Medial Epicanthoplasty with the Skin-Redraping Technique: Technical Refinements for Predictable Outcomes

Summary:

The epicanthus is a common feature of Asian eyes. A prominent medial epicanthal fold gives the impression of blunted affect. Medial epicanthoplasty for its removal is commonly requested by Asian patients. This may be performed as an isolated procedure or, more commonly, in combination with upper blepharoplasty. Many conventional medial epicanthoplasty techniques are based on skin flap transposition and excisions, usually variations of the V-Y, W, or Z-plasties. Although these have been variably successful at correcting the epicanthal fold, scarring in the medial canthal and lower eyelid regions is common. This is particularly problematic in Asian patients, who have greater tendencies for hypertrophic scarring and scar hypopigmentation or hyperpigmentation. Recently, the skin redraping method, designed with incisions limited within the margins of the medial canthus and precise and targeted disruption of the underlying fibromuscular tissues, has emerged as the preferred surgical technique for many surgeons in Asia because of its effectiveness and superior aesthetic outcomes. This technique delivers the most inconspicuous incisions and is advantageous because it is effective in eliminating epicanthal folds of various severities. Precise execution of this technique is difficult, given the complex 3-dimensional anatomy of the epicanthus. The authors present a detailed explanation of surgical concepts of the skin redraping epicanthoplasty and provide a step-by-step guide to performing this procedure in a safe and effective manner.

The epicanthus is a common feature of Asian eyes. A prominent medial epicanthal fold gives the impression of blunted affect, and the procedure for its removal (ie, medial epicanthoplasty) is commonly requested by Asian patients. This may be performed as an isolated procedure or, more commonly, in combination with upper blepharoplasty. Many conventional medial epicanthoplasty techniques are based on skin flap transposition and excisions, usually variations of the V-Y, W, or Z-plasties.^1–4 These have been variably successful at correcting the epicanthal fold, but scarring in the medial canthal and lower eyelid regions is common.^5–8 This is particularly problematic in Asian patients, who have greater tendencies for hypertrophic scarring and scar hypopigmentation or hyperpigmentation.⁹ Recently, the skin redraping method, designed with incisions limited within the margins of the medial canthus and precise and targeted disruption of the underlying fibromuscular tissues, has emerged as the preferred surgical technique for many surgeons because of its effectiveness and superior aesthetic outcomes.^6,10–12 This technique delivers the most inconspicuous incisions and is advantageous because it is effective in eliminating epicanthal folds of various severities. Precise execution of this technique is difficult, given the complex 3-dimensional anatomy of the epicanthus. We present a detailed explanation of surgical concepts of the skin redraping epicanthoplasty and provide a step-by-step guide to performing this procedure in a safe and effective manner.

The epicanthus is a dominant phenotype of the Asian eyelid, with reported incidences of 70% to 90%.^6,13–15 The anatomic understanding of the epicanthus is that this web is formed by skin redundancy and a fibromuscular core. (See Figure, Supplemental Digital Content 1, which shows the anatomy of the Asian medial epicanthal fold. The epicanthus is formed by the outer covering of redundant skin and a fibromuscular core consisting of the medial canthal fibrous band [MCFB] and superficial part of the preseptal orbicularis oculi that inserts into the MCFB. This fibromuscular core is the anatomic structure that is responsible for the tension across the epicanthus, creating a web tenting across the caruncle in Asian eyelids. To remove the epicanthus effectively, excision of the excess skin [skin redraping] and releasing the tension across the epicanthal fold by transecting the MCFB and orbicularis oculi fibers inserting into this structure are key requirements for effective, long-term correction of this anatomy. Illustration by Levent Efe, MD, CMI, http://links.lww.com/PRS/H428.)^15–20 The skin redraping technique^6,10–12 is rapidly becoming the preferred technique for many surgeons in Asia owing to its discrete incisions and effective long-term outcomes. The name “skin redraping” emphasizes the skin excision aspect of the procedure. However, equally important is elimination of the tension in the fibromuscular band that is located within the core of the epicanthal fold.¹¹ We present a step-by-step detailed demonstration of this procedure.

METHODS

Surgical Technique

Figure 1 illustrates the surgical markings. Point A is the desired location of the new medial canthus. This is the critical point, and, depending on the degree of exposure of the caruncle desired by the patient, point A may be placed more lateral or medial. Point B is the horizontal point from point A at the free edge of the epicanthal fold. Point C is the point just medial to the lacrimal lake. In general, the distance from point A to point C ranges from 4 to 6 mm. Point D is a point along the subciliary margin. Point E is marked along and joining the medial part of the supratarsal fold. (See Video [online], which demonstrates our surgical technique for the skin redraping medial epicanthoplasty.)

Fig. 1.

