Oral presentation in the Alumni Anniversary at Birmingham and Midland Eye Centre, UK

Presentation at the Alumni and Anniversary of the Birmingham and Midland Eye Centre, UK on the 17th of December 2014 introduced by Professor Philip Ian Murray.

Doc, Can You Balance My Double Eyelids?

This patient had had double eyelid surgery done somewhere but was unhappy with the left double eyelid which appeared to be too high. Examination showed this was caused by too much fat being removed and hence the high double eyelid with sunken look. 

Uneven double eyelids treated with hyaluronic acid.

I injected 0.3 ml of hyaluronic acid Juverdem into the preaponeurotic space (arrowed) to replace the missing volume and straight away the double eyelids appeared equal.

Doctor, I have swollen eyebrow!

This 65 year-old woman presented with a rapidly expanding lesion of the right medial eyebrow and swelling of the lymph nodes over the right jaw. The swelling first started 6 months ago. She was otherwise in good health. Examination revealed a non-reducible, non-tender and fixed mass. A CT scan shows no extension into the brain or the orbit. To avoid creating obvious scar, I perform the incision along the eyebrow with some medial extension. 

Right medial eyebrow sweling of 6-month duration.

Incision made along the eyebrow and the lesion removed completely.

Patient returned one week later for suture removal.

The lesion was sent in totality and sent for histopathology. I was expecting the lesion to show evidence of lymphoma but instead the report read chronic inflammtory changes consistent with a condition termed "Kimura's disease". As the patient was asymptomatic except for some swollen lymph nodes which are small in sizes, no treatment was needed but the patient was asked to return for regular review. 

Beware of Bogus Korean Plastic Surgeons

Beware of bogus Korean plastic doctors from the Star newspaper.

Trouble brewing in South Korea's plastic surgery paradise

Kim Bok-soon cries during an interview with Reuters at her home in Seoul, Oct 14, 2014. - REUTERS

SEOUL: Kim Bok-soon disliked her nose and fantasized about getting it fixed after learning of the Korean superstition that an upturned nose makes it harder to hold on to riches. 

While waiting in a hair salon, she saw a magazine advertisement for a plastic surgery clinic and decided to go for it, despite her family's objections. 

In South Korea, where physical perfection is seen as a way to improve the quality of life, including job and marriage prospects, plastic surgery procedures can seem as commonplace as haircuts. 

Kim's doctor said he could turn her into a celebrity lookalike, and Kim decided to take the plunge, taking loans and spending 30 million won (US$28,000) for 15 surgeries on her face over the course of a day. 

When the bandages came off and she looked in the mirror, she knew something had gone horribly wrong. 

Only later did Kim find out her doctor was not a plastic surgery specialist. 

Kim Bok-soon cries during an interview with Reuters at her home in Seoul, Oct 14, 2014. - REUTERS 

Five years later, Kim struggles with an array of medical problems, and is unable to close her eyes or stop her nose from running. The 49-year-old divorcee said she was unemployed and suffers from depression. 

"It is so horrible that people can't look at my face," Kim, crying, said in her tiny one-room Seoul flat filled with photographs from before and after the surgeries. "This is not a human face. It is more revolting than monsters or aliens." 

A record from the Seoul central district court shows that Kim's doctor faces a pending criminal case on charges of violating medical law. 

The case began in 2009 after several patients including Kim reported him to the authorities. The doctor's lawyer turned down Reuters' request for an interview. 

The boom in South Korea's $5 billion plastic surgery industry - that's a quarter of the global market according to the country's antitrust watchdog - is facing a backlash, with formal complaints about botched procedures and dodgy doctors doubling in 2013 from a year earlier. 

Some plastic surgeons say safety fears could stifle the country's nascent but fast-growing market for medical tourism, especially from China. 

Complaints range from unqualified doctors to overly aggressive marketing to "ghost doctors", who stand in for more qualified doctors and perform surgeries on unwitting, anaesthetized patients. 

Cha Sang-myun, chairman of the Korean Association of Plastic Surgeons, which represents 1,500 plastic surgeons, is worried about their reputation. Cha and some lawmakers are among those calling for tighter supervision and stricter advertising rules.

"We've got to clean ourselves up," Cha said at his clinic in Seoul's high-end Gangnam district, which is filled with plastic surgery clinics. 

"Now, patients from China are coming in the name of plastic surgery tourism but if things go on like this, I don't think they will come in the next few years," he said. 

In a notorious case last December, a high school student ended up in a coma after surgeries to fix her nose and get a "double-eyelid", a procedure that makes the eyes look bigger. 

