A Patient with Severe Eyelid Retraction

Thyroid eye disease also known as Graves' ophthalmopathy can cause severe eyelid retraction. This can result in severe dry eyes and visual impairment. This patient who was treated for Graves' disease has eyelid retraction for the past 3 years. Despite regular use of artificial tear, the eyes were always uncomfortable. She previously had botox rejection to lower the eyelid but find this costly as the procedure was repeated every 2 to 3 months. There are different ways of correcting the retraction depending on the severity, in this case I performed full thickness upper lid recession as shown below.

Severe right upper lid retraction.

The skin crease (site of the double eyelid) is marked.

Skin incision is made along the marked line.

A vertical incision is made deep to the conjunctiva and extended 

along the whole length.

A button hole is made in the conjunctiva.

The conjunctiva is cut and extended along for 2/3 of its length

on the lateral side.

The height is assessed to make sure the eyelid cover the top part 

of the cornea.

Only the is closed with 6/0 nylon.

An Unexpected Finding

This 21 year-old man was involved in a motorbike accident one year ago. At the time he was treated for multiple lacerations in a peripheral hospital. However, three months later, he developed a discharging sinus from the lateral side of his right eyelid and the eye became progressively higher.

Right eye higher than left and there was a discharging sinus (arrowed).

The local doctor did debridements a few times and put the patient on different courses of oral antibiotic but to no avail. A CT scans showed a mass in the orbital floor and was reported as possible bony granuloma. The patient was referred to my centre for removal of the granuloma.

CT scans showing a right orbital floor mass.

The orbital floor was explored by performing a lateral cantholysis to swing open the lateral orbital floor. To our surprise, a piece of wood with silver coating was found. The wood was integrated with the surrounding tissue and was removed piecemeal. The wound was irrigated with gentamicin and closed with lateral tarsal strip procedure.

A foreign body was found at the orbital floor during the exploration.

Wood removed by piece meal.

A large cavity was left after removal of the foreign body.

End of the surgery.

The Danger of Ignoring a Fast Growing Bleeding Eyelid Lesion

This woman saw me because of slight decrease in her vision. She had early cataracts in both eyes which did not need early intervention. But what grape my attention was a lesion in her lower eyelid which had a black centre.

 

An ulcerated, pigmented lesion in the right lower lid.

 

On further questioning, she mentioned the lesion appeared 6 months earlier and had got progressively bigger and sometime bled which she scrated it accidentally. The history and the appearance were suggestive of basal cell carcinoma. I advised her to have the lesion excised to avoid it getting bigger. However, she was reluctant to have any surgery done to her face because of fear of getting an unsightly scar. I showed her some of my patients who had ignored the lesion only to need multilating surgery later when the condition was in an advanced stage.

 

An old man who ignored a right lower lid basal cell

carcinoma until it destroyed the lower lid and the eye.

The orbital content, lower eyelid, some bones and adjacent tissues

were removed in a procedure called orbital exenternation.

 

 

Sometimes a shock tactics was needed to convey the wisdom of having a facial cancer removed early. She agreed to the surgery and the lesion was removed with 3mm of clear margin. After ascertaining the margin is clear of the tumour, the defect was closed with a skin flap.

 

Steps in excision of the tumour and reconstruction.

 

 

Appearance at 2 weeks after surgery.

Appearance at 4 weeks after surgery.

 

 

 

Photoshop assisted aesthetic procedure

This Taiwan aesthetic centre is accused of using photoshop manipulation to show how a celebrity face has been thinned after Botox treatment. It is suspected that photoshop is used to make his pre-treatment lower face broader.

群英醫美被譏「靠修圖整形」
 

曾擔任綜藝節目《大學生了沒》來賓的通告藝人麥基，最近成為連鎖醫美機構群英整形外科診所的肉毒桿菌素瘦臉見證人，但有網友發現，診所官網上麥基的術前照片明顯後製過，兩側臉頰下方多出一塊切角，質疑：「難道是用繪圖軟體整形嗎？」對此，群英醫學公司行銷部強調，麥基的確在診所進行肉毒瘦臉，但坦言後製美工出問題，已修正。衛生局指出，業者應該注意廣告正確性，避免誤解。

投訴組

台北陳先生說，最近瀏覽臉書時，發現群英整形外科診所的廣告，有許多素人及通告藝人的見證照，他覺得很有趣，點閱連結瀏覽群英的官方網站，逐一點閱分享的案例，其中有通告藝人麥基代言肉毒桿菌素消除國字臉，網頁上還註明醫師替他看診治療的經過，並張貼術前術後照片。

不過陳先生說，他在察看麥基的術前照片時卻發現，麥基左右兩側臉頰的邊緣，與左右肩頸的交界處，卻呈現被切割的不自然切角，讓兩側下顎各凸出一塊肉，他請周遭同事們察看，大家都笑說太扯，「明顯就有做過圖片後製，這樣是醫美嗎？」

