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Friday, May 8, 2026

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” (), which means martial or military, and “De” (), 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 () (benevolence), Yi () (righteousness), Li () (propriety), () Zhi (wisdom), and ()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 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:

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

 

Friday, April 24, 2026

Rib Remodelling (RibXcar): An Emerging Technique in Body Contouring

 

Rib Remodelling (RibXcar): An Emerging Technique in Body Contouring

This post has been long overdue as I actually attended the Rib Xcar Surgery Training program with the inventor of the technique himself Dr Raul Manzadena Cipriani & Dr Alexis Delobaux from February 2nd to February 4th 2026 at the romantic city of Paris much earlier in the year. I was the first Malaysian doctor to complete the Rib Xcar hands-on training program. 


Graduation Day!

    But firstly what is Rib Xcar


And why is this procedure changing the landscape of waist contouring and achieving the ultimate silhoutte or Waist To Hip (WHR) Ratio in females?

                                The Rib Cage and Lower Ribs contribute immensely to the WHR


         Rib Xcar can also accentuate the ideal Breast to Hip Ratio giving the most feminine curves



Rib Xcar: The Scarless Evolution of Waist Contouring and the Art of the Ideal Silhouette

In redefining femininity, few goals are as enduring—or as universally desired—as the beautifully balanced hourglass figure. Defined by a refined waist and harmonious proportions, the waist-to-hip ratio has long symbolized femininity, elegance, and confidence. 

(Note - However in Asia or in Malaysia, Oriental Chinese men {not me!} prefer the slim & straight body types as they have not evolved to appreciate curvy women yet - things are gradually changing though)

Yet for many women, achieving this silhouette isn’t simply a matter of diet, exercise, or even traditional body contouring such as liposuction. The ribcage itself—particularly the lower ribs—can set a structural limit on how narrow the waist can appear.

Today, a groundbreaking innovation is redefining those limits.

Rib Xcar introduces a new era in contouring: one that reshapes the silhouette at its structural foundation—without leaving long visible scars.


The Art of the Silhouette

The beauty of the hourglass form lies in contrast: a cinched waist flowing seamlessly into fuller hips. While procedures like liposuction and fat transfer enhance soft tissue, they don’t address the underlying framework.

Rib Xcar takes a different approach.

Rather than removing fat alone, it refines the ribcage itself, allowing for a more dramatic yet natural narrowing of the waist. The result is not an artificial look, but a sculpted enhancement of your natural proportions—subtle, elegant, and deeply transformative.


What Makes Rib Xcar Truly Different

At the heart of Rib Xcar is a defining advantage:

A "Needle-Access" Technique

Traditional rib-modification procedures required external incisions to remove the lower ribs, often leaving visible scars across the torso. 


                                                     The traditional rib modification technique

Rib Xcar changes that entirely.

By using micro-entry access points, often no larger than a millimeter, the procedure avoids visible scarring altogether. There are no long incisions, no telltale marks—just a refined silhouette.


This offers patients:

  • Complete discretion — no visible evidence of surgery

  • Confidence in any setting — from swimwear to intimate wear

  • A modern aesthetic standard — results that appear entirely natural


The Science Behind the Transformation

What makes Rib Xcar so innovative is not just the result—but the precision behind it.

Step-by-Step Overview of the Procedure

1. Precision Mapping
Using real-time ultrasound, the surgeon maps the exact position and curvature of the lower ribs (typically ribs 10–12). This ensures a highly customized plan tailored to each patient’s anatomy.






2. Micro-Access Entry
Tiny puncture points are created in the skin—so small they are designed to minimise visible scarring.



3. Ultrasonic Rib Remodeling
A specialized instrument (piezotome) delivers ultrasonic micro-vibrations that gently weaken the rib structure without cutting or removing it.




4. Controlled Repositioning


The ribs are carefully guided inward, reducing their outward flare and narrowing the waistline.

