Issue Highlights

Genital Generation
Mariel Chow delves down deep to discover what men are doing for the sake of length, and what women really want in their nether regions.
Although things aren’t said, it doesn’t mean they’re not thought about or obsessed over. Nowhere is this more applicable than in conversations surrounding our nether regions. Yes, due to the ‘hush-hush’ nature of human genitalia, we sometimes stare into bathroom mirrors quietly pondering the plight of a small dong or laxed vagina with unsightly loose skin. While it’s understandable why we’re hesitant to speak of such things, reproductive organs are vital not only for reproduction, but overall enhancement of our sexual, physical and emotional health. Hence, it’s time we get informed and be conscious of our ‘no-no’ zones as procedural awareness can either stop you from making a big mistake or conversely, undertake one of the best surgical decisions ever made.
Consultant Plastic and Reconstructive Surgeon, Dr. Yap Lok Huei has many a time come across patients who’ve subjected themselves to penile enlargement procedures. Though a lesser-known treatment, Dr. Yap reveals there’s still a market for it despite its high complication rates. As a plastic surgeon who has treated numerous botched genitalia, Dr. Yap strongly stresses the importance of public awareness, specifically against unnecessary procedures that neither provides size nor girth, but instead leave patients depressed and perplexed as to why one even considered such a needless treatment in the first place. In this article, Dr. Yap explains why men should steer clear from penile enlargement treatments and how such procedures may turn the member into an unrecognizable infected bulge that requires reconstructive surgery.
Consultant Plastic and Reconstructive Surgeon, Dr. Yap Lok Huei
Dr. Yap divulges that it is unfortunate that minimally-invasive penile enlargement treatments are still available due to demand. In most instances, some men who undergo the procedure feel they need extra girth, while others may desire length. To meet this demand, there are practitioners who inject filler material into the penis to increase its size and girth, but such procedures are ill-advised and associated with high complications rates. Dr. Yap reveals, “There are many forms of filler materials ranging from mineral oil, silicone and hyaluronic acid that are injected into the genitalia but the most common material that’s utilised by lay-practitioners is non-medical grade liquid silicone due to its wide availability.” He adds, “I have also come across traditional methods where practitioners wrap the penis (under the foreskin) with hemp or fibres to encourage girth.” Due to high complication rates, Dr. Yap warns that procedures with reasonable scientific basis such as fat grafting should be avoided as hardening, nodule formation and scarring may occur.
Dr. Yap states, “On the whole, Malaysian patients are not well-informed of the potential dangers, risks and problems that can occur because of substance contaminants, materials injected in wrong anatomical regions or if clinics simply aren’t sterile.” Dr. Yap also points out that non-medical grade silicone is capable of causing inflammatory and reactive responses. “The dangerous aspect of non-medical grade silicone is its inability to naturally break down,” Dr. Yap cautions. Although patients may not immediately find signs of complication, most will experience recurrent redness, irritation, pain, lumpiness and change in shape as well as severe tissue swelling and wildly abnormal penis appearances. Furthermore, a small number of patients may correspondingly suffer urinating troubles from urethra damage due to infection,” Dr. Yap alerts. Many also experience coital difficulties because the penis has turned an oddly cauliflower shape, caused by gross swelling.
Because injectables are made from substances that aren’t absorbable, patients may experience delayed changes where materials slowly migrate, changing the genital’s shape over time. If practitioners inject substances along the shaft to encourage length, materials will occasionally accumulate behind the penis and may result in a doughnut shape around the head. Such problems are difficult to correct because associated surgery can involve certain levels of risk to the native skin. He says, “Surgeons may find that materials – whatever they may be – are very tightly bound to the skin where substances are difficult to separate.” In which case, he explains, “Entire chunks of overlying skin will need to be removed not only because it’s stuck to materials but also because it’s badly damaged, infected and swollen.”
While Dr. Yap has not personally come across such patients, he has also heard of some men who place beads or pearls under the foreskin. There are other extreme situations where people have even inserted ball bearings under the skin to allegedly improve not only the genitalia’s width but also to prolong intercourse while improving sexual sensation for both the man and woman. He admits, “Although I don’t know how effective these insertions are, it’s definitely not something I’d recommend as the risks are too great.”
In any case, Dr. Yap fervently believes that one has to be very careful when considering penile enlargement treatments, due to complications if carried out by inexperienced practitioners. “We have accumulated information regarding liquid injectables and over the years, liquid silicone has proven to cause tissue breakdown and damage when injected in the breasts and thus, it’s not surprising they cause the same issues in the penis as well.”
When surgeons come across complications and have no choice but to excise both the underlying skin and attached injected materials, reconstructive surgery will call for significant skin resurfacing or skin grafts. In extreme situations, patients will require further additions of tissue transfer or skin flaps from the thigh. Dr. Yap explains, “Most patients can undergo sufficient penile restoration with a properly designed skin graft.” However, he does clarify that performing grafts on this location isn’t simple because one has to size skin transfers very appropriately to allow some remaining function and to permit skin stretching during erections. Likewise, surgeons must ensure that it’s tight enough that skin is in contact with the shaft because grafts need blood supply. There have also been cases where due to scarring or deposits of fibrous tissues. This can be caused by deep injections and incorrectly done fat grafts. “I have found instances where substances were injected deep into muscles and this has chances of very serious complications such as substances travelling into the bloodstream, and damaged muscular tissues,” he recalls. Should muscles not survive, surgeons will have no choice but to remove muscles resulting in loss of penile length and function.
Immediately after reconstructive surgery, plastic surgeons will need to keep an eye on grafts to ensure that the transferred skin takes. If the grafted skin settles well, the recovery period will continue for a few more weeks in terms of recouping functionality. Dr. Yap says, “Sometimes in cases of damaged function due to penile enlargement treatments, patients will have problems with intercourse before we carry out reconstructive surgery.” Therefore, because they have already lost sexual function beforehand, not everyone will regain the ability to have sex even after reconstructive surgery.”
