Issue Highlights

No Sweat!
Mariel Chow asks the experts if living with armpit stains and damp palms is a curse to be endured stoically.
Residents of tropical countries such as Malaysia know what it means to sweat. Sweltering heat coupled with humid weather causes perspiration. This natural process aims to regulate body temperature and keep the body cool. While perspiration is absolutely normal, what happens when one sweats more than necessary? Excessive release of sweat is a medical condition called hyperhidrosis. Hyperhidrosis – although benign – can hinder one’s personal life and self-esteem.
Think about it; would you like a romantic partner who constantly sports armpit stains or sweaty palms? Along with impeded self-confidence, hyperhidrosis can interfere with everyday activities. Because patients with hyperhidrosis excessively perspire in the underarms, feet or palms, they find simple activities such as clothes shopping, handshaking, writing and keyboard-use extremely challenging. Sweating can be reduced with topical creams or sprays such as antiperspirants but such products aren’t made for excessive sweaters. In situations like this, medical intervention might just do the trick. Effective hyperhidrosis treatments can be divided into both invasive and non-invasive procedures, which involve either video-assisted sympathectomies or simple Botolinum Toxin A injections.
dr-anand Consultant Cardiothoracic Surgeon, Dr. Anand Sachithanandan.
We sit down with Consultant Cardiothoracic Surgeon, Dr. Anand Sachithanandan as he explains hyperhidrosis and its linkages to the sympathetic nervous system including how sympathectomies are carried out. Likewise, Aesthetic Physician, Dato’ Dr. Ramamurthy Subramaniam (Dr. Morthy) expands on the differences between hyperhidrosis and ‘normal’ sweating, its linkages to body odour and non-invasive forms of treatment.
What is hyperhidrosis?
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Dr. Anand: Hyperhidrosis is a benign medical condition but a functional disorder. In simple terms, hyperhidrosis is abnormal and excessive sweating. As you know, everyone naturally perspires and sweating is a normal biological function. In hot climates such as Malaysia, human beings have to sweat in order to regulate the body’s ideal temperature. When we talk about hyperhidrosis however, people who suffer from this condition can excessively sweat in even cool conditions. Although it’s difficult to quantify the disorder’s severity, hyperhidrosis can hinder one’s quality of life by affecting self-esteem and choice of work. We can broadly classify the condition as primary focal hyperhidrosis or secondary hyperhidrosis. Secondary hyperhidrosis like most secondary medical conditions implies disorders caused by other factors or symptoms of an underlying condition. In cases such as this, secondary hyperhidrosis can be triggered by an overactive thyroid, diabetes and menopause. Once patients are screened and secondary hyperhidrosis is identified, doctors will need to diagnose and treat the underlying problem instead of treating the excessive sweating. For example, if patients are excessively perspiring due to an overactive thyroid, simple medications can control the problem and symptoms should improve. What we want to focus on is focal or primary hyperhidrosis and its relation to the sympathetic nervous system’s over-activity.
What’s the difference between hyperhidrosis and ‘normal’ sweating?
Dr. Morthy: There is something called the hyperhidrosis severity scale used by the USFDA where patients can rate levels of excessive perspiration. Levels of severity can be divided into hyperhidrosis and general discomfort, excessive sweating and constant wardrobe changes and perspiration despite deodorant use. Although there may be scales and classifications available, hyperhidrosis is very personal and depends on individual patients. For example, if one of its classifications say ‘perspiring to a point where it hinders natural lifestyle’, it remains subjective as some people may be reluctant to shake hands while others may wipe their hands off and shake away. Even though everyone sweats, we can vaguely classify those with hyperhidrosis to sweat in air-conditioned environments or aggressively perspire when they’re nervous or anxious. Even then however, it’s still difficult to categorise especially if one doesn’t mind the excessive perspiration. In a nutshell, diagnosis of hyperhidrosis is patient-dependent and based on self-esteem and emotional input.
approved-dr-m Aesthetic Physician, Dato’ Dr. Ramamurthy Subramaniam.
How is the body’s sympathetic nervous system a cause in primary hyperhidrosis?
Dr. Anand: The human body has something called the autonomic nervous system and it regulates processes such as our heart rate, blood pressure and sweating. There are two nerve chains on either side of the spinal column that runs from the base of the skull all the way down to the coccyx or tailbone. These nerve chains are called the sympathetic chain and have fibres that supply different organs in the body including the sweat glands in multiple bodily regions. If patients suffer hyperhidrosis, it’s believed that they have an overactive sympathetic nervous system and hence, will sweat excessively. Although hyperhidrosis can run in families, it’s equally present among patients who do not have family histories of overactive sympathetic nervous systems as well.
How does nervousness and anxiety affect in excessive sweating?
Dr. Morthy: Everyone – not only those with hyperhidrosis – sweats when they’re anxious. Patients with hyperhidrosis may perspire more in such situations, but everyone experiences similar conditions when uncomfortable circumstances arise. When one is worried or uneasy, the body’s sympathetic nervous system becomes aggravated and one will begin to flush, palpitate and have an increase in blood pressure. Moreover, you will also begin to sweat. What’s pretty cool about sweating is that it remains an indicator in polygraph tests. Just like blood pressure, body temperature, pulse and respiratory rates are markers for lying, so is sweating.
How does hyperhidrosis negatively impact patients?