5. Real-Time Verification
Ultrasound is used again to confirm symmetry, positioning, and safety throughout the process.


Visualizing the Change




Think of the ribcage as the frame of a garment:
  • Before: The lower ribs flare outward, subtly widening the waist

  • During: The structure is softened and gently reshaped

  • After: The ribcage sits closer to the body, creating a naturally cinched, elegant contour

                                           Note the micro-incision sites overlying ribs 10, 11 an 12

This is not about removal—it’s about refinement.


Sculpting the Ideal Waist-to-Hip Ratio

Even small reductions in waist width can dramatically enhance overall proportions. By narrowing the ribcage itself, Rib Xcar creates a stronger contrast between the waist and hips—one of the key elements of the hourglass figure.


When combined with complementary procedures such as liposuction or fat transfer, the effect can be even more striking—producing a smooth, continuous silhouette from ribcage to hip.

The outcome is balanced, proportionate, and uniquely tailored to each patient.


The Origin: Innovation by Dr. Raúl Manzaneda Cipriani

Rib Xcar is not just a technique—it’s the result of a deliberate effort to solve a long-standing challenge in aesthetic surgery.

https://pmc.ncbi.nlm.nih.gov/articles/PMC12466906/

Developed by Dr. Raúl Manzaneda Cipriani, a plastic surgeon from Peru (Latin America), the procedure emerged from a clear patient demand:
a smaller waist—without scars, without rib removal, and without extreme invasiveness.

The Problem with Traditional Methods

Historically, achieving significant waist narrowing involved:

  • Rib removal procedures that were highly invasive

  • External incisions that left permanent visible scars

  • Longer recovery times and increased surgical risk

Patients wanted transformation—but not at that cost.


(Me & Dr Manzadena sharing a lighter moment)



The Breakthrough Approach

Dr. Manzaneda introduced a new paradigm by combining:

  • Ultrasound-guided precision

  • Piezoelectric (ultrasonic) technology for controlled bone remodeling

  • Percutaneous access techniques to eliminate large incisions

He also refined specialized instruments to allow delicate, controlled rib reshaping—making the procedure both safer and more predictable.

The result was Rib Xcar: a technique that reshapes rather than removes, and enhances without leaving large visible scars.


A Modern Evolution in Body Contouring

Since its introduction, Rib Xcar has gained international attention and is increasingly adopted by surgeons trained in advanced body contouring techniques.


Safety Considerations

As with all surgical procedures, careful patient selection and risk assessment are essential. Potential concerns discussed in the literature and professional forums include:

* post-operative pain and recovery variability
* risk of contour irregularities
* lack of long-term structural outcome data
* need for highly specialised anatomical understanding

Patients should be fully informed of the evolving nature of such techniques and the current limitations in emerging aesthetic surgical innovations. There is limited long term data, variation in technique and training of doctors in the procedure itself, consensus guideline endorsement vary and the need for further studies in the procedure itself.

Who Is It For?

Rib Xcar is especially suited for women who:

  • Feel their waistline is limited by their rib structure

  • Desire a more defined, sculpted midsection

  • Want noticeable results without very visible scars

  • Value natural-looking, proportionate enhancement

As always, suitability depends on individual anatomy and goals, making expert consultation essential.


Final Thoughts: Beauty Without Evidence


Rib Xcar represents more than a technical advancement—it represents a philosophy.

Professional and Regulatory Context

The acceptance and regulation of newer aesthetic procedures vary significantly between jurisdictions. Not all techniques are recognised, approved, or routinely performed in every country.

This article is intended for educational and academic discussion only.
It does not constitute medical advice or an offer of treatment.

To learn more about Rib Xcar, you may access the following links :

Women are spending $20K+ to shrink their waists in viral craze experts call 'RibXcar'

Plastic surgeon reveals women are getting shocking $20k 'invisarib' procedure to contour their waists | Daily Mail Online

RibXcar: The New Way to a Defined Waistline



Sincerely yours,

Dr Khoo Lee Seng 




                       The after party at a chic Parisian restaurant below the Eiffel Tower.

                      Surgeons came from all corners of the world for training in RibXcar!