美工誤裁掉下顎處

對此，群英醫學公司行銷部專員侯冠名解釋，美工人員需要把人物照片去除背景，以利圖片編輯及網站上使用，卻沒注意多切掉臉部下顎處，造成兩處切角，會盡快處理，並強調麥基的確是有接受他們診所的醫美療程。

代言人稱確有療程

麥基此次活動的聯絡人邱雨瑄代麥基接受採訪時說，確有在診所接受療程，才會接洽這活動，沒發現圖片有問題。

台北市衛生局醫護管理處副處長杜仲傑表示，民眾如果發現醫美業者的廣告有疑義，可向衛生局檢舉，會進行稽查，台北市民若接受醫美療程發生任何醫療糾紛，可向衛生局申訴：(02)2728-7080。

The Baby Born with Missing Upper Eyelids (Coloboma)

While most of the cases I did in private practice are aesthetic cases, I do occaionally get  referred unusual cases such as tumour and congenital defects. Unfortunately, most of these functional cases appear to affiliate poorer people who could least afford private health care. On the bright side, Malaysia still has good health care system where these people could still get treatment in governement hospital either free or pay only nominal cost.

 

This baby was born with failure of the upper eyelids to fuse. This is medically termed coloboma and if left untreated can lead to scarring and blindness. The parents were poor so the baby was referred to the General Hospital for closure of the lids. The good things about working in General Hosptial is that one can see challenging conditions for honing one's surgical skills. Of course, the ability to help the less fortunate in the society is an added bonus.

a. Coloboma of the upper eyelids. b. Tenzel's flap used to close the defect.

c. Cutting the edge of the coloboma and remove the symblepharon.

d. Lifting the flap. e. Closing the defect. f. End of the operation.

 

g. Appearance at one week. h. Appearance at 4 weeks.

 

Victims of Unlicensed Aesthetic Procedures in Malaysia. A Facebook Exchange.

Recently, I posted a thought on my facebook and had the following exchanges:

I: "Saw a patient for revision of her double eyelids, she had had the operations done three times by a male "doctor" from China said to be trained in Korea. The operation was a disaster with asymmetrical and very high double eyelids. The operation was done in a hotel and the bed in the hotel room was used as the operating table. It is amazing how naïve some people are. I asked her how she got to know the "doctor", she said she was edged on by other friends who said the "doctor" was good. A group of four of them went for the knife but the results were disappointing. The doctors revise their double eyelids a few times then disappeared off the thin air. I asked if she knew the name and address of the doctor, she said he had no name card or any address. "

Not the actual patient but with similar looks

skin creases too high with too much fat taken out.

Doctor A: "This is just the tip of the iceberg. Some have it done at residential areas other than hotel and saloon. Just 2 day ago got patient have her breast implant done in saloon, she come to me coz incision site got infected with pus discharge, ask her to admit refuse then discharge with antibiotic. She is rich but not very smart."

Inflammation of the breasts after silicone injection. The patient underwent

mastectomy to have the offending agents removed.

I: "The patient is lucky earlier this year my surgical colleague performed mastectomy on a woman who had silicone injected and the breast went gangrenous not to mention a guy who had penis injection to enlarge his manhood which also went septic and had the thingy amputated."

Doctor A: "That breast implant cost her 20,000 ringgits and the man who performed the surgery could not stop shaking hands during the procedure as if it his first case. Having silicone injected into the breast is just crazy."

I : "It costs a few hundred for a big bucket of silicone and they charge thousands for each injection. The side effect takes a few month or even years to develop by then it's not their problems.  Nobody is going to touch the lesion as it is integrated into the skin muscle and nerve. Removing these things can cause uneven scars and worse still causes loop sided face if the facial nerves were accidentally cut."

A patient had persistent red and swollen forehead after injection of some

unknown agent 3 years ago; most likely to be silicone.

This woman had some filler injected in a hotel and for the

past 2 years had a swollen and hard mass over the left cheek.

Again likely to be silicone.

Persistent upper lid swelling for four years after

silicone injection in a beauty saloon.

Red and swollen cheek with tight skin after silicone injection.

The nose also appear rigid and tight.

Doctor A: "It is very difficult for the Ministry of Health to control because more than 70%  of cosmetic procedure are done by non-registered and unlicensed practitioner. As long as things go smoothly everyone keep quiet. Silicone is a lot cheaper compare with biodegradable filler."

I: "Even if things go bad, these patients have no way to complain because there are no consent forms and the personnel are not covered by medicolegal insurance because they are phony doctors. Some beauty centres get round the problems of being prosecuted by employing outsiders to do the jobs and then deny responsibility saying the place was only rented to these people. Another ploy is for these beauty centres to take patients to hotels for the procedure which exonerate the centres from allowing unlicensed personnel performing illegal procedures in their premises."

