Closing Large Facial Defects: Thinking Beyond the Skin - Closure Using Facelift Technique Concepts for Aesthetic Outcomes by Dr Khoo Lee Seng

 

Closing Large Facial Defects: Thinking Beyond the Skin - Closure Using Facelift Technique Principles for Aesthetic Outcomes

By Dr Lee Seng Khoo, Medical Director Skin Check Malaysia (Brazilian Trained Plastic Surgeon)

www.skincheckmalaysia.com

One of the interesting things about dermatosurgery and reconstructive surgery such as skin cancer or skin tumor/lesion removal is that the problem is not always solved by simply cutting away the problem and stitching the skin together. Sometimes, the real challenge begins after the lesion has been removed.

When we excise a large skin lesion from the face, we are left with a defect. The question is not merely, “Can I close this wound?” It is, “Can I close it without placing excessive tension on the skin, distorting the facial features, or leaving the patient with a reconstruction that is more conspicuous than the original problem?”

This is where a concept borrowed from facelift surgery becomes particularly useful: SMAS plication to offload tension and help achieve primary closure of selected facial defects. (Although personally I favor deep-plane facelifts endoscopic approach in elective face and necklift surgery -some of the facelift and neck lift results are depicted below)

                                           

     

             

               My lecture at IDDAQ 2026 - here i am explaining about retaining ligaments of the face.

The reconstructive dilemma

For a small defect, primary closure may be straightforward. As the defect gets larger, or when the surrounding skin is relatively inelastic, the options become more complicated. We may consider local flaps, skin grafts, or more extensive reconstruction. Each option has its place, but each also comes with trade-offs: scar length and direction, colour or texture mismatch, donor-site morbidity, and the possibility of distortion around important facial landmarks.

                                   Full Thickness Skin Grafts often have color/tone gross mismatch.

In the case discussed in our published report, a large verrucous lesion on the lateral cheek required wide excision. The resulting defect could not be closed primarily even after undermining the subcutaneous tissues. The question was whether the deeper soft tissues could be used to reduce the distance and tension between the skin edges.

Clinical problem: the defect following excision was too large for straightforward primary closure. 

We could consider many options but the resulting scar would be much larger and more extensive.

Large Inferiorly Based Bilobed Flap? - Very extensive donor site morbidity.

Full thickness skin grafts?Tone/Color Mismatch

                              Transpositional Submental Flap ? an extra scar beyond the original defect

A facelift principle, used for reconstruction

The superficial musculoaponeurotic system, commonly called the SMAS, is a fibromuscular and connective-tissue layer relevant to facial soft-tissue support. In facelift surgery, plication sutures fold and tighten this layer to reposition and support the overlying tissues lifting the SMAS in the superolateral direction. The same general principle can be adapted in selected reconstructive situations.

                                         SMAS is represented in red; skin represented in blue.

                                            SMAS (red) is plicated while skin is re-draped and pulled.

                                       Plication of the SMAS results in excess skin (blue) that can be trimmed

Rather than relying on the skin alone to bear the closing tension, multiple sutures are placed to plicate the SMAS and draw the surrounding soft tissue towards the defect. In the case described, multiple 2-0 Vicryl sutures were placed along customised vectors at approximately 45 degrees. This brought the skin edges together with very little tension, allowing primary closure without the need for a more extensive flap or skin graft.

Concept: multiple plication sutures help recruit deeper soft tissue and reduce tension at the skin edges.  SMAS is represented in red; skin represented in blue.

 On table appearance of tension-free primary closure after excision of lesion.

                                             Immediate post-surgery appearance.

Why does plication help?

The principle is simple: by infolding and tightening the deeper soft-tissue layer, we reduce the distance the skin edges must travel. The skin can then be redraped and the excess trimmed where appropriate. The objective is not to pull the skin aggressively together; it is to redistribute the load within the SMAS so the final skin closure is under less or no- tension.A tension free closure always results in a better scar after skin lesion excision.

Reverse-engineering a facelift concept: plicate the SMAS (red) as supporting layer, then redrape the skin (blue). Image from the author's teaching presentation.

It is worth emphasizing that this is not a substitute for sound reconstructive judgement. The anatomy, location and depth of the defect, skin laxity, facial nerve considerations, vascularity, and the direction of tension all matter. A technique that is useful in one cheek defect may not be appropriate for another defect in a different facial subunit.