Note- I completed my Plastic Surgery residency training at the Ivo Pitanguy Institute 38th Infirmary of the Santa Casa de Misericórdia General Hospital in Rio de Janeiro. You may read more about Ivo Pitanguy here who is credited as being the Father of Modern Plastic Surgery https://drkhooleesengplasticsurgery.blogspot.com/search/label/Ivo%20Pitanguy?m=1

To learn more about the training program at the Ivo Pitanguy Institute please check out this link

Author’s Involvement
                                
          At The Gala Dinner Graduation Party with Dr Manzadena & Dr Delaboux

This article is for academic discussion only. This procedure currently is not offered by the author in Malaysia and remains an evolving technique with ongoing evaluation.

The author has academic exposure as both a trainer and a trainee to contemporary developments in body contouring and participates in educational activities, including live surgery & cadaveric training settings, where emerging techniques may be discussed and demonstrated for academic & professional learning purposes.

For a full list of my research publications and book chapters please click 


Saturday, April 11, 2026

Chi Kung: The Medicine of Energy, Mind and Form

 

Chi Kung: The Medicine of Energy, Mind and Form

By Dr Khoo Lee Seng

In modern medicine, we are trained to observe structure, measure pathology, and intervene with precision. As a registered Western medical practitioner who completed Plastic & Reconstructive Surgery residency and also a practitioner of medical acupuncture, I have spent decades studying anatomy, physiology, and the science of healing. Yet, there exists another dimension of medicine—older, quieter, and deeply experiential—that complements what we see under the microscope.

This is the art of Chi Kung (Qi Gong).

Chi Kung is an ancient system within Traditional Chinese Medicine (TCM) that integrates movement, breath, and mind regulation to cultivate and harmonise the body’s vital energy—Qi . While Western science may describe its effects in terms of nervous system regulation, circulation, and musculoskeletal conditioning, Chi Kung approaches the human being as an integrated energetic system.


Qi, Aging, and the Silent Decline of Vitality

Aging, in Western medicine, is often described as cellular senescence, oxidative stress, and progressive degeneration. In Chi Kung, aging is understood more simply—and perhaps more truthfully—as the gradual depletion and stagnation of Qi.

When Qi flows freely:

  • tissues are nourished
  • sinews remain supple
  • the mind is clear
  • the spirit is anchored

When Qi stagnates:

  • toxins accumulate
  • fascia and sinews tighten
  • circulation is impaired
  • disease begins to manifest

If you look at the electrical circuit in the illustration, you will see that:
1. The Qì channels are like the wires that carry electric current.
2. The internal organs are like the electrical components such as resistors and solenoids.
3. The Qì vessels are like capacitors, which regulate the current in the circuit.
4. The dāntián is like a battery, which stores the charge and provides the EMF in the circuit.

Modern research does show that practices like Chi Kung can improve circulation, flexibility, balance, and even aspects of cardiovascular health . From a surgeon’s perspective, this translates into improved tissue quality, better healing potential, and resilience against degeneration.

But Chi Kung goes further—it addresses the root.


Sinews, Fascia and the Hidden Network of Health

In surgery, we see the fascia and connective tissues directly. These are not inert structures. They are living, dynamic, responsive. You may read more about the concept of fascia in the link below.

https://drkhooleesengplasticsurgery.blogspot.com/2025/07/fasciadiseaseandacupuncture.html

Figure A- Healthy Fascia which are neatly organized that allow easy gliding and smooth movements

Figure B- Aging and entangled fascia result in chronic pain, loss of flexibility and onset of degeneration.

Chi Kung traditions have long described the importance of “sinews” (tendons and fascia) as the physical expression of internal vitality. Practices such as Yi Jin Jing (Muscle/Tendon Changing Classic) specifically aim to transform these tissues—making them elastic, resilient, and energetically alive.

From a biomedical standpoint, this correlates with:

  • improved fascial glide
  • enhanced proprioception
  • reduced chronic tension patterns
                                                      Tight entangled fascia causes lymph stagnation

From an energetic standpoint, it allows Qi to flow unimpeded through the meridians which are flow within the fascial connections.

