EBM Level

Two primary distinctive anatomic features of Asian eyelids are the absence of superior palpebral folds and the presence of medial epicanthal folds [1]. Double eyelidplasty and epicanthoplasty have become the most common cosmetic procedures for Chinese patients. Numerous methods of this procedure have been reported in the literature [2–17]. However, all these methods need to correct the medial epicanthal folds through an open incision in the medial canthal region, and leave scars as well. Here we describe a newly developed technique that eliminates the epicanthal fold through the medial end of the double eyelid incision without adding any additional incision in the medial canthal region.

Materials and Methods

Patients

From July 2013 to July 2015, 252 patients (5 male and 247 female) with mild to moderate epicanthus received upper eyelidplasty. Two hundred forty-nine patients received epicanthoplasty and concomitant double eyelidplasty, and the other 3 patients underwent epicanthoplasty only. The patients ranged in age from 17 to 35, with an overall average age of 23. One hundred eighteen patients were followed up for 3–24 months, with a mean length of 8 months. The intercanthal distance was measured with vernier calipers by one physician pre- and post-operation. One senior surgeon performed all the operations. The aesthetic results were evaluated by the patients on satisfaction of the improvement of the epicanthal fold, eye appearance, and overall outcome with patient visual analog scale (VAS) scores (1, poor; 2, fair; 3, good; 4, very good; and 5, excellent). VAS is commonly used in the evaluation of postoperative aesthetic effect [18].

Methods

Pre-operation marking was performed by methylrosanilinium chloride with the patient in supine position. The first line was drawn for the double eyelid incision according to the shape of the patient’s eye. Then the skin of the medial epicanthus was pulled horizontally to the nasal side to expose the medial-most point (point A) of the lacrimal lake, which represented the original canthus. A horizontal line (line L) was then marked through point A. Afterwards, the skin was released to the original position, and the interepicanthal distance and palpebral fissure width were measured on line L. The desired location of the new canthus (point B) was marked according to a formula: [(interepicanthal distance − palpebral fissure width)/3]. The formula was formed according to the traditional aesthetic standards of Chinese eyelids. Point B was on line L or 0.5–1.0 mm lower to ensure that the oblique angle of the palpebral fissure is about 10°. The distance between the medial end of the double eyelid incision (point C) and point A was about 5 mm (Fig. 1b, g).

Fig. 1
figure 1

Schematic diagram of the scarless epicanthoplasty and concomitant double eyelidplasty. a, f Preoperative view. b, g Details of the preoperative design. Point A was the medial-most point of the lacrimal lake, which represents the original epicanthus. A horizontal line L was marked through point A. The desired location of the new canthus (point B) was marked according to a formula: [(interepicanthal distance − palpebral fissure width)/3]. Point B was on line L or 0.5–1.0 mm lower to ensure the oblique angle of the palpebral fissure was about 10°. Point C was the medial end of the double eyelid incision. The distance between point C and point A was about 5 mm. c, h Through the medial end of the eyelid crease incision, a certain sized subcutaneous blind cavity was dissected. d, i In the blind cavity, point C′ (2 mm medial to point A′) was sutured to point B′ with 5-0 Prolene. A′, B′ were the body surface projection of A, B, respectively. e, j This was the final image; the eyelid crease incision was closed as usual

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Local anesthesia (0.75 % lidocaine mixed with 1:200,000 epinephrine) was performed under the incision as well as the medial canthal region. Blepharoplasty was then performed [19]. Through the medial end of the incision, subcutaneous dissection was performed and the dense connective tissue between the skin and orbicularis oculi muscle was cut using scissors. The orbicularis oculi muscles which abnormally attached to the medial canthal ligament (MCL) were cut completely after being exposed by a skin hook. In addition, all the adhesion bands near the muscles were trimmed to thoroughly expose the MCL (Fig. 1c, h). Point C′ (2 mm medial to point A′) was sutured to point B′ with 5-0 Prolene. A, B were the projection of A′, B′ on the skin, respectively. The most crucial step in this method was anchoring the orbicularis oculi muscles and subcutaneous tissues under point C′ to point B′ with suture (Fig. 1d, i). Then the dead space would be closed by the suture as well. Lastly, the eyelid crease incision was closed and antibiotic ointment (Tobramycin Dexamethasone Eye Ointment) was topically applied. All the sutures were removed on the fifth day post-operation (Fig. 1e, j).

For the patients who underwent epicanthoplasty only (Fig. 2), we marked the incision line along the medial end of the original pretarsal fold. The length of the incision line was about 1 cm (Fig. 2a). Other steps were performed in the same way as described above (Fig. 1c–e).

