Thursday, November 27, 2014

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.

Friday, November 14, 2014

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. 

Sunday, November 2, 2014

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
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

Tuesday, October 14, 2014

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.

Friday, September 12, 2014

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"


(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)

Tuesday, September 9, 2014

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:
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.

Tuesday, September 2, 2014

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)