Where there is stiffness, there is stagnation.
Where there is stagnation, there is disease.


Toxins: Beyond the Physical

We often speak of toxins in biochemical terms—metabolic waste, environmental pollutants, inflammatory mediators.

But in Chi Kung, toxins also include:

  • unresolved emotional states - anger, hatred, apathy, jealousy, evil thoughts.
  • chronic stress patterns - worry, anxiety, greed.
  • habitual negative thinking - the refusal of accepting facts and truths.


These are not abstract ideas. They manifest physically.

Persistent anger tightens the chest and jaw.
Fear weakens the kidneys and posture.
Worry knots the abdomen.

Over time, these patterns obstruct Qi flow and alter physiology.


The Mind as the Primary Physician

One of the most overlooked truths in both Eastern and Western medicine is this:

The mind directs the body.

In Chi Kung, improper thoughts—particularly:

  • anger
  • resentment
  • blame towards others
  • internalised negativity

—are seen as major disruptors of Qi.

When a person constantly assigns blame externally, they lose internal agency. The mind becomes scattered, the breath becomes shallow, and Qi becomes chaotic. This disrupted chi is shown on the face and facial micro-expressions. A cruel person or someone who mentally unsound or even an instigator of evil can be "felt" and "seen" by their aura ("chi") and their facial appearance.

Dr Khoo Lee Seng's Plastic Surgery Blog: Leaking Qi & Depleted Jing- The Cause of All Medical Maladies & Premature Aging by Dr Lee Seng Khoo

This is not philosophy alone. It is observable.

Modern studies show that Chi Kung integrates mental focus, breathing, and movement to regulate both psychological and physiological states .

A disturbed mind leads to disturbed Qi. Disturbed Qi leads to disease.







Facial Feng Shui: The Face as a Map of the Mind

As a plastic surgeon, I have a unique vantage point.

The face is not merely anatomy—it is history.

Over time, emotional patterns sculpt facial structure:

  • chronic anger hardens the jaw and deepens lines
  • worry hollows the midface
  • resentment tightens the eyes
  • fear alters posture and expression





















Evil or cruelty can be seen on face due to manifestation of internal states.

(You may watch my webinar on Facial Feng Shui and Cosmetic Surgery here)

This is what traditional practitioners refer to as facial feng shui—the outward manifestation of internal imbalance. You may read more about Facial Feng Shui and how plastic surgery and emotion management can alter the facial structures and appearance.

https://healthcaretoday.com.my/facial-feng-shui-bridging-aesthetics-with-cultural-harmony.html

No injection or surgical technique can fully reverse what is continuously reinforced by the mind.

Chi Kung, however, works from the inside outward.


The Systems of Practice I Teach

My training in Chi Kung emphasizes both structure and spontaneity. The systems I practice and teach my students include:

Ba Duan Jin (Eight Brocades)- Wuji modification

A foundational system of dynamic movements that:

  • improves circulation
  • stretches the sinews
  • regulates organ systems


Microcosmic Orbit- Wuji Modification



A meditative practice circulating Qi through the Ren and Du meridians:

  • enhances internal energy flow
  • stabilizes emotional states
  • builds internal awareness

Yi Jin Jing - Wuji Modification


Focused on transforming muscles and tendons:
  • increases strength and elasticity
  • improves posture and structural integrity

Xi Sui Jing (Marrow Cleansing)

A deeper internal practice aimed at:

  • revitalising internal systems
  • strengthening core vitality


Standing Meditation (Zhan Zhuang)



Often underestimated, this is one of the most powerful practices:

  • develops a one-pointed mind
  • builds internal force
  • aligns structure with energy
I also practice moving meditation using Gung Fu forms that realigns the muscles and fascia to promote qi flow and cat-like reflexes.

Spontaneous Chi Flow

At higher levels, the body begins to move naturally:

  • releasing deep blockages
  • restoring natural rhythms
  • allowing the body to “self-correct”
At this stage the body will sway and move on its own accord and practitioners may jump, roll, cry or simply enjoy the movements that allows chi to flow and unblock "blocked" meridians and channels in the human body.
Example of the hand Jue Yin pericadium meridian.