How does this compare with other options?

Traditional options remain important. Local flaps can provide excellent colour and texture match, but may require longer incisions and more extensive mobilisation. Skin grafts can be useful in selected cases, though their colour, texture and thickness may differ from adjacent facial skin and a donor site is required. Larger regional or free flaps are essential for some complex defects, but may be disproportionate for a defect that can be closed safely with a simpler method.

Our approach differs from the previously described D’Arpa method, which uses a facelift incision and purse-string plication for temporofrontal defects, and from the Flicklift technique, which uses an inverted L-shaped SMAS flap suspended to the deep temporal fascia. In the technique described in our report, access and plication are performed through the defect itself; it does not require a separate facelift incision, SMAS-flap undermining, or anchoring to the deep temporal fascia.

What did the follow-up show?

The published case showed a satisfactory scar at eight months after surgery. That is encouraging, and my other case series (not published here yet) has shwon that the technique is suitable for most facial defects. Further clinical follow-up is however warranted.

Postoperative appearance and eight-month follow-up clinically along with 2 sessions of CO2 fractional laser treatment.

Can it be useful for smaller excisions too?

Definietly, yes. SMAS plication which is an aesthetic facelift technique may also be considered after selected smaller facial skin-lesion excisions when the surgeon wants to reduce tension and help minimize scar widening. The key word is selected. The decision must be based on the individual defect and the surrounding anatomy, not on the assumption that one method fits all.

For me, this is one of the more satisfying aspects of reconstructive surgery: techniques developed for one purpose can sometimes be thoughtfully adapted to solve another problem. A facelift principle can become a reconstructive tool when we understand the anatomy and use it for the right indication.

The takeaway: when a facial defect appears too large for tension-free primary closure, I would use the SMAS plication technique to reduce the size defect before closing the skin so that the tension will not be placed on the skin which can result is scar widening. The aim is not simply to close the wound. It is to close it thoughtfully, while respecting facial form and the patient's long-term appearance. I completed my Plastic Surgery residency at the 38th Infirmary Santa Casa de Misericordia Hospital under Ivo Pitanguy and my extensive experience in performing facelift surgeries allows me today to apply these same principles in skin cancer and skin lesion surgery.https://drkhooleesengplasticsurgery.blogspot.com/2020/08/ivo-pitanguy-tribute-to-legend-in.html

So yes, aesthetic surgery techniques can be used in reconstructive plastic surgery and vice versa!

I recently spoke about this topic at IDDAQ (Indian Doctors & Dermatologists Against Quackery) Summit 2026 in Chennai, India as an invited speaker and faculty instructor for facial fillers.

                                 

Further reading

Khoo LS, Ryu MH. SMAS facelift plication technique to close large skin defects. The PMFA Journal. 10 February 2026.

For more information about Dr Khoo Lee Seng and Skin Check Malaysia where he provides dermatoscopy services and skin lesion/skin cancer surgery, visit www.skincheckmalaysia.com.

The Thoughts That Aren't Yours -How conditioning, collective belief and unconscious suggestion quietly shape your reality! by Dr Khoo Lee Seng

 

"What if many of the thoughts running through your mind aren't actually yours?" Dr Lee Seng Khoo

That sounds like a strange question until you realise how the human mind is conditioned.

From the day you're born, your brain is constantly absorbing patterns. Your parents, teachers, friends, culture, religion, media, social networks—even authority figures like doctors—are all programming associations into your subconscious. This is classical conditioning. Repeat something often enough, pair it with enough emotion or authority, and eventually the response becomes automatic.

Who Programmed Your Thoughts?

After years of repetition, those thoughts no longer feel like programming.

Conditioning is simply repeated association. Humans are no exception

They feel like you.

This is what I mean by a pendulum.

A pendulum is not simply an idea. It is a collective field of belief. When enough people repeatedly believe, reinforce and emotionally energise the same narrative, it develops momentum. Like a swinging pendulum, it keeps pulling people back into the same patterns of thinking.

The remarkable thing is that pendulums rarely announce themselves as someone else's opinion.

They arrive disguised as your own internal voice.

You suddenly think:

"I'm probably too old to change now!"