Dr. Anand: Despite being a non life-threatening condition, it does affect their quality of life. When patients come to me, they may present with poor self-esteem and low confidence. A few problems patients normally experience are difficulties with sweat patches, shaking or holding hands, ink smudging and so forth. Not only that, excessive sweating can also affect one’s career choice. For example, if patients have hyperhidrosis and work as plumbers or electricians, they won’t be able to grasp tools due to overly sweaty palms.
Do patients with hyperhidrosis tend to smell more than those without hyperhidrosis?
14749668 - man with hyperhidrosis sweating very badly under armpit
Dr. Morthy: There are two schools of thought. One says yes, it does lead to increased body odour while the other disagrees. Sweat is produced by sweat glands that don’t produce any foul smells. Body odour occurs when bacteria acts on sebum or secretions from sweat. In my opinion, it’s just not true to say that those who sweat more are smellier. For example, even those who sweat minimally can present foul odours. This is due to the active bacterial flora in their bodies. Everyone has bacteria on their skin and if patients have increased levels of such bacteria, even the slightest secretions can affect in offensive odours. In fact, some clinical papers have even suggested that excessive sweating can eliminate body odour as extreme sweat actually washes away the present bacterial flora.
There are only three areas in the body which excrete body odour-linked sweat and they are the feet, armpit and groin. Should patients predominantly sweat in areas such as the palms or back, offensive smells shouldn’t be a concern. However, if patients present with hyperhidrosis in the armpit in addition to increased bacterial flora then yes, susceptibility to body odour is increased. In my opinion, there are no direct linkages between hyperhidrosis and body odour. While there are connections between the two, it still takes the presence of increased bacterial flora to induce foul smells.
Is excessive sweating normally localised to only one part of the body?
19029638 - woman sweating very badly under armpit
Dr. Morthy: From personal experiences, I haven’t found any patient who sweats profusely in one area but remains dry in another. Because sweat is triggered by the central nervous system, hyperhidrosis doesn’t normally affect single body parts. Having said that however, there are certain affected regions that annoy patients the most and it’s usually the hands or underarms. Female patients are normally more concerned about armpits, while the palms trouble males. Moreover, there are patients who have also come in for groin or sole treatment as well.
Why would patients choose to undergo invasive forms of treatment?
We are all aware of the many non-invasive forms of treatment. There are antiperspirants, iontophoresis, Botolinum Toxin A (BTA) injections etc but such treatments can be limiting, as they are temporary solutions. For example, BTA is shown to be effective for approximately four months before it wears off. Once the effects of the toxin dissipate, patients have to return to the clinic for repeat sessions. With repeated injections, patients can experience increased treatment costs, possible scarring, risk of infection and pain. Frankly speaking, when patients come to me seeking solutions, conditions are normally severe enough to warrant surgical intervention. Likewise, because patients are normally young – between the ages of 15 to 40 – they would have done their research and have often exhausted other forms of non-invasive treatment.
Who are the right candidates for surgery?
Before we approve surgery, patient selection is fundamentally important. As explained before, if patients present with secondary hyperhidrosis, we must treat the secondary problem in order to treat the condition. In cases of primary hyperhidrosis, patients will normally complain of sweaty hands, armpits or feet. If patients have localised complaints that mainly concern the hands, they are very good candidates for surgery. Postoperative success will normally depend on the affected bodily region. If patients have sweaty hands, surgical success rates will be 90 percent while patients with sweaty armpits have 75 percent success rates. If patients have sweaty feet, surgical success rates dramatically drop to 50 percent. In cases where patients have mainly or only concerns of sweaty feet, I am quite reluctant to perform the surgery as there is a 50 percent chance that patients won’t find any improvement. At the same time, because it’s a non life-threatening condition, we want patients to have good outcomes and be satisfied with surgical results.
The reason why plantar sweating has variable outcomes is due to the sympathetic chain. Because the sympathetic chains’ fibres supply different organs at different levels, surgeons won’t go too low as to not disrupt fibres that supply the bowel, bladder or heart. Surgeons will refrain from treating foot sweating exclusively because lower levels will need to be accessed and this can be risky.
How are sympathectomies carried out?
Sympathectomies are normally done through keyhole surgery. After patients are put to sleep (short general anaesthetic), two tiny incisions of no more than five-millimetres are made in the armpit. We will then place a small camera through the first incision and this allows surgeons to view inside the chest cavity. Before we can access the sympathetic chain, we must get the lungs out of the way. After the lung is briefly collapsed, the surgeon will have a good view of the sympathetic chain and he or she must identify the correct levels before fibres are cut. The chain is cut with an electrical diathermy probe (introduced via the second 5mm incision) that delivers thermal energy. After the fibres are cut at the correct levels, we will re-expand the lung and close the incision. Once one side of the body has been treated, we’ll repeat this process on the other side. Sympathectomies are normally uncomplicated and take only 30 – 45 minutes to complete. Although I have routinely performed many sympathectomies as a day-case procedure in the United Kingdom, we tend to be more conservative in Malaysia and have patients stay the night.
What can patients expect after surgery?
The beauty about sympathectomies is its instant results with no long-term medication. If surgeries are done properly, patients will enjoy dry hands as soon as they wake. In most cases, results are permanent with no need for repeated treatment, but we do warn of the very rare (one percent) potential post-operative risks.
