Issue Highlights

A Helping Hand
Mariel Chow touches on what it takes to save the body’s most used appendage.
In 2012, a robbery attempt occurred not far from Dr. Palani’s work place at the Gleneagles Hospital. “Mr. C” who had just withdrawn cash from an ATM was entering his car when unknown assailants dragged him out of the vehicle and chopped off his hand. In a panicked state, the victim quickly jumped back into his car hoping to get medical attention at the nearest hospital. Shockingly, the victim only noticed he had lost a limb when he wasn’t able to shift his car’s gears.
Upon arrival at the Gleneagles Hospital, Mr. C told the doctors that he wasn’t able to retrieve his severed hand and that it was still at the scene of crime. After about forty-five minutes waiting for the police, Dr. Palani realised time was running out as the chances of the limb surviving a replantation was already heavily reduced. He hurriedly gathered the hospital’s emergency team and went in search of the victim’s severed appendage. The limb was found, rushed back to the hospital and Dr. Palani commenced limb reattachment surgery. As the surgery was carried out quickly, outcomes were satisfactory and most of the patient’s functions were restored.
This account proves hand replantation or reattachment is possible as long as the appendage is fresh, with surgery carried out quickly. With regular physiotherapy and consistent aftercare, patients can regain at least 60-80 percent of their hand’s movement, motion and sensation. Consultant Orthopaedic and Hand Microsurgeon, Dr. Palani Ramasamy explains how hand replantation surgery works, while Consultant Plastic and Reconstructive Surgeon, Dr. Somasundaram Sathappan explains the ins and outs of cosmetic hand surgery.
Consultant Plastic and Reconstructive Surgeon, Dr. Somasundaram Sathappan
Dr. Palani, what is hand replantation surgery?
Hand replantation refers to surgical reattachments of hands or arms that have been completely or partially severed from a patient’s body. The goal of replantation surgery is to reattach and restore as much function to the affected area as possible. Surgeons will have to quickly reattach the bone and vessels to encourage stability and blood flow, which keep the hand alive. After blood flow has been established, we will then move on to reconstruction of the nerves, tendons and muscles. The order of this repair depends on both the patient’s circumstances and attending surgeon.
Consultant Orthopaedic and Hand Microsurgeon, Dr. Palani Ramasamy
What are the commonest types of trauma that could affect in a severed hand?
The commonest type of trauma would be assault injuries through the use of sharp instruments. Occasionally we find instances of severed hands caused by motor vehicle accidents and trauma. Such cases would usually affect in mangled and crushed limbs, as opposed to clean cuts. Unfortunately, reattachment surgery would normally necessitate the reduction of bone by at least one to two centimeters. This is an important step because the vessels would be in a state of tension and such ill-fated occurrences could impede blood flow, which culminates in infection. While surgeons do take cautionary steps by ensuring that blood flows smoothly and well, there are still risks of blocked vessels. Hence, it’s imperative that patients undergo good repair without tension.
What are the basic first aid steps when caring for a severed hand?
When a patient’s hand is completely severed, it has to be reattached within six hours as exceeding a certain timeframe could cause muscle degeneration and higher risk of infection, which can result in poor function. To improve the chances of a successful replantation, it is necessary to preserve the amputated appendage as soon as possible in a cool and sterile environment.
Consultant Orthopaedic and Hand Microsurgeon, Dr. Palani Ramasamy
Bodily parts without major muscles such as fingers can be preserved for about 12 hours. Conversely, major muscle-containing parts such as the arms and forearms must be re-attached and revascularised within six hours to ensure viability. Muscles tolerate ischemia (lack of oxygen) poorly, and this period of ischemia toleration can be prolonged and even doubled if environmental temperatures are low.
To maximise surgical success and optimal restoration, it’s imperative that patients place the severed hand in an iced bag but simultaneously, refrain from allowing the ice to come in direct contact with the hand. Parts should be wrapped with moistened gauze and placed inside a sterile bag floating in ice water/cubes. In terms of the open wound, it’s best that an assistant covers it up with gauze, applies pressure to stop the bleeding, and wait for medical attention.
It is also important to collect and preserve all amputated parts which may not look ‘replantable’. A microsurgeon needs all available human parts or even tissue to cover the wound at the stump and thus, prevent further shortening of the stump. In some cases like the forearm, important joints such as the elbow can be conserved for improved prosthetic success.
If one has suffered a vehicular accident where the limb is partly detached, mangled or crushed, the patient will have to apply compression to arrest the bleeding. The suitability and success of replantation surgery depends on injury type, duration of time the injury had occurred, level of amputation, the medical fitness of the patient, and his or her age.
What can patients expect after surgery? Are there any complications?
Post-operative results will largely depend on how quickly limbs are reattached. Take for example the robbery case; because the victim’s hand was found and attached quickly, functions were mostly restored. He now has moderate ability to write, grasp objects and has even regained satisfactory sensation as well.
I had another patient (Mr. Y) who sustained near total amputation of his right wrist but experienced infection post operatively. He was a lorry driver who was slashed with a machete. By the time the surgery could commence, 15 hours had been lost. This affected in repeated debridement due to infection, a long hospital stay, plus more joint stiffness than expected. Infection is caused by poor blood flow. If blood flow is impeded, tissues will degenerate. Moreover, even if the hand is successfully attached with blood flow restored, germs and toxins from previous infections or from delayed surgery can still travel through the bloodstream and cause septicemia and even death. Other complications related to late reattachments are permanent stiffness of the joints and poor recovery of the nerves. Should patients suffer severe stiffness, they will have no choice but go under the knife once more to release the contractures and endure further reconstruction work such as tendon transfers or grafting.
