A thyroidectomy is a surgical procedure in which part or all of the thyroid gland is removed. Found at the front of the neck, the butterfly-shaped thyroid gland is a crucial part of the endocrine system and produces hormones that regulate metabolism. Thyroidectomies treat thyroid conditions such as thyroid nodules, cancer, and hyperthyroidism, and can have lifelong implications for the patient.
Purpose of Thyroidectomy
Thyroidectomy is often recommended to treat a variety of thyroid conditions and cancer. These include:
- Thyroid cancer: Thyroid gland removal is typically the primary treatment for thyroid cancer, which can be detected through the presence of suspicious nodules or malignant tumors.
- Goiter: An enlarged thyroid gland, called goiter, can be due to iodine deficiency or thyroid nodules. Removing the gland, or part of it, can alleviate symptoms such as difficulty swallowing or breathing.
- Hyperthyroidism: This condition occurs when the thyroid gland produces excessive thyroid hormone. In some cases, removal of the gland can regulate hormone levels and alleviate symptoms.
- Thyroid nodules: While most thyroid nodules are benign, some may be cancerous. Doctors may recommend their removal to prevent cancer development or alleviate other symptoms.
Types of Thyroid Conditions and Cancer
The severity of the thyroid problem dictates the type of thyroidectomy procedure necessary.
- The total thyroidectomy is one option, which involves the complete removal of the thyroid gland. It’s a common treatment for thyroid cancer and is often used in severe hyperthyroidism or large goiter cases.
- Another option is the partial thyroidectomy. In this procedure, surgeons only remove part of the thyroid gland. It’s a suitable option when cancer is confined to a single lobe and the surgery is expected to have fewer complications.
- There’s also the hemi-thyroidectomy. This procedure involves extracting just one thyroid gland lobe, while the other lobe and isthmus remain. It’s typically done for patients with a single enlarged nodule or localized cancer that hasn’t spread.
- Lastly, there’s the isthmusectomy. In this case, the isthmus – the thin tissue linking the two thyroid lobes – is removed. It’s less prevalent than other thyroidectomies and is mainly used for isolated problems in the isthmus.
Regardless of the type of thyroidectomy performed, patients should be aware that each of these surgeries carries potential risks and complications. These may include damage to the parathyroid glands or vocal cord nerves and the development of infections or seromas. Bleeding, scarring, and hypocalcemia are also potential side effects that patients should discuss with their surgeon.
Recently, we’ve refined techniques such as robot-assisted surgery for thyroidectomy. This results in fewer complications and a quicker recovery. However, not every patient can benefit from these advanced methods. So, traditional surgical techniques often come into play.
After a thyroidectomy, patients often require lifelong thyroid hormone replacement therapy, such as levothyroxine, to maintain healthy hormone levels and metabolism regulation. Recovery from thyroidectomy surgery may vary depending on the extent and type of procedure performed, but patients typically resume normal activities within a few weeks.
Reasons for Thyroidectomy
A thyroidectomy is a common procedure to treat thyroid cancer, the most prevalent endocrine cancer. This gland, part of the endocrine system, produces the metabolism-regulating thyroid hormone. Usually, the type of thyroidectomy depends on the tumor’s size and reach. For instance, a total thyroidectomy is advisable when cancer encompasses the whole gland. However, if the cancer is restricted to a single lobe or part of the gland, a partial or hemi-thyroidectomy may be adequate. Lastly, in cases with more localized tumors, removal of the thyroid isthmus, known as isthmusectomy, might be required.
Goiter (noncancerous enlargement)
A goiter is a noncancerous enlargement of the thyroid gland. These growths can cause discomfort and impair a patient’s ability to breathe or swallow due to their size and location. Surgical intervention, such as a partial or total thyroidectomy, may be necessary if symptoms are severe or worsen over time. Doctors may also recommend surgery in cases where a goiter is large enough to put pressure on the vocal cord nerves, leading to potential vocal complications.
Hyperthyroidism is a condition in which excessive amounts of thyroid hormone disrupt normal bodily functions. It can be caused by conditions like Graves’ disease or certain thyroid nodules that produce excessive hormones. In some cases of hyperthyroidism, medication or radioactive iodine treatment, which works to shrink the gland, may be insufficient in addressing the issue, and thyroidectomy may be necessary. Total or partial thyroidectomy can help restore proper thyroid hormone levels in the body and eliminate the need for long-term antithyroid medications.