I: "Another toxic substance that is often used is hydrophilic polyacrylamide gel."

Chinese woman who is injected with the toxic hydrophilic polyacrylamide gel.

Doctor B: "Amazing! All this while I thought this only happens in Indonesia, because Indons are more stupid. It turns out that Malaysians are as stupid as well! China docs operating from hotel rooms, saloons, houses of rich tai tais, as well as local doctors' clinics who take commissions for "collecting" patients and allowing their clinics to be used, is very common here in Indonesia. Usually weeks before their arrivals, words will spread around, and all the tai tais will register with either a local doc, saloon owner, or in the event the surgeries are done in a residential house, the owner of the house who is usually a rich tai tai who lives in a good class bungalow. For some reasons, China docs are perceived as very experienced and talented here. I don't know why. They usually will fly in and stay for just 2-3 days, performed at least 1-2 dozens surgeries per day, then disappeared back to their countries. The most popular surgeries are upper and lower blepharoplasty."

I: "Did one revision lower blepharoplasty yesterday on a patient from Pontianak who had had surgery done in a saloon by a China doctor. Apart from the scar in the lower lids none of the fat or skin was removed and the doctor never visited again."

Doctor B: "Siliconomas are very common here. And what surprises me is the high incidence in rich tai tais. I always wonder....to be rich, you need to be smart and educated. But, it's not very educated and smart to have liquid silicone injected into one's face or breasts. These rich tai tais can afford to see qualified doctors and surgeons who practice in proper established clinics, but I wonder why they choose to have surgeries done in hotel rooms or saloons by some "flying" doctors whom they will never see again after their procedures."

I: "Sorry to offend the ladies, but most women will have anything done to their bodies if you say you got something to make them beautiful. The other day an Indonesian agent bought a woman from Pontianak for treatment. I treated her frown lines, crow feet and forehead, she took out a bunch of ringgits and after paying the fee she says "I got another thousand ringgits here, is there anything you can inject for my face?" I told her there is nothing else she needed then the agent found an excuse to speak to me privately and said "she is very rich just give her anything she will pay without questions" That's how crazy some patients are and she was in her late 50s."

Doctor B: "Even Pontianak patients are like that? I thought only those from Jakarta. I know they always carry around SGD 1000 bank notes, heaps of them, in their wallets or purses, when they go to see doctors or shopping in Singapore."

I: "Now with the high exchange rate, a lot are carrying ringgits."

A Cautionary Tale: Is the Clinic Sterile?

After posting the last blog on double eyelid disaster, I received emails from colleagues detailing horror stories about surgeries performed in saloons and hotels. However, none is as worrying as this piece of news about cut price eyelid surgery performed in oversea clinics with sub-standard sterilization.

 

"I actually have real life cases of 11 patients from Medan who all went to a small city in Thailand to get upper blepharoplasty done by a local plastic surgeon. He charged only SGD 400-450 ( 1000 to 1250 ringgits) per patient. He also threw in freebies: buy 10 get 1 free. The team leader got her surgery done for free. When they returned, one of them fell sick. Found out to have hepatitis B. When the others in the group went for blood test, all 11 of them got hepatitis B!"

Proper sterilization essential to avoid risk of infection.

 

 

Another Double Eyelid Disaster: Don't they ever Learn ?

I think I could easily fill this blog with pages and pages of eyelid disaster done by unlicensed personnel in saloon and sometimes even in hotels. I revised three or four such cases a month but I am pretty sure they are plenty more victims out there who don't know where to seek help or too embarrassed to seek second opinion.

 

This desperate housewife was referred to me by an ophthalmic colleague because of uneven double eyelids created by a beautician. She had dermatochalasis (droopy eyelids due to excess skin); the appropriate approach would be to remove the excess skin to create double eyelids of desired heights. Instead the beautician performed continuous suture technique in an attempt to create high skin creases (double eyelids). The patient was unhappy with the resultant double eyelids, not least because the height were markedly asymmetrical.

 

Inappropriate choice of technique and poor results.

Picture taken by the patient one day after suture technique by the beautician.

 

The beautician then attempted to remove the suture, she was successful with the right eye but for the left eye, the suture broke and desperate attempt was made to find the sutures using hooked needle and forceps. The patient was in severe pain as the saloon did not have the license to buy local anaesthesia (the double eyelids were performed using anaesthetic cream only) and severe abrasion and bruising occurred after half an hour of such manipulation. The beautician then asked the patient to seek medical help herself as she could do not more. The patient was left with severely asymmetrical skin creases (double eyelids)

 

High left double eyelid from retained suture and eyelid bruising

and abrasion from desperate attempt to remove the suture.

 

When I saw the patient, she was in tears and would not dare to venture outdoor without sunglasses. The asymmetrical skin creases were caused by retained suture in the left eyelid. I performed skin excision and removed the offending suture.