Cha's group looked into the incident and found the hospital that performed the surgery hired such ghost doctors, and referred the case to prosecutors.

It is still under investigation by prosecutors and nobody has been indicted, an official at the association said. 

Critics blame lax regulation, excessive advertising and society's obsession with appearance for fuelling an industry run amok. 

South Korea is home to more than 4,000 plastic surgery clinics and has the world's highest rate of cosmetic procedures - 13 for every 1,000 people in a population of 49 million - according to government data. 

The boom is gaining steam, fuelled by tourism, with the number of visiting Chinese patients tripling between 2011 and 2013, government data shows.

"Advertising too much has made people think surgeries are a commodity. People now think plastic surgeries are like buying stuff somewhere," said Cha, who has performed plastic surgeries for more than two decades. 

"But plastic surgery is a surgery too, which can risk your life," he said. 

A Miss Korea contestant in the 1980s underwent breast augmentation in 2008 in the hope that it would boost her chances of finding a husband. 

Park, 50, who is divorced and gave only her surname, ended up going to the same doctor as Kim. Due to a series of post-surgical infections, her right breast ended up half the size of the left.

"I regret it so much that I tried to kill myself twice," she said. "Plastic surgeries are like an addiction. If you do the eyes, you want to do the nose. And doctors don't say 'you are beautiful enough', but get people to do more." – Reuters

Doctor, can you make my double eyelids equal ?

A significant number of patients with unequal double eyelids actually have ptosis (droopy lid) making the double eyelid on the affected side higher. This ptosis may be compensated by overaction of the eyebrow which helps to lift the eyelid and therefore masks the droopy eyelid.  

This patient complains of unequal double eyelids and asking for the left double eyelid to be made higher. However, examination shows her right eyebrow to be higher. When the eyebrow was lowered by stopping the forehead muscle from lifting it the right eyelid appears lower. The correct procedure is to lift the right eyelid instead of making the left double eyelid higher. 

Patient complains that the left double eyelid is lower than that 

of the right. Note the right eyebrow is higher. When the eyebrow 

is lower, the right eyelid appears droopy.

Before the ptosis operation the patient was given sedative, in 

the relaxed state both eyebrows are of equal height and the right 

droopy eyelid became obvious with high double eyelid.

A posterior approach mullerectomy was performed to lift the right eyelid. 

24 hours after the procedure the right eyelid was slightly over lifted. 

4 weeks after the surgery, both double eyelids 

and eyes now appear equal.

Is Your Korean Surgeon Qualified?

In my recent public talk on eyelid surgery, a patient shared a cautionary tale with the audience. Her friend was impressed with the Korean cosemtic surgery because of the omnipresent advertisements and news showing fantastic outcomes. 

So she contacted an agent who promised her they can get her a facelift in a top Korean cosmetic  centre. The fee came to USD25,000. Off she went and had the operation in a centre near Seoul which she can’t pronounce the name and the operation was done by a surgeon who was not the one who consulted her in the cinic. The consultation was done through a Chinese interpreter as the doctors could not understand English or Mandarin. She was discharged five days after the operation and flew back home. However, the result was unsatisfactory with unsightly scars. In addition, the wounds got infected and she was admitted to a local hospital for one week of intravenous antibiotic. She contacted the agent who said they can arrange for her to return to Korea for revision but she needed to pay another USD15000. At the end, she had scar revision by a local Malaysian plastic surgeon and the surgeon checked out the name of the centre where she had the operation and found that the centre was not a cosmetic but an orthopaedic centre and the doctors were orthopaedic not cosmetic surgeons.

South Korea has 1,400 registered cosmetic surgery clinics which received over 150,000 clients from other countries in 2012. However, the popularity of Korean cosmetic surgery expertise has given rise to a number of incidents and disputes over the results of the procedures, as well as the clinics' fees and agencies who arranged the trip and the surgery as a package. Some of the clinics were found to be unqualified to perform surgery and some agencies have been found to be running scams. Many patients said they also had inadequate understanding and knowledge about the procedures they underwent.

People who plan to undergo cosmetic surgery in South Korea should go to reputable clinics and research these clinics beforehand through the internet or reputable agencies. As many surgical procedures involve advanced medical terminology and knowledge, many non-Korean patients have problem communicating with Korean doctors even if they can speak English. Therefore, it is essential that patients should select experienced travel agencies with medical knowledge to help with communication.

End note:

A recent article from theMalaysian Chinese newspaper Sinchew Daily reported that as many as 90% of theoversea clients who visited Korean Cosmetic Centre were operated by unqualified surgeons.  (see below). Many agents used the names of established cosmetic surgeons to attract business but the operations were performed by trainees. Many agents take almost 90% of the fee paid by the clients.

