Is Plastic Surgery about looking plastic or refreshed?

Carl van Wyk - Tuesday, September 30, 2014

I just had a very interesting chat with a lawyer patient who has himself had some plastic surgery. His wife was also considering more plastic surgery. We started chatting about the wisdom of plastic surgery and he said something profound: "The thing about plastic surgery is people associate someone being energetic, vibrant, knowledgeable and hard working with a youthful appearance." 

You do not want to look plastic, just good for you age. You want to be perceived as fresh and healthy.  Thankfully it seems the majority of the cosmetic medicine and plastic surgery communities agree.

So having plastic surgery is really is misnomer. You really want "refreshing surgery".

Important bits before your surgery

Carl van Wyk - Monday, May 12, 2014

At the time of your initial consultation, you will have opportunity to ask questions during the consultation. If you know of any questions you want to ask we encourage you to have them written down as one tends to forget to ask. 

Be careful not to use any blood thinners unless you have spoken to doctor about it. This includes aspirin in things like Grandpa, Disprin, Ecotrin and Corenza C. It also includes all natural remedies and multivitamins, as some may thin your blood.

Doctor aims to discuss surgery and risks involved during the consult but will again be available for questions on the day of surgery. 

On the day before surgery (or the Friday before the Monday) we will try to contact you on the relevant phone numbers you provided so as to confirm you want to go ahead, give you an indication on where on the list you will be, when to stop eating (6 hours before your planned surgery) and drinking (you may drink clean water only up to 2 hours before), when to be at the hospital and what to bring with you. This will include a list or labelled boxes of all your medication you are on.

On the day of surgery, please understand that there will be a bit of waiting around as a lot of paperwork needs to get done. You will see doctor before the surgery as well to confirm your consent to the surgery and answer any questions. Please remember to tell us if you are allergic to any medications, have had aspirin (Disprin, Grandpa, Corenza C, etc) or have had previous reactions to anaesthetics. The anaethestist will also see you for a pre operative consult to check you are fit for anaesthetic.

For children, please reassure them that we do not give them injections, that you as parent will be with them when they fall asleep and when they wake up. They will be expected to inhale a strawberry or vanilla smelling gas. As they fall asleep, they often move a bit which is normal and not remembered by them.

Please note that as far as surgical fees are concerned, we will discuss our fees with you prior to your surgery. We will normally issue you with a page that contains all the diagnostic and operating codes so that you may contact your medical aid for authorization. We will arrange the hospital bed, anaesthetist and theatre list. The page will also normally include any co-payments you may need to make to us or the anaethetist. The hospital is the third bill for surgery, as they provide the theatre time and bed for the length of admission. The hospital is normally covered by your medical aid.

We are no longer contracted in to any medical aid, but some medical aids will still cover the surgical cost in full to the patient. You will have to pay us though, as your medical aid will pay the money into your account.

For work not covered by the medical aids or cosmetic facial surgery we issue individualized quotations.

Help my child wants to be a doctor

Carl van Wyk - Wednesday, March 05, 2014

Recently I was dining with friends when we started talking about their daughter who is very serious about becoming a doctor one day. To my surprise and shock the complaint was that she is bored! Medicine is, in my opinion, the most interesting career choice available on the market, so clearly it should be everything but boring to be a would-be-doctor! Once we started talking the ideas just kept on rolling in, so I list a few ideas if you find your child is interested in the medical field but frustrated by being too young to "do anything".

- Do as much first aid training as you are allowed for your age. Even if you are too young to get the certificate it gives a valuable broad base of knowledge.

- Do some human anatomy study. Feel free to use which ever book your school uses, even if you are a few years young. Add to this Netters Atlas of Human Anatomy with its beautiful color oil paintings of the body and learn all the names of the structures you can. Medicine is a language, and to speak it you need to learn those names.

- Once you have an idea of anatomy, do some system based physiology. Buying a Dorlands Medical Dictionary is really cheap for what you get. Once you start reading on a system, say the heart, and you come to a new term or one you think you do not understand, look it up in Dorlands. To do this physiology I did Exploring Creation with Human Anatomy and Physiology from Apologia. This is great as there is great depth but not too much. Some of the chapters are up to medical school level. It does come from the creationist viewpoint, so if you are a evolution fan then try Human Physiology from Wikibooks to provide the back bone.

- Visit your local medical school. They are bound to have open days or lectures you may attend. You may even get into the anatomy museum if your parents allow!

- Do well at school. Unless you have really good marks, you will not be able to get into medical school. Even if it means studying hard at things you do not think are relevant.

- Volunteer at the local SPCA. You may think you do not like animals, but working with a vet will teach you lots about handling tissues and anatomy. I have recently had a patient who had volunteered at the SPCA and ended doing neutering of cats on her own. What a great way to start a surgical career! Handling tissues, suturing, and with no age limit and very limited risk!

- Research a topic if you hear about something in the news. For instance, a new medicine, operation of technology may make it into the news. Go get your Dorlands, check the anatomy in Netters atlas and look at Google articles.