While successful surgery is important, that’s only the first step to recovery. After reattachment, patients will awake to a phantom hand, which is why physiotherapy and temporary bracing plays an important post-surgical role. Patients may be able make minimal movements but are not encouraged to over exert as too much activity may result in ruptured tendons. We recommend that patients minimise movements for the first few days to establish optimum blood flow and circulation. Nonetheless, the earlier patients undergo physiotherapy the better. Temporary dynamic braces are used from the beginning to protect the newly repaired tendons, and to allow movements of replanted parts. Physical therapy exercises are used to prevent the joints from becoming stiff, to keep the muscles moving, and to minimise formation of scar tissue. Regular physiotherapy sessions may be required sessions over a three to six-month period.
What is the downtime related to hand replantation surgery?
Although we have reconnected the nerves, they regenerate slowly at the rate of one millimeter a day. Function restoration depends on the regrowth of both sensory and motor nerves. Sensory nerves carry messages to the brain from different parts of the body to signal pain, pressure, and temperature. Motor nerves carry messages from the brain to muscles to facilitate finger movement. If nerves beginning from the elbow require regeneration, sensation loss and downtime can easily last more than a year. Patients may be able to feel some electrical sensations after one to two months but this can cause some discomfort where the patient’s arm or hand is hypersensitive even to water. Nevertheless, such irritations are a good sign as it signifies that the patient is well on his or her way to regaining fairly good sensation and function.
Although the replanted part will never regain 100 percent of its original use, most doctors consider restorative levels of 60 percent to 80 percent to be excellent results. This of course depends on how strictly a patient adheres to physiotherapy. The more physiotherapy one religiously abides to, the better the outcome.
Cosmetic Hand Surgery with Dr. Somasundaram Sathappan
Why do the hands become aged, wrinkly and pigmented?
Hands are voluntary organs that are utilised on a daily basis. There are many joints in the hands that facilitate movement. Where there is lots of movement, there will be increased amounts of skin. If the skin is too tight and taut, your hands won’t be able to complete their full range of motion. As you age, this extra skin becomes progressively stretched, crinkly, wrinkly and thin and that’s how patients end up with those aged, witch-like hands. Pigmentation, however, is caused by solar keratosis or sun damage. Because the hands are one of the most exposed parts of the body, they are highly susceptible to UV rays, which not only affects in pigmentation but increased chances of wrinkles too. In addition, it’s unlikely that patients apply sunblock on their hands and even if they do, hand washing will likely strip it away. Unlike a face or breast lift, surgeons aren’t able to conduct a hand lift because not only are each of the fingers wrinkly, the back of the hand and palm are aged as well.
How are hand rejuvenation procedures carried out?
There are a few methods to hand rejuvenation procedures. They include fillers, fat grafting and platelet-rich plasma (PRP). If patients are in their forties and beginning to see signs of aging, the best course of action would be PRP. PRP has the great ability to rejuvenate the hands by not only reducing pigmentation but also improving collagen synthesis, which encourages thicker and tighter skin. Patients will need at least four monthly sessions for optimal results. While four sessions may provide good outcomes, the key to this treatment is regular maintenance every four months after the initial four sessions. I recommend that patients undergo consistent maintenance treatments because one’s exposure to the sun and chemicals are too consistent and possibly, never ending.
If older patients complain of exposed tendons, the best possible treatment would be fat grafting. After patients are put under general anaesthesia, we will harvest minute amounts of fat from the tummy and centrifuge the tissues. We will then take small aliquots of fat and distribute it evenly throughout the hands. I tend to mix fat grafts with both stromal vascular fraction (SVF) and PRP as the combinations increase fat uptake but also improve dermal contours while lightening and tightening the skin. Despite being a great treatment solution, only 40 to 50 percent of the grafted fats will survive. Although uncommon, patients can return for a follow-up treatment should they choose to do so.
Fillers are another option and would best suit those who aren’t ready for fat grafting. Fillers may have disadvantages, especially because the hands undergo a lot of movement, which may cause migration and granulomas. Even if the doctor utilises very dilute fillers, he or she will have to distribute the product evenly via a fanning motion, and because the hand has increased blood supply, patients may be at risk of blood clots. Cumulatively, if the fillers were to be accidentally injected into the blood vessels, major problems can occur.
Last but not least, there are also good non-invasive options such as CO2 lasers, which not only reduce solar keratosis but improve dermal quality. Despite a good alternative option, treatment may require multiple sessions. Should patients be interested in laser therapy for pigmentation reduction and increased collagen regeneration, it’s best they speak to a dermatologist or aesthetic practitioner.
The Price of Plastic Surgery Part Two: Body
Mariel Chow concludes her two-part article with a look at how much procedures on the body cost.
In the last issue I explored the true price of plastic surgery by investigating both the monetary and physical costs patients have to bear when undergoing facial plastic surgery. Like part one of this two-part series, we will now discover the cost of bodily cosmetic surgery and give patients a clear idea of how much moolah would have to be spent, and outline why painful after effects are most times unavoidable. I sit down with Consultant Plastic and Reconstructive Surgeons, Dr. Lee Kim Siea and Dr. Darren Khoo as they talk about the price tags of specific procedures, their inevitable downtime and possible risks and complications.
Disclaimer: Amounts listed in this article are ballpark figures and don’t necessarily represent all Malaysian doctors’ prices. Different plastic surgeons may charge differently, as doctors’ experience, workmanship, outcome quality and time may also be accounted for. Interested parties should always consult with their doctors to discuss possible procedures and the related fees or additional charges.

