The Diabetes Epidemic - The not so sweet news about diabetes and plastic surgery

Diabetes can affect anyone. In this article, we speak to Consultant & Reconstructive Surgeons, Dr. Somasundaram Sathappan and Dr. Margaret Leow and Diabetic Nurse Educator, Siti Nor Asiah binti Ab Khadir, who explain the disease's risks and why, when surgery is concerned, it's better to be safe than sorry.

Dr. Somasundaram Sathappan - May 27, 11:48 AM

Diabetes can affect anyone. An estimated 425 million people worldwide are affected by the chronic condition. In Malaysia alone - according to the National Diabetes Registry Report - prevalence of diabetes among adults is expected to rise by 21.6% by the year 2020. This alarming percentage should not be a surprise, because our nation 'boasts' one of the highest rates of obesity in Asia.
Diabetes is the leading cause of blindness, kidney failure, amputations, heart failure and stroke. And if that's not reason enough for someone to diet and exercise, diabetics also experience immunosupression and poorer wound healing, leading to higher rates of complications during and after surgery.
Consultant & Reconstructive Surgeon, Dr. Somasundaram Sathappan
What is diabetes?
Diabetes mellitus is a chronic disease. It is caused by inherited and/or acquired deficiency in insulin production by the pancreas, or by the effectiveness of the insulin produced. Such deficiencies result in increased concentrations of glucose in the blood, which in turn damages many of the body’s systems – in particular the blood vessels and nerves. There are two major types of diabetes: type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM). T1DM is when the pancreas fails to produce insulin essential for survival. This form typically develops more frequently among children and adolescents, but is also increasingly noted among adults. T2DM is much more common, occurring most frequently in adults, but is being noted in adolescents as well. Gestational diabetes mellitus is defined as any degree of glucose intolerance with onset or first recognition during pregnancy.
   “Diabetes can affect anyone,” says Diabetic Nurse Educator, Siti Nor Asiah binti Ab Khadir. “Nonetheless, people who are more at risk are those with family histories of diabetes. Other risk factors include obesity, high cholesterol, high blood pressure and physical inactivity. While the incidence of T2DM among adolescents are growing, risks increase as ageing continues, with patients very likely to develop the disease should they be over 40 and overweight.”
Diabetes mellitus is a chronic disease. It is caused by inherited and/or acquired deficiency in insulin production by the pancreas, or by the effectiveness of the insulin produced.
Diabetes treatment
Dr. Margaret says T1DM (aside from that occurring among the young) tends to quite problematic and difficult to manage. T2DM however, happens when patients don’t control sugar ingestion, or become fat. As such, the disease’s first-line treatment is diet control and exercise, avoiding sugary food and drinks. If diets remain uncontrolled, doctors will subsequently prescribe oral hypoglycaemic agents and other medications which aid in zero sugar absorption by the kidneys. While these drugs have the capabilities of limiting sugars, they cannot target the root problem of insulin resistance. Therefore, if problems persist, diabetics must be treated with injectable insulin, allowing the body to better absorb sugars. 
   Despite many diabetic patients being overweight, not all are fat. In general, however, Dr. Margaret does lament, “The heavier you are, the higher the risks of diabetes.” In fact, she’s even had a patient who cured his own symptoms by simply losing 12 kilos following an illness. However, when he started getting better, the poor dietary habits returned, which then prompted disease recurrence. “In my opinion, if patients did nothing more than diet and exercise, the problem can be fixed,” Dr. Margaret advises. She adds, “Honestly, and according to bariatric surgery data, patients who’ve undergone gastric bypass surgery have recovered from diabetes with nothing more than food restriction. 
Associated risks
Diabetes risks are divided into medical and surgical complications, says Dr. Margaret. Long-term medical problems include blindness from retinopathy, ischemic heart disease, peripheral vascular disease, and loss of finger and toe sensations. Once foot ulcers go unnoticed and take a turn for the worst, infections can spread to the foot and bone, leading to amputations. Likewise, diabetics may also suffer kidney disease followed by end-stage renal failure, necessitating dialysis. Dr. Margaret laments, “In Malaysia, one of the leading causes for renal failure is diabetes and hypertension.” She further bemoans, “Despite it being a hereditary disease, families still don’t watch their diets. It’s shocking to see diabetic patients with overweight children, who are also on the road to future disease!”
   In terms of surgical risks, diabetic patients present with smaller blood vessels, resulting in decreased oxygen delivery, Dr. Soma warns. He says, “When your blood vessels are small, the amount of blood flow to the tissues reduce, impeding tissue viability.” In other words, when diabetic patients go under the knife, they not only experience poorer wound healing, but also higher risks of infection due to immunosuppression. Besides, the longer patients live with diabetes, the poorer the outcome. As such, and because the damage is insidious and on-going, where vessels become teenier over time, patients may still be susceptible to post-surgical infection and poor wound healing, despite optimal sugar control. Dr. Soma asserts, “While diabetes can be eradicated through massive weight loss, this is very rare especially when patients aren’t disciplined or aware of current bodily conditions and risks.” 
Diabetics and plastic surgery
Dr. Soma shares that diabetics who don’t respond well to oral drugs need injectable insulin. Diabetics under insulin treatment cannot qualify for elective surgery because they’ve suffered diabetes for longer periods. Additionally, patients will similarly have had suffered kidney damage in conjunction with heart and liver issues. Even if patients haven’t experienced longstanding diabetes, they’re still subjected to other susceptibilities like heart attacks. At the end of the day, and because all diabetics are at risk, none of them are recommended cosmetic surgery in Dr. Soma’s practice. 