Death, Stillness, and the Return to Simplicity

Ultimately, Chi Kung is not merely about health or longevity.

It is about alignment—with oneself.

Death, in this framework, is not an enemy but a transition. A life lived with chaotic Qi, emotional turbulence, and internal conflict leads to suffering—both in life and at its end.

A life cultivated through:

  • calm mind
  • balanced emotions
  • smooth Qi flow

—leads to clarity, acceptance, and peace.


Bridging Two Worlds

As a Western-trained doctor & surgeon, I do not reject science. On the contrary, I rely on it daily.

But science, at its current stage, measures what is tangible. Chi Kung operates in a domain that is experiential, functional, and deeply personal.

The two are not in conflict.

They are complementary.

Where surgery corrects structure, Chi Kung restores function.

Where medicine treats disease, Chi Kung cultivates health.


Conclusion

Chi Kung is ultimately a practice of responsibility.

Not blaming others. Not inciting hatred. Not harboring evil thoughts or intentions. Not externalizing suffering. Not waiting for cure.

But cultivating:

  • clarity of mind
  • harmony of emotion
  • smoothness of Qi

Health is not given. It is cultivated.

Meanwhile, keep smiling from your heart! Keep pleasant thoughts if not for others, at least for your own health!

Dr Khoo Lee Seng






Sunday, March 22, 2026

When Complications Happen: Why Even the Best Surgeons Can Face Risks—and Why Patients Must Look Beyond Registration

When Complications Happen: Why Even the Best Surgeons Can Face Risks—and Why Patients Must Look Beyond Registration

Surgery is often described as high-stakes, high-skill work, and for good reason. Even the most experienced, highly trained surgeons can encounter complications. That’s a reality that is uncomfortable but unavoidable. Every patient’s anatomy is unique. Healing varies. Some procedures are inherently complex. Even in the hands of a world-class surgeon, outcomes are not 100% predictable.

Yet, in today’s medical ecosystem, complications are too often misrepresented. Patients frustrated by outcomes may “doctor hop,” seeking someone else to blame. Worse, some colleagues use these moments to throw surgeons under the bus—sometimes subtly, sometimes overtly—claiming the complication is proof of incompetence. In the worst cases, surgeons are actively vilified because of professional registration technicalities rather than clinical skill.

This is particularly apparent in Australia, where highly trained surgeons like Dr. Darryl Hodgkinson who completed Plastic Surgery residency at the famed Mayo Clinic in the United States have been unfairly targeted by his Australian colleagues because they are not registered as plastic surgeons in the country, despite decades of international experience and clinical competence.

Appendix 15 - Letter from Dr Darryl Hodgkinson and attachments.pdf

 Why Complications Happen—Even with the Best Surgeons

Surgery is not a machine; it is an interaction between a trained surgeon and a living, breathing, uniquely complex human body. Complications can occur due to:

(1) Case complexity – Patients who have undergone previous surgeries or have challenging anatomy due to threads/fillers and various energy devices present a “redo surgical terrain” that can increase the likelihood of complications.

(2)Healing variability – Age, nutrition (use of GLP injectables) or low calorie intake including low carb diets and Intermittent fasting (IF), smoking/vaping, chronic illnesses, and genetics all influence how the body recovers.

(3)Unexpected intraoperative events – Even the most meticulous planning cannot account for every variable. 

Importantly, a complication does not automatically indicate medical negligence. Medical negligence occurs only when a surgeon’s care falls below the accepted standard of practice, as judged by peers in the field. 

In contrast, many complications arise despite careful planning, skill, and adherence to professional standards. Mislabeling every complication as malpractice is misleading, harmful, and unfair to surgeons.

The celebrated neurosurgeon Henry Marsh and Surgeon General Atul Gawande emphasize that complications are an inevitable part of medical practice. What separates excellent surgeons from average ones is how they manage complications, communicate with patients, and learn from every outcome.