Though not routinely done, there are proper surgeries that can increase the penis’ height by dividing some of the ligaments that attach the shaft to the pubic bone. Dr Yap says, “There are other recent reports of newly available silicone prosthetics that I have no experience with but are described to safely increase widths after it’s placed under the skin.” Nonetheless, Dr. Yap stresses the importance of consultations with a urologist who has experience dealing with lengthening procedures.
It needs to be said that there’s great discrepancies between how men and women view sex. Dr. Yap points out, “I think that penis sizes are a greater preoccupation among men. Most women don’t think size is very important.” Ironically however, after patients have subjected themselves to penile enlargement treatments, patients suffer complications that cancel out chances of actually performing intercourse anyway.
The vagina is a private part of the body where sex, sexuality, the birth and urinary systems co-habit. For generations the organ itself, as well as the problems that come with it, was very difficult for women to deal with, let alone talk about. Why is this so? According to Turkish Consultant Plastic and Reconstructive Surgeon, Dr. Bulent Cihantimur, the vagina has always been observed as a female’s ‘special place’ and hence deemed private. He confesses, “Even in Mother Eve’s visual portraits, although the breasts are exposed, her genitalia is covered by a fig leaf.” The cause of this perception – in Dr. Bulent’s opinion – is because female genitalia act as the gatekeepers of sexual life and likewise, is a bodily region that delivers babies and where both the urethra and anus are located. Although the vagina is one of the most important organs in the female body, this incessant need for secrecy has pressured women to psychologically and subconsciously ignore or overlook their genital health and aesthetics. Dr. Bulent states, “I believe women deserve any kind of beautification, whether for the vagina, body or face and this is why I take into account the entire nether region as a whole where total beautification is necessary.”
Turkish Consultant Plastic and Reconstructive Surgeon, Dr. Bulent Cihantimur
Female genitals experience deformation as a result of childbirth and ageing. Along with more common related side effects such as enlarged vaginas, patients can experience sagging inner labias, unaesthetic outer labias, and excess fat in the mons pubis. Furthermore, they may also suffer urinary incontinence, orgasmic disorders and poor sexual sensation when vaginal loosening has taken place.
In his circles, Dr. Bulent is famed for his Genital Beautification Technique. The technique was awarded the Golden Bistoury Award at the Third World Plastic Surgery Congress in Monaco in November 2014. Dr. Bulent says, “Dr. Valter Dos Santos (Organiser and Scientific Director of the Fourth World Plastic Surgery Congress), highlighted that my Genital Beautification Technique – which was published for the first time in the American Society for Aesthetic Plastic Surgery in 2013 – provided a new perspective on the subject. Just like the face, vaginal fat, muscle and bone tissue loss is caused by ageing, and should total rejuvenation of this region be desired, Genital Beautification would be the right choice.”
Most patients who desire vaginal rejuvenation normally undergo labiaplasties. Although a good enough procedure, labiaplasties are, in Dr. Bulent’s opinion, only applicable to those who suffer from inner labia issues and not necessarily recommended to patients who experience total regional problems. “A middle-aged woman who has undergone vaginal birth cannot be rid of existing problems by simply undergoing labiaplasties because like the face, fat, muscle and bone loss have taken place,” he advises. He continues, “I have even come across patients who additionally experience urinary incontinence. Should patients desire complete vaginal rejuvenation, Genital Beautification provides total approaches to the area and its issues.”
In order to provide optimal rejuvenation results, Dr. Bulent will not only correct vaginal loosening but also improve the mons pubis and erogenous zones. First and foremost, loosening of the back tegmina is addressed, where expanding vaginal tissues undergo compression To tackle this issue, an amalgamation of the Cihantimur Fat Transfer technique and Spider Web application, where injection of fat enriched stem cells help with rejuvenation while the Spider Web process helps tighten the area. Meanwhile, the Erogenous Zone Injection application – aptly named ‘G-Shot’ – is placed on the front wall, two to three centimeters inside the vaginal opening. Dr. Bulent divulges, “G-Shot injection provides longer sexual stimulation because the region is reshaped and brought forward allowing easier, more pleasurable and longer lasting orgasms.” In addition, tightening procedures also benefits the partner as shaping of the loosened back tegmina encourages better sexual satisfaction.
The mons pubis is the hairy part between the clitoris and C-section stitches. Some women can look puffier than normal and this can cause concerns over the aesthetics of the area especially when wearing bathing suits. Moreover, increased fat deposits in this area can cover the clitoris and additionally reduce sexual sensations. When treating such problems, Dr. Bulent looks to Liposculpture applications, which along with aesthetic reductions of fatty tissue, exposes the clitoris too. What’s more, the procedure also addresses urinary incontinence brought upon by giving birth and ageing.
Dr. Bulent insists that his Genital Beautification technique is comfortable with little downtime. “The procedure is painless and begins after the preferred anaesthetic type is applied. My primary goal is a safe and comfortable operation with quick recovery plus minimal discomfort or pain.” During the recovery period, patients experience comfortable healing processes due to advantages related to the Cihantimur Fat Transfer System, Spider Web technique and Radiofrequency technology. Even more surprising, patients are discharged immediately after and can return to work after two days!
Cosmetic surgery awareness is growing rapidly and desire for aesthetic vaginal procedures is on the rise. According to the American Society for Plastic Surgery, female genital surgeries have risen 48 percent and this awareness and acceptance can help women be more conscious of their private zones. Take it from one of Turkey’s foremost plastic surgeons when he says, “Happy vagina, happy woman.”
Modern technology has come up with answers to ageing vaginal concerns. One of the solutions is ThermiVa. A non-invasive treatment, ThermiVa induces labia majora and vaginal canal tightening via radiofrequency (RF) energy. Besides aesthetics, patients have also reported enhanced sex lives and better function brought upon by improvement of vuvovaginal dryness and leaky bladders. Plastic and Reconstructive Surgeon, Dr. Rica Farah Muhammad Abdullah Ichihashi tells us more.
Plastic and Reconstructive Surgeon, Dr. Rica Farah Muhammad Abdullah Ichihashi.
Why do the labia majora and vulva continually stretch over time and why are other forms of treatment either ineffective or too painful?