Suspicious Thyroid Nodules
Thyroid nodules are small lumps that sometimes develop within the thyroid gland. While most thyroid nodules are benign (noncancerous), some can be cancerous or lead to hyperthyroidism. If a thyroid nodule appears suspicious, doctors may perform a biopsy to determine if it is cancerous. If cancer is confirmed or cannot be ruled out, a thyroidectomy may be recommended to prevent potential complications and the spread of cancer.
In some cases, even if the biopsy returns benign results, doctors might still advise a thyroidectomy due to the nodule’s size or risk of potential hyperthyroidism. Additionally, the presence of multiple nodules within the thyroid gland, known as multinodular goiter, may also warrant surgical intervention if they lead to hyperthyroidism, cause discomfort or difficulty breathing, or are suspected to be cancerous.
Types of Thyroidectomies
Undergoing a total thyroidectomy means the entire thyroid gland is removed through surgery. Doctors usually suggest this for individuals dealing with thyroid cancer, large goiters, or intense hyperthyroidism. Importantly, by removing the entire thyroid, we can prevent these conditions from coming back. This is because all the problematic tissues get taken out in the process.
During a total thyroidectomy, a surgeon makes an incision in the neck to access the thyroid gland. After the removal of the gland, the incision is closed with sutures or staples, and the patient is typically required to stay in the hospital for a short period of time. After surgery, patients usually need to take thyroid hormone replacement therapy, such as levothyroxine, to maintain normal thyroid function and metabolism.
There are some risks and complications associated with total thyroidectomy, such as injury to the vocal cord nerves, parathyroid glands, or seromas. Other potential complications include hypocalcemia, hypoparathyroidism, infection, and scarring.
Partial thyroidectomy, also known as hemi-thyroidectomy or isthmusectomy, refers to the surgical removal of a portion of the thyroid gland. This procedure is often performed for patients with thyroid nodules, smaller goiters, or less severe cases of hyperthyroidism. Partial thyroidectomy aims to preserve some of the thyroid tissue to maintain normal hormone production and reduce the need for hormone replacement therapy.
In a partial thyroidectomy, the surgeon may remove a single lobe of the thyroid (hemi-thyroidectomy) or just the isthmus, the thin portion of tissue connecting the two lobes (isthmusectomy). The decision of which type of partial thyroidectomy to perform depends on the size, location, and extent of the thyroid issue.
Similar to total thyroidectomy, the surgeon makes an incision in the neck to access the thyroid gland. After removing the necessary portion of the gland, the incision is closed with sutures or staples. Recovery from partial thyroidectomy generally involves a shorter hospital stay and a quicker return to normal activities as compared to total thyroidectomy.
Although partial thyroidectomy has fewer associated risks and complications as compared to total thyroidectomy, it is still an invasive procedure and carries some risks. The potential complications with partial thyroidectomy can include injury to the vocal cord nerves, parathyroid glands, or lymph nodes. Other possible complications may involve infection, seromas, scarring, and temporary or permanent hypothyroidism, which may require thyroid hormone replacement therapy.
In recent years, there has been a growing interest in minimally invasive thyroidectomy and robot-assisted thyroidectomy techniques. These approaches are aimed at reducing the size of the incision, minimizing scars, and improving overall recovery for patients undergoing thyroid surgery.
Regardless of the type of thyroidectomy performed, it is crucial for patients to follow their surgeon’s postoperative care instructions and maintain regular follow-up appointments. The recovery process may vary from person to person, and it is essential to monitor thyroid function to ensure that appropriate hormone levels are being maintained. This will help in preventing complications and promoting a smooth recovery for patients who have undergone thyroidectomy.
Preparation for thyroidectomy surgery
Before a thyroidectomy surgery, doctors order imaging tests such as ultrasound, computed tomography (CT) scan, or magnetic resonance imaging (MRI) to get detailed visual information of the thyroid gland, its size, structure, and the presence of any nodules or tumors. Ultrasound, in particular, is crucial for measuring the size and location of the nodules and determining if nearby lymph nodes are affected. These imaging tests help the surgical team plan the appropriate surgical approach and identify any potential complications.