 

The excess skin was removed and the suture identified (arrows).

 

The retained suture was removed.

 

 

 

What is the lesson from this case? The case speaks for itself.

Beautiful Eyes in Different Races

The eyes play a very important role in the perception of general facial attractiveness but is there a universal standard for beautiful eyes? The study by a group of Korean plastic surgeons show that though there are some shared features of attractive eyes across races there are also particular features of attractiveness that are race specific. (Biometric Study of Eyelid Shape and Dimensions of Different Races with Reference to Beauty. Seung Chul Rhee, Kyoung-Sik Woo, Bongsik Kwon. Aesth Plast Surg 2012: 36: 1236 - 1245.)

 

They analysed the eyes of average versus attractive female faces in the Koreans (which can apply to Chinese and Japanese too), Caucasians and Africans. Some of the interesting results are mentioned here.

 

 Diagram showing the structures measured: 1= interpupillary distance;

2 = intercanthal distance; 3 = palpebral fissure width;  

4 = palpberal fissure height; 5 = skin crease height and

6 = fissure obliquity (slant of the eye).

Average Korean face (right) and attractive Korean face (left).

The study shows attractive Korean faces have relatively wide-set eyes (the intercanthal distance) and bigger palpebral width (bigger eye opening). The double eyelids of the attractive face is higher than average and  have less epicanthal folds with more exposure of the nasal eye white. In additional, the eyes are less slanty (8.87 in attractive eyes versus 9.77 in average eyes).

Average Caucasian face (right) and attractive Caucasian face (left).

Average African face (right) and attractive African face (left).

 

For the Caucasian and African, attractive eyes seem to share the same features. The attractive eyes are described as having acute shape like that of  Jaguar's eyes. They have slightly narrower eye opening and more interestingly unlike the Korean eyes, attractive eyes are more slanty than the average eyes (for Caucasian eyes, the slant of attractive eye is 7.13 degrees versus 4.12 in average eye and for African eyes, it is 9.98 versus 5.39)

Attractive African and Caucasian with Jaguar's eyes.

 

Droopy Eyelids: More than Excess Skin.

Droopy eyelid is a common condition that can affect the vision by occluding the visual field. However, the term droopy eyelid can mean different things to different patients. Therefore, whenever I receive an email or a phone call "Doc, I got droopy eyelids can you remove the skin for me?" I always insist the patient must come for a full consultation before I can decide which surgical technique to use. The two most common causes of droopy eyelids are:

a. excess upper eyelid skin that hangs over the eyelid margins to cover the visual fields; medically this is called dermatochalasis.

b. poor lid opening caused by problem with the muscle (levator) that open the eye; medically this is called ptosis.

In dermatochalsis (excess upper eyelid skin), the correction is by removing the excess skin. In ptosis (poor eye opening), the correction is aim at strengthening the muscle that open the eyes ie. the levator. An easy way of differentiating the two is to gently lift up the excess upper eyelid; if the eye under the skin is open normally then the cause of the droopy eyelid is excess skin (see picture below).

This patient complains of droop eyelid. By gently lifting the skin of the upper eyelid,

the eye opening is normal. Therefore, he has excess skin (dermatochalasis)

as the cause of his droopy eyelid.

The following pictures show six patients who complained about droopy eyelids. Can you identify which one has excess skin (dermatochalasis) and which one has lid opening problem (ptosis)?





In patients with ptosis, the eye opening are narrow. Patients A, B and D

 have ptosis as the cause of the droopy eyelids and patients  C, E and F

have excess upper eyelid skin as the cause of the droopy eyelids.

The following pictures show the pre- and postoperative photos of patients have had corrections of their droopy eyelids.

This patients had dermatochalasis. The excess skin was removed.

Another patient with dermatochalasis. The postoperative

photo was taken three weeks after the operation.

An elderly woman who has had problem driving because of excess skin

that is interfering with her visual fields. I performed bilateral

upper blepharoplasty. The photo below was

taken one week after the operation.

This patient came to me after having her excess skin in the upper lids removed

by a plastic surgeon six months earlier. Despite the operation, she complained

that she was unable to open her eyes. Examination revealed that her droopy

eyelids were caused by poor function of the muscles that open the eyes.

I performed  bilateral levator resection to open the eyelids.

A patient complained of droopy left eyelid. She has ptosis in both eyes

but more obvious in the left eye. I performed bilateral mullerectomy.

The photo below was taken three weeks later.

A patient who has bilateral ptosis and dermatochalasis. As the main

concern of this patient was poor lid opening, I performed Muller

muscle plication to open his eyes. The postoperative

picture was taken 3 days later.

A patient with bilateral significant ptosis. Bilateral mullerectomy was performed.

The postoperative picture was taken at one month.