Reoperation of epicanthal reconstruction using a modified reverse skin-redraping method

Abstract

With the increasing adoption of medial epicanthoplasty or reconstruction procedures, the number of patients undergoing reoperations is also increasing. However, the surgical techniques useful for reoperations and the potential difficulties during reoperations have not been adequately elucidated. We aimed to describe the use of our modified reverse skin-redraping technique to improve cosmetic outcomes in patients who had previously undergone epicanthal reconstruction. From January 2014 to January 2021, we performed reoperations using our modified reverse skin-redraping technique in patients who had previously undergone epicanthal reconstruction. The main reason for the reoperations was cosmesis. The patients’ ages ranged from 21 to 46 years (average, 28.7 years), and the follow-up periods ranged from 6 to 12 months. A total of 389 patients (311 females and 78 males) underwent reoperations, of which 324 patients (83%) underwent 1 reconstructive surgery and 65 (17%) underwent reconstructive surgeries more than twice after primary epicanthoplasty. The postoperative intercanthal distances could be increased or decreased depending on the preoperative design. After reoperation, 22 patients (5.6%) required additional reoperation. Reoperation of epicanthoplasty is technically challenging. The scarred round shape of the medial epicanthus during the reoperation poses difficulties, and the optimal technique to be used remains unknown. We believe that selection of an individualized restoration method that suits the purpose of surgery is important for patients who require reoperations. In this respect, we suggest that our modified reverse skin-redraping method is a suitable option for improving esthetic outcomes.

1. Introduction

The medial epicanthal fold is a unique feature of Asian eyelids, and its prevalence has been reported to range from 50% to 90%.^[1] This feature results from the preseptal part of the orbicularis oculi muscle and excessive fibrous tissue around the medial canthus,^[2] and may limit the application of blepharoplasty, with the amount of epicanthal release being related to the overall size of the eyes.^[3] Medial epicanthoplasty is frequently performed separately or simultaneously with double-eyelid surgery. Various medial epicanthoplasty techniques that are based on the application of a local flap with rearrangement of adjacent skin have been reported in the literature, including Y-V epicanthoplasty,^[4] W epicanthoplasty,^[5] Z epicanthoplasty, skin-redraping method,^[6] and various modifications of these techniques. With the increasing usage of epicanthoplasty procedures such as double-fold surgery, the proportion of patients expected to undergo reoperation or 3 or more rounds of surgery is also increasing. However, the appropriate techniques for management of unsuccessful results with a small area of skin has not been clarified in the literature, and the selection of re-operation methods in these patients has also not been adequately reported.

We had previously described successful reconstruction of a complicated medial epicanthal fold. Although no single technique can allow complete recovery of the complicated epicanthal fold, we advocated a reverse skin-redraping method for reconstruction in cases with unsatisfactory initial surgical results, and to achieve superior results with an easily applicable technique for an overcorrected epicanthus with an acceptable scar. Using this approach, we were able to restore the naturally pointed medial canthus in various cases. However, we subsequently encountered patients who desired greater esthetic correction after medial epicanthal reconstruction, including closure of the unsatisfactorily widened medial epicanthus after primary medial epicanthoplasty, and began to consider an appropriate surgical technique for these patients. Our modified skin-redraping method could be used to enhance cosmetic outcomes to yield a pointed and curved medial epicanthus. In the present study, we aimed to describe reoperation with our modified technique to improve cosmetic outcomes in patients who had previously undergone epicanthal reconstruction (correction of an unsatisfactory result with primary epicanthoplasty).

2. Materials and Methods

The study was performed in accordance with the tenets of the Declaration of Helsinki and approved by Public institutional ethics committee of the Ministry of Health and Welfare (2021-1784-002). Informed consent was obtained from the patient for publication of this case report details. From January 2014 to January 2021, we performed our modified reverse skin-redraping technique for reoperation in patients who had previously undergone epicanthal reconstruction. We defined “epicanthal reconstruction” as reoperation (closing or narrowing) necessitated by unsatisfactory primary medial epicanthoplasty outcomes, including the presence of scars, a distorted medial canthus shape, asymmetry, changes in the patient’s appearance with over-exposure of the caruncle, and functional complaints such as dry eyes or incomplete eye closure. Despite undergoing successful epicanthal reconstruction, some patients may wish to improve the esthetic outcomes such as scars and changes in the interepicanthal distance or the angularity of the medial epicanthus. We defined these procedures as “reoperations of the reconstructed medial epicanthus.” Thus, in contrast to the indications for the primary epicanthal reconstruction, the main reason for the subsequent reoperation was improved cosmesis. The patient ages ranged from 21 to 46 years (average, 28.7 years), and the follow-up period ranged from 6 to 12 months. All operations were performed by single surgeon (C.Y.J) at least 6 months after the previous reconstruction. We analyzed “interepicanthal distance” which refers to the distance between the innermost points of medial epicanthus at preoperatively and 6 months postoperatively, to confirm the effectiveness of the procedure at the long-term follow-up.