Stretching of the labia majora and vulva tissues is contributed to numerous age-related changes such as decreased dermal thickness and collagen synthesis, changes in collagen quality, and reduced blood and nerve supply. The labia and vulva undergo immense deformation and stretching caused by time and vaginal childbirth. Regular Kegel exercises are useful adjunct practices to sustain the strength and tighten the pelvic floor muscles. They may delay symptoms of vaginal laxity and surrounding tissues, but do not overcome age-related changes of muscle loss and decrease in nerve supply.
Invasive vaginal tightening involves tissue cutting or a stripping or burning of tissues. As you can imagine, lasers that burn tissues utilize high energies and this can lead to significant downtime in terms of pain and discomfort. ThermiVa is so far the only system that’s able to offer tightening and tissue contraction with benefits of increased moisture and collagen production without downtime or pain.
What is ThermiVa and how does it work?
ThermiVa is a US FDA-approved device that emits RF waves which result in undeviating controlled energies to the labia and vaginal tissues. In response, tissues contract and over time, more contractions will occur as the body responds by laying new collagen and more importantly, increased blood supply to the treated area.
What are ThermiVa’s benefits and who can best benefit from its treatments?
Rejuvenation of the labia and vagina results in tightening and contraction of the tissues, which is what some patients want. However, this also gives an indirect benefit of better urinary control because the vagina’s outer wall is very close to the urinary tract. Rejuvenation of the vaginal tissues causes moisture restoration and production of normal vaginal discharge. As a result, there’s increased blood flow to the areas, with some patients even reporting they’re more ‘aware’ of their nether regions! It’s thought that ThermiVa does somehow rejuvenate nerve supply to these areas and although more research is needed, we already have reports that women have returned with orgasmic feedback! Excuse the pun.
Any woman who has noticed signs of ageing in these areas is suitable for treatment. So, patients experiencing problems like sagging of the area around the vagina, vaginal laxity and decreased sensation or pain during intercourse can benefit. Other appropriate candidates are those who experience dryness and mild urinary symptoms.
What can patients expect during the treatment and how many sessions will one need?
Patients can expect very comfortable treatments that are done only by me alone, with no assistant, to ensure discretion. Treatments take 30 to 45 minutes. There is no downtime, and patients are “good to go” immediately after. Three monthly treatments are needed for a baseline effect. Then, an annual or bi-annual treatment is needed, depending on lifestyle and expectations. The earliest known improvement by my patient was just a few days after. She reported enhancements of urinary control, noticing she needn’t rush to the bathroom first thing in the morning. Optimal effects normally occur two or three weeks after.
Everyone deserves better sex lives. Not only meant for reproduction, coitus relieves stress, boosts confidence levels and even induces the release of happy hormones. Vaginal tightening treatments are sometimes impractical because they’re either too invasive or expensive. Plus, if one is simply looking for temporary vaginal contraction for nothing more than sex, why even undergo unnecessary procedures? PK24 is one of the most well-known vaginal tightening creams on the market. USFDA-approved and clinically-tested, PK24 has been proven to provide natural rejuvenation that’s safe and effective. PK24 benefits ladies of all ages and is great for young women who want to spice up their sex life. It also works wonders for pre- or post-menopausal women who yearn for improved sexual gratification as well as lubrication. Nevertheless, even if women aren’t sexually active, PK24 can be added to everyone’s routine vaginal care, just as they would moisturise the body and face. Aesthetic physician, Dr. Raman Hundal-Simpson explains.
Aesthetic physician, Dr. Raman Hundal-Simpson
What is PK24 and how does it help women achieve vaginal tightening?
PK 24 has been designed to deeply hydrate the internal walls of the vagina. The ‘plumping’ effect within these walls significantly narrows the vaginal diameter, which is how vaginal tightening is achieved. PK24 heightens physical sensations and feelings of pleasure for both partners by increasing the friction experienced during penetration.
Along with vaginal tightening, what other benefits does PK24 possess?
After PK24 application, a majority of women found increased abilities for orgasms and almost all reported increases in orgasmic frequencies as well. Some women find they need a ‘time-out’ from sex due to vaginal dryness. Whilst PK24 was not specifically designed as a lubricant, four in five women reported lubrication improvement plus added abilities of sustaining good levels of lubrication throughout intercourse without concerns of drying out. A single pump onto the tip of the index or middle finger is all that’s required. It should be massaged into the vaginal walls in a circumferential manner until fully absorbed. PK24 works within ten minutes, and its effects last up to 24 hours. The tightening effects peak between eight and 12 hours after application. For this reason, women wishing to achieve maximal tightening effect should apply PK24 12 hours apart, twice a day. Women who prefer discreet use however, are recommended the cherry flavour as the scent lasts three hours.
There are no long-term effects after 36 hours provided that PK24 is used as directed by the doctor. Bathing or exercise after application does not affect results. The product can be used for as long as required, especially if patients anticipate future coitus. Decision to stop or continue use is purely up to the patient.
What are your personal opinions of PK24?
When we first offered the product, we didn’t expect such positive response. Very often, during follow-up consultations, the patients come in smiling and gushing about how PK24 has transformed their sex lives for the better. Of course, as physicians, we feel good that we have helped improve our patient’s quality of life.
How Will I Know?
Kuhashvini Rajasegar reports on how it actually feels to undergo some of the most popular Aesthetic treatments on the market today.
In the past, I couldn’t even dream of being in the shoes of people who were able to go for pricey beauty procedures. Now, here I am, doing it as part of my job, trying my best to uphold the trust placed in the publication with integrity and honesty. A minefield of pimples and acne scars has plagued me ever since my years as an adolescent. My face has been subject to almost every facial wash under the sun. I finally came to believe that the only way I would ever have a blemish-free face was to splurge on expensive concealers. So of course I jumped when Queen’s Avenue Clinic offered me a go at getting rid of my blemishes.
