2-in-1: Plastic surgery and ENT surgery in single sitting

SINGAPORE - When Mr Yeo Khee Kay, 78, went to the Khoo Teck Puat Hospital (KTPH) for a check-up on his leg in August last year, a doctor at the orthopaedic department noticed a black spot on the tip of his nose.

Concerned, he sent the retiree to the otolaryngology (ear, nose and throat) department.

The black tip turned out to be slow-growing basal cell carcinoma (a form of skin cancer), caused by long-term sun exposure.

But Mr Yeo was fortunate on two counts.

First, the cancer had not spread beyond the skin, which boded well for his recovery.

Second, there was an ENT surgeon in the department who not only could excise the cancer but also reconstruct his nose in a procedure called rhinoplasty.

This saved him a trip to another hospital with a plastic surgery department, which KTPH does not have.

Increasingly, ENT departments at hospitals are offering reconstructive surgery for patients who need it after ENT surgery, saving them extra operations or trips and money to have it done.

KTPH is the latest hospital to offer facial plastic surgery at the ENT department. It started doing so early last year.

Changi General Hospital and Tan Tock Seng Hospital have had such a service since 2011, and Singapore General Hospital first offered such a service more than five years ago.

Being able to offer patients reconstructive surgery adds to the holistic management of their medical conditions, the hospitals said.

Often, as in the case of patients at KTPH, it is more convenient for them as they would not have to go to another hospital for reconstructive surgery.

This means that patients avoid a second operation under general anaesthesia, the use of which carries risks in itself, said Dr Barrie Tan, consultant and head of the otolaryngology department at SGH.

Possible complications from general anaesthesia include permanent nerve damage, causing paralysis or numbness, serious allergic reaction to the anaesthetic and, very rarely, death.

"Sometimes, it is best to have immediate reconstructive surgery as the immediate defect is best assessed at the time of primary surgery and can be corrected the most accurately then," said Dr Tan.

Having both types of surgery done in one sitting also means the patient does not have to undergo a second period of post-operative healing and rehabilitation.

An operation done separately later on may have problems such as dealing with scarring at the original operative site that may make the second-stage surgery more difficult.

Patients can also save money if they combine the operations rather than have the operations done separately.

They will not need to pay for the fees of using an operation theatre and general anaesthesia for a second time.

Correcting deformities

Many times, the reasons for both types of surgery are linked and have to be addressed.

For instance, some patients can have nasal obstructions due to external deformities. These are usually related to the nasal septum (the cartilage and bone in the middle of the nose that separates the left nasal cavity from the right nasal cavity) being deviated, often giving the appearance of an external deformity.

Patients often need to have such obstructions surgically removed because they cause difficulties with breathing, which can be extremely bothersome to the patients, said Dr Tan.

Since the nasal obstruction often needs to be surgically removed, it makes sense to correct the external deformity at the same time, he said.

Previously, many patients who had their nasal obstruction corrected by ENT surgeons would not have subsequent reconstructive surgery for their external appearance, said Dr Tan.

Only a few would see a plastic surgeon subsequently to address the deformity in their external appearance.

ENT surgeons with facial plastic surgery training also do reconstructive work to cover defects in the head and neck after cancerous tumours are removed.

"Primarily, these patients come to our department for a medical condition that warrants surgery and, as part of the complete management, there is a need to also offer facial plastic procedures to complement the primary surgery," said Dr Tan.

Dr David Loke, consultant and head of the otolaryngology department at KTPH, said its facial plastic service acts as a one-stop service for its patients to help them enjoy a good quality of life.

More than 120 patients have undergone such surgery at KTPH since the service started.

At KTPH, about 1 per cent of the patients of the ENT department would require some form of facial plastic surgery after surgery for medical purposes.

The majority of patients have functional nasal problems or sustained facial and nasal injuries in road traffic or industrial accidents.

A functional problem of the nose is any problem that affects the ability of the nose to breathe and smell.

Previously, such KTPH patients were referred to the National Skin Centre and other hospitals respectively for dermatological and plastic surgery after the ENT surgery.

Dr Sandeep Uppal, ENT surgeon and consultant at the KTPH otolaryngology department who is trained in facial plastic surgery, said patients who wish to be treated by their own dermatologist or plastic surgeon can still choose to do so.

The reconstruction could be arranged to be done in the same operation as the ENT surgery or separately.

Sharing of skills

Hospitals are increasingly able to offer this service because more of their ENT surgeons are going for further training in facial plastic surgery.

Previously, ENT consultants did not acquire these facial plastic surgery skills during their fellowship training for further specialisation.

ENT surgeons who want to specialise in the area have to serve a one-year fellowship in facial plastic and reconstructive surgery in overseas centres offering this, during which they receive dedicated training in both the functional and aesthetic aspects of facial plastic surgery.

Dr Ian Loh, a consultant at the ear, nose and throat department at CGH, did his training in South Korea.

He said other surgical disciplines which partner with plastic surgery included surgery of the eyes and surrounding structures, and maxillofacial surgery.

It is not unusual for areas to be shared by different specialties, he noted. For example, the field of sleep medicine is shared by ENT surgeons, respiratory physicians and psychiatrists.

"Such an arrangement can be synergistic as each surgical discipline works on a skill subset most familiar to them," he said.

For now, the ENT departments that perform facial plastic surgery do not offer purely aesthetic facial plastic services or operations as surgery is currently done only in conjunction with repairing facial injury.

But ENT surgeons are working with the professional and credentialing bodies to provide purely aesthetic services.

"While that would be an expansion of our existing role, it is not currently an urgent priority as patients who have need for purely aesthetic operations can consult colleagues in plastic surgery to have them performed," said Dr Tan.

For Mr Yeo, convenience was the reason he chose to have his rhinoplasty at KTPH. He lives with his wife and a domestic helper near the hospital and they are familiar with it.

The cancerous tip of his nose was excised and the nose was reconstructed with a skin flap.

Dr Uppal had to make sure the tissues supporting the tip of the nose were not compromised and did not droop as a result of the cancer surgery.

Mr Yeo is pleased with the results of his surgery, even though the skin has not completely finished healing.

Dr Uppal has told him the aesthetic results will improve over time.

He is already happy with how he looks.

"I had the black dot for so long, I'm glad it's gone. I'm a handsome boy again," said the grandfather of four.

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