When Colleagues Exploit Complications

Unfortunately, some surgeons face more than just medical challenges—they face "professional politics". Complications can be weaponized by colleagues who have ulterior motives: turf wars, financial competition, or a desire to maintain control over a specialty. 

Patients can be subtly brainwashed into believing they have been wronged if the operating surgeon is not formally registered as a specialist.

Take the case of Dr. Darryl Hodgkinson Despite being fully trained in the specialty of Plastic Surgery at the Mayo Clinic and internationally experienced, and highly competent, some colleagues encouraged patients to sue him simply because he was not registered as a plastic surgeon in Australia. The following sources provide insight into his professional challenges:

* Dr. Hodgkinson’s own letter and supporting documents

https://cosmeticmedicalpracticesubmission.info/appendices/Appendix%2015%20-%20%20Letter%20from%20Dr%20Darryl%20Hodgkinson%20and%20attachments.pdf

* [Sydney Morning Herald report on alleged cartel behavior among Australian surgeons]

https://www.smh.com.au/healthcare/australian-surgeons-accused-of-cartel-behaviour-to-control-fees-20160922-grm5rh.html)

The SMH article highlights systemic pressures where groups of surgeons allegedly attempted to control fees and restrict competition—a backdrop that makes it easier for colleagues to vilify competent surgeons who are “outsiders” to the system and are trained abroad or in another system.

Registration vs Competence: Why Titles Aren’t the Whole Story

Many patients assume registration as a plastic surgeon guarantees the best outcomes. While registration is legally significant, it does not necessarily indicate experience or skill in every cosmetic procedure. Conversely, many surgeons who are not registered as plastic surgeons in their country Australia for example - Dr Patrick Tansley (British trained plastic surgeon & former Hunterian professor) and Dr Darryl Hodgkinson (American trained plastic surgeon and founder of an International Cleft Mission Society - Operation Restore Hope) have extensive training, including accredited aesthetic surgery programs, and are perfectly capable of delivering excellent outcomes.

Dr Patrick Tansley FRCS Plast was denied entry to the Australian Specialist Register

[ACCSM Guidance on Qualifications and Competence in Cosmetic Surgery (PDF) emphasizes that specific training, experience, and professional development can matter more than formal registration especially in aesthetic plastic surgery.

https://www.accsm.org.au/download/?id=media&doc=189 

[PMFA Newsdiscusses how registration and specialist status are distinct from actual procedural expertise.

IN RESPONSE TO: Plastic surgery and aesthetic medicine - specialties and specialists | The PMFA Journal

Liposuction | The PMFA Journal

https://www.thepmfajournal.com/features/post/plastic-surgery-and-aesthetic-medicine-specialties-and-specialists

 Professor Dr Andrew Burd and Dr Lee Seng Khoo on Training and Competence

Dr. Andrew Burd and Dr. Lee Seng Khoo, in their PMFA journal articles, underscore a critical principle: competence in aesthetic surgery comes from specific, structured training, case experience, and continuous professional development—not solely from registration as a plastic surgeon. Key points from their paper include:

1. Procedure-specific training matters most – A surgeon may be registered in plastic surgery but have limited experience in a specific cosmetic procedure for example a complex procedure such as RibXcar https://nypost.com/2025/03/31/lifestyle/women-are-spending-20k-to-shrink-their-waists-in-viral-craze-experts-call-ribxcar/ or orthognathic two jaw surgery https://www.mahoganyoralsurgery.com/double-jaw-surgery/#:~:text=Double%20jaw%20surgery%2C%20also%20known%20as%20bimaxillary,bite%2C%20or%20crossbite%20*%20Obstructive%20sleep%20apnea

Competence comes from dedicated practice in that procedure.

2. Mentorship and ongoing education are essential – Continual learning and peer-reviewed assessment improve outcomes and patient safety.

3. Outcome-based evaluation – Surgeons should be assessed by their results and complication management, not just by certificates or titles.

In short, PMFA guidance emphasizes that training, skill, and professionalism are far better predictors of safe outcomes than registration alone.

International Examples: Lessons for Patients

Joe Niamtu a friend and surgical mentor of mine faced disputes with the American Board of Plastic Surgery but went on to become a world-leading facelift surgeon.

