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.

Double Eyelids and Fat: Case 1

The anatomy of the Chinese eyelids (also that of the Korean and Japanese) is different from that of the other races in that the orbital fat descends more inferiorly due to lower insertion of the orbital septum. This is the main reason why the Chinese has absent or lower double eyelids (skin creases) and a fuller eyelid. An understanding of this anatomical difference is essential for surgeon who perform double eyelid surgery (Asian blepharoplasty). The following cases illustrate the importance of this this anatomical difference.

This 34 year-old woman underwent double eyelid surgery 5 months earlier. She was unhappy because of the presence of extra lines radiating from the central double eyelid. This was caused by incomplete removal of the fat so that the skin and the levator (the muscle that moves the eyelid ) can not form good adhesions.

Extra lines radiating laterally from the main double eyelid.

To remove the excess line, the residual fat and the levator muscle was resutured to the skin and the overlying muscle called orbicularis oculi.

Steps taken to erase the extra lines. a and b. Marking was done to remove some 

of the skin. The lower marking corresponded to her double eyelid (skin crease).

 c. and d. The skin and ocularis muscles were removed from the marked area. 

e. The orbital spetum was open and the fat isolated and excised. 

f. and g. after the fat excision, the extra line disappeared. 

h. The levator was then sutured to the overlying muscle and skin. 

Appearance of the eyelid at 3 months.