Fine needle aspiration
Fine needle aspiration (FNA) is a diagnostic procedure that involves collecting a small sample of thyroid tissue using a thin needle. The needle is guided with the help of ultrasound imaging to ensure proper placement in the target area. The tissue sample is then examined under a microscope by a pathologist to look for abnormal or cancerous cells. FNA is useful in determining if a nodule is malignant or benign, which in turn helps the surgeon decide on the extent of thyroidectomy required.
Vocal cord assessment
The recurrent laryngeal nerves, responsible for controlling the movement of the vocal cords, run very close to the thyroid gland. Injury to these nerves during surgery can lead to a temporary or permanent change in voice quality or difficulty in swallowing. To minimize this risk, the patient’s vocal cord function is evaluated before surgery through a laryngoscopy. This procedure involves inserting a flexible tube with a camera through the nose or mouth, allowing the doctor to visualize and assess the movement of the vocal cords. This pre-operative assessment helps the surgeon determine how to protect the nerves during the surgery and anticipate any potential complications.
Patients undergoing thyroidectomy surgery may need to adjust their current medications or take new medications to prepare for the procedure. For example, patients with hyperthyroidism or Graves’ disease may need to take anti-thyroid medications before surgery to minimize the risk of thyroid storm, a life-threatening condition caused by a sudden release of thyroid hormones. Similarly, those taking blood-thinning medications, such as aspirin or warfarin, will need to stop or temporarily adjust their doses to reduce the risk of bleeding during surgery. It is important for patients to discuss their entire medication list, including supplements and over-the-counter drugs, with their healthcare team at least a few weeks before surgery to allow sufficient time for any necessary adjustments. Proper medication management helps optimize patients’ health and minimize the risk of complications during and after the procedure.
Before undergoing thyroidectomy, patients may undergo a series of tests to help the surgical team ensure they are healthy enough for anesthesia and surgery. These tests may include blood tests to evaluate kidney, liver, and thyroid function, as well as an electrocardiogram to assess heart health. Additionally, patients may be asked to meet with an anesthesiologist for a pre-operative evaluation, during which they will discuss anesthesia options, potential risks, and any personal or family history of anesthetic complications.
Fasting and bowel preparation
Before surgery, doctors often request that patients refrain from eating or drinking for at least 8 hours. This measure significantly reduces the risk of aspiration when anesthesia is administered. Sometimes, a laxative or an enema may be required to cleanse the bowels prior to the operation. Your healthcare team will provide other necessary pre-operative instructions. It’s important to adhere to these guidelines meticulously. Doing so will contribute to a successful surgery and facilitate a smoother recovery process.
Mental and emotional preparation
Undergoing thyroidectomy can be an emotionally challenging experience for patients, particularly if they are facing a cancer diagnosis. It is important for patients to engage in open communication with their healthcare team, ask questions, and express any concerns they may have. Seeking support from friends, family members, or support groups can also help patients cope with the stress and anxiety associated with surgery. Taking proactive steps to address emotional well-being before surgery can improve patients’ overall surgery experience and aid in the recovery process.
Overall, adequate preparation before thyroidectomy surgery, including imaging tests, fine needle aspiration, vocal cord assessment, medication adjustments, and pre-operative evaluations, ensures a smoother surgical experience, minimizes potential complications, and promotes a successful recovery for patients.
Thyroidectomy surgery procedure
A. Anesthesia and intubation for Thyroidectomy
To start the thyroidectomy surgery, the patient receives general anesthesia, guaranteeing unconsciousness and painlessness during the procedure. After this, as soon as the patient is completely sedated, the anesthesiologist carries out intubation. Intubation involves inserting a breathing tube through the patient’s mouth and into their trachea or windpipe, connecting them to a ventilator to maintain their breathing during surgery.
B. Access to the thyroid gland
Next, the surgeon will create an incision to access the thyroid gland. There are different methods of incisions, depending on the needs of the patient. The standard incision, also known as the open thyroidectomy, begins at the front of the neck and opens the skin in a horizontal line parallel to the collarbone. This approach provides a direct view of the area and enables the surgeon to identify and preserve surrounding structures, such as vocal cord nerves and parathyroid glands.
In some cases, minimally invasive techniques may be used, such as video-assisted thyroidectomy or robot-assisted thyroidectomy. These methods involve using smaller incisions, surgical cameras, and specially designed instruments to remove the thyroid gland. These techniques may cause less trauma and scarring than a standard open thyroidectomy and typically have shorter recovery times.