Firstly, bleeding during any surgery is a possibility and this can result in larger incisions. Secondly, there are instances where the lung doesn’t fully re-expand. If this happens, we’ll place a small tube through the same incision to allow air release and lung re-expansion. We will remove the tube usually a day after surgery. The third risk is ptosis of the eye. Because the sympathetic nerve fibres supply different bodily structures, including the eyelid muscle, possibility of abnormal nerve supply and hence incorrect cutting of the fibres could result in subtle and temporary eyelid drooping. The fourth side effect is recurrence due to reattachment of the sympathetic chain. Although we cut the chain under minimally-invasive video-assisted thorascopic vision, microscopic fibres that are difficult to see may be left uncut and can reattach over time. Albeit rare, affecting only five percent of all surgeries, it can be a long-term possibility that patients should be made aware of.
The last and most common side effect is compensatory hyperhidrosis where excessive sweating shows up in other parts of the body. For example, although the procedure was successful with patients enjoying dry palms and armpits, they may notice sweat elsewhere. This complication affects approximately 30 percent of patients and may even occur several months later. Other bodily regions that may experience compensatory hyperhidrosis are the back, thighs and lower abdomen. Despite a common aftereffect, most patients don’t tend to mind it as prime problems are treated. As surgeons, informed consent is very important and once patients are told of possible side effects, they will be more accepting.
Patients are expected back in the clinic to have their stitches removed and can experience two days of downtime. They may suffer slight soreness, which lasts up to a week but are allowed back in the office in no time. Conversely, patients who practice heavy lifting or manual labour may need a bit longer to recover.
Why should patients opt for non-invasive forms of treatment? What are the many types of non-invasive treatments available?
Those with hyperhidrosis can always opt for invasive procedures but some patients aren’t always ready to go under the knife. In terms of non-invasive options, the first line of treatment is always antiperspirants. Although topical treatments may aid normal individuals, patients with diagnosed hyperhidrosis usually can’t benefit from its effects. Likewise, antiperspirants can only reduce sweating in the armpits. The second treatment type is called ionthophoresis. During this procedure, patients will hold minutely charged electrical products and later soak their hands or feet in water in order to reduce sweating. This treatment type isn’t popular because not only is it unable to treat armpits, results are too inconsistent. The best non-invasive treatment of hyperhidrosis is Botolinum Toxin A (BTA) injections. BTA treatments have been very effective in treating hyperhidrosis in the armpits, palms, feet, groin, chest and face. Success rates are at least 95 percent and failure rates remain subjective due to measurements of sweat reduction as opposed to zero improvement. At least 80 percent of my patients report 60 to 70 percent improvement rates while only five percent have reported less than 50 percent. Nonetheless, it’s unlikely that patients experience no improvement at all.
How are the injections carried out?
Before treatments begin, affected areas will be anaesthetised with either numbing cream or ice. Should patients complain of underarm sweating, topical anaesthetic will be applied. Conversely, because numbing cream doesn’t work well on the palms, patients are encouraged to hold on to ice for improved comfort. We will inject BTA intra-dermally or into the skin. It’s impossible for doctors to inject the toxin directly into the sweat glands because they’re difficult to identify. Once the entire affected area is treated, BTA will prevent the release of neurotransmitters responsible for muscle contraction. Sweat glands are made of muscle and because BTA prevents muscle contractions, sweat cannot be excreted. BTA is very safe and doesn’t interfere with the production, development and manufacturing of sweat. It does however, effect in sweat’s delivery.
How long do BTA injection treatments last before patients have to return for a follow-up?
Patients who undergo BTA for hyperhidrosis should expect improvements after five days. Excessive sweating will tremendously reduce after five weeks and results should last between four to five months. Patients will find a reemergence of sweat at the six-month mark and this is an indication for repeated sessions.
Keeping Sight Right
Cosmetically appealing eyes are good to have, but optimum ocular function is really what’s most important, writes Mariel Chow.
The eyes are one of the body’s best qualities, with both men and women agreeing that they are an important factor when selecting a potential partner. While symmetry, eye colour and long lashes may be cosmetically appealing, what’s the point of flawless beauty if ocular function is not at its best? Cataracts, glaucoma and poor eyesight are common, and at times, very serious conditions. Apart from causing unattractive outcomes such as cloudy eye colour or even the loss of an eyeball, cataracts and glaucoma will and can cause deficiencies such as blurred vision, blindness, bloodshot eyes and pain. Along with ocular diseases, shortsightedness could also be a nuisance as one has to constantly wear glasses or contact lenses which sometimes affect in visual aid maintenance, lost appliances and lens allergies.
Sight is one of the body’s most important senses and treatment of ocular diseases is key to a healthy, happy and more functional lifestyle. In this article, we speak to Consultant Ophthalmologist and Oculoplastics Surgeon, Professor Dr. Chua Cheng Nen as he explains the many symptoms related to cataracts and glaucoma and their treatments. Later, Consultant Ophthalmologist, Dr. Jason Ngo Chek Tung chimes in to give us the low down on LASIK surgery and how everyone can have perfect vision for the rest of their lives with only one simple treatment.