醫生與中間人勾結牟利‧韓整形醫師九成“山寨＂

2014-08-26 17:07

（韓國‧首爾26日訊）受“韓流”的影響，越來越多的人前往韓國做整形手術，希望自己能“改頭換面”、令人驚艷。但當地媒體披露，韓國的“山寨整形”醫生高達90%。

據韓國《朝鮮日報》報道，韓國掛牌的整形醫院的醫生共達1.5萬人，其中整形外科專業醫生只有10%（1400多人），許多整形醫院為了招攬患者，在廣告中用經驗豐富的專業醫生做宣傳，但實際操刀的是新手或實習醫生。

來自廣州的李姓少女今年4月透過中間人介紹，花了2千200萬韓元（合2萬多美金）聘請首爾的整容名醫割雙眼皮、隆鼻以及在臉部注射大腿內側抽取的脂肪。

該少女剛開始很滿意整形效果，但後來赫然發現自己的會陰部位，也就是肛門和陰部中間一處狹小地方有些怪怪的，追問下才知道，動刀的是個實習生，懷疑他因經驗不足，導致原本因該從大腿內側抽取脂肪，卻變成在會陰抽取。

隆鼻導致流膿半個月

另一名中國女子今年初到韓國接受隆鼻手術，但醫生手術後竟忘記拿出她鼻子內的紗布，導致她的鼻子持續流膿長達半個多月。

韓國當地就有醫生爆料，韓國整形界其實醫療秩序混亂，為了賺錢，被國外中間人牽著鼻子走。也有不少醫生與中間人勾結，只顧追求眼前利益。

《朝鮮日報》還披露，很多中介公司和旅社均由黑幫操控，嚴重扭曲整形業的生態。

收1億韓圜只給醫院1千萬

據報，有中間人收取中國顧客1億韓圜後，只給醫院1千萬韓圜，餘數全獨吞。換言之，真的靠整容賺錢的是中間人而非整形醫生。

報道還建議，若不想成為山寨整形醫生的實習對象，最好不要到中間人介紹的醫院，而是前往資歷較深的私人醫院。

（星洲日報／國際）

How Do I Know if the "Doctor" is Legal?

I saw two patients over the weekend who had had disastrous silicone injections performed by "doctors" in beauty saloon and hotel respectively. I asked them why they did not verify the credentials of these doctors before having something done to their face (Not that these "doctors" need their credentials verified as not decent doctors will perform surgery in beauty saloons or hotels as there are against the laws). But most of the public are ignorant of these and often pressured by agents into having unsafe procedures. In addition, most people don't know where and how to check if somebody is really a doctor.

Complications from silicone injections. Patient at the top had lower

 lid injections three years ago to give her good cheekbones but the 

silicone has migrated downward. Unlike hyaluronic acid which can 

be removed by injecting enzyme, silicone is integrated into the facial 

tissues and removal usually leaves scars. Patient at the bottom had lip 

silicone injection which got thicker with the passing 

of the years due to inflammation. 

In Malaysia, only doctor is allowed to carry out medical procedures. And all qualified doctors must register by laws with the Malaysian Medical Council. You can verify if the person is really a doctor by visiting:

http://mmc.gov.my/v1/index.php?option=com_wrapper&Itemid=50

and type in the real name of the doctor, if the name is not found the person is practising illegally in Malaysia. 

Hopefully these simple verifications can save some patients from life-long disfigurements. But again never have medical procedures in beauty saloons and hotels as they are not the safe places for surgery.

Total Upper Eyelid Removal in a Patient with Lid Cancer

This 72 year-old woman from a remote village presented with a one-year history of a rapidly growing lesion of the upper eyelid. The lesion bled easily and contained cheesy substances. Biopsy showed sebaceous cell carcinoma. Untreated this condition can grow rapidly and cause death by either spreading to other parts of the body or destroy the surrounding tissues (see pictures below). In this patient, the upper eyelid was removed and reconstructed using lower eyelid (Cutler-Beard's technique). The flap was left for 6 to 8 weeks to allow formation of new blood supply before being open.

A rapidly growing mass in the right upper lid 

destroying most of the eyelashes. 

The mass involved nearly all the upper eyelid and biopsy 

showed this to be sebaceous cell carcinoma. 

A young man who ignored a rapidly growing left eyelid lesion which turned up 

to be sebaceous carcinoma until it invaded deeply destroying 

most of the ocular tissues. 

Another case of sebaceous cell carcinoma which invaded 

the brain despite previous surgery. 