Electric Dermal Roller with Queen’s Avenue Clinic
I had an appointment, and I was really looking forward to it, but I was in the dark about what was going to be done. Dr. Elizabeth Lee and Dr. Nicole Lee Peck Kuan looked at my face from every angle possible and then said, “An electric dermal roller would do the trick.” At that moment, I felt a chill down my spine. An electric dermal roller sounded terrifying, but I was so tired of having to wear makeup every single time I stepped out, that I decided to take the plunge.
Dr. Elizabeth Lee
I anxiously made my way to the treatment room where Mr. Christopher kindly explained the ins and outs of the treatment. The aesthetician started off with a cleanse before applying a generous amount of topical numbing cream. She then dimmed the lights, switched on some 1980s slow jazz and told me it would take 30 minutes for the cream to work. I then did what any responsible employee would do in my position. I napped.
Dr. Nicole Lee Peck Kuan
When she returned, the aesthetician washed my face and started the actual treatment using the electric dermal roller. When the electric rod actually touched my skin, I couldn’t help but heave an euphoric sigh of relief. I felt absolutely no pain! In reality it was like getting a face massage. The aesthetician very gently moved the rod in circular motions around my entire face, especially my problem areas (cheeks and forehead). It took just 20-30 minutes for the entire treatment.
I glanced over at a mirror, not expecting much visible improvement. But I was over the moon at my reflection. Just a single treatment managed to do what a lifetime of facial scrubs could not! To add to my joy, the aesthetician told me that in seven days I would see an overall improvement in my skin condition, especially a reduction in oiliness. I was cautioned against exposing my skin to direct sunlight for the best results.
I found that as time passed, my acne scars dramatically decreased. At the seven day mark, I could not wait to take an ‘after’ picture of my newly-treated face. Family and friends started to notice the tangible improvement of my skin. This gave me the impetus to embark on a proper skincare regiment in the hopes of prolonging the positive effects.
Skin Lightening with Dual Yellow Laser
Before anyone pounces at me for lightening my skin because they think I am ashamed of my Asian heritage; take a breather. Growing up in Malaysia and being the girl that didn’t mind kicking a ball or two under the scorching sun, my skin paid the price for my early tomboy days. The UV rays without a doubt took a toll on my skin, causing me to suffer the bane of skin discolouration before I even knew what it meant. I have never really let it bother me too much, although there are times, especially in my vainer moments when I just sit down for hours, Googling various solutions to this predicament.
While writing an advertorial on Dual Yellow for the previous issue, I realised that it could be a solution to finally getting to the bottom of my skin pigmentation issues. My session was at My Clinic in Uptown, Damansara. Upon arrival the friendly staff asked me to have a seat and I couldn’t help but notice just` how busy the clinic was. I was then invited to Dr. Hoe Yut Hung’s consultation room to discuss my skin condition and how I would benefit from Dual Yellow treatments. After taking a long, hard look at my skin, Dr. Hoe said, “I don’t think a single treatment would be enough, let’s do two spaced between two weeks and you’ll see a bigger improvement.”
Dr. Hoe Yut Hung
The aesthetician, Brenda, started off with a thorough cleanse followed by a generous slather of a transparent gel that had a slight cooling effect on my face. With cucumbers over my eyes, Brenda directed a bright laser beam over my face. As she was moving the handpiece gently over my face, she explained to me that Dual Yellow distinctly emits two lasers at different wavelengths of light, a yellow and green light. The green light has the perfect wavelength at 511 nm to effectively treat skin discolouration by reducing the production of melanin, the substance that creates pigmentation of the skin.
If I were to say that the treatment with Dual Yellow was a hundred percent pain-free, it would be a blatant lie. In truth, it felt like a slight prickling sensation, especially on my forehead and cheeks where my skin was most affected. Despite some minor discomfort, it was extremely tolerable to the point that Brenda and I chatted the entire 15 minutes of treatment. I was ready to leave after the laser when Brenda said there was one last step and this was the icing on the cake – a soothing face mask. This was undoubtedly my favourite part. A cooling whitish-green mask was placed on my face and I was left to take a 20-minute snooze.
Brenda then returned to the treatment room to remove the mask and schedule my next session for two weeks later. Because there was zero downtime involved, I was able to apply some light makeup and leave for work.
I was extremely satisfied with the outcome after my second treatment with Dual Yellow although I was warned that the results wouldn’t be jaw dropping with just two sessions. Post-procedure, I found my face to not only be baby-butt smooth, but also noticeably brighter, with more even skin tone, especially on my problem areas. Unsurprisingly, the discolouration on my face showed a significant reduction and I’m glad that the results have lasted till today.
I genuinely have nothing but raving reviews for Dual Yellow and cannot thank Dr. Hoe and his amazing staff enough for their hospitality and the treatments.
Body Contouring with Accent Prime
It’s time for me to come clean. I have never treated my body like a temple. I have put my body through fad diets and have failed time and time again by either gorging on unhealthy Malaysian treats or sneakily eating McDonalds Big Macs at midnight. I am definitely feeling the pressure to make a lifestyle change. I cannot ignore the signs of my poor choices any more. I phoned the Director of HealMatrix Sdn. Bhd., Danny Leong straightaway and asked to sample one of their best body contouring devices. He graciously allowed me to try out Accent Prime. I was beyond excited.
Danny Leong
I walked into Idealyst Clinic and was immediately led to the treatment room where my measurements were taken. While this was all done, the aestheticians, Lee Zie and Fatien took their time to give me an inside on the ins and outs of Accent Prime. Utilising ultrasound and radio frequency, Accent Prime can target adipocytes (cells that are primarily composed of adipose tissue) and tighten collagen, producing effective and long lasting results. Since I’ve heard of this brand before, I knew I was in good hands and expected nothing short of a great outcome.