Price: RM20,000 – RM30,000
Dr. Lee: Prices of breast augmentation will be subject to the size, shape and brand of the implants used. Additionally, because breast augmentations are normally done under general anesthesia, price disparities will also depend on chosen hospitals and their respective fees. In my practice, the only brands of implants used are either Allergan or Mentor. I don’t offer the cheaper or lesser-known brands because they are, at times, not medically registered. In fact, I have come across implants in the price range of a few hundred Ringgit up to a few thousand. In my opinion, patients shouldn’t undergo augmentation mammaplasties and opt for implants of lower price ranges. Instead, they should select implants with proven track records with added approvals by multiple international medical bodies. At the end of the day, implants of cheaper qualities can be dangerous as they are susceptible to leaking and rupturing. Apart from brands, size and shape play a role in price tags. For example, anatomical or tear drop implants are more expensive than round implants and can incur additional charges upwards of RM1000.00.
What can patients expect during surgery?
Dr. Lee: Most of my cases are done under general anaesthesia. In short, I will make a cut, create a pocket, place the implant and close with incision without drains. At the end of the day, doctors will have to be confident in chosen pocket types and ensure that anatomical implants are placed in appropriate positions as poorly placed implants can affect in rotation and odd-looking shapes. There are three different methods to implant placement – through the armpit, nipple or under the breast. While I do allow patients to choose, I believe that the infra mammary (under the breast) approach remains the easiest and least problematic of the three. Despite infra mammary incisions being my favourite option, all three approaches do come with its own pros and cons.
The armpit incision’s greatest disadvantage would be the obvious scar. Although there are possible chances of scars resolving into inconspicuous creases, scarring on Asian skin isn’t as forgiving and can be rather pronounced even if it gets lighter over time. Secondly, choosing this method will affect in increased dissection, as the armpit approach is the furthest away from final implant positions. As such, patients will have to endure increased amounts of pain as more trauma is involved. Last but not least, and if patients choose anatomical implants, patients will incur additional costs as scopes will have to be used to ensure that implants are placed in vertical positions. In other words, because dissection paths aren’t visible, omitting scopes could lead to higher chances of hematoma or blood clots.
The second method is the peri areolar (through the nipple) incision. In my opinion, scars related to the peri areolar cut are comparatively more visible to the infra mammary incision because once underwear is removed, an evident semi-circular scar will be visible. Furthermore, once the bra is removed, the first thing you or your partner will look at are the nipples. Secondly, if patients are mothers and breastfeeding, peri areolar incisions may affect milk flow as ducts may be cut during the procedure. Apart from that, nipple sensation may also be reduced as nerves could also suffer a similar fate. Thirdly, patients with small nipples may not be suited to larger implants, as bigger implants will not be able to squeeze through such small incisions. Last but not least, there have been studies to prove that peri arealor incisions affect in higher occurrences of capsular contracture.
In terms of the inframammary fold, scars are well hidden behind clothes and even when patients stand up naked. In fact, scars are only visible when patients lie down. In my opinion, this method remains the easiest approach because the placement of pocket is just above the cut.
What can patients expect after surgery?
Dr. Lee Kim Siea
Dr. Lee: In my practice, breast augmentation patients are given two options. They can either choose to undergo a day procedure where patients are allowed to return home a few hours after surgery, or they can choose to be admitted for one night. Patients can expect some pain after the procedure because breast augmentation surgery does affect in muscle injury from implant placement under or above the muscles. Despite such discomfort, we will try to reduce the pain as best we can by prescribing painkillers and injecting local anaesthetic before patients wake up. Patients may experience the highest levels of discomfort on the first night and this is why I normally recommend that patients be admitted for one evening. After patients are released, I encourage them to return for a follow-up five to seven days after the procedure.
There’s a possibility that results look unnatural immediately after the procedure, especially if implants are large. Nonetheless, patients needn’t be too worried as final results may only be found after three months, with scars taking even longer (six months to a year) to settle.
What are the side effects or complications related to breast augmentation?
Dr. Lee: Patients will be continually monitored a day after surgery to ensure that no signs of hematoma or blood clots are found. Although extremely rare, patients who come down with a fever on the third to fifth day will be checked for infection. Other possible complications are of course hypertrophic scars and assymetry. Asymmetry can be due to asymmetrical sizes of the patient’s natural breasts. If this happens, doctors will have to compensate the disparity by utilising asymmetrically sized implants. Another form of asymmetry is shape asymmetry where the chest wall differentiates or if the implant has rotated. Furthermore, the surgeon’s handiwork could also lead to dissatisfaction, especially if there is malpositioning of the implants where either the upper or lower pole may look too full, or if the implants were unevenly placed.
The last possible complication is capsular contracture where the implant can harden early or over a period of a few years. Moreover, it can also cause an additional complication of asymmetry as capsular contracture causes implants to move to higher positions. There are multiple theories as to why capsular contractures occur. These include sub-clinical infection, blood clots or a negative reaction to the implant, causing scar tissue formation. To reduce chances of capsular contracture, doctors should be vigilant and reduce the amount of blood clots and ensure that pockets are dry, with no bleeding, if possible.
Dr. Darren Khoo
Dr. Darren: The commonest side effects after undergoing breast augmentation are temporary pain, swelling, bruising and even tightness in the chest. Such side effects are temporary and will last no more than a few weeks. On average, patients will be allowed to return to work after seven days and will be comfortable enough to return to normal physical activity after two weeks. While this may be, it is recommended that patients refrain from practicing any heavy lifting or over-exerting themselves for a couple of weeks. Apart from the complications Dr. Lee has explained, other risks can include implant rupture and leakages, changes in breast sensation and fluid accumulation.