C. Removal of thyroid gland and surrounding lymph nodes (if necessary)
The surgeon gains access to the thyroid gland, and the removal extent relies on the specific condition. Some patients might require a total thyroidectomy, implying the whole gland is removed. However, in other instances, only a portion of the gland is eliminated through a partial thyroidectomy, hemi-thyroidectomy, or isthmusectomy.
When the surgery’s purpose is to combat thyroid cancer, it could necessitate the removal of adjacent lymph nodes. Extracting lymph nodes enables the surgeon to assess cancer’s spread beyond the thyroid, possibly reducing the risk of recurrence.
During the procedure, the surgeon will carefully work to avoid damage to the nearby parathyroid glands and nerves connected to the vocal cords. The parathyroid glands are four small glands located near the thyroid gland that regulate the body’s calcium levels. Preserving these structures is essential as damage to them can lead to complications such as hypoparathyroidism and hypocalcemia, requiring long-term calcium and vitamin D supplementation.
Keeping the vocal cord nerves safe is essential. Damage to these nerves may cause dysfunction, hoarseness, or swallowing issues. During surgery, doctors may use a nerve monitoring device. This is to ensure the nerves stay undamaged.
After removing the required part of the thyroid gland and any nearby lymph nodes, doctors will seal the incision. They use either sutures or surgical glue. A drain might be inserted near the wound. This aids in removing excess fluid and avoiding complications like seromas or infections.
Post-surgery, doctors will closely monitor the patients. They provide pain relief as needed. Most patients spend one to two days in the hospital for observation. Then, they carry on with their recovery at home. Post-surgery, doctors may prescribe thyroid hormone replacement therapy. Levothyroxine, for example, helps maintain proper metabolism and overall health during recovery.
Possible side effects and complications
One potential side effect of thyroidectomy is bleeding. Although bleeding is relatively uncommon after thyroidectomy, it can be quite serious when it occurs. It may result in hematoma formation, which is a collection of blood outside blood vessels. If the hematoma becomes large or expands rapidly, it can cause breathing difficulties due to compression of the windpipe. In such cases, immediate medical intervention is necessary to remove the hematoma and prevent further complications.
Hoarseness/Voice Change (Nerve Injury)
During thyroidectomy, there is a risk of damaging the nerves that control the vocal cords. These nerves, called the recurrent laryngeal nerves, are in close proximity to the thyroid gland, and injury to them can result in hoarseness or changes in voice quality. This side effect may be temporary or permanent, depending on the extent of nerve damage. In some cases, voice therapy may be recommended to help restore normal voice function after surgery.
Hypocalcemia (Parathyroid Gland Damage)
Hypocalcemia, or low levels of calcium in the blood, is another potential complication of thyroidectomy. The parathyroid glands control calcium levels in the body. Sometimes, they get damaged accidentally during surgery, causing a condition. This condition, hypocalcemia, can lead to various symptoms. You might experience muscle cramps or numbness and tingling in your hands or feet. Seizures can result from extreme cases. To combat hypocalcemia, doctors typically prescribe calcium and vitamin D supplements post-surgery.
Seromas are fluid-filled pockets that can develop under the skin at the surgical site. They result from the body’s natural healing process as it produces fluid called serous fluid to help protect and cushion the area. Seromas typically resolve on their own, although in some cases, they may require drainage or additional treatment if they become infected or excessively large.
Like any surgery, there is a risk of infection following a thyroidectomy. Infections are usually treated with antibiotics, but in rare cases, they may require additional surgery to remove the infected tissue. To minimize the risk of infection, it is essential to keep the incision site clean and follow the surgeon’s postoperative care instructions.
Scarring is a common consequence of any surgery, and thyroidectomy is no exception. The extent and appearance of scarring depend on various factors, including the patient’s skin type, the surgical technique used, and the surgeon’s skill. Minimally invasive and robot-assisted thyroidectomy approaches can help reduce scarring by using smaller incisions and more precise dissection techniques. Over time, most scars will fade and become less noticeable, but in some cases, patients may seek additional treatment, such as laser therapy, to improve the appearance of their scars.