40270009 - surgeon team in uniform in front of eye vision surgery operation room at medical clinic
According to Prof Dr. Chua, a cataract is a condition which causes the clear lens to become opaque, preventing sufficient light rays from entering the eye, and thus causing blurred vision. This ocular condition mainly affects the elderly. Recent Malaysian studies have found that 80 percent of people over the age of 60 have some form of cataract. Although uncommon, cataracts can also be present among young patients. Risk factors for early cataracts include ocular injury, steroid use and diabetes. Congenital cataracts or cataracts among infants are also a rare possibility, affecting three or four out of 10,000 live births. Prof Dr. Chua explains, “Some of these congenital cataracts are inherited and some are caused by infections that occur during pregnancy.”
dr-chua-chung-nen Consultant Ophthalmologist and Oculoplastics Surgeon, Professor Dr. Chua Cheng Nen
Prof Dr. Chua says cataracts are the world’s leading cause of blindness and he stresses that patients should visit an ophthalmologist as soon as they experience blurred vision. Other symptoms patients should look out for include frequent purchasing of spectacles due to increased short-sightedness, dull colours, poor vision in bright light, haloes around light, difficulty reading, watching TV or driving at night. “Once patients complain of these symptoms, the ophthalmologist will examine the eyes using a slit lamp to confirm the presence of cataracts,” Prof Dr. Chua shares. He also adds that not all cataracts are visible to the naked eye, unless the condition is highly advanced. Furthermore, it’s worth noting that ophthalmologists will additionally look for occurrences of other eye conditions such as glaucoma or macular degeneration as well.
Ophthalmologists will examine a patient’s near and distant vision and look for any lens opacities with a slit lamp. Moreover, intraocular pressures will also be checked to exclude glaucoma. Lastly, pupils will be dilated using topical medications such as tropicamide so that retinas can be examined and abnormalities can be excluded. Prof Dr. Chua warns, “Patients may experience blurry vision for about two hours after pupil dilation and aren’t advised to drive during this time.”
He ascertains that symptoms related to age-related cataracts such as poor vision can be reduced through the use of spectacles, magnifying glasses or stronger lighting. He also suggests that studies are looking into eye drops that may even reverse the condition. Despite short-term measures and possible non-invasive methods, the only effective treatment is surgery. The eye specialist may use one of two methods for cataract removal. “The first method is called extracapsular cataract extraction and involves a longer surgical incision that’s applicable when the cataract is too thick and cannot be broken into small pieces,” Prof Dr. Chua explains. The second and more common surgical type is called phacoemulsification. It involves smaller incisions and fortunately effects in shorter recovery periods.
The extracapsular cataract extraction method involves a ten-millimetre incision made on the white of the eye, above the iris. The cataract is later removed in one piece through the surgical opening. Lastly, the anterior lens capsule is also removed in the process with the posterior lens left in place. The second and more common surgical type – phacoemulsification – is practiced in 90 percent of all cataract cases. Prof Dr. Chua says, “A small, narrow probe with an ultrasonic tip is inserted into the lens. The emitted waves will break the cataract into tiny pieces.” Like the extracapsular cataract extraction method, the anterior lens is removed in the process and fragments are carefully extracted via a small suction device.
Prof Dr. Chua points out that after the cataract is removed, the specialist will insert an artificial lens that will remain permanently in the eye. “The implant is inserted in the space between the iris and the posterior lens capsule and held in position by special loops that are part of the implant’s design,” he reveals.
Ocular operations require the use of tiny instruments and a microscope. Before surgery, eye drops will be applied to aid in pupil dilation and surgical facilitation. “If the patient is anxious, some sedatives may be given. Patients will experience zero discomfort as topical anaesthetic eye drops will be applied,” he declares. After the eye is cleansed and covered in linen, an instrument called the retractor is used to keep the eye open and prevent blinking. Additionally, pupil dilation leads to blurred vision and patients will not be able to see the instruments used to operate. Prof Dr. Chua cautions, “The treated region will remain covered until it is examined and patients are advised against wetting or having any type of foreign body in the eye.” Sensitivity to light is common so patients are encouraged to wear sunglasses over the next few days, especially if they go outside.
Cataract surgery is normally performed one eye at a time. Prof Dr. Chua asserts that this is due to risks of infection that although rare, can be very serious. Although this may be the norm, surgery on both eyes may be applicable for patients who have difficulty making two trips. These patients are commonly those with Down’s syndrome or who suffer psychiatric conditions. In cases like this, operations are normally performed under general anaesthesia.
Glaucoma is a condition which affects the optic nerve. It is usually caused by build up of pressure within the eye. If left untreated, vision will progressively worsen. Visual loss is irreversible. The high intraocular pressure in glaucoma causes damage to the nerves that convey vision to the brain. When the nerves are damaged, they cannot regenerate and with time, vision will be lost when nerves are destroyed. Prof Dr. Chua states, “Glaucoma is usually caused by increased intraocular pressure. The eye produces a nourishing fluid called the aqueous humour and it circulates around the tissues of the inner eye and drains through an outflow channel called the trabecular meshwork.” Normal intraocular pressure is when there is balance between the amount of fluid present and the amount that’s drained away. If the meshwork within the eye is impaired, pressure begins to build up due to the collection of fluid.
Glaucoma can affect the eyes in two ways. Chronic glaucoma – which is more common – develops gradually and is often without signs or symptoms. According to Prof Dr. Chua, glaucoma is often called the thief of sight, as visual loss is unnoticeable during the condition’s early stages. Acute glaucoma, on the other hand, is less common and occurs suddenly, with patients experiencing a sharp rise in eye pressure affecting in pain.