Price: RM12,000 – 32,000
Dr. Lee: Tummy tucks are divided into the mini tummy tuck or full tummy tuck. Mini tummy tucks are a simpler procedure where I will not plicate the muscles or create a new belly button, but will remove excess tissue on the lower portion of the stomach. Prices of mini tummy tucks can be anywhere between RM4,000 to RM7,000 depending on whether patients opt for local or general anaesthetic. If patients are much larger, they will probably have to undergo a full tummy tuck where surgeons will plicate the muscles, remove significant amounts of tissue, and create a new belly button. While full tummy tucks can be done under local anaesthetia, I prefer that patients be put under, especially if they have large amounts of loose skin and are much larger.
What can patients expect during the procedure?
Dr. Lee: Patients undergoing mini tummy tucks needn’t undergo invasive surgery and hence, have a choice of either local or general anaesthetic. Should patients choose local anaesthetic to reduce costs, we can either provide sedation with local anaesthetic or local anaesthetic alone. Once patients are comfortable, we will do nothing more than remove the excess skin and stitch them up. In regards to the full tummy tuck, most patients are normally placed under general anaesthesia. Later, we will cut according to the predetermined flaps, elevate the tissues, plicate the rectus muscles, remove excess tissues, stitch the incision and lastly, create the patient’s new belly button.
What can patients expect during surgery?
Dr. Lee: Full tummy tuck patients are encouraged to be admitted into hospital for at least one night. Compared to many other cosmetic procedures, tummy tucks don’t cause much post-procedural pain but will affect in tightness. To reduce such discomforts, we will prop the patient up and place pillows under the knees during the recovery period. Patients will be further advised to refrain from standing up straight for at least a few days. Should they need to walk or stand, it’s best that they maintain a bent position and gradually straighten their bodies over the coming week. Unlike the full tummy tuck, patients undergoing the mini tummy tuck needn’t be admitted into hospital and will not be required to maintain a bent-over stance after surgery, as tightness is less of an issue. Like most surgery, tummy tuck patients are expected to return for a follow-up five to seven days later.
What are the side effects or complications related to tummy tucks?
Dr. Lee: Again, common surgical complications like infection and hematoma are a possibility. Another risk could also be skin necrosis especially if doctors try to combine liposuction and tummy tucks in one sitting. Reasons behind this are due to compromised circulation especially along the midline or just above the pubis. Another issue that may arise is seroma. Because tummy tuck procedures compromise the body’s lymphatic drainage system, fluid can form under the flaps. Should this risk arise, we may have to utilise needles to aspirate the fluid accumulation. Next, because patients undergoing a fully tummy tuck tend to have a long scar from hip to hip, keloidal scars can be a problem, especially in the region directly above the pubis. Lastly, smokers may be more susceptible to problems. This is why we encourage smokers to quit for at least a month before surgery.
Dr. Darren: In my practice patients are admitted for at least two to three days and common side effects are normally pain, swelling, bruising, scarring and tightness. I advise patients to start walking as soon as possible to reduce swelling and prevent blood clot formation in the legs. As explained, patients may have to walk in a hunched position for at least two to three days, as the tummy will feel tight. Nonetheless, such side effects are temporary and patients will soon experience physical normality in one to two weeks. In terms of downtime, patients are advised to be off work for two weeks depending on how physical their jobs are. Strenuous activity should be avoided for at least six weeks as the body is still healing. Even though most of the bruising and swelling does disappear within three weeks, it is important that patients keep physical activity to a minimum. Lastly, it’s crucial that patients stick to a recommended diet and exercise routine to maintain their new physique. Early complications related to tummy tucks can include bleeding, hematoma, scarring, infection and fat necrosis. As time passes, patients may encounter late onset complications including, numbness, contour irregularities and asymmetry.
Price: RM3,000 to RM32,000

Liposuction combined with fat grafting: RM30,000 to RM40,000
Dr. Lee: Liposuction prices depend on how large the patient is and how much fat requires removal. In addition, instruments used will also play a role in the fees. If the procedure is simple and doesn’t involve the usage of technologies such as ultrasound or waterjet, prices will be much cheaper. As a seasoned plastic surgeon, I’ve conducted liposuction via multiple technologies and now only employ Vaser Liposelection because it produces better results, and allows higher volumes of suction with decreased bleeding. Not only that, because Vaser emits ultrasound heat, patients can enjoy additional skin tightening as well. At the end of the day and although I only offer Vaser Liposelection at higher prices, patients have a choice and should they desire liposuction procedures at cheaper rates, they can always enquire with other doctors. Unlike facelifts or tummy tucks where predetermined excess skin is removed, surgeons can only liposuct a limited amount of fat, depending on each patient. If a patient’s aspirate is bloody, we may only remove three to four litres of fat. If a patient’s aspirate is yellow with little blood, we can liposuct up to five to six litres of fat.
Dr. Darren: The estimated costs of power-assisted liposuction will depend on how large treated areas are and whether local or general anaesthesia is utilised. If patients request for full body or full abdomen liposuction with general anaesthesia, it is recommended that patients stay at least a night for improved recovery. While this may be, patients are given a choice and should they choose to undergo full abdomen liposuctions with local anaesthesia and sedation, prices will be much cheaper as they needn’t be admitted into hospital.

What can patients expect during the procedure?
