Launch of New Book for Sarawak Heart Foundation

I am pleased to announce the publication of the new book "Picture Diagnostic Tests for Postgraduate Medicine" today. The book was written with the help of the Ophthalmology and the Cardiac Department and published by my company Marudi Publication. All proceeds from the sale of the book will be donated to the Sarawak Heart Foundation.

  

Lauching the book with Prof Sim (right) and Dr Koh (left).

The book is now available from the Sarawak Heart Foundation

 in the Heart Centre.

Excision and reconstruction of a Lower Lid Lesion

This man was concerned about his lower eyelid xanthelasma which had troubled him for the past 10 years and had got bigger. He had tried trichloroacetic acid and laser treatment but without success. The lesion was excised closed to the margin and a rhomboid flap was used to cover the defect.
(Special thanks to Dr Ho Shu Fen, Dr Chin Ong and Dr Andy Yew for assisting the operations and taking the pictures).

Steps showing the excision of the xanthelasma and use of rhomboid flap to cover the defect. The main concerns in this procedures are lower lid ectropion (eversion of lower lid) and scarring. The former requires the use of flap that does not cause too much tension on the lower lid margin and the later needs meticulous suturing technique to minimal scarring. 

Excisional Biopsy of a Lower Eyelid Basal Cell Carcinoma

This patient had a lower eyelid ulcer for the past year. The appearance was typical of basal cell carinoma, an excisional biopsy was done with 3mm clear margin. A rotational flap was used to cover the defect as shown. 

Doc, what is this in my lower eyelid?

This 70 year-old woman presented with a rapidly enlarging lesion in her right lower lid. The lesion bled easily whenever she rubbed her eye. Examination revealed an ulcerated lesion involving almost half of her right lower eyelid and there was out-turning of the eyelid (ectropion) due to scarring. 

Figure 1. Right lower eyelid basal cell carcinoma with ectropion. 

The appearance was consistent with basal cell carcinoma, a type of skin lesion that typically occurred in sun-exposed skin such as the face and hands. Although cancerous, this type of skin cancer does not spread to distant part of the body. However, if left untreated, it will slowly destroy the surrounding tissues. 

Figure 2. A patient with extensive basal cell carcinoma destroying 

most of the right eyelid, the tumour also invaded deeply. Exenteration 

in which all the ocular tissue were removed leaving behind the 

bony orbit had to be performed. 

The best treatment option is excision with some clear margin to ensure complete excision. Because the lesion in this patient was large, the excision required extensive reconstruction. In this patient, the reconstruction was done using rotation flaps as shown in the photos below.

Figure 3. a. Marking of the lesion with 3mm clear margin; 

b and c. Complete excision of the lesion; 

d. the posterior lamellar was replaced with tarsal plate from the upper lid; 

e and f; the tarsal plate of the upper lid was rotated to the lower lid; 

g. the tarsal plate was sutured to the cut edge of the lower lid; 

h. the anterior lamellar was replaced with upper lid myocutaneous graft; 

i. the upper myocutaneous flap was rotated to the lower lid defect; 

j. to avoid flap retraction the cheek was elevated and sutured to the lateral orbital rim; 

k. the rotation flap was sutured in placed and the harvested area was closed as in upper blepharoplasty; 

l. the right eye was tightly packed for 24 hours to prevent haematoma beneath the flap. 

Doc, why do I have so many lines along my double eyelid?

This 36 year-old woman with a history of allergy underwent double eyelid (Asian blepharoplasty) 2 years ago. Initially the double eyelids in both eyes were symmetrical and well-defined. However, in the last 6 months, she noticed the appearance of extra lines in her right upper eyelids which got worse over time (see Figure 1). History revealed she often rubbed her eyelids due to itchiness.

Figure 1. Poorly defined double eyelid 

in the right upper eyelid with extra lines. 

