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Medial Epicanthoplasty: Key Technique for Patients with Monolid



Double eyelid surgery stands out as the most frequently undertaken cosmetic surgical procedure across Asia. The distinctiveness of Asian eyelids lies in the presence of the epicanthal fold alongside a single eyelid, with its prevalence ranging from 50% to 80%. Unlike Caucasians, where the caruncle and plica semilunaris are observable on the rounded medial canthal angle, the epicanthal fold in Asian eyelids conceals the caruncle and lacrimal lake in 70% of cases. This characteristic not only widens the perceived distance between the eyes but also affects the appearance of the nasal upper lid contour, overall palpebral fissure height, and horizontal length.


The optimal intercanthal distance, averaging around 35 mm, is crucial for aesthetic balance and is interconnected with eye size and facial width. Achieving an aesthetically pleasing outcome typically involves exposing 80 to 90% of the caruncle.


The epicanthal fold is not merely a superficial skin fold; it encompasses the preseptal part of the orbicularis oculi muscle and excess fibrous tissue around the medial canthus. Factors contributing to the formation of the epicanthal fold include hypertrophy of subcutaneous fat, dislocation of the orbicularis oculi muscle, alterations in muscle tension, and underdevelopment of the nasal root. Recent studies indicate that the medial part of the orbicularis oculi muscle undergoes narrowing and condensation during medial eye movement after eyelid formation. This causes the pretarsal part to become superficial to the preseptal part, ultimately constituting the epicanthal fold.


This blog will focus on effectively addressing patients with monolid eyes through the technique of Medial Epicanthoplasty.


Cosmetic medial epicanthoplasty is a surgical procedure designed to address and release the epicanthal fold, typically performed in conjunction with double eyelid surgery. This combination addresses two critical aspects. Firstly, the procedure lengthens and transforms the medial corner of the palpebral fissure, where the scleral triangle, the exposed sclera on either side of the cornea within the eyelid fissure, plays a significant role. Normally, the lateral triangle is larger and more defined than the nasal triangle, particularly in individuals with a medial epicanthal fold, characterized by a smaller nasal triangle. Medial epicanthoplasty aims to reveal a more nasal scleral triangle while simultaneously reducing the interepicanthal distance without affecting the intercanthal distance. This adjustment creates a harmonious balance between the nasal and lateral scleral triangles by uncovering the concealed caruncle.



Secondly, the shape of the eyelid crease is closely tied to the configuration of the epicanthal folds. Eyelid creases can be categorized as nasally tapered, parallel, or semilunar, with Asians predominantly exhibiting nasally tapered or parallel types.



The relationship between the crease line and the epicanthal fold determines whether it is an onfold, outfold, or infold crease. Surgeons typically opt for an infold crease in patients with an epicanthal fold, aiming to avoid the aesthetically displeasing and often invisible medial one-half of the crease. Without medial epicanthoplasty, creating an outfold crease may result in an unnatural appearance, with two lines at the medial canthus.


The shape of the lacrimal caruncle is another critical consideration, varying among triangular, round, or hook-shaped types. In Asian patients, the triangular caruncle is the most common. The amount of epicanthal fold release is determined based on the overall size of the eyes, with caution exercised in hook-shaped caruncles to prevent an aggressive appearance caused by excessive elimination of the downward-running epicanthal fold along the outer curvature.


Surgeons must conduct a comprehensive evaluation of patients, considering factors such as the shape and degree of the epicanthal fold, skin redundancy, extent of skin hooding, and soft tissue tension. Additionally, bilateral epicanthal folds in the same patient may differ in size and shape, emphasizing the need for precise and symmetrical epicanthal fold release. Notably, exposing 80% to 90% of the caruncle in Asians is deemed more natural than exposing the entire epicanthus, contributing to a balanced and aesthetically pleasing outcome.


Different Medial Epicanthoplasty Techniques

In recent years, the field of medial epicanthoplasty has seen a surge in the development and modification of surgical techniques. A variety of approaches, including the Y-V epicanthoplasty, W epicanthoplasty, Z epicanthoplasty, and redraping epicanthoplasty, along with their numerous adaptations, have emerged. Each technique addresses specific aspects of the epicanthal fold, emphasizing the need for tailored approaches based on the severity of the condition and the individual patient's characteristics.


Among the diverse techniques, Z epicanthoplasty has gained prominence, especially for mild-to-moderate epicanthal folds. Conversely, the W epicanthoplasty, also known as the Mustard method, has demonstrated effectiveness in treating more severe epicanthal folds. Redraping epicanthoplasty, characterized by its versatility, is performed irrespective of the degree of the epicanthal fold and minimizes scarring.