"People like me never become wealthy."

"My addiction to vape and drugs will probably get worse."

"Business is difficult now."

"Everyone says the economy is bad."

Where did those thoughts originate?

Did you consciously create them?

Or were they inherited?

Most people never ask.

---

Think about medicine.

We know today that expectation alone can change physiology.

The placebo effect is so powerful that new treatments are often compared against it rather than against doing nothing. Even more fascinating is the nocebo effect—the opposite phenomenon—where negative expectations can create real symptoms, greater pain, slower healing and worse outcomes.

A doctor who says,

"Most people recover very well."

and another who says,

"You'll probably suffer from this for the rest of your life."

may be describing the same condition.

Yet the expectations they install can produce very different biological responses.

The words become conditioning.

The conditioning becomes expectation.

Expectation influences perception, behaviour, stress hormones, immune responses and even pain.

This isn't magic.

It's the subconscious responding to suggestion.

PICTURE THIS!

Imagine a patient sees one doctor who says, "Your MRI is terrible. I'm surprised you're even walking." The patient leaves terrified.

They seek a second opinion.

The second doctor reviews the same scans and explains that many people have similar age-related changes without significant pain, and that the imaging findings don't necessarily explain the symptoms.

The MRI never changed. Only the interpretation did.

Yet the patient's experience, expectations and behaviour changed dramatically.

Hypnosis works through a similar mechanism. The conscious critical mind relaxes, allowing suggestions to be accepted more readily by the subconscious. The subconscious doesn't argue. It simply accepts repeated emotional suggestions as reality.

Pendulums operate in much the same way.

FOOTNOTE - Medicine is not immune to confirmation bias or professional disagreement. Occasionally, patients are told by a second practitioner that a previous doctor "missed something" or "managed it incorrectly," only for independent review to conclude that the original management was appropriate. Such disagreements may arise from differences in clinical judgment, hindsight bias, incomplete information, or communication styles rather than actual negligence. For patients, the psychological impact can be profound: once doubt is planted by an authority figure, anxiety can escalate, trust erodes, and the nocebo effect may amplify symptoms—even before any objective evidence has changed.

---

History repeatedly reminds us that collective belief is not the same as truth.

Doctors once appeared in cigarette advertisements recommending smoking.

Parents brought children into shoe stores where fluoroscopic X-ray machines were used simply to measure shoe size.

For decades, low-fat, high-carbohydrate diets were promoted as unquestionable nutritional wisdom before the evidence became far more nuanced.

Joseph Lister's antiseptic methods were initially rejected because they challenged established medical thinking.

None of this means medicine is wrong.

It means human beings—including experts—are susceptible to consensus, authority and conditioning.

A belief repeated often enough begins to feel self-evident.

That's exactly how pendulums survive.

---

This is also why I'm cautious about fortune telling systems like BaZi, Zi Wei Dou Shu and even Feng Shui when they're presented as fixed destiny rather than reflective tools.

Imagine someone is told,

"You have weak wealth luck."

"This ten-year luck pillar is terrible."

"Your chart shows failed relationships."

"This year is dangerous."

“You will get pregnant in December this year.”

“This man is not your true love.”

Most people don't simply hear those words.

They begin looking for evidence to confirm them.

Their attention changes.

Their behaviour changes.

Their confidence changes.

Their decisions become more cautious.

Their nervous system enters expectation.

Eventually the prediction appears to come true—not necessarily because destiny demanded it, but because the subconscious was conditioned to organise perception and behaviour around that expectation.

The fortune teller may have unintentionally performed a hypnotic suggestion.

The prediction became the pendulum.

The person began living inside it.

The same can happen when someone is told they have "bad genes," "a weak constitution," or "will always struggle because of their family."

These statements can become identities rather than observations. It is for this reason, I have left the realm of destiny reading although I am certified in Ziwei, Bazi & geographical Feng Shui.

---

This is why one of the most important questions you can ask whenever a thought appears is incredibly simple:

"Is this actually my thought?"

Did it arise naturally from your own observation?

Or did it arrive carrying someone else's fear?

Someone else's limitation?

Someone else's conditioning?

Someone else's pendulum?

You see, when a belief reaches critical mass, it stops feeling like an opinion and begins feeling like reality itself.