Prof Dr. Chua reports that although glaucoma commonly affects elderly patients, there are several risk factors that increase the chances of one suffering from the condition. He explains, “Family history can be a factor, if one’s parents or siblings develop glaucoma, there are significant risks that one may develop it too. In such instances, it’s essential that high risk patients undergo annual checkups as they may aid in early detection.” Apart from family history and age, Prof Dr. Chua expounds that ethnic groups such as the Chinese may be more susceptible to glaucoma as well. Moreover, patients with diabetes or those who use certain medications such as steroids may also be at risk. Lastly, patients with long-sightedness may also have increased chances of acute glaucoma.
As previously explained, it may take a long time before patients with chronic glaucoma experience any problems. “Effects are inconspicuous because glaucoma tends to damage the outer edge of the visual field and works slowly inward,” Prof Dr. Chua shares. Patients may only notice problems after the disease begins to affect the central part of one’s eye and vision. Treatment can prevent the impairment from becoming worse but unfortunately isn’t able to reverse the damage. Conversely, acute glaucoma will usually bring patients straight to the clinic and to the attention of eye specialists early, as vision will become blurred and suddenly affect in painful, red eyes.
Chronic glaucoma is detected via three indications. First, there must be high intraocular pressure of more than 21mmHg. Next, loss of optic nerves can be examined in the back of the eye and finally, an abnormal visual field is done using a computer. On the other hand, acute glaucoma can be detected via very high intraocular pressure of more than 40mmHg and closure of the angle at the front of the eye through which fluid drains.
Prof Dr. Chua confirms that treatment aims are to reduce pressure in the affected eye, either by fluid drainage or reduction of produced fluid. He clarifies, “The usual treatment for chronic open angle glaucoma is eye drops as it helps prevent damage to the optic nerve by controlling eye pressure.” The effectiveness of the drops will be monitored during regular glaucoma checkups, with some patients needing a combination of eye drops to help control the pressure. “It’s essential that patients do not stop the eye drops without instructions from the eye specialist. Patients are required to continue using the drops for life,” Prof Dr. Chua emphasises.
Although the majority of chronic glaucoma cases can be controlled non-invasively, patients whose pressure cannot be controlled may be recommended laser treatment to the angle of the eye in which fluid drains. Prof Dr. Chua further adds that should both eye drops and laser treatment fail, specialists will recommend glaucoma surgery or trabeculetomy. He says, “Trabeculectomy is a procedure where a hole is created at the top part of the eye to allow fluid to better drain, and thus reduce pressure.” Unlike patients with chronic glaucoma, those with acute glaucoma will undergo a special laser procedure to create a hole in the iris to aid in correct fluid drainage.
Trabeculectomy involves the creation of a new channel in the white wall of the sclera through which fluid flows out into a space underneath the conjunctiva. “A successful trabeculectomy is the creation of something called a ‘bleb’ or a small elevation which is usually covered by the upper eyelid,” says Prof Dr. Chua. The surgery is usually done in an outpatient setting under local anaesthesia. The local anaesthetic is injected beside the eye, which makes the eye both numb and blurred. Later, a paper drape is placed over the patient’s face and a clip keeps the eye open. Prof Dr. Chua suggests that although the patients may be able to grasp light and shadow, they won’t be able to see the surgery carried out. During the procedure, additional medication may be used to prevent scarring as it may affect in poor drainage. The surgery takes about twenty minutes to half an hour to complete and upon completion a patch is taped over the eye, which won’t be removed until the next day. “Frequent follow-ups over the next few weeks is required and all surgical patients will need to be reviewed a day after surgery,” Prof Dr. Chua maintains. He adds that if all is well a day after surgery, patients can return for a review a week later and once more a week to three weeks later. The amount of follow-ups will depend on how well the eye is settling. Frequent visits are most times required.
dr-jason-ngo Consultant Ophthalmologist, Dr. Jason Ngo Chek Tung.
LASIK or Laser-Assisted In-situ Keratomileusis is a procedure, which corrects refractive errors by reshaping a patient’s corneas. According to Dr. Jason, candidates who are eligible should be 18 or older, with healthy and stable eyes and sufficient cornea thickness. He explains, “LASIK removes the need for vision correction aids such as spectacles or contact lenses.” Dr. Jason also adds that apart from improved facial aesthetics, eradication of contact lenses or glasses can remove the need for vision aid maintenance and lens intolerance.
First and foremost, the femtosecond laser is applied to the patient’s cornea to create a flap. After the flap is created and gently lifted, the excimer laser is used to reshape the cornea. “After the cornea is reshaped, the flap will be placed in its original position and will naturally reattach on its own within a few days, without the need for suturing,” he says.
Before the advent of LASIK surgery, ophthalmologists carried out the procedure manually with nothing more than the surgeon’s skill and a blade. Dr. Jason shares, “The main difference between the manual and bladeless method is that flap creation is more consistent and precise in thickness”. He goes on to state that choosing the appropriate surgical type is especially important among patients with flat and steep corneas. “Manual procedures aren’t appropriate among patients with flat and deep corneas as it may respectively cause buttonhole or loose flaps,” he warns. To provide better surgical outcomes, Dr. Jason reports that he sticks to bladeless procedures as chances of complications are drastically reduced.
What can patients expect?