The Uchida Method

The refined Uchida Method represents a innovative approach to medial epicanthoplasty, harnessing the power of W-plasty for the effective removal of muscles and fibrous tissues within the epicanthal fold. While this technique has demonstrated considerable efficacy in correcting the epicanthal fold, it is essential to note that it may potentially result in scarring.


In the execution of the modified Uchida Method, precision is paramount. Five strategic points are carefully placed in proximity to the epicanthal fold, forming the basis for the creation of a W-shaped incision. Each point serves a specific purpose in reshaping the targeted area. Point A, for instance, marks the surface projection of the most medial point of the lacrimal lake, providing a crucial reference for the procedure. Points B and C are meticulously positioned 3 mm above and below point A, respectively. Points D and E denote the upper and lower ends of the epicanthal fold, defining the extent of the surgical intervention. Finally, point F is strategically placed adjacent to the medial end of the lacrimal lake.


The subsequent step involves the incision of lines connecting these points, skillfully performed using a no. 11 blade. A deliberate subcutaneous dissection is then executed, allowing for precision and control throughout the procedure. The careful execution of this phase sets the stage for the creation of a small triangular flap by connecting points FABD and FACE. Points F and A are then skillfully sutured, and two smaller triangular flaps are thoughtfully trimmed and secured in place.


While the modified Uchida Method boasts efficiency in addressing the epicanthal fold, the potential for scarring necessitates a nuanced approach. Surgeons implementing this technique must balance the need for effective correction with meticulous postoperative care to minimize any visible scarring. The method's reliance on W-plasty, with its tailored incisions and strategic flap creation, contributes to its effectiveness in achieving the desired cosmetic outcome. As with any surgical procedure, the choice of technique should be personalized based on the unique characteristics of the patient and the severity of their epicanthal fold.


Z epicanthoplasty

The realm of medial epicanthoplasty encompasses diverse surgical techniques, and among them, the modified Z epicanthoplasty stands out as one of the most widely recognized approaches, gaining prominence since its initial description by Park. Over time, various adaptations have emerged, and two notable methods within this category are Park's Z epicanthoplasty and root Z epicanthoplasty.



Park's Z epicanthoplasty involves a meticulous sequence of steps. Point A serves as the surface projection of the most medial point of the lacrimal lake, setting a pivotal reference for the procedure. Point B is identified as the lower end of the epicanthal fold, while point C is strategically positioned, maintaining a distance from point A equivalent to that between points A and B. Point D finds its place adjacent to the medial end of the lacrimal lake, and point E designates the upper end of the epicanthal fold. The incision is executed following the pre-designed line in the order of DB-A-C-E. This incision outlines a triangular area connecting points A, C, and E, which is then meticulously removed. Subsequent to this, a subcutaneous dissection is performed beneath the triangular flap connecting points A, B, and D. This flap is then transpositioned to the ACE position. A crucial step involves the smooth movement of point B of the triangular flap to point C without tension. Points B and D are sutured to points C and A, respectively, with careful attention to minimal tension to prevent a dog-ear effect. The excess skin is trimmed, and the incision lines are meticulously sutured.



Root Z epicanthoplasty, another modification, follows a distinct yet equally precise protocol. Point A, the surface projection of the most medial point of the lacrimal lake, anchors the procedure. Point B is identified as the central point of the epicanthal fold, and point C marks the lower end of the fold. Point D is strategically positioned adjacent to the medial end of the lacrimal lake. The incision is made following the designated line in the order of D-C-B-A. Subcutaneous dissection is performed around this incision line, and a skin flap connecting points ABC and BCD is transpositioned with minimal tension. Points D and C are sutured to points B and A, respectively, ensuring minimal tension to avoid a dog-ear. The excess skin is then meticulously trimmed, and the incision lines are sutured with precision.


These modified Z epicanthoplasty techniques showcase the sophistication and adaptability within the field, emphasizing the importance of precision, tension management, and tailored approaches to achieve optimal aesthetic outcomes while minimizing potential complications such as scarring or the formation of dog-ears.



Redraping epicanthoplasty

The redraping epicanthoplasty, pioneered by Oh et al., presents a distinctive and innovative surgical technique for addressing the epicanthal fold, offering a nuanced approach to achieve natural and aesthetically pleasing outcomes.