- Do some real research. There is no age restriction stopping you from asking a valid scientific question and doing some research to get to an answer. You will need to be careful not to step over any ethical lines, so approach a like able doctor, teacher or researcher and ask if you could help, get involved or design your own project. As long as you do no one harm in any way (which is why you need to check with someone with an ethics background), you may well come up with something interesting enough to get published. Examples would be doing a survey among your teenage peers on topics that you feel strong about. Try to avoid too controversial a topic. But you will need to end up with a message of sorts aimed at an audience. Read all publications you can find around your question on Google Scholar Search, set a valid question, ask for help with statistics, set up data gathering, analyse and write it up. Get someone to have a look, even if its your grandmother. Working with the language of medicine will get easier over time. 

- Go work in your local pharmacy and learn the drugs commonly prescribed by the local doctors. Then read up about each of these. You will need to be closer to 16 for this one...

I trust this will keep anyone interested in a career in medicine busy and a long way away from bored! But it will also come in handy when you do end up studying medicine as the framework needed to have an overview of medicine to add new knowledge to is worth it. 

Feel free to write in your story, I will happily add it to my website!

Snoring surgery: UPPP

Carl van Wyk - Friday, November 22, 2013

UPPPUvulu-Pharyngo-PalatoPlasty (UPPP or UP3) is the name of an operation done to improve snoring and mild sleep apnoea. Those suitable are patients with large tonsils and a long floppy soft palate. The photo was taken 4 weeks after UPPP surgery and still shows some dis-solvable sutures in place

This friendly chap came with a complaint of severe snoring, apnoea episodes, nasal obstruction and mouth breathing at night. He also had day time tiredness, and an Epworth score of 7 (10 or above I normally request a formal sleep study). His exam showed large tonsils and a long palate. Nasal endoscopy showed very large turbinates blocking his nasal airway.

He had a UPPP and Nasal Turbinoplasties done. He unfortunately bled suddenly around day 9 after a seemingly normal recovery. He was admitted and in theatre the bleeder was dealt with and he was discharged a day later.

He is now 2 weeks post op. He currently has pain of around 3 out of 10 (10 being severe), and the most pain was 8 out of 10 around day 6 after the initial surgery.

He is very pleased, as is his wife. He has stopped having apnoea episodes, snored only lightly on his back and not at all on his sides. He feels much more rested in the mornings and his Epworth score today is only 3.

Large and blocked nose needing reduction

Carl van Wyk - Friday, November 15, 2013

A young man who was having difficulty breathing after trauma during a fall on the nose. He had severe deflection of the septum, anterior and superiorly, which made standard septoplasty ineffective. He also had very large turbinates (shelves on the side of the nose) blocking his nasal airway further, as well as sinus infections. He underwent a closed approach reduction rhinoplasty / subtotal nose reconstruction, turbinectomies and sinus washouts. He is now more than a month post op and his nasal airways are patent. His appearance has also improved as his nose is now more in line with his facial proportions.

Another Nose Reconstruction

Carl van Wyk - Friday, November 15, 2013

Subtotal nasal reconstruction done in a young man with severe deflection of the septal cartilage anteriorly after an injury left him with total left nasal obstruction. An external approach was used, with extracorporeal septoplasty to reposition and build in structure to the nose with sutures and his own cartilage. He is now 1 month post op.

Nasal Reconstruction 1 month later

Carl van Wyk - Wednesday, October 30, 2013

Update on the nasal reconstruction post. He is now a month post-op and doing well. 

Tonsil stones and chronic tonsillitis

Carl van Wyk - Sunday, October 27, 2013

When patients tell me that they get little yellow stones that smell awfully bad combined with a sore throat, the likely diagnosis is that of chronic tonsillitis. The resulting bad breath can be debilitating socially and in the workplace. And unfortunately, will most likely persist unless a tonsillectomy is done. While there have been some reports on radiofrequency treatments, long term antibiotics and subtotal tonsillectomy as alternative, I find that doing a tonsillectomy solves the problem with very little risk. 

Tonsil StonesThe picture was taken upside down as from the surgeons point of view in the theatre and shows the little yellow stones that came out after I pressed on the tonsil. These were not visible before the surgery.

So why do people try to avoid tonsillectomy? Lets talk frankly about the potential complications.

The first is not really a complication, more of a result. Pain is usually described as around 6 out of 10 in severity. Most will say that its only when they swallow that it hurts. Others describe it like tonsillitis pain but without the fever and actually less painful than severe tonsillitis. The healing process takes around 10 to 14 days, so the painkillers often need to be taken for at least the first week and when needed for the week after. I strongly believe in pre-emptive analgesia, meaning that you do not wait for the pain to get unbearable before you take medication. We start during the surgery with Dexamethazone, local and systemic analgesia even before the surgery starts. And then as prescribed regular pain medication for the week. We combine two painkillers in children (Paracetamol and a mild muscle relaxant like Tenston syrup or similar, with an NSAID such as Diclofenac) and three in adults (Tenston SA, Xefo and if needed Tramadol). Note that the pain may peak around day 5 to 7 after the surgery.