LASIK surgery will take about 20 minutes for both eyes and patients will feel comfortable throughout the procedure, as processes are absolutely painless. Dr. Jason asserts, “There is no pain or itching immediately after surgery, but there may be chances of mild discomfort similar to onion chopping exposure.” Although this may be, discomfort should last no more than a day. Along with that, some patients may also experience mild sensitivity to light at night and experience halos or glares. Like the discomfort, light sensitivity will also diminish and patients can expect glare-free vision after the first postoperative week.
Patients will also be prescribed eye shields or patches that should be worn at night. This is to avoid eye rubbing during sleep. Furthermore, Dr. Jason also advises patients with young children to be cautions of accidental eye hitting as well. Other things to steer clear of are eye makeup and eye cream. He also advises, “Patients should avoid getting any water, sweat, dust or smoke in their eyes and hence circumvent activities such as swimming, saunas or facial treatments for at least a month.”
Dr. Jason reveals that patients will see quite well immediately after the procedure but can expect perfect vision after a month. The results of LASIK surgery normally lasts a lifetime unless patients develop other ocular diseases such as cataracts later in life.
Dr. Jason reveals that patients will see quite well immediately after the procedure but can expect perfect vision after a month. The results of LASIK surgery normally lasts a lifetime unless patients develop other ocular diseases such as cataracts later in life.
before-and-after-lasik-surgery Before and after LASIK surgery
Although LASIK surgery may be the commonest form of correction, technological advancements have gone far and beyond to provide patients with additional options that are safer and more efficacious. In short, surgical intervention to correct shortsightedness can be viewed as First generation (the manual method that utilises a blade to create a corneal flap), while the second generation is LASIK which employs a blade to create a flap. It’s very precise and effects in fast recovery periods, and the Third generation. Called the SMILE procedure, it doesn’t require a flap and is done via minimally invasive methods (keyhole surgery) and hence, is very safe. Dr. Jason reveals, “This technique utilises a femtosecond laser, which cuts a lenticule within the corneal stroma. The same laser is used to cut a small incision (about one fifth the size of a standard LASIK flap) along the periphery of the lenticule. Later, the surgeon uses a specially designed instrument to separate and remove the lenticule, leaving the anterior lamellae of the cornea intact. Unlike standard LASIK surgery, there is no need for the excimer laser.
The Good, The Bad and The Ugly
Mariel Chow rounds up a panel of professionals to discuss the upsides and dark side of plastic surgery.
Plastic surgery is a medical specialty that corrects bodily imperfections through cosmetic or reconstructive surgery. A multi-billion dollar industry, both the masses and elite alike are turning to plastic surgery to improve not only function, but also quality of life. While reconstructive surgery plays a big role in the overall healthcare of the public, cosmetic procedures have turned into a booming business, with everyone wanting a share of the pie. With physical beauty becoming a need more than a want, patients have become progressively demanding and callous in the hopes of perfection. As this pursuit of beauty continues, patients are seeking cheaper options and unscrupulous doctors have taken advantage by offering invasive procedures they aren’t trained to practice.
picture of beautiful woman beautiful woman in spa salon
How does reconstructive surgery benefit patients?
Dr. Somasundaram Sathappan (Dr. Soma): One of the great attributes of plastic surgery is of course reconstructive procedures and its contribution to the masses and society’s overall healthcare. I personally believe the public should be made aware of our contributions, as many assume our practices mainly involve cosmetic surgery. To be very honest, reconstructive surgeries consist the bulk of a plastic surgeon’s work and consume 70 percent of a doctor’s working day. Examples of such mainstream reconstructive surgeries are normally burns, hand and craniomaxillofacial surgery, cleft palates, head and neck cancers and reconstruction of various bodily defects. These are the positive aspects of plastic surgery, which can be enjoyed and taken advantage of by everyone. Furthermore, such procedures are very affordable and available free of charge in government hospitals or covered by medical insurance.
dr-somasundaram Plastic and Reconstructive Surgeon, Dr. Somasundaram Sathappan.
Plastic surgeons are sometimes rumoured to be money-grubbing doctors who only care about profit. The public must understand that most Malaysian plastic surgeons have significant reconstructive practices and do play significant roles in medicine and public healthcare. Although this may be, it’s an undeniable fact that there are surgeons outside Malaysia who only practice cosmetic surgery and hence, prioritise profits. In my personal opinion, if there are doctors who choose to undergo four to five years of plastic surgery education and only three months of aesthetic surgery training simply to practice cosmetic surgery, there’s no denying they’re in it for money and not for the love of his or her profession. In summation, good plastic surgery is achieved when surgeons not only save lives, but improve a patient’s general wellbeing.
Plastic and Reconstructive Surgeon, Dr. Matthew Yeo. Plastic and Reconstructive Surgeon, Dr. Matthew Yeo.
Dr. Matthew Yeo: Reconstructive surgery involves improving function and quality of life of patients who are suffering from disease or pathology. Satisfaction may be found in all aspects of successful reconstructive surgery. Successful reconstructive surgery is a combination of appropriate patient selection, good surgical planning, meticulous execution and good postoperative care. Successful outcomes are gratifying to both patients and plastic surgeons alike.
How does cosmetic surgery fall in the confines of ‘good’ plastic surgery?