The lost double eyelid (skin crease) was caused by dehiscence (loss of attachment) between the skin and the underlying tissue mainly the levator aponeurosis (the muscle that's responsible for opening the eye). The dehisence was likely to arise from constant eyelid rubbing. Indentation of the eyelid skin showed that the double eyelid can be restored and the extra lines eliminated (Figure 2).

Figure 2. The top picture shows the right eye had well-defined double eyelid

(white arrow) which disappeared towards the corner of the eye (black arrow). 

Indentation of the skin using a paper clip shows the double eyelid 

can be restored with elimination of the extra line. 

There are many ways of correcting this problem. However, the easiest way with a short down-time is to indent the skin with a non-absorbable suture (Figure 3). The principle is similar to the suture technique for Asian blepharoplasty. 

Figure 3. Steps showing how the skin crease was restored. 

a. two marks are made along the original double eyelid near the corner of the eye; 

b. stab incisions were made at the sites marked; 

c. a non-absorbable suture was passed deep through the incisions catching the tarsal plate; 

d. the suture was then passed back through the incision this time just below the skin; 

e. the two ends of the suture were tied; 

f. at the end of the procedure.

At the end of the procedure, there was some puffiness. However, the patient was able to return to work. The recovery could be sped up with ice compress. 

Figure 4. Picture taken one hour after the procedure showing 

well-defined double eyelid despite the swelling. 

Doc, can you stop tears from running down my face?

This 68 year-old has been troubled by constant watering of the right eye for the past three years. She has seen many eye doctors but despite applying different eyedrops the condition fails to improve. Syringing of the nasolacrimal duct reveals blockage of the nasolacrimal duct. This condition typically affects elderly woman and thought to be a type of degeneration.  

Figure 1. Normal tear drainage system.

Figure 2. Diagram showing blocked nasolacrimal duct 

causing watering eye. 

Figure 3. Diagram showing how the blockage can be by-passed 

by creating an alternative passage for the tear. 

To bypass the blockage, an alternative passage is created by creating a connection between the lacrimal sac and the nasal cavity. The procedure is called dacryocystorhinostomy (DCR). The steps of the procedure done on this patient are shown in the photos below. The procedure is carried out under general anaesthesia.

Figure 4. a. Marking is done nasal to the right eye; 

b. incision is made and the skin and muscle are pulled away; 

c. an incision is made along the periosteum and peeled away from the bone; 

d. a hole is created by breaking the bone of the nose (rhinostomy); 

e. once the bone is removed the underlying nasal mucosa can be seen; 

f. the nasal mucosa is cut to create an anterior flap; 

g. the lacrimal sac is identified by inserting the lacrimal probes through the nasal puncta; 

h. the lacrimal sac is also cut to create an anterior flap; 

i. to improve the success rate of DCR, silicone tubing is inserted; 

j. the tube is passed from the punta through the lacrimal sac and nasal cavity and out through the nostril; 

k. after the tubing is passed, the anterior flaps of the lacrimal sac and nasal cavity are sutured; 

l. at the end of the procedure, the tubing is removed 6 weeks later. The new passage allowed the tear to bypass the blocked nasolacrimal duct. 

Doc, what are these swellings in my upper eyelids?

This 60 year-old woman is bothered by swellings in her upper eyelids near the nose. Examination shows these swellings were soft to the touch and can be pushed inwards (see figure 1). The features suggest these swellings were caused by prolapse of the medial fat pad. 

Figure 1. The patient is concerned by the swellings in her upper lids 

near the nose (areas circles in blue).

Anatomically, the upper eyelid contains two fat compartments: medial and central and the lower eyelids three: media, central and lateral (see figure 2). In young people, the fats are not visible but with age, the fat may become protruded due to weakness of the overlying structures such as muscles and septum (the fibrous tissue that separates fat from the muscles). 

Figure 2. Picture showing the right eye of a 70 year-old man with severe fat prolapse.

A = medial fat pad; B = central fat pad; 

1 = medial fat pad, 2 = central fat pad and 3 = lateral fat pad.