There is a small chance of bleeding after tonsillectomy. Those that bleed usually stop again, but bleeding more than a teespoon worth I ask to be phoned. Severe bleeding occurs around 1 to 2 out of a hundred cases and may need further surgery to stop. The parents are usually worried that they will miss bleeding, but I can assure you that they are usually very obvious, spitting blood, or vomiting blood. We start with some medication to help clotting (tranexamic acid) and only those that do not stop will end up going to theatre again. The risk of bleeding is there for around 2 weeks, so no far off holidays or long haul flights in this period please! You may go, but stay close to medical care, not somewhere in the bush!

Other issues to be aware of is that the singing voice may change slightly but usually they adapt well after a few months. Damage to teeth may occur in theory but I have yet to see one case. The jaw joint, i.e. TMJ, is stretched and may be sore for a while after.

In South Africa, there is a cultural perception that if your tonsils are taken out as an adult you will die from the procedure....thankfully this is not the case, as you have more reserves than when you were 2 years old. There is a mortality (i.e. chance of dying) from the procedure, estimated to be in the range of 1 in 40000. The only one I have heard of was a special needs child that was left on his/her own at night and started bleeding but nobody was close enough to hear. Had the bleeding been acted upon by bringing the child to hospital the outcome would likely have been very different. For this reason with small children and special needs children I ask the parents to have them in the room with them or close by in the first 2 weeks.

But after doing over 800 tonsillectomies I feel I can say with confidence that the operation works, parents are normally very happy with the outcome and patients find their quality of life improved. Especially those with little yellow stones!

Anatomy Fun at the George Educational Expo

Carl van Wyk - Sunday, October 27, 2013

What fun we had last week at the George Educational Expo. Organized by a committee chaired by Mrs. Berinda Breytenbach, there were over 45 exhibitors selling a wide range of educational stuff. Then there were lectures by leaders in the field tackling all from legal to practical issues surrounding education with a focus on parent led education.

But the fun part was to be found in the side hall where the kids entertainment included book reading, dancing, how to fix your bike, videos, intermittent explosions from hydrogen bubbles, cookies, popcorn, go carts .... you get the idea. I had a table and got talked into Biology and Science experiments. It turned out to be a ball of fun as I sourced some half pig head, a cow femur and knee joint, lamb kidneys, pig hearts and lungs, a trachea and mixed this with expired medical things...

The best had to be the yeeeewwwhh reaction from some of the girls. I then explained this stuff is in Viennas and processed meat. Since they have already eaten it, they may as well touch it! It mostly worked! We dissected the heart open and looked at the valves, strong muscles and fibrous capsule. We opened the knee joint and felt (they all got gloves, used up a whole box!) the slippery surfaces and strong tendons and ligaments. We cut through the lung tissue showing the small tubes dividing into ever smaller tubes and cut through the kidneys to show how "wee" is made. The boys could not figure out what on earth the funny plastic tube was for... it was a adjustable flange tracheostomy tube.... so I promptly did a circular cut into the trachea and inserted the tracheostomy tube, blowing up the cuff to every ones amusement. The highlight was when I cut out the pig eye from the socket, showing the muscles, optic nerve and the gelatinous fluid with the lens after cutting it open. 

Some of the kids came back repeatedly, this girl in the photo simply could not get enough of feeling and dissecting with the wooden tongue depressors!

The event ended with a braai for the exhibitors and parents and overall the hard work put in by the committee set the stage for a great event. Congratulations to Berinda and her team.

Nasal reconstruction

Carl van Wyk - Wednesday, September 11, 2013

These photos are before and after shots taken only a week after nasal reconstruction surgery (septorhinoplasty in the rest of the world). He had a very blocked nose due to a very skew septum (division between the sides of the nose) that blocked the internal and external valves of his nose on the left. During surgery I first removed the blocking cartilage, and then used it to rebuild structure into his nose. This included a spreader graft (cartilage placed to open the nose at the upper lateral cartilage area), a columella strut graft (strip of cartilage to help hold the tip), cephaplic trimming (taking off the upper part of the lower laterals cartilages to improve tip definition), diced cartilage (as in cut in tiny pieces) to help give the nose more height. He also had osteotomies (breaking the nasal bones very precisely) to re position the nose to the midline. 

Note he had an open approach. There is a small scar running across the columella, the bottom of the nose. It is already difficult to see. It will end up in a shadow below the tip that one will have to look for carefully to see.

Note that he is still very swollen, and over time I would hope for some more tip definition to become evident. With an open approach the swelling takes a while to settle, easily 6 months or more. 

Given his anatomy, personality, expectations and physical traits both surgeon and patient are happy. And he can now easily breathe, had minimal pain and no bruising. Will keep you posted over the months as the swelling subsides.