Dr. Lee: Liposuction procedures can be done under both local and general anaesthesia. If treated areas are small, then local anaesthetic will suffice. If there are multiple, larger regions, it’s best that patients be placed under general anaesthesia and admitted for at least a night. Liposuction can take anywhere between an hour to four or five hours depending on how many areas require suction. In fact, if we have to turn the patient around, that action itself could take up to twenty minutes. After patients awake from surgery, there are instances where oozing from the puncture holes can occur. Although oozing is common, patients can mistake it for bleeding and this is why it’s best that patients are admitted for at least one evening. On the second day, patients will undergo dressing changes and be placed in compression garments before they return home. Along with oozing, patients may experience a certain amount of pain and tenderness, which can last a few weeks. In addition, bruising and swelling are occurrences, which may respectively take a few weeks to a couple of months to resolve. To reduce side effects during the recovery period, patients are encouraged to undergo additional treatments such as radiofrequency and lymphatic drainage to improve recovery and reduce the swelling’s longevity. Like most surgeries, patients are expected to return for a follow-up after five to seven days.
What are the common complications related to liposuction?

Dr. Lee: The commonest complication is dermal irregularities where the skin can look rippled or loose especially if patients underwent large volume liposuction. If need be, surgeons may additionally advocate fat grafting to correct the rippling effects. In general, I frequently combine both liposuction and fat grafting as we may recycle the extracted adipose tissue and re-inject it in areas such as the buttocks and breasts. Secondly, patients may also complain of poor outcomes if desired shapes aren’t achieved. To reduce chances of unmet expectations, it’s imperative that patients understand that stubborn pockets of fat cannot be removed even if ultrasound technologies are utilised. Lastly, liposuction can be a rather dangerous procedure as cannulas can puncture the abdominal cavity and injure the spleen, liver and intestines. Also, surgeons have to pay close attention to the aspirate. If the aspirate is bloody and too much fat is removed, patients can lose a lot of blood.
Dr. Darren: The commonest side effects to liposuction surgery are temporary swelling, bruising, soreness and numbness in and around treated areas. Minor risks related to liposuction are irregular contours, hematoma and seroma while severe complications could include skin necrosis, infection, lidocaine toxicity and pulmonary embolus. Apart from this, there are further risks related to high volume liposuction of more than four litres of fat and although extremely rare, patients may be exposed to hypothermia, thromboembolism, pulmonary fat embolism syndrome and pulmonary edema. Moreover, there are chances of lignocaine toxicity, hemorrhaging, abdominal viscus perforation, sepsis, acute respiratory distress syndrome and anaesthesia related complications.
Prices: RM9,000 to RM 30,000
Dr. Lee: In my practice, patients undergoing facial fat grafting will additionally enjoy the benefits of PRP combinations while fat grafts to the breasts will be amalgamated with stem cells for improved uptake. While buttock fat grafts are not combined with other treatments, patients can expect larger adipose tissue volumes with prices much cheaper if compared to breast augmentations. While patients are able to omit cell-enriched grafts from their procedure to reduce costs, most of my patients do regularly request for additional stem cell treatments as it produces better results.
What can patients expect during the procedure?
Dr. Lee: Facial fat grafting will normally take two or three hours including grafting. Breasts with cell-enriched fat grafts may take up to four or five hours while fat grafting in the buttocks may take anywhere between three to five hours depending on how much fat is transferred. Although facial fat grafting will need nothing more than local anaesthetic and sedation, I recommend breast and buttock patients to be put under general anaesthesia as surgical time is much longer. Grafted fat is normally harvested from the tummy, inner thigh and flanks but fat can be generally reaped from any part of the body. Like liposuction, I recommend that patients be admitted into hospital for at least one night especially if they have undergone breast or buttock enhancements.
Dr. Darren: In my practice, micro-fat grafting to the face can be done without general anaesthesia unless it’s combined with additional procedures. In fact, the procedure is so simple and quick that my patients are given nothing more than local anaesthetic without any need for deep sedation. While this may be, light oral sedation and analgesics may be provided upon request. If patients are undergoing higher volume fat grafting (breasts and buttocks), it’s best that patients be admitted for at least one or two days as general anaesthesia will be administered.
What can patients expect after the procedure?
Dr. Lee: Like liposuction, patients can expect pain in areas where fat was harvested. On the second of third day, bruising can occur in both the harvested and grafted regions. Despite the bruising, facial fat grafting patients can undergo laser treatments to reduce such symptoms and improve healing. In a nutshell, all fat grafting side effects will be similar to that of liposuction.
What are the side effects and complications related to fat grafting?
Dr. Lee: While infection is the first thing a surgeon worries about, it is an uncommon complication. Next, patients must understand that graft uptake is variable and in general, only half of the transferred fat survives. In fact, size immediately after surgery drastically reduces during the first month, and patients can expect final and definite sizes only after the sixth month. To further put this in perspective, patients can only expect to go one or one and half cup sizes up. The third possible complication will be oil cyst or calcification formation. Patients can rest assured that such lumps are benign, clearly identifiable and easily treated.
Dr. Darren: Patients can expect bruising and swelling that can respectively last up to two weeks and four weeks. In terms of possible complications, there are chances of unsatisfying results, seroma, hematoma, irregular contours, uneven results from liposuction, fat necrosis and asymmetry.
Why are more people opting to go under the knife despite the exorbitant costs?
Dr. Darren: Cosmetic surgery has undergone significant technological and conceptual changes in recent years. Everybody wants to look good and cosmetic surgery intends to provide patients with younger, rejuvenated and more attractive physical looks and physiques. In my opinion, many men and women are choosing to go under the knife despite the exorbitant costs because such procedures are one of the fastest and most effective routes to personal fulfillment. While some people undergo surgery for career opportunities, others may choose to do so due to personal or romantic reasons. Whatever the motivation may be, patients are becoming progressively aware of plastic surgery’s advances and this has translated into more patients enjoying natural, consistent results without increased downtime.
