones and also reducing the sympathetic activity for control of symptoms. Two drugs commonly used to reduce thyroid hormones are propylthiouracyl and carbimazole. Both these drugs reduce the production of thyroid hormones in the body. Propanolol, a beta-blocker commonly used in hypertension, is used for symptomatic control in patients with thyrotoxicosis.
Radioactive iodine ablation of the thyroid gland can also be used as a first line treatment of thyrotoxicosis. Thyroid follicular cells are destroyed by the radiation emitted. However, this is contraindicated in patients who are pregnant, breastfeeding, who plan to get pregnant within 6 months or who are in contact with children.
Surgery (thyroidectomy) is indicated in patients with large goitres, patients who are contraindicated for radioiodine ablation and patients who wish to have their thyroids removed. This is considered as the definitive treatment for thyrotoxicosis. Patients will have to be started on anti-thyroid medications prior to surgery to reduce the risk a thyroid storm which can be deadly. The risks and complications of thyroid surgery will be discussed in the next article.

The Thyroid Gland

The thyroid gland is an endocrine (hormone secreting) gland which is anatomically located in our necks. It consists of two lobes (left and right) which is connected by an isthmus. It has a rich blood supply and consists of thyroid cells which secrete triiodothyronine (T3) and also thyroxine (T4). These hormones help regulate the metabolic rate of our bodies. Too high or too low levels of T3 or T4 will lead to symptoms of hyper or hypothyroidism.
Lying within close proximity to the thyroid gland on each side are the superior laryngeal nerves, the recurrent laryngeal nerves and the parathyroid glands. The superior laryngeal nerves helps maintain a high pitch voice and the more important recurrent laryngeal nerve is the principle nerve supply to our vocal cords. Any injury or damage to this nerve will cause hoarseness of voice and difficulty in breathing. The parathyroid glands are important for calcium regulation in our body.Common problems associated with the thyroid gland are generalised swelling of the gland (goitre), solitary nodule within the gland, hyperthyroidism or hypothyroidism and thyroid cancers.
Goitres can occur due to iodine deficiency, physiological changes associated with pregnancy and puberty, due to thyroid hormonal imbalance or as part of an inflammatory process. Solitary nodules are usually benign or malignant tumours of the thyroid cells. Hyperthyroidism occurs due to an increase in levels of T3 and T4 in our bodies and hypothyroidism occurs due to low levels of thyroid hormones.
Thyroid cancers are more common in women and are divided into a few types according to the type of cells which turn malignant. Approximately 10% of all thyroid nodules are cancers.
We will discuss further on the diseases affecting the thyroid gland in the next article.