People stop asking, "Is this actually true?" and begin asking, "How do I fit into this truth?"

That's a profound shift.

Instead of examining the belief, we reshape ourselves to conform to it.

Children do this instinctively.

If everyone around them believes that success is only possible for certain people, they don't question the belief.

They question themselves.

"Maybe I'm just not one of those people."

If society repeatedly says,

"Meeting a soul mate is difficult."

People begin expecting difficulty.

If everyone says,"Aging means decline."

People unconsciously begin living as though decline is inevitable.

If enough authority figures repeatedly declare, "This is just who you are."

Eventually we stop hearing it as advice. We hear it as identity.

That's how pendulums grow.

Not because they are necessarily true.

Because enough people have stopped questioning them.

Over time the collective belief becomes so widely accepted that challenging it feels almost irrational, even when history repeatedly shows that accepted truths evolve.

CAVEAT

Your mind is like a garden.

Every day, thousands of seeds are planted by family, society, media, experts, friends and strangers.

Most people spend their lives watering every seed without ever asking who planted it.

Wisdom begins the day you realise you don't have to.

Choose your thoughts & company as carefully as you choose your food.

One nourishes the body. The other shapes your reality.

Before accepting any thought—including those in this article—pause and ask: "Is this really mine?"

Curiosity is the beginning of wisdom. Independent thinking is the foundation of freedom.

Until next time, stay curious, stay compassionate, and think independently.

With love,

Dr Khoo Lee Seng

 

Demonstrating Traditional Chinese Medicine (TCM) examination and diagnosis methods during the University of New England's International Training Program in Medical Acupuncture for Physicians.

THE ORPHEUS ILLUSION - LIFE & MEDICINE by Dr Khoo Lee Seng

 The Orpheus Illusion- Life & Medicine

Why do we keep looking backwards?

In Greek mythology, Orpheus descends into the underworld to rescue his beloved Eurydice. Moved by his devotion, Hades lord of the underworld agrees to let her return—but on one condition.

"Do not look back until both of you have reached the surface."

Simple enough. This should be a piece of cake so Orpheus thinks.

Yet as Orpheus walks towards the light, doubt creeps in. He hears footsteps behind him. Is Eurydice really there? Has Hades deceived him?

Just before reaching daylight, he turns.

In that instant, she disappears forever to live with Hades in the underworld.

Perhaps the tragedy wasn't that Orpheus looked back.

Perhaps the tragedy was that he believed what he saw behind him was more real than where he was going.

I call this the Orpheus Illusion.

MY LIFE IN MEDICINE

As a doctor, one of the first lessons you learn is this:

Symptoms are not causes.

A fever isn't the infection.

Chest pain isn't the blocked artery.

Lung cancer doesn't happen in day.

By the time symptoms appear, the disease has often been developing silently for weeks, months, sometimes years.

Medicine teaches us something profound.

The visible is usually the consequence of something invisible.

Why should consciousness be any different?

Most people believe their present circumstances define their future.

"I' am addicted to cannabis, smoking, vaping, alcohol.."

"My relationship isn't working."

"My health is deteriorating but there is nothing I can do"

"This is just my life. What can I do?" " This is my nature"

But what if your present isn't showing you your future?

What if it's simply revealing your past?

There is always a delay between consciousness and manifestation.

YESTERDAY'S NEWS

Your thoughts. Your emotions. Your assumptions. Your identity. Your programmed consciousness...

All eventually become visible—but not immediately.

Your present moment is delayed feedback from a previous state of consciousness.

In other words, your present is yesterday's news. Old news, if you may!

THE SCREENPLAY WAS ALREADY WRITTEN

Imagine walking into a cinema halfway through a film. The hero is losing.

Everything appears hopeless.

Would you conclude that's how the story ends?

Of course not! You know the script was written long before you entered the theatre

Life is remarkably similar.

Many of us walk into today's circumstances and assume they are writing tomorrow's ending. They aren't. They are watching yesterday's screenplay still unfolding. Your very same habits have caused  the screen to unfold the play and very often with the same "endings". And they wonder why if it is always the same stories in their life replaying- some even consult with intent to believe the soothsayers and fortune tellers telling them this is "fate". This is when our habit evolves to become an addiction silently on auto-pilot.