Precautions and Recovery
Although the aforementioned side effects and complications are possible after thyroidectomy, steps can be taken to minimize their occurrence. Choosing a skilled and experienced surgeon is critical, as they are more familiar with the anatomy and potential complications. Additionally, patients can follow all preoperative and postoperative care instructions provided by their healthcare team, which may include dietary modifications, wound care, and activity restrictions.
During the recovery process, it is essential for patients to monitor their symptoms and report any concerning changes, such as excessive pain or signs of infection, to their healthcare providers. Regular follow-up appointments are typically scheduled to ensure proper healing, monitor thyroid function, and adjust thyroid hormone replacement therapy if necessary.
While complications and side effects can occur after thyroidectomy, most patients experience a successful surgery and recovery. Understanding the potential risks and taking appropriate precautions can help minimize the likelihood of complications and improve overall outcomes following thyroidectomy.
Recovery after thyroidectomy
Hospital stay duration
After a thyroidectomy, the duration of the hospital stay varies depending on the individual and the type of surgery performed. Generally, patients are discharged within 24 to 48 hours after the procedure. In some cases, a longer stay may be required due to complications or the need for additional monitoring and care.
Care for incision and stitches
Proper care of the incision site is crucial for optimal recovery. The incision is usually located at the base of the neck or along the collarbone and will typically have stitches or surgical glue to hold it closed. It’s essential to keep the area clean and dry to prevent infection. Patients should follow their surgeon’s instructions for wound care, which may include applying prescribed ointments or medications. The stitches may be dissolvable, or the patient may need to return to the doctor to have them removed, usually 7 to 10 days post-surgery.
Medication for thyroid hormone replacement
Since the thyroid gland produces essential hormones for the body, patients often need thyroid hormone replacement therapy after a thyroidectomy. Levothyroxine is the most common medication prescribed for this purpose. It’s crucial to work closely with an endocrinologist or primary care doctor to determine the appropriate dosage and monitor the levels of thyroid hormone in the bloodstream. This will usually involve regular blood tests and may require adjustments to the medication dosage over time.
Resuming normal activities
Surgery recovery differs for everyone, but usually, normal activities resume in one to two weeks. However, strenuous activities and heavy lifting should be avoided for at least two weeks. This precaution prevents strain on the incision site and other complications. Next, light activities like walking are typically recommended for recovery. Should your job entail manual labor, you might need to alter your duties or take time off.
Follow-ups with endocrinologist and primary care doctor
It’s crucial to regularly visit both your endocrinologist and primary care physician for effective post-thyroidectomy recovery and health monitoring. Usually, you should plan for an endocrinologist visit three to six weeks after surgery to monitor thyroid hormone levels. Treatment adjustments may be necessary at this time. Even though appointment frequency varies, it’s crucial to attend all scheduled visits. Maintaining clear dialogue with your healthcare team is also vital for effective long-term thyroid health management.
As you move through the recovery process, adhere strictly to your doctor’s guidelines and promptly voice any issues or complications. By cooperating with healthcare professionals and playing an active part in your recovery, you can optimize thyroidectomy outcomes and safeguard your overall health.
Monitoring for complications
To minimize risks and ensure a successful recovery, it’s important to stay vigilant for potential complications that may arise after thyroidectomy. Complications can include infection, bleeding, swelling, or seromas (fluid collections) around the incision site. Additionally, some patients may experience damage to the vocal cord nerves due to their close proximity to the thyroid gland. This can result in hoarseness, voice changes, or difficulty swallowing. Hypocalcemia (low blood calcium levels) is another possible complication, particularly if the parathyroid glands were inadvertently damaged or removed during surgery.
If any of these symptoms emerge, it’s crucial to promptly alert your healthcare provider so that appropriate interventions can be taken. In some cases, additional treatments or surgery may be necessary to resolve complications.
Adjusting to life without a thyroid
Getting used to life post-thyroidectomy can be a bit of a challenge. This is because it involves learning to handle thyroid hormone replacement therapy. Additionally, you have to keep an eye out for potential complications. During this adjustment phase, staying patient and communicating with your healthcare providers is crucial. It’s vital to keep your thyroid hormone levels steady. Not only that, but they also need to be closely watched. This helps prevent symptoms linked to over or under-treatment. For instance, fatigue, mood swings, weight gain, or trouble focusing.
Participating in support groups or connecting with others who have undergone thyroidectomy can also be helpful during the adjustment period. Sharing experiences and learning from others who have faced similar challenges can provide valuable insights and emotional support.