Dr. Matthew: Cosmetic surgery involves improving the function and quality of life in patients, in the absence of disease. It falls on the same continuum as reconstructive surgery and plastic surgeons are familiar with both reconstructive and cosmetic surgery. Similarly, good outcomes from cosmetic surgery require good patient selection, and appropriate execution by appropriately trained specialists, i.e. qualified plastic surgeons. Successful cosmetic surgery results in improved self-confidence and reduces anxiety, and results in better psychosocial functioning of patients.
dr-heng Plastic and Reconstructive Surgeon, Dr. Heng Kien Seng.
Dr. Heng Kien Seng: The first and most important advantage brought upon by cosmetic surgery is the improvement of one’s self-esteem. Furthermore, there are many who undergo aesthetic procedures not only for physical confidence but to boost self-assurances when seeking life partners. Beauty and natural youth is fleeting and windows of opportunity for love can get smaller as time passes. During this limited timeframe, both men and women want to look their best in the hope of abundant and plentiful options. Relationships aside, more people are opting for surgical procedures to advance employment opportunities. Everyone has a degree now and should two competing job candidates have zero experience, employers will probably judge one based on his or her physical appearance. Moreover, there are certain businesses that necessitate good looks. For example, if one is a beauty product or aesthetic treatment salesperson, it’s essential that he or she look the part and appear as youthful or beautiful as the products or treatments intend. Lastly, those who are experiencing declining relationships such as marital woes may also take advantage of improved self-confidence brought upon by cosmetic surgery. Despite being a last ditch effort to save one’s marriage, with low chances of reconciliations, there have been instances where relationships maintain their present state or even improve. Although I never guarantee reunions, I believe reconciliations are due to a partner’s remorse after considering the physical pain a wife or husband had to endure just to save a marriage.
Dr. Soma: Yes, I agree with Dr. Heng. Cosmetic procedures whether blepharoplasty or breast augmentation still fall under the realm of ‘good’ plastic surgery as it improves self-esteem and relationships. Honestly, people will be surprised at what a full head of hair and lack of a beer belly can do for a man. While cosmetic procedures are sometimes deemed superficial, such enhancements do greatly matter to a fair few. At the end of the day, it really doesn’t matter how superficial a defect may be. If certain flaws emotionally scar a patient, cosmetic surgery may be the key to improved quality of life. However, because aesthetic operations are elective, it’s the doctor’s responsibility and duty to deliver good outcomes through reasonable expectations and minimal complications.
What are the ‘bad’ qualities of aesthetic surgery?
Dr. Soma: The ‘bad’ aspects of plastic surgery are divided into unreasonable patient expectations and unrealistic doctor assurances. An example of unreasonable expectations could be hair loss patients who expect a full head of hair after a single hair transplant procedure. It’s just not possible. Patients must understand that certain cosmetic or aesthetic procedures will require a few treatment sessions before desired results are achieved. Patient awareness is vital and doctors have the responsibility of educating their patients and not overpromising and providing unrealistic assurances.
Unrealistic assurances are very uncommon among plastic surgeons because we err on the side of caution. In fact, we will argue against unnecessary procedures if we can help it. Plastic surgeons tend to be more conservative because we understand surgical limitations. Should patients expect extras that can’t be delivered, we argue against it. When patients seek certain procedures and have unrealistic expectations, we will show them before and after photos of previous patients to give them an idea of possible outcomes. If they have increased expectations and luckily achieve what they have desired, fair enough. Conversely, if expectations weren’t achieved, it doesn’t mean surgery was unsuccessful, but more likely, that expectations were improbable.
Dr. Heng: I believe that patients tend to have unrealistic expectations because of the images presented in the media. Patients are constantly bombarded with picture perfect models with stunning faces and bodies whenever they watch television or flip through glossy magazines. Because of this, patients assume that such flawless physical attributes are attainable with cosmetic surgery. What patients fail to understand is that surgery will have its limitations based on one’s distinctive physical features such as muscle and bone structure. As Plastic Surgeons, we tailor each procedure based on a patient’s attributes and have them undergo a grading system. If there is a scale out of ten with ten being the most beautiful, it’s nearly impossible for surgeons to turn patients from a two to a perfect ten. Despite surgeons doing their level best and creating the best outcomes, perfection is most times unachievable.
Additionally, unrealistic assurances will result in excessive expectations that cannot be met. As a result, patients will be extremely upset with outcomes especially after exorbitant fees have been paid. Doctors have a responsibility and shouldn’t promise results they can’t deliver. As Dr. Soma has pointed out, unrealistic assurances aren’t common among Plastic Surgeons as we’re highly trained, but we have come across our fair share of disgruntled patients.
031 Plastic and Reconstructive Surgeon, Dr. Matthew Yeo.
Dr. Matthew: A subgroup of patients seeking cosmetic surgery suffer from depression or anxiety disorders which predisposes them to unrealistic expectations. Some patients may also suffer from body dysmorphic disorder. It is unfair to say that patients on the whole “commonly have unrealistic expectations” – it is important for patients to seek qualified plastic surgeons so that they may receive realistic preoperative counselling about the anticipated results and potential complications. Plastic surgeons also undergo rigorous training in aesthetic surgery and are best placed to deliver results relating to rejuvenation and enhancement.
What are the ‘ugly’ attributes of cosmetic surgery?