Have they ever thought who wrote the "screenplay"? Or they let their subconscious wants and habits auto-write the "endings" although they wanted a "happy ending"?

Sorry guys but Bruce Lee does beat up these bunch of thugs and kills the boss's son. (The Big Boss-1971)

PHANTOM IDENTITIES

One of the most fascinating conditions in medicine is phantom limb pain.

A patient loses an arm.

Yet months later, he still feels pain in fingers that no longer exist.

The limb is gone. The brain's map has not.

I sometimes wonder whether many of us are living with "phantom identities" acting out our subconscious saying one thing consciously but then actually manifesting another. 

The criticism or inferiority ended years ago. Yet we still feel inadequate.

The relationship is over. Yet we still feel abandoned or wronged.

The failure is long past. Yet we continue living as if it happened yesterday living as if we must avert this.

The event has disappeared. The imprint remains.

https://my.clevelandclinic.org/health/diseases/12092-phantom-limb-pain

The Buddha called this samsara.

Not merely the cycle of rebirth.

But the endless repetition of conditioned experience.

We look at today's circumstances and say "This is reality." 

Then we believe the same things.

Feel the same emotions.

Make the same choices dressed differently & think we evolved.

And tomorrow faithfully recreates yesterday with the same effect only the actors & actresses differ.

The wheel turns because we keep looking back subconsciously.

Healing begins the moment we stop confusing the symptom with the cause.

The scar is not the wound.

The echo is not the voice.

The present is not the source.

It is the consequence.

That doesn't mean denying reality. It means understanding its place.

https://www.instagram.com/reel/DABVnKSNz-y/?utm_source=ig_web_button_share_sheet

(Watch Dr Lee Seng Khoo performing laser for scars and rejuvenation - healing old scars)

There is a beautiful saying:

"If you can allow the old to exist without entertaining it, it will pass, and the new will be born."

Notice it doesn't say fight the old.

Or erase it.

Simply stop feeding it.

Even after successful surgery, healing takes time.

The body changes first.

The scar softens later.

Consciousness works much the same way.

The new is born inwardly before it becomes visible outwardly.

WALK ON

Perhaps Orpheus was never being tested for obedience.

Perhaps he was being invited to trust the unseen.

We make his mistake whenever we let today's circumstances dictate tomorrow's possibilities.

We keep asking yesterday for permission to create the future. And we only change the surface not the deeper psyche.

Maybe that's the illusion.

Maybe awakening is simply refusing to look back.

Some of us walked on and then when things begin to unravel in unfamiliar territory (different movie unfolding) - we immediately revert back to the old simply because that program was stronger & been around longer (it is at least familiar and known to us).

Because the future that we actually wanted has never been hiding behind us. It has always been waiting ahead. Yet we couldn't control our old subconscious impulses and seek excitement- instant dopamine hits & validation out of habituated behaviour while secretly planning our own burn-out, failure and regret subconsciously. Better the Devil you know as they say.....

∎ THE ORPHEUS PAPERS Paper No. 001

"The doctor learns that symptoms conceal causes. The philosopher learns that appearances conceal reality. Perhaps they have been studying the same mystery all along."

— Dr Lee Seng Khoo

"The visible is usually the consequence of something invisible."

"Your present is yesterday's news."

"Perhaps the tragedy wasn't that Orpheus looked back, but that he believed what was behind him more than what lay ahead."

Wu De (武德): The Moral Spine of My Hands — Reflections of a Martial Artist, Surgeon, and Medical Acupuncturist

 

Wu De (武德): The Moral Spine of My Hands — Reflections of a Martial Artist, Surgeon, and Medical Acupuncturist

There is a moment before every incision I make with the surgical blade—a stillness that feels familiar. It is the same quiescent feeling that precedes the first punch or kick or even the swing of the sword, the same awareness before blade meets the skin. In that moment, I am not only a surgeon, nor merely a doctor or acupuncturist—I am a practitioner of Wu De (武德), martial virtue.

Combining the two Chinese characters, “Wu” (武), which means martial or military, and “De” (德), which translates to virtue or morality.

Together, they represent the idea that medical and martial arts practice should not only focus on physical skills but also emphasize the development of character, integrity, and ethical behavior.

