Once or twice a year I travel to Ethiopia to operate on children and adults with severe facial deformity. These trips are funded by a charity known as Facing Africa. The CEO of the charity is Chris Lawrence. Chris, his wife Terry and their very able, hard-working team organise everything so that the surgery that is carried out is equal to the standard of the developed world. This means transporting high quality equipment, well-trained and experienced surgeons (plastic and maxillofacial), anaesthetists, ward and theatre nurses to Ethiopia. Facing Africa also puts into place everything needed to care for the patients before and after surgery.
The paradigm is the brief transplant of surgical expertise and conditions of the developed world into the under-developed one to allow us to perform complex surgery.
Facing Africa ensures that nursing and plastic surgery care is provided for the patients several weeks after we have all left. The logistics are complex and arduous. The charity primarily seeks out patients with Noma. This is a disease affecting mal-nourished children and is a condition only seen in poor countries. Noma starts as an intra-oral ulceration that quickly spreads to the rest of the mouth and face causing devastating destruction of both soft and hard tissue. There is a range of facial deformities that results from Noma such as missing lips, cheek and nose, loss of supporting structures that hold the eye in place or a total fusion of the jaw so they cannot open their mouths. In some unfortunate cases all these elements of deformity can be present in one patient. It is estimated by the WHO that there are about 140,000 cases of Noma a year in the world. The mortality rate is probably well over 90%, so only a small percentage will eventually be treated by Facing Africa. The charity searches for patients in cities as well as in remote parts of Ethiopia and although the primary aim is to find men, women and children with Noma, inevitably patients with facial deformity due to other diseases such as neurofibromatosis, vascular anomalies and facial tumours are also selected. This is because, for a short while during the duration of the mission, specialised surgical and anaesthetic expertise is available to help manage these difficult cases.
The surgical phase of the mission lasts for two weeks although patients are pre-treated for several weeks before we arrive. Their general condition is improved and on the day of our arrival we hold a major outpatient session. All the patients are examined and a management plan confirmed. The surgery is carried out in central Addis at a large, modern Korean Christian Mission hospital. This year we operated on 34 patients. For the first time I led a Facing Africa mission clinically. I felt privileged but also a little daunted. However I need not have been anxious because the team had a natural unity and it was a so good to be working with such dedicated, skilled, happy and positive colleagues. I will describe some of my surgical experiences in my next newsletter but I would like to relate one incident, which had a profound effect on me.
Shortly after the mission started, two nuns visited me. Contrary to my own ignorant pre-conceptions about nuns, they were young and attractive. In a charming French accent the senior nun requested that I treat her younger colleague who had a skin condition of one of her ears, which required minor surgery. I of course agreed and she had surgery within the hour, which was a service better than most healthcare delivery systems in the world! The next day the same senior nun came to see me with another junior sister with exactly the same ear problem. Again, I agreed to help. The third day the nun came again with her driver with another kind of skin condition on the ear, which needed surgery. By this time I had become the butt of a few jokes from my colleagues that I had become the personal plastic surgeon to God’s servants on Earth. After treating the driver the nun asked me in her delightful French accent.
“Dr Hiroshi. Thank you very much for your help. Is there any thing that I can do for you?”
I thought for a moment and very diplomatically I answered, “ Please pray for the success of our mission”.
This was obviously the correct answer as she replied that she most certainly would and invited the team to visit her convent. On the last day of our mission we had time to visit the nuns in central Addis Ababa. As our transport van entered the gates there was a sign overhead, which read:
Mother Teresa Hospice for The Incurables and The Dying.
A premonition ran through me similar to that which befell Dante as he entered Hell with the poet Virgil. The nun met me and explained to us the nature of her work. She explained that there are six hundred patients in the hospice. A lot of them are indeed incurable or dying. About forty patients die every month. “We care for them as much as we can”, she stated in a matter-of-fact way. She showed me the wards and I truly felt that if I had entered one of the circles of hell. Row upon row of sick men lying in beds arranged close together. Amputees, paralytics, terminal HIV and typhus cases along with some patients with the worst fungating tumours I have ever seen on their faces and bodies. The golden light of the late afternoon filtered through upper windows, casting an ethereal glow interrupted by black shadows flittering on the dying. Some had empty dark eyes where all hope and life seemed to have evaporated. Yet interspersed were men burning with the desire and a desperation to live. The nun asked my opinion on some of the gigantic facial tumours. I answered that we would need a biopsy diagnosis before I could be sure but even in my World, their chances would be slim and treatment would most probably be palliative.