Dr. Soma: The ugly side of cosmetic surgery is when unlicensed doctors attempt plastic surgery and cause deformities or even commit manslaughter. Not only is money lost, patients may end up with defects they didn’t even have to begin with. There have been an increasing number of aesthetic physicians and unlicensed international doctors who aren’t practicing invasive procedures such as liposuction and high volume fat transfer which result in unspeakable complications.
To be fair, there are two schools of aesthetic physicians. Firstly, there are the good ones who are reasonable and conservative. The second group, however, is out for money, practices surgery they aren’t familiar with, and have no regard for a patient’s wellbeing. These are the type of doctors who aren’t properly trained but believe they’re capable of performing invasive procedures after undergoing a short three-day course. To give you an example, I had a patient who experienced sepsis and nearly died after undergoing large volume fat transfer with an aesthetic physician. She was admitted into the Intensive Care Unit and I fortunately managed to draw out all the oil cysts and pus in her breasts while maintaining some form of cosmesis. Additionally, there are unlicensed surgeons from China and Korea who are performing ‘backdoor’ surgeries in beauty spas and hotels as well. While I have not personally treated such patients, news from both the grapevine and media have reported at least ten deaths in the last three or four years!
Although complications among unlicensed doctors are common, I must admit that even plastic surgeons experience hiccups too. For example, I remember a time when one of my patients suffered infections after a breast augmentation. I immediately removed the affected implant and she was forced to live with deformities for two months before a new implant could take its place. Even though this was my one and only breast augmentation complication, problems can arise. Despite this fact, plastic surgeons are highly trained and we have the know-how and ability to treat difficulties before they turn for the worst.
Dr. Heng: Yes, the ugly attribute of cosmetic surgery is of course complications. Although postoperative glitches can happen, complications will drastically reduce should patients opt for trained and licensed plastic surgeons that perform procedures in aseptic environments. Conversely, if patients select untrained and unlicensed doctors – illegal international surgeons or local general practitioners – who perform prohibited high-risk procedures in improper locations, chances of complications will likely increase.
I always remind patients that famous and popular surgeons from China or Korea very rarely leave their home countries to perform surgeries overseas because they earn enough back home. Moreover, they will never risk the chance of getting caught for practicing illegal procedures in an unauthorised country.
There are also many Malaysians who travel all the way to Korea to undergo cosmetic surgery. From personal experience, some have come back with good results while others have returned with unfortunate complications. Furthermore, there are local beauticians who band together with the Koreans to encourage overseas surgery. While I cannot deny that some Korean doctors are good, it’s just not true to say that all of them are better. In addition, patients have to pay much more, endure increased travel time and of course, no opportunities of follow-ups with their surgeons.
Apart from unlicensed international doctors, there are many non plastic surgeons who are offering highly invasive surgical procedures. In my professional opinion, such doctors are putting patients at great risk.
Because there is an increasing number of doctors who have to compete amongst themselves, they have no choice but to offer procedures like high volume liposuction and high volume fat transfer to maintain a steady stream of clients. It is unfortunate that although guidelines clearly rule against such surgeries among non plastic surgeons, illegal procedures are still practiced in order to be competitive. From personal experiences, I’ve come across horrifying complications including, infections of the breasts and chin, necrosis of the nose, nerve palsy and even fillers in the brain.
Necrosis of the nose due to illegal procedures
Unauthorized injections to the chin
Unauthorized Injections to the lips
Eyelids done by unqualified practitioners
Breasts enhancement done by unqualified practitioners
What conscious efforts should the government and patients take in order to eradicate illegal surgeries?
Dr. Matthew: The Ministry of Health maintains a list of qualified plastic surgeons in Singapore and this is accessible via the Internet. Being treated by qualified plastic surgeons that have undergone appropriate training is the best way of attaining optimal results, while minimising incidences of complication. Additionally, there is the Ethical Code and Ethical Guidelines which all registered Singaporean doctors must abide by.
Dr. Soma: All Malaysian doctors must adhere to the rules and regulations spelled out in the Malaysian Guidelines on Aesthetic Medical Practice and LCP (Letter of Credential and Privilege). It’s a shame to say that although legislations are in place, enforcement is lacking with prosecution practically unheard of.
Secondly, patients must realise that cosmetic surgery is elective. You don’t need cosmetic surgery, you want cosmetic surgery and one will not die if one doesn’t have it. Because aesthetic surgery is unnecessary for survival, it should be done well with minimal chances of complication. Likewise, patient assessment is important and plastic surgeons must ensure that patients are healthy, have reasonable expectations and enough financial support.
Last but certainly not least; all doctors should be well trained and honest with their patients. If certain practitioners don’t have the required abilities, they can always undergo appropriate training, which is readily available. Likewise, doctors should always start small and practice smaller, simpler procedures before bigger, more complicated ones. In other words, get your skills in line before attempting anything out of your comfort zone.
Dr. Heng: Illegal surgeries practiced by unlicensed doctors happen often but no action has been taken. In fact, many doctors know who exactly are performing such procedures, but the Malaysian Ministry of Health has inadequately corrected this problem. Likewise, there are plenty of rules and guidelines for doctors to follow, but beauticians and aestheticians have yet to be regulated. In my opinion, the government should be taking well-conceived steps against all unlicensed surgeons, general practitioners and even beauticians. There isn’t enough enforcement and if the Malaysian Ministry of Health really wants to crack down on such personnel, they could always take conscious efforts of either introducing spies or rewarding patients who make formal complaints.
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