   In Dr. Margaret’s practice however, viability for elective surgery depends on how controlled symptoms are and what type of surgery is desired. She suggests, “If the procedure is small (double eyelid creation), it may be admissible, because surgeries are clean and superficial.” She adds, “While such elective procedures aren’t allowed in government practices, private hospitals may permit them by offering more antibiotics for longer.” Despite the fact, Dr. Margaret does warn that too much antibiotics aren’t always encouraged due to potentialities of super bug resistances. 
   Although cosmetic surgery isn’t always endorsed, reconstructive surgery is many times a must. If patients are caught in life and death situations, like burns and tumours, surgeons have no choice but to go ahead with treatment. Dr. Soma insists, “As surgeons, we have to work with what we are given.” He however adds, “Still, we must also explore non-surgical options like antibiotics and wound dressings before promoting invasive surgery. Nonetheless, and if surgery is the only and best option, it’s essential we optimally stabilise patients before performing procedures.”
Pre-operative and consultative necessities.
Since a thorough stabilisation of one’s comorbidities is needed pre-surgery, doctors must assess how long patients have been living with the disease including its gravities. Moreover, a thorough investigation of patients’ drug history must be conducted before they’re referred to an endocrinologist. “A comprehensive diagnostic check is needed because the whole body must work in synchronicity for it to function,” Dr. Soma informs. He further states, “For injuries to heal, the whole body has to work together. You can’t assume if one organ doesn’t function well, but another is strong, that bodies are healthy.” 
   Dr. Margaret sustains that should patients remain adamant on surgery or when procedures are necessary, blood tests are required to investigate disease severities. She says, “If comorbidities are proven to be in good states, we can move forward with surgery. If problems are present, I will refer patients to an endocrinologist or their own physicians to have comorbidities managed.” In short, Dr. Margaret may still perform surgeries as long as patients are at lower risk and informed of diabetes’ associated complications. 
   In regard to the types of diagnostic performed, diabetic patients normally undergo blood tests as an outpatient. If sugar levels are high, Dr. Margaret may admit patients a day before surgery to have sugar levels under control. Should tests show very high blood sugars, doctors may ward patients a few days prior to surgery. In the event individuals are admitted in hospital, repeated blood tests can be taken three or four times daily or before meals. Despite the multiple forms of diagnostic examinations, Dr. Margaret’s prefers the HBA1c test because it investigates sugars over the past three months. This means patients aren’t able to cheat by fasting. If blood sugar levels have always been high, diagnostics will result in the affirmative. Once patients have undergone all relevant examinations and been given the green light, Dr. Margaret recommends one more blood and urine test to affirm controlled symptoms and optimal renal function before surgery. Last but not least, patient will also undergo ECGs and chest x-rays to corroborate healthy hearts which aren’t prone to heart attacks during operations. 
Diabetic patients during surgery 
Because diabetic patients don’t heal as well as healthy individuals, operation techniques may differ during surgery. Aside from stabilising patients, surgical plans have to be made clear as surgeons normally keep surgeries minimally intrusive, preferring only to perform what’s necessary in order for better recuperation and limited infection. “Where plastic surgery is concerned, we do what we can do limit open surgery. If procedures require a flap for example, I may just replace that technique with a safer skin graft instead,” Dr. Soma comments. He adds, “While cosmesis is hindered, patients must understand that beauty is secondary to ideal recovery and less morbid complications.”
   Like Dr. Soma, Dr. Margaret also opts for easier, less invasive surgical options, as diabetics experience more medical and surgical risks. Nevertheless, Dr. Margaret does share all options, but may choose not to take on patients if she’s uncomfortable with their choices. She argues, “Gone are the days where doctors make the decisions. While patients always prefer better cosmetic outcomes, I do advise that invasive surgeries in conjunction with comorbidities will increase instances of heart attacks, strokes and deaths during surgery.”
Diabetic patients after surgery
Patients suffering comorbidities like diabetes and hypertension are encouraged hospital admission following surgery. This is done not only to guarantee safe sugar levels but to support ideal healing as well. Likewise, Dr. Margaret will also ensure nominal bleeding, infection and hematoma during procedures. She’s also more cautious with dressings subsequent to surgery, and may even attach drains where necessary. Dr. Soma adds that patients must mobilise or undergo post-operative rehabilitation as soon as possible. This is done in order to avoid stasis and deep vein thrombosis which exponentially intensifies the longer patients lay in bed. Finally, and because diabetics are susceptible to infection, peri-operative antibiotics are a must. Doctors may similarly provide more attention and assistance to those at higher risks. 
Sunway Medical Centre
How to manage diabetes with Diabetic Nurse Educator, Siti Nor Asiah binti Ab Khadir
  • Be mindful of what you eat, and follow a balanced meal plan.
  • Exercise regularly.
  • Take your prescribed medicine. Closely follow all guidelines on how and when to take your medications. 
  • Monitor your blood sugar and blood pressure levels at home. 
  • Keep all appointments with healthcare providers. Undergo all recommended laboratory tests as ordered by your doctor. 
  • T1DM has no known cure. T2DM lasts a lifetime. However, some have managed to get T2DM under control with very minimal doses of diabetes tablets or no medication at all. This can be achieved through ideal weight maintenance pertaining proper diets, regular exercise and close monitoring with healthcare professionals.

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