(Left) Markings for the skin redraping medial epicanthoplasty. Point A is the desired new medial canthus location. Point B is at the free edge of the epicanthal fold, and point C is a point about 1 mm medial to the lacrimal lake. Point A is the critical point and will determine the amount of exposure of the caruncle. In general, point A is located at the corresponding point of the cutaneous transposition of point C. It may be adjusted to cater to the patient’s specific requests. In patients wanting more natural results (eg, less exposure of the caruncle), it may be positioned more lateral (less skin excision), and in patients requesting greater caruncle exposure, it may be positioned more medially (more skin excision). Point D is along the subciliary margin. This may be adjusted to cater to the extent of skin redraping or excision required. In patients requiring more skin excision (to address greater skin excess), it may be adjusted more laterally. The length of this incision should be kept to the minimum length required. Point E is along and joining the medial part of the supratarsal fold. (Right) The planned incisions shown with the medial canthal area stretched out. Illustrations by Levent Efe, MD, CMI.

Video. This video demonstrates our surgical technique for the skin redraping medial epicanthoplasty.

Download video file ^{(53.6MB, mp4)}

The procedure is performed under the operating microscope or surgical loupe (2.0× to 4.0×). Local anesthesia is infiltrated and the skin is incised. (See Figure, Supplemental Digital Content 2, which shows the key steps in the skin redraping medial epicanthoplasty. [Above, left] The incision is made precisely. The incision from point A to point C is made deep with a no. 11 blade, cutting the underlying MCFB. The rest of the incisions from point C to point D and from point C to point E are made carefully with a no. 15 blade, just cutting the skin. [Above, center] The skin is carefully lifted off the orbicularis oculi [in the subcutaneous plane] sharply for a distance of 3 to 4 mm from the incisions from point C to point D and from point C to point E. Medially subcutaneous dissection stops at about point A. The extent of this subcutaneous dissection is indicated by blue. [Above, right] The dissection then transitions to an intramuscular [orbicularis oculi] plane. The extent of this dissection is indicated by green. [Below, left] The MCFB and fibers of the preseptal orbicularis oculi that insert into it are completely cut. [Below, center] The dotted lines indicate the skin excision, performed to remove the excess skin for the skin redraping. This is done by conservatively excising only the true skin excess. [Below, right] Point A is sutured to point C in a tension-free manner using a 7/0 Ethilon suture. This is the key suture in the closure. The rest of the incisions are closed in a meticulous manner using a single-layer closure. Illustrations by Levent Efe, MD, CMI, http://links.lww.com/PRS/H429.) The incision from point A to point C is made with an 11 blade in a precise stab and taken deep, cutting the underlying MCFB and the preseptal orbicularis that inserts into it.^19,20 The rest of the incisions (point C to point D and point C to point E) are made with a 15 blade, with these incisions cutting just the skin. The skin flaps are then sharply separated from the dense fibrous attachment to the underlying orbicularis oculi over the medial canthal area. Care is taken to avoid damage to the lacrimal canaliculus by staying just under the skin in the subciliary area for at least 3 to 4 mm from the incisions.⁶ As the dissection progresses from the incisions, the plane of dissection should be taken deeper into the intramuscular (orbicularis oculi) plane to raise a composite skin muscle flap to prevent skin flap devascularization and subsequent scarring and contracture. The extent of undermining is determined by the epicanthal fold to be corrected with more undermining necessary for more prominent folds. After completion of the skin flap mobilization, a myotomy of the MCFB and the preseptal orbicularis oculi inserting into the band is made with sharp iridectomy scissors to completely divide the MCFB. This maneuver eliminates the tension tenting up the epicanthus. With this cut and elimination of the tension across the epicanthus, point A comes to be approximated with point C. The excess skin superior to point C is excised as a triangle, and carefully redraped and sutured as part of the medial supratarsal crease. Inferior to this, the excess skin is also conservatively excised in 2 triangles, as shown in Supplemental Digtial Content 2 (below, center). Point A is then sutured to point C with Ethilon 7/0 suture in a tension-free manner. The remaining incision line is closed carefully along the medial ciliary margins. The sutures are removed 6 days after surgery.

After surgery, the patient is closely followed up. Scar massaging with silicone gel creams is initiated from 2 weeks after the surgery. If early hypertrophic scars are observed to be developing, intralesional injections of a mixture of triamcinolone and 5-fluorouracil is administered to soften the scars. Microbotulinum toxin (1 U each side) may also be a useful additional adjunct to reduce contractile tension of the underlying musculature.^21,22 In general, if required, the injections should be started 1 month after the surgery, and 1 or 2 treatments are generally sufficient to soften the scars.

Figure 2 and Supplemental Digital Content 3 show the long-term surgical outcomes of this technique. (See Figure, Supplemental Digital Content 3, which shows a 38-year-old woman with a previous incision upper blepharoplasty who presented with slight upper eyelid asymmetry [right]. She requested slightly more pretarsal show and a parallel outer-type upper eyelid crease. A revision incision upper blepharoplasty [hinge upper blepharoplasty] and a skin redraping medial epicanthoplasty were performed. In the incision design, point E was not connected to the medial end of the upper eyelid incision, and was positioned 1 mm below it. In the closure of the upper eyelid incision, care was taken to firmly fixate the dermis of the medial upper eyelid crease to the pretarsal tissue to secure the medial crease firmly. [Left] Three years after surgery, a crisp, symmetric, parallel upper eyelid crease is present. The epicanthal fold was effectively corrected and the scars are virtually invisible, http://links.lww.com/PRS/H430.)