Before treatment began, Lee Zie wiped skin oils and grease from my abdomen while Danny went to set up the machine to the appropriate setting for my body. Because I opted for treatment on my abdominal area, the UltraSpeed handpiece was used. This applicator features a plate type sonotrode that emits guided ultrasonic waves through concentric profiles to homogenously heat the targeted tissue, effectively disrupting stubborn fat cells while leaving the surrounding tissues unharmed. Lee Zie then lathered on a transparent thick gel while I fidgeted nervously, imagining the pain I had to endure for the next hour or so, considering how big my problem was, literally. She either felt my nerves from across the room or read my mind because she laughed and said, “There’s nothing to worry about, it’s painless.” And she was right! I am not lying at all when I say that it felt like a warm massage when the UltraSpeed was moved in circular motions all around my stomach. Lee Zie and I were chatting away when I heard the timer go off and she said, “Okay, all done.” I looked at my watch and was shocked that the treatment only took 20 minutes. She then explained that with UltraSpeed, treatment time is greatly reduced due to the revolutionary technology that comes with this applicator.
I was warned pre-treatment that a single session with Accent Prime wouldn’t be enough to cut the gut but I would see satisfying results seven days post-procedure. And true enough, I did. To be extremely candid, immediately after the treatment I was a little disheartened that the outcome wasn’t what I hoped it would be. But it was all made up for when I saw an almost four inch decrease in my lower abdomen area in just seven days. I took an after picture on the seventh day and compared it to the before and was extremely pleased with the results. Although the number on the scale didn’t budge, I definitely did lose girth. I obviously knew I wasn’t going to be beach-body ready in a single treatment. This for me was more of a stepping-stone to make healthier choices in the future. So thank you, Danny and the entire team, for not only allowing me to experience a superb treatment with Accent Prime, but also for giving me the platform to make a change in my lifestyle.
Facial Contouring with Venus Viva and Botulinum Toxin
I have a love-hate relationship with Kim Kardashian, but I cannot deny her the crown when it comes to having a perfectly contoured face. Her signature heavily shadowed hollows, high cheekbones and chiseled jawline have skyrocketed in popularity over the past few years to the point that everyone I know is contouring as part of their regular makeup routine. I myself have tried to learn the tricks of the trade, but having a naturally round face; it gets extremely difficult for an amateur like me to achieve her sculpted look with just makeup. I was prepared to try something a little more invasive than just bronzers and highlighters, so I called up Dr. Anjalee Mohandas Nair to ask if I could try out one of her best facial contouring treatments, and she graciously obliged.
Dr. Anjalee Mohandas Nair
I walked into Lyfe Clinic the next day and received a very warm welcome from Dr. Anjalee before being led into the treatment room almost right away. We exchanged pleasantries before she asked me to clench my jaw to palpate it. She immediately realised that I had masseter muscles with very different strengths on either sides. She told me to feel it for myself and true enough; it was extremely obvious that the left side was bulkier than the right and I had my own personal chewing habits to blame.
After that, she spent almost half an hour briefing me on all the treatments that were available in her practice. The moment I heard her say Venus Viva, I knew that it would be the treatment I’d sample, not only because it’s FDA approved, but also because I wanted a gentle therapeutic procedure that would provide me immediate results with minimal downtime.
Dr. Anjalee started off with a cleanse that followed with a spread of a transparent thick gel. Because of its microfocused fractional radiofrequency energy that deeply heats the skin rather than burn it like other laser devices, I knew that the treatment with Venus Viva was going to be a breeze. I sat back on the treatment chair as Dr. Anjalee guided a small probe that resembled a hair dryer in a step-wise fashion especially across my jawline. Although the fractional radiofrequency pulses emitted are ablative and cause very small microscopic pores in the skin of heated dead cells, I personally felt nothing. Within 15 minutes, it was done. I was ready to pack my things and head out for lunch when Dr. Anjalee expressed a lack of satisfaction in the final outcome. I glanced at a mirror nearby and although results were somewhat visible, they weren’t mind-blowing. Dr. Anjalee then revealed that a single treatment with Venus Viva would not be enough for me since my facial shape was more on the rounder side and offered to pair it with another procedure. She took a look at my face and asked me, “What about botox?”
I immediately felt a lump in my throat because not only was I newly introduced to the world of cosmetic procedures; I never imagined myself going through with any minimally invasive procedure because of my deathly fear of needles. Dr. Anjalee must have sensed my apprehensiveness because she patiently sat down and had a thorough talk with me about the ins and outs of getting botox. I’m not going to lie, it definitely did push me to bite the bullet and finally conquer my fear of needles.
Before I could chicken out at the last minute, Dr. Anjalee slathered numbing cream on my jaw line (basically to give me the physiological confidence to go through with the injection). She then switched on the TV, played my favourite episode of Modern Family and left me to relax in that snug treatment room. After about half an hour, she stepped into the room with the syringe containing the botulinum toxin and I entered a panicked state. I sat up, shut my eyes and clenched my jaw. Within moments, Dr. Anjalee injected the botulinum toxin and truth be told, it was a mere two out of ten on the pain scale. She used a three-point injection technique and within minutes, it was all over. An ant has bitten me in the past and that was genuinely more painful than getting botox. I was pleasantly surprised.
My face was visibly slimmer, and the shape of my face was now more oval than round post botox. Dr. Anjalee told me that the results get even better after 72 hours and that left me grinning from ear to ear. I ran my fingers down my jaw and I could feel the reduction in the bulkiness of it. I left feeling more Kim K than I ever thought I would, thanks to Dr. Anjalee for not only the amazing treatments, but also for giving me the push I needed to get over my fear of needles.
When Trust Fails
Mariel Chow explores the implications to suing your surgeon over procedures gone wrong.
Surgical complications can be a nasty affair. From asymmetry, deformity and necrosis to infection and death, medical complications can sometimes be misconstrued as negligence, in which case patients believe monetary compensation is in order. Yet, medical malpractice claims should not be taken lightly. Apart from being expensive and time consuming, case trends have proven that courts tend to favour doctors and hospitals as opposed to injured or dead plaintiffs. Even if patients believe they have a strong, winnable suit, seeking compensation for medical negligence is extremely arduous and convoluted, with very little guarantee for success. To make things a little easier for the layman and legally unqualified, Consultant Plastic and Reconstructive Surgeon, Dr. Somasundaram Sathappan and Senior Partner at Salehuddin and Associates, Afifuddin Ahmad Hafifi explain the difference between medical complications and answer common medico-legal FAQs.
Consultant Plastic and Reconstructive Surgeon, Dr. Somasundaram Sathappan.
