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.