Fig. 2.

A 35-year-old woman with previous incision upper blepharoplasty 10 years previously presented for revision upper blepharoplasty, medial epicanthoplasty, and lower blepharoplasty [left]. She requested wider palpebral apertures and parallel outer-type upper eyelid creases with correction of the epicanthal fold. She underwent upper blepharoplasty with levator advancement, skin redraping medial epicanthoplasty, and extended transconjunctival eye bag removal (Wong CH, Mendelson B. Extended transconjunctival lower eyelid blepharoplasty with release of the tear trough ligament and fat redistribution. Plast Reconstr Surg. 2017;140:273–282). In the incision design, point E was not connected to the medial end of the upper eyelid incision, and was positioned 1 mm below it. In the closure of the upper eyelid incision, care was taken to firmly fixate the dermis of the medial upper eyelid crease to the pretarsal tissue to secure the medial crease firmly. [Right] Three years after surgery. The epicanthoplasty incisions were virtually invisible and natural parallel upper eyelid creases were created.

DISCUSSION

Conventional medial epicanthoplasty techniques, such as the Mustarde 4-flap, V-W plasty (Uchida procedure), modified Park epicanthoplasty, and various Z-epicanthoplasties, rely on local transposition flaps and skin excisions to achieve the desired correction.^1–4,23 The skin redraping technique is conceptually different from these approaches in that the desired outcome is achieved with 2 equally important maneuvers: first, the complete and wide separation of the medial canthal skin flap from the underlying orbicularis oculi; and second, the complete disruption of the MCFB and preseptal orbicularis oculi to eliminate tension along the medial epicanthus to prevent recurrence of the banding.^19,20 In addition to the discrete placement of the incisions, a further advantage of this technique is that it may be used for epicanthal folds of various severity. The extent of the correction may be precisely controlled by tailoring the extent of skin excision and by the aggressiveness with the myotomy and muscle division, with more skin undermining and extensive myotomy needed for more severe epicanthal fold.

The critical role of release of the fibromuscular condensations underlying the epicanthal skin has been stressed in the literature.^{15,18–20,24–26} The nomenclature is inconsistent, and this structure has been called various names. Park and Hwang¹⁵ refer to a “fibromuscular core”; Lee et al.²⁵ describe it as the “superficial insertion of the medical canthal ligament”; and, more recently, Wang et al.^19,20 used the term “medial canthus fibrous band.” It is generally accepted that complete transection of the MCFB and myotomy of the preseptal orbicularis oculi is important in effective elimination of the medial epicanthal fold. This then allows tension-free redraping of the epicanthal skin over the myotomized orbicularis oculi with excision of the skin excess.

Medial epicanthoplasty is a procedure designed to remove the medial epicanthal web to create a more parallel upper eyelid crease with more exposure of the caruncle. An “overcorrected” epicanthoplasty can result in overexposure of the caruncle and an aggressive appearance with an overly narrowed intercanthal distance. Asian eyes commonly have one-third of the caruncle covered.⁶ This is a good reference point to begin the discussion on the patient’s preferences. In patients who desire a more natural correction of the epicanthal folds, preserving at least some of coverage of the medial third of the caruncle is prudent. In patients desiring a more opened look and a parallel crease, greater exposure of the caruncle is indicated. This degree of exposure of the caruncle is adjusted in the design of the procedure. In patients who want more exposure, point A is placed more medially, the extent of undermining is greater, and the division of the MCFB and orbicularis oculi is more aggressive.

When performing this procedure with a combined upper blepharoplasty, the patient’s desire for a tapered or parallel upper eyelid crease is considered. In the design for a slightly tapered or “inner” crease, point E is continuous with the upper eyelid incision. In a parallel or “outer” type upper eyelid crease design, point E should not connect with the upper eyelid crease incision. Instead, point E should be positioned 1 to 2 mm below the medial extent of the upper eyelid crease incision followed by slightly more aggressive excision of the upper triangle (point A to point C to point E). The medial upper eyelid crease should also have its dermis securely fixed to the medial pretarsal tissues. This will predictably create the outer fold medially (Fig. 2) (see Figure, Supplemental Digital Content 3, http://links.lww.com/PRS/H430).

The authors have used this technique since 2017 and performed this procedure successfully in 116 patients, with high patient satisfaction and low revision rates. One patient (0.8%) required revision medial epicanthoplasty for a residual unilateral epicanthal web. The revision procedure can be repeated with the same operative technique. The scars were all inconspicuous and satisfactory, owing to meticulous technique and attentive postsurgical wound care. No patient required or requested scar revision.

DISCLOSURE

The authors have no financial interest in any of the products, devices, or drugs mentioned in this article, and have conflicts of interest to disclose.

PATIENT CONSENT

Patients provided written informed consent for the use of their images.