What is the difference between complications and negligence?
Dr. Soma: A complication can happen in any medical procedure. Although irreparable damage due to complications remain rare, it can still be deemed a setback, which still doesn’t necessarily warrant successful suits. Negligence is when a patient suffers untoward damage because the doctor, hospital and nurses didn’t take adequate care. Not taking adequate care is when surgeons aren’t careful during surgery or recklessly cut important tissues or vital organs. For example, if plastic surgeons conduct a routine tummy tuck and accidentally leave a pair of scissors in the patient’s body, that can be considered negligence. However, should a patient die of fat embolism or septicemia after liposuction, it can be ruled as a complication. In a nutshell, while death, irreparable damage, asymmetry or deformity can sometimes be deemed a complication, negligence – in essence – is when surgeons haven’t taken adequate professional care. In my opinion, there is a difference between complications from the perspective of doctors and from the perspective of lawyers. What I mean here is common complications which generally arise in surgeries. To illustrate, where the patient has adhesions - then the chances are high that he may suffer perforation of the gut during surgery. Now, whilst this may be a “common complication”, in most cases it would not be deemed a “legally acceptable complication” because in most cases, the perforation may not happen if not for the lack of care of the surgeon.
Telling the difference between negligence and complications can be very difficult as there are grey areas in between. A simple complication can be misconstrued as negligence where it’s believed that surgeons didn’t take adequate care. Case in point, if a breast implant gets infected, and this hiccup is the surgeon’s first reported complication, then you can’t blame the doctor for negligence. However, if the surgeon has conducted three breast augmentations in a row with all three experiencing infection, then that can be considered negligence as this could mean some of his techniques or operating theatre equipment aren’t quite right.
Afifuddin: For the purpose of establishing standard of care, the duty of a doctor can be categorised into three parts: Duty to diagnose, duty to treat and duty to warn and disclose any risk. The previous assessment applied for medical negligence is the Bolam v. Friern Hospital Management Committee (1957) test. This test provides that the doctor will not be guilty of negligence if he or she had acted in accordance with a practice accepted by a responsible body of medical persons skilled in that particular art. But this principle, which lasted for many years, was departed in the case of Roger v. Whitaker (1992) (applied in the Federal Court’s case of Foo Fio Na v. Dr. Soo Fook Mun and Anor - 2007) where the court decided that Bolam’s test couldn’t be applied in the realm of duty to inform and instead, preferred a material risk test. In other words, the doctor is duty bound by law to inform his patient – who is capable of understanding – regarding information of the risks involved in any proposed treatment in order to allow patients to make informed judgments and decide whether to proceed with procedures or not. Therefore, it’s the doctor’s responsibility to notify patients of the involved risks and failure to do so may incite negligent suits. In summation, it’s up to the court to decide whether the conduct of the doctor was negligent or not.
Senior Partner, Salehuddin and Associates, Afifuddin Ahmad Hafifi.
Must surgeons explain all procedural steps and their related complications?
Dr. Soma: Yes, they must. Every patient must be given complete explanations of the pros and cons of all procedures. If patients aren’t fully aware of the ins and outs of surgeries, with patients suffering complications, they can sue their surgeons. Furthermore, even if surgeons have explained all advantages and disadvantages of each procedure, patients can still sue you, as their right to sue will always be present. In addition, even if complications aren’t dire or highly physically damaging, patients still have the right to sue surgeons. To which point the surgeon can be sued or whether patients can even win the suit will be at the discretion of the court. The court will ultimately decide whether the omission on the part of the surgeon is serious enough to be deemed as negligence or a complication. For instance, if surgeons explain all forms of liposuction complications from life-threatening types including fat embolism to non-life-threatening ones such as asymmetry and dimpling, all informed negative outcomes could be considered complications even in the event of death.
Likewise, should a patient suffer complications that were not previously explained and believes the surgeon acted negligently, the court can still rule the outcome as a complication especially if the surgical setback could have happened anyway. In fact, there has been a liposuction case in Malaysia where the patient died but the court actually ruled that death was a complication instead of negligence.
Afifuddin: Patients can deem irreparable damage as negligence if it’s proven that negative outcomes were due to the doctor’s failure to exercise standard of care as provided by Rogers v Whitaker. Take, for instance, a patient who seeks consultation with a doctor. If the doctor fails to disclose all inherent and material risks and proceeds with the procedure without the patient’s knowledge of the involved possibilities, such unreported complications or death could be deemed negligence as long as the fault is proven as a negligent act.
Other instances where complications can be deemed negligent are when doctors have been proven sick, tired, or intoxicated during surgery. Part II of the Code of Ethics of MMA provides that a doctor must not have committed any conduct derogatory to the professional code of ethics. He or she is expected to at all times observe proper standard of personal behaviour in maintaining the profession’s dignity, and failure to do so may subject a practitioner to negligent suits.
Are doctors required to conduct full medical examinations if patients say they don’t have any prior illnesses or allergies? Will the doctor be absolved in the event of complication due to the unreported illness or allergy?
Dr. Soma: No, it doesn’t absolve the doctor of any responsibility. Before commencement of any surgical procedure, doctors will normally subject patients above 50 years old to a few blood tests, an ECG and a chest x-ray. If the patient develops an unknown allergy or complication during surgery, that’s beyond us and we’ll need to do essential emergency treatments without the patient’s consent. Surgeons will then have to provide written statements regarding complications during surgery and the need for additional treatment. This cannot be considered negligence because doctors were not told of the patient’s prior illness or allergy. For example, I once had a patient who suffered a heart attack on the surgical table and I did whatever necessary to prevent death. There was no way I could’ve known his blood vessels in the heart were going to be blocked as I can’t be conducting angiograms on all my surgical patients.