Joe Niamtu on LoveThatFace https://www.lovethatface.com/2008/09/14/only-use-a-board-certified-plastic-surgeon/ discusses how patients should focus on surgeon experience, outcomes, and procedural expertise.



https://www.styleweekly.com/a-battle-between-competing-surgical-fields-spills-into-the-courts-and-patients-are-caught-in-the-middle/

Niamtu had to fight for his right to be allowed to perform Facial Plastic Surgery including facelifts and eyelid surgeries in a court battle way back in the 1980. He won and as they say the rest is "history"!

Patrick Tansley FRCS Plast, a British trained plastic surgeon, faced systemic barriers and was refused entry to the Plastic Surgery specialist register in Australia despite being highly qualified.

Banned surgeon considers legal action | The Advertiser

Cosmetic Surgery Regulation in Australia: Who Is to Be Protected—Surgeons or Patients? - Patrick Tansley, Daniel Fleming, Tim Brown, 2022

Mr Patrick Tansley Supreme Court Libel Action Melbourne -

In the United States, the Skim Milk article highlights conflicts between facial plastic surgeons and traditional plastic surgeons, demonstrating how professional politics can distort public perception.

Battle Over Beauty : In Changing Face of a Turf War, Cosmetic Surgeons Gain Ground - Los Angeles Times

The Georgia Society of Plastic Surgery published an article called “Things Are Never What They Seem, Skim Milk Masquerades as Cream.” This article called plastic surgeons “cream” and facial plastic surgeons and cosmetic surgeons “skim milk.” A lawsuit for slander and libel was filed by the Facial Academy and the Cosmetic Association. E. Gaylon McCullough, MD, past president of the American Academy of Cosmetic Surgery and secretary of the Facial Academy of Plastic Surgery, testified at the trial. The jury returned a guilty verdict against the plastic surgeons and awarded the largest judgment in history against medical organizations. The plastic surgeons were told to pay $1.5 million in punitive damages.

[Skim Milk article]

https://www.lovethatface.com/files/2013/04/Should-Cosmetic-Surgery-be-Limited-to-Certain-Specialties1.pdf

How Evil Narratives Can Mislead Patients

Unscrupulous colleagues can manipulate patient perception in subtle ways:

* Suggest that complications automatically indicate malpractice 

* Emphasize registration over competence to cast doubt on the surgeon (cases of Darryl Hodgkinson & Dr Patrick Tansley)

* Encourage unnecessary litigation to protect personal or financial interests 

Patients must recognize: that not every complication is negligence, and specialty registration status alone does not define competence. Hitler managed to convince many a folk by brainwashing in his Neo-Nazi heyday, and yet no one stopped to think for themselves.

Excerpt from Article "Don't make Your patient a Victim - When Doctors Criticize Other Doctors"

When Doctors Criticize Other Doctors

“Doctors will throw each other under the bus,” said Susan H. McDaniel, M.D., lead author of the study from the University of Rochester Medical Center. “I don’t think they even realize the extent to which they do that or how it can affect patients.” 

Provider jousting comes in many forms. When one physician criticizes another, both may be at increased risk for litigation. When a patient hears criticism, they may feel the care they received was inappropriate. The words they hear may lead them to seek legal counsel regarding litigation. A glance away, a look of incredulity or an offhand comment may also be enough to trigger the feeling that care was inadequate even if it wasn't.


How Good Surgeons Handle Complications

The hallmark of excellence in surgery is how complications are handled:

Transparency – Discuss risks and realistic outcomes openly.

Reflection– Analyze what occurred and refine techniques.

Empathy – Treat patients with understanding & respect, not blame.

Henry Marsh’s philosophy reminds us: complications are inevitable, but they are opportunities for improvement, learning, and better patient care.

Even when every accepted precaution is taken, the human body can heal unpredictably, which is why surgery always includes careful follow-up and candid discussion of possible outcomes.

Only 2 types of doctors never have surgical complications: those who don’t operate and those who aren’t truthful.