Fig. 2
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Patient underwent epicanthoplasty only. a Preoperative view. b Preoperative design. The incision line was marked along the medial end of the original pretarsal fold. The length of the incision line was about 1 cm. Then the procedure was performed in the same way as above (Fig. 1c–e). c Immediately after surgery

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Results

From July 2013 to July 2015, a total of 252 patients underwent eyelidplasty with the aforementioned method. One hundred eighteen patients who were followed up for 3–24 months (8 months in average) had satisfactory results (Figs. 3, 4, 5, 6, 7). The intercanthal distance decreased from 36.5 ± 2.6 mm pre-operation to 32.7 ± 2.3 mm at 3 months after the post-operation (paired t test, p < 0.05). A trend of minor retraction was noticed 6 months after the operation (33.0 ± 2.4 vs 32.7 ± 2.3 mm, p < 0.05, paired t test). Compared with pre-operation, the intercanthal distance decreased by an average of 3.5 mm at 6 months post-operation (paired t test, p < 0.05) (Table 1). However, no patient complained about the minor retraction. No lacrimal duct injury or hematoma occurred. Mild redness was found in a small number of patients but disappeared within 1–2 months. Epiphora occurred in 9.2 % of cases post-operation and all recovered within 2 weeks. Mean patient VAS scores were 3.6 ± 0.8 (range 0.7–5.0), 4.0 ± 0.9 (range 1.8–5.0), 4.2 ± 0.8 (range 2.5–5.0) reflecting satisfaction with improvement of the epicanthal fold, eye appearance, and overall outcome, respectively (Table 2).

Fig. 3
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A 28-year-old woman with no double-eyelid fold and mild epicanthal folds. The patient underwent epicanthoplasty and concomitant double eyelidplasty. a Preoperative view. b Six months post-operation

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Fig. 4
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A 25-year-old woman with moderate epicanthal folds and no double-eyelid fold. This patient underwent double-eyelid plasty and concomitant epicanthoplasty. a Preoperative view. b Twelve months post-operation

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Fig. 5
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A 22-year-old patient with no double-eyelid fold and moderate epicanthal folds. This patient underwent double-eyelid plasty and epicanthoplasty with this new method. a Preoperative view. b Six months post-operation

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Fig. 6
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a This 27-year-old patient had no double-eyelid fold and a moderate epicanthus. The patient underwent epicanthoplasty combined with incisional double-eyelid plasty. b Twelve months after the operation, this patient was very satisfied with the result

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Fig. 7
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A 26-year-old patients with moderate epicanthal folds and no double-eyelid fold. This patient underwent epicanthoplasty and concomitant double eyelidplasty. a Preoperative view. b Six months after the operation

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Table 1 Result of the intercanthal distance value change
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Table 2 Satisfaction scores from 118 Patients regarding aesthetic results 6 months post-operation
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Discussion

Medial epicanthus is characterized by a skin crease extending from the upper eyelid across the medial canthal area to the lower eyelid [20]. The incidence occurs in more than 50 % of the Chinese population, and around 50–90 % of Korean and Japanese populations [21]. The presence of an epicanthal fold often worsens the aesthetic result of double-eyelid blepharoplasty. With higher demand for a more appealing aesthetic view, the correction of the epicanthal fold is necessary. Most of the current methods are transposition flaps in the medial canthal region to redistribute the medial canthal skin, such as modified Z-plasty [3], Y–V plasty [6] and lazy S-curve plasty [5]. Although these methods can effectively remove the epicanthal fold, they are prone to leaving visible hypertrophic scars in the medial canthal area in Asian populations, which limits their popularity.

To solve this problem, we developed a new technique that corrected the medial epicanthus through the medial end of the eyelid crease incision. According to our preliminary clinical results, the intercanthal distance at 6 months post-operation was 5.2–19.4 % shorter (7.5–21.7 % compared with other epicanthoplasty techniques [21]), which represented its stable aesthetic results.

The design of this method was based on the anatomic characteristics of the epicanthus (Fig. 8a, b). However, the mechanisms involved in the development of the epicanthus are not entirely clear [5]. From our clinical experience, we have several findings. When dissecting the medial canthus area, there were dense connective tissues between the skin and orbicularis oculi muscles. After cutting and dissecting, the orbicularis oculi muscles which were abnormally attached to MCL could be noticed. After these muscles were cut off completely, most of the epicanthal fold disappeared. This phenomenon was consistent with Liús theory [22]. So, the abnormal attachment of the orbicularis oculi muscles was the main causes of the formation of the epicanthal fold. In addition, all the adhesion bands adjacent to the malpositioned muscles were the causes for the formation of epicanthus. In our method, we trimmed and released all of the adhesion bands completely to ensure a thorough correction of the epicanthal fold.

Fig. 8
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The anatomic characteristics of the epicanthus. a After cutting and dissecting the dense connective tissues between the skin and orbicularis oculi muscles, the attachment of the orbicularis oculi muscles to MCL can be noticed. In addition, adhesion bands adjacent to the malpositioned muscles can be noticed as well. b After removing and trimming these orbicularis oculi muscles and adhesions, the MCL was exposed throughly

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According to our experience, there are several points that should be noticed during the procedure: (1) The range of dissection should be appropriate to fully relieve the abnormal tension of the skin at the inner canthus while avoiding further damage. The dissection layer should not be too deep to avoid injuring the lacrimal duct. It is also important to maintain some orbicularis oculi muscle under the skin to avoid skin necrosis. (2) Due to the elasticity of MCL, it is important to over-correct a little bit to reduce postoperative recurrence. (3) 5-0 Prolene sutures can provide enough anti-tensile strength with less inflammation reaction during the fixation of MCL.

Conclusion

This new epicanthoplasty method with concomitant double-eyelid plasty leaves no scar in the medial canthal area, and provides an ideal aesthetic effect. The best candidates are patients with mild to moderate epicanthus. However, a learning curve should be expected when applying this procedure to avoid possible complications.