Afifuddin: Patients seeking damages must show that practitioners have breached the required standard of care. There must be a causational link between the doctor’s negligence and the damage to the patient where it‘s proven that due to the doctor’s direct failure to exercise caution, he or she unfortunately experienced unwanted complications. Along with the Bolam test, the ‘But For’ assessment can too be applied. Patients must show that the injury suffered would not have happened if not for the negligent act of the doctor. Hence, there must be a direct link of the death or complication based on the wrongful act of the doctor. Take Hasan Datolah v Kerajaan Malaysia (2010) for instance. Because the patient who suffered paralysis experienced complications due to late treatment and not the practitioner’s negligence, the court dismissed the appeal and upheld that the doctor was not responsible.
In what circumstances can patients sue a surgeon? Does this only include injury and severe complications? How about asymmetry and deformity?
Dr. Soma: When you go to court and sue a doctor, the quantum of injury (provided that negligence is confirmed) will be calculated based on the sum of injury and pain suffered which would include the pain suffered in any remedial surgeries and procedures, all claimable surgical costs, all other incidental costs like paralysis and the need for nursing care and domestic help. In addition – if patients were to suffer paralysis due to surgery - the court now awards costs of purchasing modified vehicles and house renovations. In cases of asymmetry and deformity, patients will have the right to sue. To further illustrate, a plastic surgeon was sued after conducting a rhinoplasty because the results were not what the patient expected. Nonetheless, the judge decided the nose looked perfectly fine and that the patient didn’t deserve any damages. While beauty is in the eye of the beholder, the court can believe otherwise and rule that there was no effected damage. Conversely, if the surgeon caused the nose to look worse, then obviously there will be compensation. In any case, patients can choose to sue doctors for anything under the sun and may even seek monetary compensation after slipping on a clinic’s wet floors.
Afifuddin: Patients with asymmetry would have the right to sue if they are not satisfied with the results. But, whether they can win the suit is another issue altogether. Like Dr. Soma has rightly explained, beauty is in the eye of the beholder and a successful suit will depend on whether your surgeon has promised you perfect results based on your desires. If he or she has done so, you will have the right to sue and possibly win the suit should your surgeon guarantee the desired results as per the informed specifications.
Even if the surgeon offers reparative procedures, patients can still choose to sue. While this may be, it’s not advisable to do so since the doctor has offered remedial surgery to correct the error. In the event you choose to sue anyway, it’s up to the court to decide if such asymmetry and deformity had in any way caused emotional distress. Be warned though; cases of such nature very rarely get any time in court due to their infrequency.
Will doctors be liable when patients consent to complications or refuse remedial treatment?
Dr. Soma: Whether patients consent to risks is irrelevant and if they want to sue, they can. It’s the lawyer’s responsibility to advise patients on whether chances of a successful suit are high. Secondly, it’s up to the court to decide whether patients deserve compensation. Surgeons or doctors will not be liable for negligence if patients refuse aftercare. If an international patient were to suffer complications following surgery and chooses to fly home immediately, surgeons will not be held accountable if patients refuse remedial treatment. Although it may be our responsibility to advise patients of possible complications, we cannot force them to undergo aftercare. Should they suffer damaging outcomes due to a surgeon’s advice not being heeded, we cannot be held responsible. Moreover, all provided advice must be documented in black and white and doctors must prove that all aspects of the surgery including hospital admittance and possible remedial treatments were written down.
Afifuddin: We can relate this to the ‘But For’ test and whether the patient can show that complications were directly linked to the act of the doctor. If not, then the doctor is clearly not liable for damages. Your doctor is not responsible for your wellbeing if you choose not to heed his recommendations. If it’s been proven that your doctor has provided the appropriate care before, during and after surgery, the patient won’t have a course of action to sue.
Can a doctor be sued based on secondary complications?
Dr. Soma: Yes, the surgeon can always be sued. If the patient suffers septicemia after liposuction, he or she always has the right to sue even if secondary complications were noted in consent forms. Whether the court agrees with the patient is a different issue but the patient always has the choice.
Afifuddin: Yes, I agree that the patient has the right to sue. The issue involved is not whether the information provided in the consent form is adequate but whether any information on the risks involved was given in the first place. For instance, if patients were not told of secondary complications and experience infection or septicemia after surgery, the likelihood of winning the suit is greater. In short, the doctor must have been proven to have acted below the standard of care required in his profession and as such, caused a patient’s loss and injury.
Who would be liable if patients suffered complications from defective medical devices or products?
Dr. Soma: If a patient suffers damage due to a defective implant or machine, the supplier would be liable. When surgeons recommend implants to patients, they have to be clear and explain what brands are used and how long warranties are. Additionally, doctors must ensure that products meet the minimum standards of the Medical Devices Act. After the government approves products, doctors will assume that such implantables or injectables are fit for use. Likewise, doctors can do their due diligence and find out more about certain brands before buying into them. My personal ‘QC’ is to always certify that products are FDA-approved and if they are, I’m fine with them.
Would patients be liable for damages if they undergo surgeries with unskilled doctors and suffer complications?
Dr. Soma: Doctors who are unskilled or practice out of their scope of specialty are unquestionably liable when complications arise. Hospitals have committees that look into credentialing where they will find out a doctor’s forte and capability. If a doctor is found to practice certain procedures that result in concurrent complications, the committee can haul the doctor up, question him or her and investigate the reasons behind the recurrent problems. Once the doctor is investigated, he or she will be firstly counseled and sent for training. If the doctor is trained but still repeats the same mistakes, he or she will be let go. While it’s very rare that hospitals report such doctors to the Malaysian Medical Council (MMC), they can.
Afifuddin: The MMC may institute disciplinary proceedings when a practitioner appears to have seriously disregarded or neglected his professional duties to his patient. One of the examples of infamous conduct is when a doctor has endangered the welfare of the patient by persisting independent practice of a branch of medicine in which he has no appropriate training or knowledge where he or she has not acquired the necessary experience. If it’s made aware that he possesses no skill as required by the proposed treatment, he should not have conducted such procedures. If he does so, he can be considered criminally negligent. Should it be proven that the doctor was aware that he does not possess the required skill, but knowingly exposes the patient to such harmful risks like death, he or she can be criminally charged under Section 304A of the Penal Code. Doctors practicing out of their scope of specialty are considered grossly negligent because such conduct results in possible recklessness in which the patient is knowingly exposed to risk of injury.