The swellings are easily removed through a limited incision along the skin creases (double eyelids). To get to the fat pad, the incision needs to go to through 3 layers namely: skin, orbicularis oculi muscle and the orbital septum. The fat needs to be handled with care to avoid bleeding into the back of the eye. After enough fat was taken the wounds are closed with sutures which are removed in one week.  

Figure 3. The patient shown in figure 1 undergoes fat incision under local anaesthesia.

a. marking along the skin crease (double eyelid); 

b. the fat is teased out from the medial fat compartment; 

c. the fat was clamped with a pair of artery forceps to prevent bleeding; 

d. the fat is excised and cauterized (burnt); 

e. at the end of the fat excision; 

f. the wound is sutured with 6/0 nylon. 

PDF articles from Cosmetic Surgery and Beauty Magazine

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Postoperative Review

Just done clinic including reviewing 12 operations I did yesterday. Some of the pre-and post-operative pictures are shown below with patients' permission. 

The top picture shows a patient with right ptosis preoperative which was corrected with posterior approach conjunctivomullerectomy. The swelling is minimal. 

The second picture shows a patient who had had suture technique for double eyelids some years ago, a limited incision techniques and epicanthoplasty were done to widen and lengthen the eyes. 

The last picture shows a patient who developed right ptosis following cataract surgery 10 years ago. Again the right ptosis was done with posterior approach conjunctivomullerectomy with minimal swelling. 

一切從眼睛開始 translated article from Cosmetic Magazine.

Did 4 cataract surgery today and received this article from Cosmetic Magazine.

Learning a New Word: "Pulchronomics"

A quiet day without clinic, so went to see my accountant about the GST. Afterward, went to Starbuck and read a book I bought in Kinokuniya. The book is titled "In Your Face" with the subheading "The hidden history of plastic surgery and why looks matter". Although written for the public, it was an entertaining and educational read for any doctors who perform aesthetic facial surgery. In page 124, I learnt a new word "pulchronomics". The term can be defined as the economic advantages of looking attractive. Pulchronomic appears to be a key factor in the mushrooming of aesthetic procedures in the last decades. With the increased competition in marketplace, looking attractive and young allow ones to get more customers and retain jobs these are especially true for those working in the beauty lines. No surprisingly, quite a number of my patients are either beauticians or cosmetic sale persons. 

Picture 1. A beautician before and after upper and lower blepharoplasty. 

Picture 2. A sales woman of a cosmetic counter. 

Before and after upper and lower blepharoplasty. 

 

A Patient with "Kissing" Naevus

Kissing naevus, also known as divided naevus, is a rare form of congenital anevus that usually occurs on adjacent parts of the upper and lower eyelids of one eye. When the eyelids are closed the eye appears to be covered by one large nevus. It may cause functional and aesthetic problems. This 60 year-old woman had had this lesion since birth and for the past three years there was an increase in size causing problem with eye opening. Examination shows no signs of malignant transformation. The patient was keen to have the lesion for both cosmetic and functional reasons. 

Picture 1. Left kissing naevus causing problem with

left eye opening and lower lid ectropion. 

The next series of photos show how the lesions were excised and the lids reconstructed. Before the operation, eye examination shows loose lower eyelid from chronic stretching of the lesion, so excision with direct closure was planned. The upper eyelid also showed lid stretching but it was thought the amount of excision may required additional steps to close the defect so reversed Tenzel's flap was planned. 

Picture 2. a. Drawings showing site of planned excision and reversed Tenzel flap. 

b. The lower lesion was excised in pentagon fashion. 

c, d and e. To facilitate direct closure, canthotomy and cantholysis of the lower eyelid were performed. 

f. Pentagon excision of the upper eyelid lesion.

Picture 2. g. At the end of excision; h. Layered closure of the lower eyelid; 

i. The cut edges of the upper eyelids can be apposed without tension so Tenzel flap was not done. 

j. Layered closure of the upper eyelid.