Steps of upper eyelid reconstruction in this patient. a-c. The upper eyelid

 was excised with normal looking tissue to ensure the margin is free 

of tumour. d-g. Full thickness lower eyelid was used to cover

 the defect. This was done in 3 layers: conjunctiva of lower lid 

to conjunctiva of upper lid; orbicularis muscle of lower lid 

to levator of the of the upper and skin to skin. 

h. End of the procedure. 

Appearance of the eye at one week post-operative. The patient was

discharged and given date for opening the flap in 2-month time. 

(To be continued)

August Lectures on Eyelid Surgery

Common Eyelid Problems given on the 25th August, 2014 to Penang Optometrists and

on the 31st August, 2014 to 19th Sarawak Optical Trader Society (SOTA).

Public talk on the 30th August, 2014. 

Doc, Could You Inject Me This Skin Whienting Serum Which I Bought on Line?

Recently I received a few requests from patients who wanted me to inject skin whitening serum (美白针）for them in the clinic. When I declined, they invariably said they are willing to pay extra for the procedure. I explained to them the reasons why I didn't want to do it:

a. This skin whitening serum is not a listed medication and no self-respecting doctor will inject any medication which is not licensed. In Malaysia, most of the injections are done by beauticians in their clinics where basic sterilization and resuscitation equipments are not available. 

b. There is no evidence that it works.

c. No decent doctors will inject any medications that patients bought on-line. 

Out of curiosity, I decided to find out more about this skin whitening serum but could not find any articles in main line scientific publications. However, I eventually found a Taiwanese book in Kinokuniya Bookshop which gave a detailed explanation of this "magic" serum. Apparently, this serum was first concocted by a Taiwanese doctor to push sale in his aesthetic clinic. The previous life of this serum was meant for patients with chronic hepatitis B. Lisamin and vitaminc C are added as anti-oxidants and marketed as skin whitening serum. There is little evidence the serum works and the person who administered the serum uses certain tricks to convince the patients otherwise. The commonest trick is to get the patient to lie down during the intravenous injection for hours. In this position, the blood flow to the skin is reduced and the patients will appear fairer at the end of the procedure. 

Here are some of the highlights of the chapter on skin whitening serum. 

A Woman with Reading Difficulty and Headache

This 58 year-old complained of persistent headache and problems with reading for the past year. She underwent bilateral cataract surgery two years ago. She had undergone a battery of tests for her headache including MRI but not organic causes could be found. She also changed her reading glasses many times but without improvement in her reading vision. When I saw her I noticed she had exceedingly high eyebrows and deep forehead furrows indicative of frontalis overaction (excessive use of the forehead muscle to lift up the eyebrows and the eyelids). Her distant vision was good at 6/6 with glasses but reading was a problem. When she read a book, her eyelids could be seen to cover most of the eyes (see pictures).

Exceedingly high eyebrows (right picture) and eyelids covering 

both eyes when she attempted to read a book. 

Her headache and problem with reading were both related to ptosis (droopy eyelids from problem of the muscle that open the eyelid). When her forehead muscles were disabled by pressing the fingers over the top of the eyebrows, the ptosis got worse.

Increased ptosis when the forehead muscle was stopped from 

acting by pressing the fingers over the areas above the eyebrows.

I performed ptosis surgery to lift both eyelids. The technique chosen is a modifie posterior approach  conjunctivomullerectomy. In this technique the scars are minimal with faster recovery. The steps of the operation are shown in the pictures (1-14) below. 

Steps 1-8 showing shortening of the conjunctivomuller complex via a posterior approach. 

Steps 9-14 showing stitching the cut end of the conjunctivomuller complex 

to the tarsal plate to open up the eyelid.

Appearance of the eyes before (right) and one week after the operation. 

  

A Young Woman with Constant Watery Eyes

This young woman complained of watery eyes associated with recurrent discomfort and red eyes. Examination revealed that her eyelashes were rubbing against her eyes. She had a condition called epiblepharon. 

Ocular irritation from epiblepharon. 

The arrows shows the excess skin that pushes the eyelashes inward. 

Cross-section diagram showing eyelashes rubbing on the eye.

In epiblepharon, there is extra fold of skin in the lower eyelid which pushed the eyelashes inward against the eyes. Although this condition typically presents in childhood, this patient's condition was overlooked and presented only now. Most cases of epiblepharon do not require surgical treatment as the condition outgrow itself because as the face grows longer, the skin will be stretched and the lashes rotate into a normal position (the eyelashes pointing out rather than pointing in). While waiting for nature to correct itself, the use of lubricants can reduce the symptoms of irritation and redness. However, if the condition persisted beyond childhood or if there is eye injury from the eyelashes such as corneal abrasions and scars, surgical correction is the treatment of choice. In such cases, the excess skin and the underlying muscle are removed and the skin is sutured back together to roate the eyelashes outward. The incision is made just below the eyelashes. Although the scar is initially noticeable, this fades over several months and usually becomes unnoticeable in about 6 months. 