Medical malpractice suits can be very convoluted and take many years to conclude. Why are such suits much more complicated when compared to run-of-the-mill civil suits?
Dr. Soma: It depends on the case. To win a medical malpractice suit, it needs to be proven that improper care was taken. Some cases are pretty straightforward while other cases are rare with sub-specialties that people don’t know about. Medical malpractice suits are challenging to sue successfully because it’s difficult to prove negligence. Lawyers have to advise patients of the difference between complications and negligence, as there are greys areas in between.
Afifuddin: Negligence is defined as the failure of a person to exercise the duty of care towards others, which a reasonable or prudent doctor would have done in similar circumstances. If it’s agreed by most colleagues of a similar standing that the act was in fact negligent, then complications or damages that arise due to the error will be deemed negligent. Complications, on the other hand, are an unanticipated problem that arises following a procedure or treatment or an illness that aggravated the original surgery. It could happen due to unforeseen errors or be unavoidable due to inherent risks that could have not been prevented. Equally, such complications become negligent when a healthcare professional fails to provide a patient with an acceptable standard of care. At the end of the day, it’s up to the court to make a decision based on the facts and circumstances of the case.
Will medical consent forms absolve surgeons from any liability?
Dr. Soma: No, they don’t. Even if you have informed consent running into pages, written explanations of all possible complications may still subject doctors to a suit. When patients sign the consent form, they are agreeing to allow surgeons to perform the mentioned procedure on them. While they are not agreeing to accept the possible complications stated, they are acknowledging that complications have been explained.
Afifuddin: The law states that consent must be acquired from the patient or an authorised person before any procedure is conducted. Failure to do so will carry a fine of up to RM10, 000 or three months’ imprisonment or both on conviction. Most Malaysian private hospitals are bound by the guidelines provided by the Hospital Accreditation Standard and Joint Commission International where on matters related to consent, an informed consent must be given to the patient before any surgery takes place. A doctrine of informed consent requires a doctor to give patients sufficient information in regards to the nature of the proposed treatment and implications. This is illustrated in the case of Tan Ah Kau v Government of Malaysia where the failure of the doctor to inform the patient of the treatment’s subject matter and risks shows that the consent obtained was invalid because he failed to understand the nature of such treatment and consequences that may arise. Thus, consent will only waive a doctor’s liability if he has fully explained the nature and consequences of proposed treatment as that shows he has exercised duty of care.
But the question that needs to be asked is whether such disclosure of information extends to the patient’s relatives as well. For example, will the doctor be required to explain the ins and outs of certain procedures to a husband of a patient? This is a new development as illustrated in the case of Abdul Razak bin Datuk Abu Samah v Raja Badrul Hisham bin Raja Zezeman Shah (2013). Although the deceased patient was told of the inherent risks, the court found in favour of the plaintiff because he was not told of the risks involved. This is an alarming step because it would open suits taken by or on behalf of the patient’s family members when seeking damages. So, this would also extend the duty owed by the doctor to not only his patients but his loved ones as well.
Can verbal consent be upheld in court?
Dr. Soma: With regards to consent forms, the law does not merely look at whether the consent form was signed. What’s important to prove is that the ‘material risks’ of the surgery were explained and that to the best of the doctor’s knowledge, the patient understood explanations. For instance, there is no proper informed consent if the explanation was done in English when the patient only understands Tamil. Judges do accept verbal consent if it can be proven that verbal explanation was given. However, it’s better to have it in writing so that it’s easier to prove if the patient denies that the ‘material risks’ were not explained.
Afifuddin: A doctor is duty bound to disclose all inherent and material risks of proposed treatment when giving advice. It’s not a requirement for advice to be made into writing and as long as the doctor has exercised his duty in disclosing relevant information, it’ll be enough to waive liability. MMC 2013 (Provision 14) has adopted consent guidelines where doctors should not treat the consent form as a substitute for possible verbal information or ensuring that he or she understands the risks involved. The likelier the risk, the more specific details should be – written or otherwise. Inaccurate consent forms including verbal information may infer that the patient was ill- informed. In law, an information sheet cannot be substituted for a full and frank discussion with a patient.
Should doctors be criminally charged for medical malpractice?
Dr. Soma: I don’t believe malpractice should be criminally charged in cases of death by complication, as there was no intention to kill. Conversely, if the patient passes because the doctor didn’t have the necessary skill and caused death, there will be repercussions where doctors may be criminally charged by the government.
Afifuddin: If patients would like to proceed with criminal proceedings against a doctor, they must lodge a police report regarding the offences committed. This police report will be known as a first information report, which will set in motion the process of criminal justice. Once a police report is lodged, the investigation will commence and if the police find there is indeed a case, it will be forwarded to the Deputy Public Prosecutor for prosecution by the state. It must be noted that criminal proceedings can only be initiated by the state and therefore, investigations can only commence once police reports are made. If investigations prove there are valid criminal offences, the state will initiate proceedings against the party at fault. It must be noted though; there is no specific section in the penal code that constitutes medical complications as a criminal offence. Nevertheless, if it can be shown that the doctor had the intention to harm or cause injury then certain provisions will allow criminal proceedings to take place. It’s still up to the state prosecutor to decide whether criminal charges can be brought up against a particular individual.
What sort of lawyer should patients seek when taking action against a doctor?
Afifuddin: Patients should be comfortable with their lawyers and ensure that legal representatives understand patients’ grievances and problems. It’s up to patients to decide which particular lawyer they wish to engage but it’s important to remember there are counsels who specialise in certain aspects of the law.
At which court should patients sue their doctors?
Afifuddin: The monetary claim amount will be a deciding factor in determining which court the case should be tried. It’s vital that both the lawyer and patient quantify total damages suffered in order to decide values of the claim. For monetary claims not exceeding RM100,000, the suitable court to try the matter is the Magistrate’s Court. If the claim is more than RM100,000 but does not exceed RM1,000,000, then the Sessions Court will be appropriate. Failure to quantify total damages and selecting the wrong court can cause losses; as such courts cannot award more than the power it has been conferred.

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