In the implementation of the redraping epicanthoplasty method, precision and artistry play key roles. Point A, the surface projection of the most medial point of the lacrimal lake, serves as a crucial reference for the procedure. Point B introduces an imaginative incision line connecting points A and C, where the epicanthal fold is traversed. Unlike rectilinear designs, this imaginary incision line takes on a slightly triangular or round form, with the vertex located at point B.


Point C is strategically positioned adjacent to the medial end of the lacrimal lake, marking a pivotal point for the procedure. Point D designates a subciliary incision, and the length of the line connecting points C and D is determined by the distance between points A and C. Following the meticulous design, an incision is made in the order of A-B-C-D, paving the way for a carefully planned subcutaneous dissection around the incision line.


During the dissection phase, special attention is given to the removal of the orbicularis oculi muscle situated under the epicanthal fold, contributing to the refined transformation of the targeted area. Subsequently, points A and C are sutured together without tension, preserving the natural contours of the region. To further ensure an optimal aesthetic result, excess skin is trimmed with minimal tension, mitigating the risk of a dog-ear effect.


In the final stages of the redraping epicanthoplasty, the incision lines are delicately sutured, emphasizing the importance of precision and finesse. This meticulous approach, from the initial design to the final suturing, underscores the surgeon's commitment to achieving both functional and cosmetic enhancements with minimal scarring and a natural postoperative appearance.


In summary, the redraping epicanthoplasty technique represents a refined and sophisticated method within the realm of medial epicanthoplasty, demonstrating the importance of thoughtful design, precise execution, and tissue management to create aesthetically pleasing outcomes while minimizing potential complications.



What Are The Common Complications?

1. Asymmetric folds represent a prevalent complication following Asian blepharoplasty, with reported incidences reaching as high as 35%. This asymmetry can manifest as variations in height or shape, and its origins are multifaceted. Factors contributing to asymmetry include variations in preoperative marking, differences in the width of excised skin, uneven tension during supratarsal fixation, failure to establish firm adhesion of the levator to the dermis, and discrepancies in the amount of fat excision. Additionally, late fading of the crease on one side compared to the other may contribute to asymmetry. Some practitioners advocate a cautious approach, recommending a waiting period of 6 to 9 months before considering any surgical revision to account for asymmetry resulting from prolonged postoperative edema.


2. Excessively high folds are observed in approximately 6 to 7% of patients undergoing Asian blepharoplasty. A fold is deemed too high if it surpasses the superior border of the tarsal plate, typically measuring 5 to 8 mm in Asian patients. Such high folds can impart an unnatural or startled appearance and may arise due to adhesions between the orbicularis and skin above the level of surgical fixation. Aggressive undermining or overresection of subcutaneous and orbital fat are also implicated in the development of excessively high folds, as well as aggressive resection of preaponeurotic fat pads, leading to a hollowed supratarsal sulcus and, occasionally, the formation of multiple skin folds.


3. Fading or disappearance of the lid fold occurs in 0 to 3% of cases, with a higher incidence associated with suture techniques, particularly when absorbable sutures are used. The primary cause is attributed to the failure to establish a permanent adhesion between the levator and muscle or dermis. In cases requiring reoperation, inadequately debulked tissue is often encountered.


4. Blepharoptosis, characterized by drooping of the eyelid, can occur as a complication if the levator is damaged or scarred, hindering its normal function. This may happen if the level of aponeurosis fixation to muscle or dermis is too high. Additionally, inadvertent separation of the levator from the tarsal plate during tissue excision has been reported as a cause of ptosis. Ectropion, the eversion of the lid margin, may result when the levator is attached too close to the ciliary margin or at a level exceeding normal skin tension. This can occur if the inferior incision is placed too low or if the inferior skin flap is sutured too high on the levator.


5. Bleeding complications, ranging from prolonged ecchymosis to massive hematoma, are potential outcomes following Asian blepharoplasty, with causes and rates of occurrence aligning with those observed in blepharoplasty procedures in other populations. Awareness of these complications underscores the importance of meticulous surgical technique, careful patient selection, and postoperative monitoring to ensure optimal results and minimize adverse effects.


Reference:

Medial Epicanthoplasty: What Works and What Does Not (2020)

Simple epicanthoplasty with minimal scar (2007)

Restoration of the medial epicanthal fold: reverse skin redraping method in patients unsatisfied with epicanthoplasty (2013)

Cosmetic Surgery in the Ethnic Population: Special Considerations and Procedures (2009)

 

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