SOME ASPECTS OF PLASTIC (COSMETIC) SURGERY IN ORIENTALS. Singapore

Transcription

1 SOME ASPECTS OF PLASTIC (COSMETIC) SURGERY IN ORIENTALS By KHOO Boo-CHAI, M.B. 1 Singapore Is there a difference in the type of cosmetic surgery operations done in Orientals? Opinions have been expressed, from time to time, that there is a difference, but nothing concrete has been produced to substantiate or disprove it. A study of a large series of cosmetic surgery operations performed in our clinic will therefore be of some interest and may, it is hoped, provide the answer. Until recently, our clinic together with the surgical I. Plastic construction of the superior palpebral fold 2. Rhinoplasty 3. Rhytidectomy 4. Blepharoplasty (upper, lower and both eyelids) 5. Mammaplasty 6. Others Millard (U.S.A.) 4-month period in II 15 TABLE I Edgerton! Mutou (U.S.A.) (Japan) December 1957 January 1961 to April 1959 to November I ,63o 1,O Present Author (Singapore) January 1959 to December Five most common cosmetic surgery cases 1,349 62"7% "3% 144 6"7% 124 5"8% % ,2... Total ,576 [ 2,152 I units in the state-owned General Hospital were the only two centres serving the whole 1"9 million population of Singapore in plastic and reconstructive surgery. The state-owned hospital treated most of the fresh burns and facial malignancies but little or no cosmetic surgery is done there. Hence, our experience can be considered as fairly representative of the type of cosmetic surgery done in this part of South-East Asia. All the cases operated on during the eight-year period from January 1959 to December 1966 (inclusive) were reviewed. During this period, 5,333 plastic surgical cases were operated on. Of these, five of the most common cosmetic surgery operations, listed in order of frequency, were selected for study. These amounted to 2,5o6 cases. However, 354 were rejected because data on them were not complete. Hence, our present study is based on an analysis of complete data taken from 2,I52 cases. This series, when compared with similar ones from Japan (Mutou, 1964) and from the States (Edgerton et al., 196o ; Malsels and MiUard, 1966) (Table I) provides some interesting observations. 1 Address: 621 Geylang Road, Singapore, 14 6

2 PLASTIC (COSMETIC) SURGERY IN ORIENTALS 61 I. Plastic Construction of the Superior Palpebral Fold.--In our series, plastic construction of the superior palpebral fold ranks as the most common cosmetic surgical operation among the Orientals and it accounts for more than half of the total number of cases. This is also true for the Japanese series. Most of our cases are women in the 2o to 24 (47 per cent.) age-group (Table II). Because of its prevalence among the Orientals, accounts of this operation have been published from the Philip- A FIG. I B A FIG. 2 B Photographs taken before (left) and after (right) plastic construction of the superior palpebral fold. (Top, right) two years after operation, i~ (Bottom right) four years after operation,

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4 PLASTIC (COSMETIC) SURGERY IN ORIENTALS 63 pines (Sayoc, I954), Korea (Millard, I955), Japan (Uchida, I962), Hawaii (Fernandez, I96o) and Singapore (Boo-Chai, I96Z, I963). Taken by and large, the various techniques can be divided into those that use the external skin approach and those that use the coniunctival approach. Nowadays, we use the coniunctival approach routinely because this method is easy to perform and leaves behind no scars on the eyelid skin (Figs. I and 2). In the Oriental eyelid, the skin attachment of the levator palpebra: superioris is absent. The principle underlying the operation is to connect the eyelid skin to the levator at a desired level (usually 5 to 8 ram. from the lid margin) by means of fibrous adhesions or with exogenous suture material. When the eye opens, the pull of the muscle is transmitted to the skin and the fold is formed. The reasons given for this operation are socio-economic, domestic and, lastly, local beliefs and superstitions. To most people, the bright " round eye "is mord attractive than the " slit eye ". It is therefore important for those intending to practise in the Orient to know the principles underlying this simple but at times demanding operation. 2. Rhinoplasty.--In the two series from the States, rhinoplasty comes first in order of frequency. In our series, however, rhinoplasty ranks next to plastic construc- TABLE III Sex Distribution of the Cases Female Male Total I. Phstic construction of the superior palpebral fold I~ % 29 2"I% 1, Rhinoplasty "5% 23 5"5% 4r6 3. Rhytidectomy I % 2 I "4% I44 4- Blepharoplasty I2I 97-6% 3 2-4% I24 5. Mammaplasty ii9 ioo% II9 Total z,o95 57 z,i5z 97"3% 2"7% tion of the superior palpebral fold. Because of the triad of facial features of those of Mongoloid racial stock--the slit eye, the fiat nose and high cheek bones--augmentation and not reduction rhinoplasty is called for. Initially, we used an autogenous bone strut taken from the iliac crest, but for some time now we have been using a subcutaneous prosthesis made from silicone rubber (medical grade) which is introduced via an alar rim incision to build up the nasal bridge. The prosthesis is so constructed that it extends from the" golden point -1 to the nasal tip. During the operation, the two alar cartilages are also exposed and apposed under direct vision with fine monofilament nylon sutures. When there is overhanging of the nostril side-wall, trimming according to the technique described by us (Boo-Chai, I964) is carried out. In our hands, this extra effort is worth while because it gives superior cosmetic results (Figs. 3 and 4). Here again, most of the 1 A point in the midline between the orbital ridge and the intercanthal line.