Steps of correction of epiblepharon. a and b. The excess skin were marked; 

c. the skin is excised; d. the underlying muscle (orbicularis) is removed 

to exposed the orbital septum; e. the orbital septum and the underlying fat pad 

were cautherized; f. the tarsal plate (arrowed) was revealed after the septum and 

fat pad were shrunk; g. suture was passed through the skin; h. suture passed 

through the tarsal plate; i. suture passed through the skin again and j. tying of 

the suture rotate the eyelashes outward. 

Eyelashes were rotated outward at the end of the surgery.

Doc, can you extend my double eyelid?

This girl with puffy eyelids underwent small incision double eyelid surgery two months ago. The result appeared satisfactory, however, she wanted the double eyelid to extend out further.

Right eyelid before and after small incision 

double eyelid surgery. 

What the patient wished. The desired extension of 

the double eyelid was created by using a paper clip.

I performed a small incision fat removal combined with suturing of the orbicularis to the levator aponeurosis to give the desired result.

a. Marking was made along the desired double eyelid; 

b. Incision was made through the skin, orbicularis and orbital septum; 

c. The preaponeurotic fat was prolapsed and removed; 

d. sutures of the orbicularis and levator were made 

followed by skin to skin lid closure. 

Pre and postoperative pictures (immediately postsurgery). 

The double eyelid had been extended and 

the outer eyelid less puffy due to fat removal. 

Doc, Can You Perform Suture Technique on My Puffy Eyelids?

Suture technique for creating double eyelid is useful in thin upper eyelids. However, in  puffy eyelids the failure rate is high because the fatty tissue in front of the levator muscle will prevent adequate adhesion between the muscle and the skin. Small incision technique in which some fat is removed is the recommended technique as it has the advantage over the full incision technique in having a shorter downtime. However, some patients are adamant in having any incision done to the eyelids for fear people would know they have had double eyelid surgery. In such patients, I modify my suture technique to increase the longevity of the double eyelids by removing fat through the mini-incisions. 

A patient with puffy eyelids but didn't want any incision technique.

Modified suture technique. a. Three markings were made 7 mm above the eyelid 

margins; b. 3 stab incisions were made through the markings and the orbicularis 

and orbital septum were removed using forceps and Vanner scissors; c. fat was

 prolapsed through the small incisions; d and e. the fat was clamped and excised; 

f, g and h. 6/0 vicryl sutures were used to form the double eyelid.

The picture below was taken two weeks after the operation.

Another patient with the modified suture technique. 

The picture below was taken four months later. 

Another patient with the modified suture technique. 

The picture below was taken 6 months later.

Doc, could you balance my double eyelids?

This patient wanted to even out his unequal double eyelids (skin creases) and had seen plastic surgeons who recommended creating a higher double eyelid for the left eye. However, the patient wanted the right double eyelid to be lowered. Examination revealed that his right eyebrow is higher than the left. Further history revealed that the double eyelids was equal in height until he developed a right eyelid infection from stye 7 years ago.

Right double eyelid (skin crease) and 

the eyebrow were higher than the left.

Eyelid examination (see below) showed he actually had a right droopy eyelid and this was masked by the compensatory lifting of the right eyebrow. If surgery were done to make the left double eyelid higher, the difference in the eyebrow height will become more marked and the patient was unlikely to be happy. 

Patient lifted both eyebrows widely. 

The right eye appeared smaller than the left eye.

The right eyebrow was stopped from lifting 

and the right eye became smaller.

The correct diagnosis was right droopy eyelid (ptosis). This was  most likely to result from dehiscence of the muscle (levator muscle that opened the eye) from the eye infection that he had 7 years ago. The treatment of choice was right ptosis operation. However, he was sceptical about the diagnosis as the two plastic surgeons he consulted both recommended left double eyelid surgery. To convince the patient,  two jabs of botox were injected into the forehead to lower the eyelid.

2 X 4 units of botox were injected into the frontalis 

just above the eyebrow (red spots).

When seen two weeks later, there was an obvious right mild ptosis. The patient was now happy with the diagnosis and agreed to a right posterior approach ptosis operation.

Right eyebrow was lowered with botox. 

The right eye became smaller due to ptosis.