The drugs to treat TB and HIV are free in Ethiopia. The TB wards were full of patients in various stages of convalescence. The nun informed me that one of the problems treating TB at the Hospice was that anti-tuberculous medication takes at least six months to work so some patients will abscond when they feel better. Many do not understand that the disease will return if their course of drugs is not completed. The female wards were just as extreme and crowded with HIV and TB patients. I will never forget the poor woman who was clearly insane raging against the world and wandering aimlessly around. Then in the final ward I saw hope. The nuns take in mothers who have babies born illegitimately (probably from abuse, rape or prostitution). Their families and society have rejected these young women. The nuns take care of them for about three months. During this time they teach them skills such as sewing or cooking so they have some chance of supporting themselves.
The nun suddenly excused herself. It is time to pray. We have to do this several times a day. They let us observe their prayers, which was held in a small chapel. There were about eight nuns chanting The Lord’s Prayer. They all knelt as one in front of a wooden Christ nailed to a cross. It was mesmeric. I have never felt such unquenchable faith and power. As our transport van rumbled out of the hospice on the first stage back to our own World we were all stunned into silence. The patients in the hospice were the “lucky ones”! Were we all just scratching the surface? There must be thousands out there who never make it to the nuns or to Facing Africa. What did this all mean? The human condition and the vast extent of its misery? Or the presence of immense beacons of charity and hope? I have to believe there will always be both. Its up to all of us to ignite the beacons…… and finally this experience has totally changed my attitude and understanding of nuns and the true meaning of their calling.
It has been announced that the private practice of Mr Hiroshi Nishikawa has been awarded the 2015 Customer Service Award from WhatClinic.com.
The Customer Service Award acknowledges excellence in response and handling of prospective patients’ enquiries and requests for consultation.
Mr Nishikawa and his team pride themselves on a quick and thorough response to all enquiries, and no question is too silly or trivial for an answer. An avid volunteer, Mr Nishikawa regularly goes overseas for charity work and guest lecturing opportunities. To accommodate patients he often opens additional last-minute consultation times and is known for staying late in the evenings or seeing patients on Saturdays to deliver this high level of customer service.
2014 was another record year for WhatClinic.com with over 17.5 million people from 245 countries and territories using the online portal to research and find qualified consultants for cosmetic and reconstructive procedures, representing a 15% increase from the previous year.
“It is always nice to be recognised for good work, and providing a pleasant experience for patients is a priority for me and my team,” says Mr Nishikawa, from his clinic at The Westbourne Centre in Birmingham. “WhatClinic.com’s website helps patients find qualified and regulated consultant surgeons for all areas of cosmetic surgery, including breast and facial rejuvenation which I specialise in, and gets the booking process started.
We are very pleased to have received the Customer Service Award and will continue to provide this high level of care to each and every patient.”
I recently attended the 58th Annual Meeting of the Japanese Society for Surgery of the Hand in Tokyo. Although I am not a hand surgeon I was very privileged to give a lecture on the management of vascular anomalies. These are rare vascular tumours, composed of abnormal blood vessels, which can affect any part of the body. For many years, I have had been part of a multidisciplinary team at the Birmingham Children’s Hospital and at the Queen Elizabeth Hospital Birmingham, which deals with these difficult problems.
I enjoyed the conference immensely. I think my lecture went well. Even though the conference was not in my field I learnt much. One of the most brilliant lectures that I attended, concerned the musician’s hand given by a London hand surgeon called Ian Winspur. He was a man of much experience. He has had his learning curve and one of his themes was how to choose the best option for his very special patients, whose livelihoods and careers depends on pain-free playing of their instruments. This depended so much on his great surgical knowledge of the mechanical and postural problems that can affect the playing of a musical instrument. Often the simplest non-surgical course with clever adjustments of the instrument itself or subtle alterations in the posture of the musician or changes to the way the instrument is held, would correct the problem. Sometimes surgery is needed but also there were occassions when intervention could be worse than the disease or the patient may not be compliant with the intense physiotherapy and re-training required postoperatively.
I saw so many parallels to my work. There is some truth that surgeons may take ten years to master and understand an operation and then the next ten years will be spent learning when not to do it! In cosmetic surgery the outcome is so much about judgement of technique and a prediction of outcome. However one element that puts cosmetic intervention in a different place from functional surgery (such as the treatment of hands) is that the outcomes measures are in many ways more complex. There is the apparent result as judged by the surgeon; however the most important one is the result perceived by the patient. Like understanding the needs of a musician, Ian Winspur’s talk reminded me that the “listening” is the single most important facet of management. This will determine the pathway and the destiny of the patient.