3. Surgical technique

The basic principles of the surgical technique were similar to those described in our previous article on reconstruction of a complicated medial epicanthus.^[6,7] Our previous method was focused on “closure of the over-exposed lacrimal lake and scar removal” whereas the current one allowed free adjustment of the interepicanthal distance, making both closing and opening of the epicanthus possible, because patients who had already undergone epicanthal reconstruction with an unsatisfactory shape, visible scar, and “increased interepicanthal distance” required this procedure to resolve these problems simultaneously. The amount of reoperation was adjustable, reducing the need for overcorrection as before. Similar to our previous article, the design was started by marking points A, B, and C. “Point A” was the innermost point of the medial epicanthus 1 to 2 mm from the lacrimal lake. “Point B” was marked upward of Point A, with the line AB serving as a baseline, and an elective line was drawn along the subciliary line. Finally, “Point C” was marked 5 to 12 mm away from the lacrimal punctum, along the previous subciliary line (the distance was adjusted according to the amount of closure) (Fig. 1). After marking the baseline connecting A, B, and C, local anesthesia was injected. An incision was made on the drawn line, and wide submuscular dissection was performed to the lower lid direction when sufficient tissue is obtained (Fig. 2). This was a key step for obtaining a naturally pointed and curved medial epicanthus that could reduce the skin tension and allow sufficient movement of the skin-muscle flap. After making an incision, the newly shifted point A – “point A′” was marked by pulling the skin to a medial direction with the thumb (Fig. 3). More specifically, the newly formed medial inner point of the epicanthus (Point B′) was a point sutured together with the lower skin flap, orbicularis oculi muscle, and medial canthal tendon and was located on a line connecting Point B and Point A. Point B′ could be adjusted to modify the amount of correction, since the amount of correction increased as point B’ moved more medially. A temporary suture was performed from Point B to Point A, and the previous scar was located between Point A′ and Point B. Scar revision in this area (red circle) was performed to obtain a naturally pointed medial epicanthus without scar contracture (Fig. 4). A temporary suture connecting a part of Point A and Point B was removed, and this area was used for mini-epicanthoplasty (Fig. 5). Redraping of the skin between Point B and Point A toward the medial direction and closure allowed a change in the skin vector, eventually yielding esthetic epicanthoplasty outcomes. On releasing the thumb, A′B became the front side of the newly formed epicanthal fold, and the folding point around B became the epicanthal fold. A part of the previous scar could be located on the newly formed epicanthal fold (Fig. 6). All stitches were removed on postoperative days 4 to 7, and the patients were followed up for at least 6 months. During this period, usage of scar ointment and taping were encouraged.

Figure 1.

Preoperative design: Point A is marked at the innermost point of the medial epicanthus, 1–2 mm from the lacrimal lake. Point B is marked upward to Point A. The AB line becomes a baseline, and “Point C” is marked 5–12 mm away from the lacrimal punctum, along the subciliary line.

Figure 2.

Submuscular dissection: Red line shows the extent of dissection. Sufficient dissection can ensure a naturally pointed medial epicanthus by reducing skin tension with sufficient movement of the skin-muscle flap.

Figure 3.

Medial shift of the incision line: After making an incision, point A shifted to “point A′ ,” which was marked by pulling the skin to a medial direction with the thumb.

Figure 4.

Temoporary suture and medial epicanthoplasty: Temporary suture is performed from Point B to Point A. Then, the previous scar is located between Point A′ and Point B. Scar revision in this area (red circle) should be performed to obtain a naturally pointed medial epicanthus without scar contracture.

Figure 5.

Temporary suture connecting a part of point A and Point B is removed, and this area is used for mini-epicanthoplasty (red circle: area of scar revision).

Figure 6.

On releasing the thumb, A’B becomes the front side of the newly formed epicanthal fold, and the folding point around B becomes the epicanthal fold.