Why should patients choose qualified surgeons and how do experienced surgeons justify their surgical prices?
Dr. Lee: I think the best advice I can give to patients is that invasive plastic surgery shouldn’t be taken lightly. If patients have the desire to go under the knife, it’s best they choose surgeons who are not only qualified, but carry out procedures in suitable, certified and sterile environments. Deaths have been reported in each and every procedure we have talked about, and most times, illegal practitioners practicing surgery in non-medical spaces such as hotel rooms and spas affect in casualties. Plastic surgeons offer procedures at differing prices and such fees are justified based on how much the doctor values his or her own handiwork.
Moreover, as a surgeon becomes more popular or highly recommended, his or her time becomes more precious and it’s only natural that one is fairly compensated. More importantly however, surgeons should do their level best to aim for consistent results. While it’s near impossible to provide perfect results all the time, surgeons shouldn’t allow poor results either. In other words, as long as the surgeon continually produces consistent results, he or she is able to justify higher surgical prices. In addition to time and consistency, high prices can also be justified by how much warranty doctors offer after surgery. In my practice, treatments of possible complications are already included in my fees and this gives patients peace of mind that further surgical charges won’t be incurred if things go south.
Servicing All Your Dental Needs
The Imperial Dental Centre puts clients first, always.
The Imperial Dental Specialist Centre is a one-stop dental centre which provides comprehensive solutions for all your dental, skeletal, soft tissue as well as craniofacial needs. Accredited by the Malaysian Healthcare Travel Council as Malaysia’s premier dental centre, the Imperial Dental Specialist Centre was awarded the best International Dental Clinic in 2016 and is highly recommended for excellence in customer service and quality initiatives. In this article, we sit down with Consultant Orthodontist, Dato’ Dr. How Kim Chuan as he explains orthodontic treatments and orthognathic surgery for severe cranial discrepancies. Later, we speak to Dental Surgeons, Dr. Stephanie Chong and Dr. Ariel Loke as they respectively talk about dental digital imaging and teeth whitening treatments. Later, Dental Surgeons, Dr. Kong Sheng Earn, Dr. Yew Kai Shang and Dr. Raymond Su chime in to discuss laser crown lengthening, post, core and crowns and E-Max dental prosthetics.
Orthognathic and Orthodontic Services with Dato’ Dr. How Kim Chuan
Dato’ Dr. How Kim Chuan
Here at the Imperial Dental Specialist Centre, we offer a combination of services that amalgamate both orthodontic treatments and orthognathic surgery to correct severe cranial facial discrepancies. When patients suffer from severe under bites or dental facial discrepancies, such cases are generally beyond the scope of orthodontic treatment and will necessitate surgical correction.
Dato’ Dr. How Kim Chuan
While surgical correction with a maxillofacial surgeon is required, patients presenting with severe under bites will first and foremostly need orthodontic care before surgery can be performed. Patients with cranial facial discrepancies are initially required to undergo orthodontic treatment because surgeons will not be able to establish appropriate dental occlusions or bites without preliminary bracing or Invisalign treatment. In short, comprehensive treatment plans will require appropriate orthodontic planning and initial dental movements into suitable positions. Later, a maxillofacial surgeon will step in to surgically correct the jaw. Once surgical intervention is carried out, patients will have to undergo one last round of orthodontic care before treatments are finally complete.
What can patients with severe dental discrepancies expect during orthodontic treatment?
When patients with severe under bites opt for treatment,we will recommend orthodontic care to correct his orher dental occlusion or bite. Although patients are able tofunctionally bite down and eat before any form of treatment, severe cranial facial discrepancies do affect in facial disfigurements that can only be corrected with a combination of orthodontic and surgical care. In order to correct the disfigurement, teeth alignment has to be decompensated to prepare for jaw surgery in anticipation for the new jaw position. In other words, suitable orthodontic care will affect in poorer or impeded occlusions where patients won’t be able to bite but conversely, attain improved facial shapes. Once the teeth are remedied, surgical care will conclusively result in normal facial forms with teeth that comfortably occlude as well.
Previous patients
Based on the pictures attached, you can clearly see that this patient suffered from cranial facial discrepancies where his bite is completely misaligned. Furthermore, it’s also evident that after orthodontic treatment, the patient’s teeth alignment was decompensated to prepare for jaw surgery in anticipation to the new jaw position. However, once surgical treatment was carried out, the patient not only looked much better but additionally achieved improved oral function as well.
Before and After Orthonagthic Surgery + Orthodontic Treatment Profile
Before & After Treatment in Profile View
Before & After Treatment in Profile View Smile
Before Treatment in Occlusal View
During Treatment in Occlusal View
After Treatment in Occlusal View
Before Treatment Lateral Cephalometric X-Ray
After Surgery OPG X-Ray
Lateral Cephalometric Superimposition with Profile Picture
Eastman Analysis Chart
Before and After Orthonagthic Surgery + Orthodontic Treatment Profile
Before Treatment in Occlusal View
After Treatment in Occlusal View
Clincheck Before Invisalign Treatment
Clincheck After Invisalign Treatment
Clincheck After Surgery
Unlike what most would assume, severe cranial discrepancies will not necessitate extended periods of treatment time.
After 12 to 15 months of orthodontics, patients should be prepped and ready for surgery. After surgery, patients will experience a recovery period of four weeks coupled with another six months of orthodontic care.
