Dear Dr. Jahn: My sister-in-law needs a kidney. None of her family or friends is a match, but I’m the closest, so we’ve enrolled in a kidney exchange program in the hope that someone else’s donor will match her and some other recipient will match me. We’ve been told that this may happen within the next four months. The surgery is performed “single port” through a 2”-3” incision around the navel. That’s an improvement over the standard procedure with separate holes for the camera, the scissors, and the extraction. Do you have any idea how long after the surgery I can resume singing?
AFJ: Your question is a very specific one, but I need to answer it in general terms, since it really pertains not to the kidney donation but the postoperative effects of laparoscopic surgery.
Before the era of laparoscopic surgery, surgeons would open the belly using a large incision which often cut through abdominal muscles. Following surgery, a week might pass before your intestines resumed their function, and several months before the muscles would completely heal. With laparoscopic surgery, the disruption is much less—the trauma to the abdominal wall is minimal and the internal organs do not stop working as before.
Nonetheless, despite the tiny incision, the surgery (in this case, removal of a kidney) is not minor, and you will need to recuperate. My suggestion is to follow the surgeon’s instructions about when you can resume normal activities, such as exercising. There will be some edema of the abdominal muscles, but I suspect that once you can safely and comfortably exercise, lift, and bear down on the toilet normally, your support mechanism will be ready to resume singing. That addresses the support side of singing.
Keep also in mind that general anesthesia with an endotracheal tube will cause some swelling of the vocal folds and adjacent pharynx. You will need to rest your voice about two weeks before you can resume vocalizing. Be aware that when you do start to sing, your laryngeal position may be high, both from the irritation and the subsequent vocal rest. Begin by working on sustaining (support) and passaggio (laryngeal muscle tension) before adding power and revisiting the high notes (edema).
—Dr. Jahn
Dear Dr. Jahn: Thank you so much for this opportunity to ask you questions about medical problems and their relation to our voice! My question is about rhinoplasty. When I was 11 years old, I broke my nose in an accident. It is now bent to one side and has a large bump that can be seen when looking at my profile. I’m still able to breathe but only through one nostril. I am now 20 years old and have thought about getting it fixed. I’m just really worried that it might affect my resonance or breathing or change my voice somehow.
I have had a consultation with a great plastic surgeon specializing in rhinoplasty, and he said that nothing will change [except] that I will be able to breathe much better and that [my nose] will be straight. I’m very worried though; I would like your opinion on the subject. Honestly, I’m fine with the appearance of my nose. I don’t think it’s garish looking—but if there is any chance of my voice changing because of a surgery, then I would opt out immediately. What are your thoughts?
AFJ: From your description, it does sound like you would benefit from surgery, but to correct your deviated septum and possibly to improve the cosmetic appearance. It has been my experience, after many procedures on singers, that the voice does change after septorhinoplasty. This change, however, is often for the better! Particularly in patients with nasal obstruction, they find that their post-operative voice is bigger and more forward. They are now able to put the voice into the mask with less effort. This is due to increased resonance in the nasal cavities. I have even had patients tell me that they can now access notes that they couldn’t reach before. I find this more difficult to explain than the mask issue, but am relating to you what patients have told me.
I have two concerns regarding your surgery. One, please make sure that your doctor doesn’t reduce the overall size of your nose excessively—this could have a negative effect, especially if you develop scarring from the incision inside the nostrils. The other important issue: please make sure the septal deviation is fully corrected. From the vocal point of view, appearance is less of a concern than function.
—Dr. Jahn
Dear Dr. Jahn: Six years ago I had second-stage breast cancer. I needed a mastectomy. At the time I decided to receive a T-flap reconstruction which was done at the same time as my mastectomy. Twenty-two lymph nodes were taken but returned clean. This was followed with six months of chemotherapy and five years of tamoxifen.
Since the surgery and treatment, I have had some difficulty with breath support. When I sing for longer periods of time, my muscle, which was untwisted and pulled up to form the breast, spasms on me. It is very sharp, but quick, and then over. Can you please discuss how and if chemo and tamoxifen affect the voice, and also if this reconstruction can cause difficulty with the breath support?
Could you also discuss what I might do to strengthen the muscle or some breathing exercises I might do to heal? The voice is just not what it was, and it is very frustrating. I was never told, “Oh, by the way, you can maybe beat this cancer, but you may lose the ability to sing like you once did.” It would have been nice to know what to expect.
AFJ: First of all, congratulations on the successful outcome of your surgery. Regarding your singing, there are two issues that I can address with you. First, the reconstruction. The flap you had performed contains muscle, which gives the reconstructed breast its bulk. Although I don’t do this kind of surgery, it is my understanding that surgeons try do denervate the muscle flap—i.e., interrupt its motor nerve supply so that it doesn’t twitch or contract inappropriately. What you are describing sounds like a flap that might contract with your singing efforts. The muscle still “thinks” it is in its original anatomic location and contracts with the other muscles that you use to support, to exhale, to sing.
I am not sure what the best treatment for this might be. I do know that some of these flaps atrophy a bit over time so, depending on when the surgery was done, waiting might be an option. One interesting possibility you could raise with your surgeon is whether the nerves to the flap could be injected with Botox. I am not aware that this has been done or, indeed, could be done—but it might solve the twitch problem for you, up to three to four months at a time.
Regarding the voice quality, tamoxifen is most likely the culprit. This is a drug that is given for estrogen-sensitive tumors and acts like an estrogen antagonist. In effect, it can mimic menopause: up to 80 percent of women on tamoxifen report hot flashes, many others have irregular periods, vaginal bleeding, and other signs of hormonal change. The chemotherapy (prior to your tamoxifen) may be an issue only to the degree that it might have caused dryness in your vocal tract.
Without minimizing the negative vocal effects of your treatment, the most important thing is to treat, control, and cure your breast cancer. The methods we have today are far superior to what was available when, say, Kathleen Ferrier was battling breast cancer. Please concentrate on the positive effects of your treatment—and try to work around your vocal limitations with the knowledge that the cancer has been aggressively and effectively addressed.
—Dr. Jahn