Long-term care and monitoring
Once recovered from surgery and adjusted to thyroid hormone replacement therapy, patients must remain proactive about their health. This includes regular follow-ups with healthcare providers, routine blood tests to monitor thyroid hormone levels, and maintaining a healthy lifestyle. In cases where thyroidectomy was performed due to cancerous growth, ongoing surveillance and check-ups are essential to monitor for potential recurrence or metastasis.
Questions to ask your doctor before thyroid surgery
Hospital stay duration
After a thyroidectomy, the duration of the hospital stay typically ranges from one to three days, depending on the patient’s specific condition and the extent of the surgery. In some cases, the patient may be discharged on the same day if deemed medically stable.
Care for incision and stitches
Proper care of the incision site and stitches is essential for optimal healing. Keep the area clean by gently washing with mild soap and water. Avoid scrubbing or rubbing the incision, as this can cause irritation. Your doctor may provide specific instructions for incision care, including when to remove any dressings and how to manage any swelling or discomfort.
Medication for thyroid hormone replacement
After a thyroidectomy, thyroid hormone replacement therapy may be necessary since the body no longer produces these hormones naturally. Levothyroxine is a commonly prescribed medication for this purpose. It is essential to follow your doctor’s instructions regarding the dosage and frequency of this medication and to have regular blood tests to monitor thyroid hormone levels, as adjustments may be necessary over time.
Resuming normal activities after a Thyroidectomy
It is crucial to gradually and progressively resume normal activities post-surgery while avoiding strenuous exercise or heavy lifting for at least a few weeks. Follow your doctor’s recommendations regarding suitable activities and timelines for returning to work, driving, and specific exercises. It is essential to listen to your body and avoid overexerting yourself.
Follow-ups with endocrinologist and primary care doctor
Regular follow-up appointments with your endocrinologist and primary care doctor are necessary for monitoring your recovery and overall health. In these meetings, your doctors will assess your incision healing, hormone levels, and overall well-being. They may also order additional imaging or blood tests as needed to monitor any potential recurrences of thyroid issues.
Thyroidectomy necessity and alternatives
Before undergoing thyroid surgery, discuss the necessity of surgery and explore potential alternatives with your doctor. Ensure that you understand the reasons for recommending surgery and what non-surgical options, if any, are available for treating your condition.
Surgeon’s experience and complication rate
When choosing a surgeon for your thyroid operation, inquire about their experience and complication rate. Select a surgeon with extensive experience and a low complication rate, as this increases the likelihood of a successful and smooth surgery process.
Coordination with the medical team
Ensure that your medical team is well-coordinated and communicates effectively to streamline your surgical experience and follow-up care. This includes not only your surgeon but also your primary care doctor, endocrinologist, and any other healthcare professionals involved in your care.
Adherence to published guidelines
First, select a surgeon and medical team following the thyroid surgery guidelines. Professional associations, like the American Thyroid Association, issue these. Then, you’ll ensure receipt of the most current and evidence-supported care throughout your surgery.
Possible risks and complications
Discuss potential risks and complications associated with thyroid surgery with your doctor. These may include infection, bleeding, injury to the vocal cord nerves, and hypocalcemia (low calcium levels in the blood) due to damage to the parathyroid glands. Understanding the possible complications will help you make informed decisions and prepare for any post-operative challenges.
Recovery process and restrictions
Your doctor will provide detailed instructions on the recovery process and any temporary or long-term restrictions after surgery. This may include limitations on lifting heavy objects, resuming exercise, and returning to work. Adhering to these guidelines will help ensure a smooth recovery and prevent complications.
Life after Thyroidectomy surgery
Ask your doctor about what to expect in your daily life following thyroid surgery, particularly regarding hormone replacement therapy, dietary adjustments, and any necessary lifestyle changes. It is essential to understand how your body may be affected and how to manage any new restrictions or requirements.
Scarring and cosmetic concerns
Discuss scarring and cosmetic concerns with your surgeon before undergoing thyroid surgery. Some surgical techniques may leave a smaller, less noticeable scar than others. Your surgeon may provide recommendations on how to minimize scarring post-operatively, such as massaging the scar area, using silicone gel and sheets, or applying topical treatments like vitamin E or onion extract.