Severe facial discrepancies and Invisalign treatment
Patients suffering from severe facial disfigurements can either undergo orthodontic treatments with braces or Invisalign. The advantage related to Invisalign is that when compared to braces, Invisalign aligners are invisible and non-obvious. Furthermore, Invisalign also provides digital visualisations of treatment, which allows patients to foresee future treatment plans and give them a rough idea of when surgery will take place. In addition, not only are Invisaligns more precise, they may also affect in shorter treatment times because aligners can be changed at a quicker pace while achieving the same results. Last but not least, because post-surgical recovery periods will affect in jaws being wired shut, patients are forced to be on liquid diets. With Invisaligns however, patients undergoing their recovery period are given the option of removing their aligners, which allows them to comfortably open their mouths and eat.
Dental Digital Imaging with Dr. Stephanie Chong
Dr. Stephanie Chong
The Advantages of Diagnostic Imaging
Diagnostic imaging and techniques help to develop a more cohesive and comprehensive treatment plan not only for dental surgeons and their teams but patients too. Diagnostic imaging can be used for several purposes including decay identification beneath pre-existing fillings, disclosure of bone loss accompanied by periodontitis, and revelation of changes in the bone or root canal due to infection. In addition, diagnostic imaging also has capabilities of disclosing abscesses and other developmental abnormalities such as cysts and tumours and assist in treatment plans for implants, orthodontics, dentures, undermined caries and other dental procedures.
The imaging modalities can be divided into two-dimensional and three-dimensional modalities. Such images can include periapical radiographs, panoramic radiographs, occlusal radiographs, lateral cephalograms, posteroanterior skull views, cone beam computer tomography or CT scans and many more.
Digital Versus Conventional Radiographs
Once photographic film has been exposed to X-ray radiation, it needs to be traditionally developed via certain processes which expose the film to a series of chemicals in a dark room as films are sensitive to normal light. This process is not only time-consuming; patients too could be exposed to additional radiation if retakes are necessary due to incorrect light exposures or mistakes in the imaging’s developmental processes. Digital x-rays, which replace the film with an electronic sensor, address some of these issues and are fast becoming the gold standard in dental digital imaging. Apart from needing less radiation, digital radiographs are processed at a much quicker pace, often instantly viewable on a computer screen.
Why are digital radiographs necessary for dental imaging?

(A) Shows no apparent decay
(B) Arrows points to an extensive area of demineralization
(C) A large underlying decay within the crown
(D) Pulp chamber has been exposed the mesial portion of the tooth is lost
Your practitioners will always weigh the pros and cons of recommending dental radiographs, as he or she understands the risks associated with radiation exposure. Hence, a dentist’s decision to take an X-ray has to always be patient-specific and risk-based. Because modern X-ray devices and image capturing are highly sensitive, the amount of radiation required for diagnosis is extremely minimal, almost next to nothing if patients are frequent flyers and constantly in a plane. Furthermore, dental radiographs only takes images of necessary structures so patients can be rest assured that other bodily tissues will not be exposed to radioactive energy. For further precaution, your dental practitioner may even encourage patients to shield the rest of their bodies by wearing a lead apron as a precaution and for improved safety.
Teeth Whitening with Dr. Ariel Loke
Dr. Ariel Loke
Dental whitening treatment is a cosmetic procedure, which allows lightening of the tooth’s colours via an application of chemical agents that oxidises the organic pigmentation of the teeth. Dental discolourations can be divided into intrinsic and extrinsic stains. Intrinsic staining has multiple causes, which include aging, fluorosis, tetracycline staining, trauma, caries and dark restoration and congenital defects. Extrinsic stains, however, are caused by patients’ daily habits such as coffee, tea or wine intake, nicotine use, poor dental hygiene and plaque. Although teeth whitening treatments may easily manage most forms of extrinsic and intrinsic stains, severe discolourations such as tetracycline staining and congenital dental defects like dentinogenesis imperfect may require restorative procedures like veneers or crowns. In a nutshell, appropriate patient indications for teeth whitening treatments are generalised staining, smoking or dietary pigmentation, mild white spots or fluorosis and trauma.
Teeth Whitening for Dental Trauma
Before Laser Whitening
Before non-vital bleaching
1 week during non-vital bleaching
2 weeks of non-vital bleaching
Post Laser Whitening
When patients suffer dental trauma, they can experience tooth discolourations especially if there is blood pigmentation, a necrotic pulp, root canal fillings or filling materials and root resorption. If patients have suffered dental trauma, an internal bleaching or ‘non-vital bleaching’ of the darkened, dead tooth can be done after root canal treatment. During a ‘non-vital bleaching’ procedure, dentists will insert bleaching agents such as sodium perborate or carbamide peroxide into the pulp chamber and seal it. Patients will then find a progressive lightening of the darkened, non-vital tooth and can expect good, natural-looking results after two weeks.
Teeth Whitening for Generalised Staining
In-office vital bleaching can yield high satisfactory results in just one visit. Laser whitening is one of the latest dental whitening methods and utilises bleaching agents such as hydrogen peroxide or carbamide peroxide. After said chemicals are applied on the teeth’s surface, heat generated by the laser will not only speed up but enhance whitening processes. While positive outcomes are highly likely, results aren’t permanent and can return especially if dietary and poor lifestyle habits don’t change. Lastly, patients may experience post-treatment sensitivity which lasts anywhere between 24 to 48 hours. To reduce chances of discomfort, it’s best that patients refrain from eating or drinking anything too cold or hot for at least two days.
Laser Crown Lengthening with Dr. Kong Sheng Earn
Dr. Kong Sheng Earn
Laser crown lengthening is a procedure which exposes more teeth by removing the gums that conceal them. Crown lengthening for the reduction of gummy smiles was traditionally carried out via scalpel and careful excision of the excess gums. This procedure will not only reduce a patient’s gum exposure during smiling and talking but also allows the tooth to appear longer. Despite being a good treatment with positive outcomes, traditional crown lengthening procedures require meticulous planning and pre-operative measuring of how much teeth dentists would like to expose, versus the amount of gums that necessitate excision.