4. Results

At total of 389 reoperations (311 and 78 in female and male patients, respectively) after reconstructive epicanthoplasty were performed during the 7-year period. This method could be applied regardless of the severity of the epicanthal fold. While 324 patients (83%) underwent 1 reconstructive surgery, 65 (17%) had undergone more than 2 reconstructive surgeries before our operation. Postoperatively, the intercanthal distances increased or decreased depending on the preoperative design. Interepicanthal distance increased in 256 patients (66%; mean change in distance, 1.32 mm), showed no change in 89 patients (23%; adjustment of the shape of the epicanthus), and decreased in 44 patients (11%; mean change in distance: 0.74 mm). Reoperation of the reconstructed epicanthus with our modified reverse skin-redraping method showed successful results in most cases. Mild redness of the surgical scar was noted in the first 1 to 2 months, but it faded by 6 months. Except for a scar ointment, no other therapies such as steroid injections were routinely used for hypertrophic scars. The postoperative complications included overcorrection, undercorrection, mild inflammation, asymmetry, shape change during the follow-up period, and scarring. Over- or undercorrection was defined as a correction more than or less than 1 mm, respectively, in comparison with the targeted interepicanthal distance. On the basis of these indications, 37 cases showed overcorrection (9.5%), 11 showed undercorrection (2.8%), 24 showed inflammation (6.2%), 33 showed asymmetry (8.5%), 32 showed scarring (8.2%), 5 showed temporary lagophthalmos (1.3%) in the medial canthus, and 35 showed shape changes (9%). Most of these cases showed improvements over several months, preventing the need for further correction. However, 3 cases required filler injections for mild scar depression, and 22 patients (5.6%) required reoperations (Table 1).

Table 1.

Complications and cases requiring reoperations.

Complications	Number (%)	Reoperation number (reoperation rate: % of each complication)
Overcorrection	37 (9.5%)	10 (10/37: 27.0%)
Undercorrection	11 (2.8%)	2 (2/11: 18.2%)
Inflammation	24 (6.2%)	0 (0%)
Asymmetry	33 (8.5%)	5 (5/33: 15.2%)
Shape change during follow-up	35 (9%)	4 (4/35: 11.4%)
Scar	32 (8.2%)	5 (5/32: 15.6%)
Temporary lagophthalmos (caruncle exposure)	5 (1.3%)	0 (0%)

4.1. Case 1 (0 mm: no change in the interepicanthal distance)

A 24-years-old woman who had undergone an epicanthal reconstruction 12 months previously visited our clinic. She had initially undergone medial epicanthoplasty and showed overexposure of a caruncle and a blunt canthal shape after the procedure. She subsequently underwent epicanthal reconstruction using a VY advancement flap at another hospital. Although the overcorrection was resolved, the medial epicanthus became blunt and tension of the epicanthal fold (tenting of the skin) was observed (Fig. 7). We performed a reoperation using the modified skin-redraping method with mini-epicanthoplasty. The interepicanthal distance was not changed, but a naturally pointed medial epicanthal shape was obtained.

Figure 7.

Case 1: (no change in the interepicanthal distance) images obtained preoperatively (left) and 6 months postoperatively (right).

4.2. Case 2 (reduction in the interepicanthal distance: –0.7/–0.5)

A 31-years-old woman who had previously undergone epicanthal reconstruction with a VY advancement flap visited our clinic. Although the functional complications (overexposure, widened interepicanthal distance, and blunt epicanthal shape) improved after the previous epicanthal reconstruction, the blunted medial epicanthus and scar adhesion persisted. She wanted to improve her epicanthal shape. We performed the reverse skin-redraping method with mini-epicanthoplasty, in which the inner point of the medial epicanthus was moved to a lower medial portion and the scar was released with sufficient dissection. As a result, the interepicanthal distance decreased by 0.7 mm and 0.5 mm, and the blepharoplasty line was naturally changed to infold without any manipulation (Fig. 8).

Figure 8.

Case 2: (–0.7/–0.5: Decrease in the interepicanthal distance) images obtained preoperatively (left) and 3 months postoperatively. The blepharoplasty line was naturally changed to infold without any manipulation.

4.3. Case 3 (increase in the interepicanthal distance: +0.8/+0.7)

A 29-years-old woman who showed severe scar adhesion and distortion of the medial epicanthal shape visited our clinic after a previous medial epicanthal reconstruction. Although severe functional problems had been corrected by the previous epicanthal reconstruction procedure, she desired to improve the scar and medial epicanthal shape. We performed our method with wide dissection and were able to release the scar without any scar excision. The interepicanthal distance was inferolaterally rearranged from 39.0 mm to 40.5 mm. At the 1-year follow-up examination, the patient expressed satisfaction with her epicanthal shape (Fig. 9).

Figure 9.

Case 3: (+0.8/+0.7: Increase in the interepicanthal distance) images obtained preoperatively (left) and 1 year postoperatively (right).

