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.