Wu De is often translated as “martial morality,” but this translation is insufficient. Wu De is not a static code to be memorized—it is a living tool, a way of enacting virtue through conduct, decisions, and relationships. It is something one does, not merely something not merely something one knows. It is a way of living – a way of one’s conduct in life.

 

Traditionally, Wu De is rooted in the ethical foundations of Chinese philosophy, especially the five Confucian virtues: Ren (仁) (benevolence), Yi (义) (righteousness), Li (礼) (propriety), (智) Zhi (wisdom), and (信)Xin (trustworthiness). These are not abstract ideals; they are practical guides governing how one acts in moments of consequence—whether in combat, in healing, or in silence.

The Body Trained, The Mind Tempered

Martial training begins with the body but matures in the mind. Wu De teaches that skill without virtue is dangerous, and power without restraint is chaos. In classical understanding, martial ability (Wu Gong) (武功) must always be balanced by moral cultivation (Wu De) (武德).

This principle became foundational in my surgical practice. The scalpel blade is not unlike a weapon—it can harm or heal depending on the intention意 and discipline behind it. Wu De reminds me that technical mastery alone is insufficient; it must be governed by clarity of purpose and ethical restraint.

A doctor or surgeon, like a martial artist, must constantly ask: Is this action necessary? Is it just? Is it proportionate?

Just because I as a trained martial artist may fracture a man’s jaw and dislocate his elbow in a fight does not mean I should. Is the action warranted for the circumstances? Can I subdue my opponent without unnecessarily maiming him for life?

Some surgical colleague in private once relayed to me (in confidence), that to him now every abdominal pain in absence of other pressing issues is appendicitis and he will not hesitate to remove an appendix which he reckons is harmless even if the diagnosis isn’t appendicitis. When pressed on why he does this- the gentleman reiterates that he needs to make enough money for his family and growing expenses including children in international schools, family holidays and expensive home and car mortgages.

Wu De as a Way of Life, Not a Role

Wu De extends beyond the training hall. It governs how one speaks, listens, teaches, and learns. It shapes relationships—between teacher and student, practitioner and patient, senior and junior. It is reflected in how one carries oneself both inside and outside formal practice. Respect is a two-way street between master and student in martial arts.

Do not speak ill of another but yet many doctors throw shade over others due to professional jealousy or due to intense market competition.Doctors badmouthing each other. Does it affect medical students' career choices? - PubMed And the constant belittling and bullying is prevalent in the medical hierarchy particularly in surgical or specialist training. Juniors see and emulate very bad behaviours from some toxic seniors (many whom are very subpar in their field of work to begin with hence this behaviour is used to mask that inadequacy) that later extends beyond the confines of hospital but to their own lives outside.https://journals.lww.com/wpsy/fulltext/2022/04010/the_culture_of_bullying_in_medical_training_must.2.aspx

Lies, rumors and character assasination are common in the medical world

In medicine, this translates into professionalism that is not performative but internalized. Respect is not reserved for authority—it extends to patients, colleagues, and even to the uncertainty inherent in the human body.

The traditional martial world understood Wu De as something that defines the practitioner before they even act—like a silent credential visible through conduct. In the hospital, this becomes equally true: one’s presence, composure, and integrity often speak before one’s technical skill is demonstrated.

Humility and the Limits of Control

One of the enduring lessons of Wu De is humility. Not as modesty alone, but as an accurate recognition of limits.

 

In both martial arts and medicine, there is a gradual realization: control is never absolute. A fight can turn ugly – you may realize now you are facing multiple assailants or some may be armed. A surgery can complicate intra-operatively or post-operatively. A patient can respond unpredictably. Wu De tempers the illusion of mastery of life with awareness of the unknown or ambiguity.

Confucian virtue Zhi 智(wisdom) is not merely knowledge—it is discernment. It is the ability to perceive the right action within context, not blindly follow “rules”. 

The only Surgeon who has Zero (0) complications is the one doesn't operate at all!

This is especially relevant in surgery. Protocols guide us, but judgment defines us.

Compassion as Applied Strength

Wu De reframes compassion as an active force. In martial terms, it is the ability to neutralize harm without unnecessary violence. At higher levels of skill, one resolves conflict without destruction.

In medicine, this becomes the principle of minimizing harm—not only physically, but psychologically and emotionally.