5 64 BRITISH JOURNAL OF PLASTIC SURGERY cases are women in the 2 to 24 years age-group. Although the sex ratio in Singapore is x,o7o males to i,ooo females, wc were surprised to find that very few men come up for cosmetic surgery operations (Table III). A FIG. 3 B A FIG. 4 B Photographs taken before and after augmentation rhinoplasty. Note the remodeuing of the nasal tip. 3 and 4. Rhytidectomy/Blepharoplasty.--Our cases for rhytidectomy are on the whole younger than their Western counterparts. The skin of the face is the first portion of the body to show effects of age. In Singapore, which is only i 15' north of the Equator, the excess heat and high humidity seem to have an adverse effect on the facial skin. It is interesting to note that the indigenous Malaysians bear up to the

6 PLASTIC (COSMETIC) SURGERY IN ORIENTALS 6 5 weather conditions extremely well. Our cases are mostly first or second generation immigrants from the coastal areas of the Chinese mainland. The mean age for rhytidectomy is 37' I years. Half of the cases (5I per cent.) are in the 35 to 44 age-group and their ages vary from 24 to 52 years. Edgerton (Edgerton eta[., x964) in a detailed study, recorded the mean age for rhytidectomy as 48.5 years and his cases varied from 29 to 72 years of age. Our patients usually come to us hoping to regain some measure of youth which they once had. Most of their husbands are businessmen and, at this age-group, they are A FIG. 5 B Photographs taken before and three years after rhytidectomy. financially well off. The wives frequently accompany their husbands on their social calls and business dinners, Hence they consider it specially desirable to look young and vigorous. The technique we use is fairly straightforward. The incision is placed within the hairline. Undermining is extensive but we do not plicate the subcutaneous tissues (Fig. 5). In our blepharoplasty group, the patients choose this operation because they are not confident enough to undergo the more severe operation of rhytidectomy. They prefer to confine themselves to a simpler operation hoping to remove the more prominent signs of aging about the eyes (Figs. 6, 7 and 8). We place our incision beginning at the inner canthus, just below and parallel to the ciliary border and this curves downwards and outwards for a few millimetres at the lateral canthus. The wrinkled skin is undermined down to the level of the inferior orbito-palpebral sulcus. With a pair of fine-toothed dissecting forceps the loose muscle layer is picked up and a strip is excised. The underlying encapsulated fat is then removed. The muscle layer is closed with fine plain interrupted catgut sutures. This excision of a strip of muscle removes superfluous lax tissue and tones up the orbicularis oculi. The excess skin is excised and the skin layer is dosed with 6/o silk on an atraumatic needle.

7 66 BRITISH JOURNAL OF PLASTIC SURGERY A FIG. 6 B A FIG. 7 B Photographs taken before and after blepharoplasty for herniation of infra-orbital fat. A FIG. 8 B Photographs taken before and after blepharoplasty for upper and lower eyelid wrinkles.