Picture 3. Appearance of the eyelid at the end of the operation. 

The excised lesions were sent for histopathologic study. The eyelid is expected to open in a few weeks time when the swelling subsides. (To be continued.

Repair of a Shortened Eye with Blinker Effect

This man sustained multiple laceration of the left outer eyelid 6 months ago in a motorcycle accident. The wound was poorly repaired giving rise to apparent shortening of the left eye and a blinker effect (see pictures 1 - 3).

Picture 1. The left outer corner is covered by the skin due to

 poor reconstruction making the eye looks smaller.

Picture 2. The covering of the left outer corner of the eye

gives rise to a blinker effect.

Picture 3. A blinker on a race horse to direct the vision forward.



There are several methods for correcting such defects. However, as this defect resembles epicanthal fold in the inner corner of the eye (see picture 4), I decided to correct the defect using skin redraping method. This has the advantage of minimal scaring. The steps of the procedure are as shown below (picture 5).

Picture 4. Epicanthal folds before and after epicanthoplasty

using the skin redraping method.



Picture 5. Steps of skin redraping. 

Special thanks to Dr Yew Yen Harn and Dr Lausanne Chua for assisting 

the operation and taking the photos.

Picture 6. Before and after the  reconstruction. 





Ptosis Surgery.

Happy Labour Day. Did three eyelid surgery today. All ptosis performed with posterior approach.

Some Patients Done Recently.

Three procedures cover most of my oculoplastic cases: Asian blepharoplasty; eyebag surgery and ptosis (droopy eyelids). Below are some selected patients from last months.  

Patient a is a male patient who has had small incision operation for double eyelids. the double eyelids should not be made too high or the eyes become feminized. Patient b had bilateral small incision double eyelid surgery coupled with non-surgical rhinoplasty. Patient c has had bilateral double eyelids done elsewhere by a plastic surgeon, shecomplains the eyes look sleepy, and examination reveals bilateral ptosis. Bilateral posterior conjunctivomullectomy was done to lift the eyes by 2mm.

Total Excision of the Upper Eyelid in a Patient with Sebaceous Cell Carcinoma

This 72 year-old woman from a remote village developed a rapidly growing lesion of the right upper eyelid. Examination showed the whole upper eyelid was invaded by the tumour. Biopsy revealed sebaceous cell carcinoma. This type of cancer is more common in Asians than other races and is not related to sun exposure like basal cell carcinoma or squamous cell carcinoma. I excised the whole upper eyelids and replaced it with the lower eyelid using a technique called Cutler-Beard's flap in August last year. 

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. 

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. 

For various reasons the patient was unable to return for secondary surgery until February this year (6 months after the primary procedure). After opening the flap, she was able to move her eyelid normally and there was no recurrence of the tumour. 

a. Appearance of the right eyelid 6 months after the Cutler-Beard's procedure.

b, c, and d. Opening up of the flap. e. right eyelid at 3-week after lid opening. 

A Rapidly Enlarging Upper Eyelid Lesion

This European man, who has been living in Malaysia for the past decade, presents with a left upper eyelid mass which grows rapidly over a period of two months. The lesion bleeds easily when touch but otherwise painless. A biopsy shows this to be a squamous cell carcinoma. Skin cancer is relatively uncommon amongst native Malaysians because the presence of increased melanin offers protection against ultraviolet light which is the main cause of skin cancer such as basal cell carcinoma and squamous cell carcinoma. Europeans who live in sunny countries are at increased risk of skin cancers as their skins have less melanin. 

Preoperative appearance showing a large lesion 

involving one-third of the upper eyelid.

I excise the anterior lamellar with 5 mm clear margin. After getting clearance of the lesion from the pathologists, the raw surface is covered with bilobed flap. The patient has good result even at 3-week postoperative. The scar in white skin tends to heal better and less noticeable than patients with darker skin. 

Pictures showing stages of tumour excision and reconstruction.

3-week postoperative.