When considering cosmetic or reconstructive surgery:

1. Research qualifications and training carefully – Look beyond titles.

2. Evaluate procedural experience – Ask how many of the specific procedure the surgeon has performed.

3. Ask about complication management – Good surgeons will discuss risks openly.

4. Be aware of professional politics – Recognize when criticism may reflect turf wars rather than incompetence. And a medical professional who speaks ill of another not only violates the Hippocratic Oath but such behavior reflects on their own unprofessionalism and personal integrity in the "noble profession". 

Henry Kawamoto MD world renowned Plastic & Craniofacial Surgeon, stated in his lecture at the Kawamoto workshop in Egypt that he will never respect any colleague who speaks ill of another colleague & as he says as professionals and decent human beings - first deal with the problem, refrain from bad-mouthing any colleague & realize that we were not there during the procedure and hence not in a position to judge. If we do judge, be a professional and judge quietly, heal adequately and be a good doctor. 

5. Consult multiple sources – Use PMFA, Australian College of Cosmetic Surgery, and reputable articles to verify information which is non-biased.

EPILOGUE

A scar may widen unexpectedly. Swelling may persist longer than anticipated. A wound may heal unevenly. A small area of tissue may not settle exactly as planned. Occasionally, revision surgery becomes necessary—not because the original operation was careless, but because biology does not always follow textbook expectations.

This is true across all fields of surgery, including plastic and aesthetic surgery. Even in internationally respected centres, surgeons with extensive experience and excellent outcomes still encounter complications. What matters most is not whether a complication ever occurs, but **how it is anticipated, explained, recognised early, and managed responsibly.**

For this reason, responsible surgeons discuss risks before surgery, not after problems appear. Every operation carries known possibilities such as bleeding, infection, asymmetry, delayed healing, scar variation, or the need for further refinement. These are not hidden possibilities; they are part of the reality of operating on living tissue.

Patients often ask whether perfect results can be guaranteed. The honest answer is no surgeon can ethically promise perfection. Surgery improves, reshapes, reconstructs, and refines—but it always takes place within the limits of human anatomy, tissue response, circulation, scarring tendency, and healing biology.

This does not reduce the importance of skill. On the contrary, training and judgment matter enormously. Surgical experience helps reduce avoidable risk, improve decision-making, and guide safe responses when healing does not proceed exactly as expected. But even the most experienced surgeon cannot fully control every biological variable after an operation is complete.

The true measure of surgical professionalism is therefore not the unrealistic absence of all complications, but careful patient selection, thoughtful planning, technical discipline, close follow-up, and honest communication throughout recovery.


REFERENCES

* [Sydney Morning Herald – Australian surgeons accused of cartel behavior] 

https://www.smh.com.au/healthcare/australian-surgeons-accused-of-cartel-behaviour-to-control-fees-20160922-grm5rh.html

* [ACCSM PDF – Qualifications in Cosmetic Surgery]https://www.accsm.org.au/download/?id=media&doc=189

* [Skim Milk – Facial plastic surgeons vs plastic surgeons] https://www.lovethatface.com/files/2013/04/Should-Cosmetic-Surgery-be-Limited-to-Certain-Specialties1.pdf

* [PMFA News – Specialist registration vs competence] https://www.thepmfajournal.com/features/post/plastic-surgery-and-aesthetic-medicine-specialties-and-specialists

IN RESPONSE TO: Plastic surgery and aesthetic medicine - specialties and specialists | The PMFA Journal

* [Style Weekly – Surgical turf wars in court https://www.styleweekly.com/a-battle-between-competing-surgical-fields-spills-into-the-courts-and-patients-are-caught-in-the-middle/

* [LoveThatFace – Board certification vs experience] https://www.lovethatface.com/2008/09/14/only-use-a-board-certified-plastic-surgeon/

* [Joe Niamtu – world leader in facelift surgery]https://www.lovethatface.com/

* [Darryl Hodgkinson – Letter and attachments PDF

Appendix 15 - Letter from Dr Darryl Hodgkinson and attachments.pdf



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