8 PLASTIC (COSMETIC) SURGERY IN ORIENTALS 67 Mammaplasty.--In the Orientals, mammaplasty is usually done for the hypoplastic breast. We very seldom encounter the huge breasts seen in some European plastic surgery clinics. Consequently, our experience with reduction mammaplasty is rather limited. For augmentation, we initially employed the injection method using an average of IOO ml. of medical grade silicone (dimethylpolysiloxane) for each breast. This preparation is supplied by the manufacturers in the gel state at room temperature and it is introduced into the retro-mammary space by means of a specially designed metal syringe. A careful follow-up of these cases has given us good reason to look for a better method. We now use a modified Cronin technique with a specially designed inflatable silicone bag to suit the smaller Oriental torso (Boo-Chai) (Fig. 9). A FIG. 9 B Photographs taken before and after augmentation mammaplasty using a new type of inflatable silicone bag. In this series, we find that there are two interesting groups of cases. There is the younger 2o to 24 year age-group many of whom are employed in the entertainment world and the desire to possess big breasts is obvious. However, in the next five-year age-group we have many housewives who marry early, have children at very close intervals and breast feed all of them. They end up with smau shrivelled-up breasts which gives them a feeling of inadequacy in regard to concepts of the body image. This gives rise to a situation of considerable strain in their married life. Correction of this sense of inadequacy associated with the small breast seems to them the first step in the road back to a happy marital relationship. In conclusion, we find that even among the various overseas Chinese communities living together in this country, there is a difference in their response to cosmetic surgery (Tables IV and V). The Cantonese, 1 although they constitute only I8'9 per cent. of the general population, provide 39"3 per cent. of our patient population. The Hakka community account for 11 "4 per cent. when their strength is only 6.2 per cent. of the population. Together, these two communities make up half of our patient population. The Cantonese, the most travelled of all the overseas Chinese, to.gether with the Hokiens are the principal merchants in Singapore. They come from Kwangtung province. The Hokiens come from around Amoy in southern Fukien province. The Teochews are from a prefecture and port of that name in Kwangtung near the Fukien border. The Hakkas, a rural people, come from the mountains of north-east Kwangtung and south-east Fukien. The Hainanese come from the island of Hainan in South China.

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10 PLASTIC (COSMETIC) SURGERY IN ORIENTALS 69 TABLE V A Dart Chart showing the Percentage Distribution of the Patient Population in relation to the Total Chinese Population in Singapore according to, the Census x957. PERCENTAGES L t I i I I I i I i I CANTONESE HOKIEN TEOCHEW HAKKA HAINANESE ~////////////////fl 18.9 ] 39.3 ~'////////////////////////////////////A 4.6 I I 3o.9 ~///////////////////A 22 5 ~ 9. 9 ~7~6.2 ~"~'~ 7.2 m SHANGHAIN ESE F;] % of Chinese population OTHERS 1~7/] 3.4 []2.9 SUMMARY % of patient population An eight-year review of the five common cosmetic surgical operations done in our clinic shows that there is a difference in the types of operations for Orientals. Because of the facial characteristics of these people, plastic construction of the superior palpebral fold is a very common operation. Next comes augmentation rhinoplasty. Cases for reduction rhinoplasty are seldom seen. Similarly, augmentation and not reduction mammaplasty frequently engages our attention out here in the Orient. Another interesting finding is that our cases for rhytidectomy are On the whole much younger in age than those seen in the West. The mean age for this operation is 37"I years. The various operation techniques carried out in our clinic are briefly described. Lastly, we found that even among the various overseas Chinese communities living in Singapore there is a significant difference in their response to cosmetic surgery. REFERENCES Boo-CHAI, K. (1962). Singapore med. fl. 3, 132. (1963). Plastic reconstr. Surg. 3 x, 74. (1964). Plastic reconstr. Surg. 34, 81. Boo-CHA1, K. Breast augmentation with a new type of inflatable silicone bag. To be published. EDGERTON, M. T., JACOBSON, W. E. and CANTER, A. (I96). Br.,7. plast. Surg. 13, 136. EDGERTON, M. T., WEBB, W. L., SLAUGHTER, R. and MEYER, E. (1964). Plastic reconstr. Surg. 33, 53. FERNANDEZ, L. R. (196o). Plastic reconstr. Surg. 25, 257. MAISELS, D. O. and MILLARD, D. R., Jr. (1966). Br. fl. plast. Surg. x9, 187. MILLARD, D. R., Jr. (1955). Plastic reconstr. Surg. i6, 319. MUTOU, K. (1964). flap. fl. plast, reconstr. Surg. 7, 2z. SAYOC, B. T. (1954). Am. fl. Ophthal. 38, 556. UCHIDA, J. (1962). Br. fl. plast. Surg. 15, 217.