Teeth appear short as gingiva covers the clinical crown
Immediately after laser crown lengthening of the upper and lower teeth. Note the immediate aesthetic improvement after the teeth are exposed.
A week after the laser crown lengthening procedure. The gums have fully healed and remains at the planned stable position.
Before laser crown lengthening
After laser crown lengthening
Laser or Light Amplification by Stimulated Emulated Response is widely used and known for its applications in the industrial, military and medical sectors. With ever-improving scientific and technological advances in the dental industry, laser technology is now a staple in dentistry and practitioners can utilise laser energies at specific wavelengths and intensities for various clinical uses including laser crown lengthening. Laser replaces the conventional scalpel and is far superior when compared to traditional surgical methods. First and foremost, laser beams are of course far less frightening than a scalpel or blade. Secondly, because lasers don’t affect in bleeding due to the heat and coagulative properties of the beam, the treatment is less invasive and reduces downtime and bacterial infection while improving healing as well.
In the images attached, the patient is currently undergoing orthodontic treatments but still suffers from a gummy smile due to excessive gingiva. In this patient’s case, we have not only improved her smile line by recommending orthodontics but also combined the treatment with laser crown lengthening to improve cosmetic outcomes. In other words, by applying braces, we are able to push the teeth in while utilising laser energies to achieve optimal dental exposure.
Post, Core and Crowns with Dr. Yew Kai Shang
Dr. Yew Kai Shang
Teeth can be weakened due to decreased dental structures and such problems can be attributed to multiple causes including caries, previous restoration, fractures or trauma, and endodontic access and instrumentation from root canal treatment. When a patient has suffered retained roots from affected dental structures, dentists can choose to either save or extract them based on the anatomical position of the tooth, the functional load on the tooth, the amount of remaining tooth structure and the tooth’s aesthetic requirements.
Root Canal Treatment and Post
Based on the images provided, we were able to save the patient’s tooth through root canal treatment followed by a post, core and crown. Root canal treatment is the process of removing the inflamed or infected pulp tissue within the tooth caused by bacteria. This treatment is especially applicable to those who have suffered deep tooth decay, a cracked tooth and traumatic dental decay. After the tooth has been treated, a post is placed within the tooth’s root as it provides retention for restorative treatment, which involves the core and crown. Furthermore, the post is essential because it provides the tooth with coronal stability. In summation, post placement is recommended if the remaining coronal structure offer inadequate retention for final restoration and when there is sufficient root length for the accommodation of the post while maintaining adequate apical seal.
The Core and Crown Placement
Patient veering away from removable dentures to fixed prosthesis (crowns).
Post placement in preparation of coronal tooth structure.
Cemented Crowns
Radiograph of central incisors with dislodged crowns due to trauma
Radiograph after root filling or obturation followed by post placement.
The core aids in restoration by anchoring the crown, and is made up of amalgam or composite. Apart from retaining and anchoring the crown, core restoration has the ability to replace carious, fractured or missing tooth structures. Core restorations are normally recommended if the placement of missing coronal tooth structure is necessary or when the enhanced retention and resistance to displacement of final restoration is needed to prevent fractures. Last but certainly not least, final restorations will involve crown placement, which has the ability to not only protect the treated tooth, but also restore dental function while providing good aesthetic results.
E-Max crowns with Dr. Raymond Su
Dr. Raymond Su
Full ceramic crowns or E-Max crowns are crowns which offer the best aesthetic results. They are normally placed on the anterior teeth. Based on the images, this patient presented with severe discolouration from trauma and many fillings within the teeth. On top of that, he also complained of dental crack lines caused by severe bruxism. Because this patient was unhappy with his appearance and complained of aged looks when he smiled, I recommended that he undergo full crowns on his upper anterior teeth. After undergoing four E-Max crowns, we were not only able to improve his smile but additionally take years off his face as well. Moreover, because this patient suffers from dental grinding at night, I have also recommended that he wear a night guard to not only protect his original teeth but his new crowns too.
Why should patients choose E-Max crowns?
There are three forms of crowns available – full ceramic crowns, zirconia and porcelain fused to metal (PFM) crowns. Although PFM crowns may be a perfectly viable option, patients will age and undoubtedly experience receding gums. Once gums recede, the ugly black margins of the metal will be rather obvious. This is especially apparent if PFM crowns are placed on the anterior teeth. To improve aesthetics, patients undergoing dental prosthesis on the front teeth should opt for full ceramic crowns because not only are dark margins avoided, E-Max crowns are translucent and naturally reflect light just like a natural tooth. Furthermore, because PFM crowns are made of metal, colours are opaque and come off looking unnatural when light is reflected against the prosthesis.
How is the treatment carried out?
Before Treatment
Before Treatment
After Fitting of the Emax Crown
After Treatment
Before full ceramic crowns are attached to the patient’s tooth, we will firstly grind the teeth down to an appropriate size. After the teeth sizes are reduced, temporary crowns will be provided, as the laboratory will need at least a week to manufacture the full ceramic crowns. Once patients return to have their new E-Max crowns placed, the shape and size of the prosthesis can be further altered should patients be unhappy with the prosthetics’ look, colour or shape. In my opinion, E-Max crowns provide patients with great long-term aesthetic solutions. E-Max crowns can be very durable if patients practice good oral habits and undergo regular maintenance and check-ups with their dentists. What’s more, outcomes are very natural while providing the best possible aesthetic results.
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March, 2017


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