Compassion is present in:

• choosing a less invasive intervention when necessary but not hiding behind a less invasive intervention because you are not capable or competent in performing such a procedure (in such cases please refer to medical colleagues who could) Or teaching a martial arts student how to fight on the street or spar when you have ZERO (0) such experience yourself first-hand! Send them to those who have done so and can teach!
• 
  
  
  
• taking time to explain rather than rushing and not trying to be “right” (even if you clearly are because it is better to “kind” sometimes than to be “right” all the time),
• acknowledging suffering without distancing from it. (empathy)https://drkhooleesengplasticsurgery.blogspot.com/2020/12/cleft-surgery-life-free-from-bullying.html

Here, Ren(仁)(benevolence) becomes not sentiment, but disciplined care.

Discipline, Conduct, and the Invisible Practice

Wu De is often misunderstood as etiquette—bows, titles, rituals. But these are merely outward expressions. The essence lies in internal discipline: consistency, accountability, and self-regulation.

We see many people who only pedestalize those on top and of use to them like bosses or head of departments BUT they patronize and ill-treat others “beneath” them. In life, I believe in treating everyone & yes everyone from the cleaner and the trash-man with respect.

In the operating theatre, discipline manifests as steadiness under pressure. In acupuncture, it appears as sensitivity rather than force. In daily conduct, it becomes integrity—doing what is correct even when unseen.

Wu De 武德 emphasizes that virtue is not situational. It is continuous.

Restraint and Right Action

Perhaps the most difficult aspect of Wu De is restraint. The ability not to act.

In martial arts, the highest skill is avoiding unnecessary conflict. In medicine, it is avoiding unnecessary intervention.

Modern medicine often rewards action—procedures, prescriptions, interventions. Wu De introduces a counterbalance: just because something can be done does not mean it should be done.

Just because selling more fillers may make an aesthetic doctor more monies does not mean he should. https://drkhooleesengplasticsurgery.blogspot.com/2020/08/filler-fatigue-what-your-doctor-does.html Similarly peddling false hope to parents of children with Cerebral palsy and Autism by pushing courses and courses of intrathecal stem cells as a “cure” just to profit does not mean we as medical professionals should do so!Haste Makes Waste: There Is No Solid Evidence to Translate the Use of Stem Cells into Clinical Practice for Children with Autism Spectrum Disorder - PMC

This aligns with Yi 義(righteousness)—the moral clarity to act appropriately within context, not merely efficiently.

Integration: Martial, Medical, and Human

As a medical acupuncturist, I navigate both biomedical science and traditional philosophy. Wu De serves as a bridge—not as a relic of the past, but as a functional framework for modern practice.

It reminds me that:

• healing is relational, not purely mechanical, there is a psychological and emotional aspect to it.Dr Khoo Lee Seng's Plastic Surgery Blog: EMOTIONS THAT CAN MAKE YOU SICK & EVEN IMPEDE HEALING POST SURGERY by Dr Khoo Lee Seng
• presence influences outcome,” being PRESENT with the patient – not checking your phone every minute, answering messages and taking calls during treatment”
• and the practitioner is part of the treatment (to constantly improve your clinical skills and judgement & to not be motivated by profits alone).https://drkhooleesengplasticsurgery.blogspot.com/2025/12/what-god-forgot-to-tell-surgeons.html

Across all three disciplines—martial arts, surgery, and acupuncture—the same principle holds: skill must be guided by virtue, and virtue must be expressed through action.

Conclusion: The Quiet Standard

Wu De 武德 is not visible in titles or credentials. It cannot be quantified or easily taught through lectures. It is cultivated through repetition, reflection, and responsibility.

It is present in the restraint before a strike, the precision of an incision, and the sensitivity of a needle.

It is how one chooses to act when action carries weight.

In the end, Wu De 武德 is not about being a martial artist or a doctor—it is about becoming a person whose actions consistently align with clarity, responsibility, and humanity. This is severely lacking in today’s culture of excess, chasing trends, flexing and a loss of concentration and focus in a digitally dominated world.

And in that sense, every patient encounter, every procedure, every interaction becomes part of the same lifelong practice. A practice towards perfection of the human psyche and the art of self- realization & self-actualization.

This is Wu De 武德.

Unapologetically yours

Dr Khoo Lee Seng