I later attended the conference banquet that took place at the Keio Plaza Hotel. A military band played, the fine wine flowed. I sat next to Professor Yasuo Yamauchi, a charming and very distinguished retired professor of orthopaedics. I explained to him that I left Japan to live in England when I was three years old so he had to forgive me for my poor Japanese. He asked me in perfect English. “How do you find Japan?” I replied that each time I return to my country I feel a mixture of bewilderment and pride. The pride is where I find Japan now and its place in the World. I can always feel the many parallels between the UK and Japan. Both islands at the edge of huge continents. Europe and Asia. There were parallel historical developments until the sixteenth century when Japan isolated herself from the rest of the world. Crashing back into World affairs in the late nineteenth century with rapid industrialisation, this eventually culminated in the catastrophe of the Second World War. Then there was post war industrial re-birth and an economic miracle and then in the last twenty years one of the longest industrial depressions in history; although Japan still remains the third largest economy in the World. And now Japan is heading for a path that is difficult to predict. The bewilderment stems from experiencing a country of contrasts and my own place in it. Tokyo looks like the next century, yet in the quiet hills surrounding the small town of my father’s birth nothing much seems to have changed. Professor Yamauchi smiled and said that one can never deny ones origin and it is true. Japan is such a complex, historical and bewildering country with an ancient traditional culture that has somehow embraced both the modern West and the East. My own personal feelings cannot be expressed simply and I hope to do so in other newsletters.
For every vocation there are defining events that perhaps encapsulates their professional core. This has often been expressed in films. At the end of the movie the policeman will have caught the criminal after a breathless chase and state. “ You’re nicked”. The judge will pronounce sentence and the black cap will be placed on his head.
I deal with many patients with facial deformity as well as those with purely cosmetic problems. I have long-held the belief that the psychosocial implications for both these groups are part of the same spectrum and the degree of anxiety or concern are not dissimilar.
Recently, the European Cleft Organisation (ECO) has launched a project called Face Value. They have started a pilot training programme for healthcare professionals and NGOs to allow delivery of psychosocial care and support for patients with facial deformity.
This type of training is seldom on the Medical School curriculum and I applaud this project.
It will help to change the culture of our attitude to deformity as well as improve support for all patients who have true problems with their facial appearance, ranging for the disfigured to the cosmetic.
Twice a year I have the privilege of examining for the final exit exams known as FRCS Plast for plastic surgeons reaching the end of their training. In this country, senior plastic surgical trainees have to pass this in order to gain a certificate of completion of training (CCST). Only until candidates have achieved this
“20% of patients surveyed were not sure what the outcomes were meant to be of their surgery – shocking!”
The British Association of Plastic, Reconstructive & Aesthetic Surgeons (BAPRAS) have recently launched a campaign aimed at the general public entitled “Think Over before you Make Over”. I fully support this area of public education because I also sincerely believe that awareness of the implications of cosmetic surgery is so important.
Cosmetic surgery is not a product but must be regarded as a form of healthcare delivery. Its standards, safety and outcomes should be held to the same levels as all branches of medicine and surgery. It is therefore sad to review the results of a recent BAPRAS-sponsored survey. It found that 25% of patients do not check the credentials of the surgeon operating on them. 20% were either not informed of or were not aware of the risks of their procedure and 20% were not sure what the outcomes were meant to be before going ahead with surgery. Incredibly 25% were not aware if there were any aftercare services, should anything go wrong.
I believe that one of the reasons for these statistics reflect the aggressive marketing and sales practices, which bombard vulnerable patients seeking advice and help about their cosmetic surgical needs. I fully endorse the BAPRAS campaign as there needs to be some benchmark of trust in an aggressive marketplace where exploitation by potentially under-qualified practitioners can and will occur due to commercial pressures.
For more information on the Think Over Before You Make Over campaign and the full advice guide please click here: Think Over Before You Make Over.
Mr Nishikawa has been fully registered on the GMC Specialist Register for Plastic Surgeons since March 1996, and fully registered member of the General Medical Council since August 1983 (GMC registration number 2573614).
7 March 2015 at The Westbourne Centre – Cosmetic Surgery Open Morning with Mr Nishikawa
Mr Nishikawa and his cosmetic surgery colleagues will be hosting a Cosmetic Surgery Open Morning at Birmingham’s The Westbourne Centre, giving you the opportunity to meet the consultants and broadly discuss cosmetic procedures.
If you are considering cosmetic surgery but are not quite sure what questions to ask, this is your opportunity to find out first-hand information for free. There will be FREE 10-minute private discussions with the expert cosmetic surgeons and plenty of patient stories and practical information on hand.
You can also see the beautiful Westbourne Centre medical facility, including the operating theatre, where all of Mr Nishikawa’s private procedures take place.
These 10 minute sessions are not long enough for a full consultation and will not include a physical examination. If you decide you would like to take the next step then a full consultation will be necessary and can be booked on the day.
Spaces are limited, especially for Mr Nishikawa, so contact Sarah.Taylor@westbournecentre.com to book your place, or call 0121 456 0897.
Mr Nishikawa has been asked to provide answers to questions asked around the world by people considering cosmetic surgery – read on to see his answers!