5. Discussion

Medial epicanthoplasty, especially in combination with upper blepharoplasty, has become a popular treatment option for epicanthal fold removal among Asian patients over the past decade. Despite concerns over the loss of ethnic identity and the noticeable scar, these operations are being performed indiscriminately based on Western standards in many cases. With the increasing frequency of epicanthal reconstruction or reoperations, there has also been an increase in the incidence of various unwanted complications. The known epicanthoplasty restoration techniques primarily focus on reducing the interepicanthal distance by a simple reversal based on the principle of a local flap. Although restorations with such methods can improve functional problems, they can also lead to various esthetic problems, prompting patients to seek additional epicanthal reoperation for improved cosmesis. However, the existing literature on the available surgical techniques for such patients is quite limited, and operators face difficulties in deciding the extent of surgery and the operative method for such patients. To our knowledge, the present article is the first describing a series of reoperations after medial epicanthus reconstruction along with detailed descriptions of the surgical technique. Despite showing improvements in functional problems, many patients opt for reoperations to address esthetic issues after medial epicanthal reconstruction, and an optimal reconstruction technique for such patients has long been a topic of importance for us. Such a procedure would require a completely different operative perspective from reconstruction procedures that focus on solving functional problems. In most cases of reoperation, aesthetic correction is not recommended since the functional problems have already been resolved and the operation is only necessary for shape adjustment or scar revision.

The existing literature contains only a few reports describing the use of reverse Z plasty,^[8] VY advancement and turnover flap,^[9] and our skin-redraping method.^[7] Currently, the VY advancement technique method,^[10] which was reported by Shin et al, is possibly the most frequently used technique for reoperation. This method is designed as a reversal of the conventional YV method and offers the advantage of being technically easy and reproducible. It can decrease skin-flap tension and facilitates the transition of the medial epicanthus. However, this method can only increase the interepicanthal distance (unlike our method, which can increase or reduce the distance depending on the case requirements) and may be associated with greater flap contracture since it requires reuse of previously reconstructed scar tissue. Because of the absence of a repositioning procedure between the orbicularis oculi muscle and medial canthal tendon separated by the previous medial epicanthoplasty, this method is associated with a high recurrence rate, which results in a round and tenting shape of the medial epicanthus. Moreover, if additional shape adjustment is desired after medial epicanthal reconstruction using this method, then it may be difficult to use this method again. To overcome these limitations, a recent modification^[11] was reported that uses fat and orbitalis muscle graft to fill the small space created after transposition. In this method, an autologous fat graft is applied to the donor site that becomes depressed after transposition; the filling of the small space can result in wound dehiscence of fluid accumulation that would result scar stiffness. However, this method is also focused on epicanthal reconstruction, making it unsuitable for reoperations involving small and precise shape adjustments.

Our method is based on the skin-redraping technique, which has undergone several modifications since it was first reported in conventional medial epicanthal reconstruction. In this method, a pointed medial epicanthal shape can be created by performing mini-epicanthoplasty after partial closure, and the interepicanthal distance can be increased or reduced by various applications. In addition, the use of thin and elastic eyelid skin and muscles through sufficient dissection precludes the reuse of scar tissue, unlike other methods. The usage of tissues with excellent blood supply can also result in fewer recurrences due to less flap contracture. Changes in the eye shape through very small amounts of transposition are possible, while the area showing the surgical scar is smaller than that in the VY method, which involves a part of the scar being folded. Our method places the scar in an area that is not readily visible, and it can be viewed as an excellent method that is applicable in cases with difficult round shape of the medial epicanthus due to multiple previous operations. Another advantage is that even when the operative outcomes are unsatisfactory, the same method could be used to freely open or close and make epicanthal shape changes (the authors used the same method for reoperation in 9.5% of cases). However, a major limitation of this technique is the steep learning curve for accurate design, intraoperative positioning, and sufficient dissection in such a small area, because of which familiarization with the technique requires much time. The epicanthal area is composed of a very small amount of skin, and its shape or impression may change through very slight manipulation, and scars in this area often become problematic, especially among Asians. A scarred round-shaped medial epicanthus as a result of reoperations can be very difficult to manage, and the ideal technique for such cases remains unknown. We attempted to modify the techniques for epicanthoplasty, epicanthal reconstruction, and epicanthal reoperation after reconstruction to account for the different goals of each surgical procedure. We thought that selection of a restoration method that suits the purpose of surgery through an individualized technique for patients who require surgery is important. In this respect, we suggest that this method could be the best option for improving the esthetic outcomes of reoperation of a reconstructed medial epicanthus.

6. Conclusions

Reoperation after epicanthoplasty is technically challenging. Despite the increasing adoption of medial epicanthoplasty, the difficulties in resolving unsatisfactory outcomes can be considered as a characteristic of epicanthoplasty. Therefore, medial epicanthoplasty should be performed carefully with consideration for the indications, and we hope that the findings of this study will facilitate the development of guidelines regarding the choice of reoperation techniques after epicanthoplasty.

Author contributions

Conceptualization: Yoon Jae Chung.

Data curation: Yoon Jae Chung.

Investigation: Yoon Jae Chung.

Methodology: Yoon Jae Chung.

Supervision: Bo Young Park.

Writing – original draft: Bo Young Park.

Writing – review & editing: Bo Young Park.