Epicanthoplasty

Introduction  

Epicanthoplasty is a cosmetic surgical procedure that removes the epicanthal (Mongolian) fold or lengthens the inner eye parts to make the eye bigger and improve appearance.  An epicanthal fold is a crease on the skin brought about by the excessive development of the orbicularis oculi muscle and other structures in the medial canthus region. This procedure is popular among the Asian people who do not have a superior palpebral fold (supra-tarsal crease) but often have a congenital epicanthal fold on the corners of the eye. The epicanthus stretches from the upper eyelid to the lower eyelid covering the medial canthus. Therefore, it impairs eyelid beauty since it makes the eyes look laterally small and tired.

There is medical or lateral epicanthoplasty alongside several corrective procedures used to remove the epicanthal fold. They include the Mustard’s four flap method (plus its modification), modified Z-plasty method, V-M plasty, W-pasty, and Y-V advancement. However, the biggest problem with epicanthoplasty is the formation of a scar that further creates unpleasant aesthetic appearances. This is because Asian skin is prone to hypertrophic (abnormal enlargement) scar tendency. All the procedures mentioned above create the out-fold type of double eyelid fold, often with disastrous consequences and are no longer popular. Medial epicanthoplasty is preferred to lateral epicanthoplasty because, with the latter, there is a tendency of a recurrence and relapse.

The most preferred method to remove the fold is medial epicanthoplasty in combination with a blepharoplasty (removes droopy eyelids) technique. Some suggest that a combination of epicanthoplasty and lateral canthoplasty promises greater results. Others combine epicanthoplasty with the orbicularis levator fixation technique to create a double eyelid crease. The scar-hiding procedure is suitable for mild to moderate epicanthus. Other conventional procedures may correct severe epicanthus deformities like epicanthus inversus.

The Western world thought that the small Asian eyes were not as appealing, hence the desire to create wider eyes surgically. It is believed removing the epicanthal fold gives the patient a more Caucasian look. However, there is controversy on whether epicanthoplasty can rid the patient of their ethnic appearance because the results are only minimal. Unlike other races, an Asian epicanthic eye has only a single eyelid. Therefore, epicanthoplasty and related surgical procedures such as double eyelid seek to create another eyelid.
 

Also Known As

• Westernization
• Inner corner fold removal
• Mongolian fold correction

Preparation & Expectation Before Surgery

A responsible adult should drive the patient home, and the patient must not be alone for 24 hours after surgery. The patient must first and foremost be in good health and a non-smoker to undergo the procedure. It is strongly recommended that the patient avoids food and drinks at least 6 hours before the surgery. S/he should also avoid certain blood-thinning medications like aspirin and ibuprofen. No alcohol or drugs should be taken one week before surgery.

Relevant information will be taken from the patient, including a history of previous eyelid surgery and prescription medications. Information on ailments such as colds, infections, boils, etc., is also necessary. Skin products like creams and lotions should not be applied because they can add bacteria to the skin and increase the risk of infection.
 

Types, Purpose & Procedure

Patients are placed in a supine position (head facing upwards). The surgeon administers local anesthesia or twilight anesthesia (hypnoanesthesia).

Many procedures can be used in epicanthoplasty. The following description is of a scar-hiding procedure. The surgeon: 

• Makes incision marks using a felt-tip syringe marker to estimate how wide the inner eyelids will be cut. The patient can keep the eyes open or closed, depending on the surgeon’s instructions.
   
• Spreads out the medial canthus fold by pulling the nasal skin super-medially.
   
• Makes an incision through the skin and dissects the dense fiber between the muscle and skin to raise the skin on the medial canthus region.
   
• Cuts off the dislocated orbicularis oculi muscle to completely release the tension crossing the epicanthus.
   
• Repositions the medial canthus skin. If the lacrimal lake is not well-exposed, the medial canthus tendon can be folded. But if the lacrimal lake is exposed enough, the medial canthus tendon is not folded.
   
• Extends the lower lid incision to the lateral and tissue underneath the incision. The patient is then asked to gaze straight ahead, where the surgeon stretches and removes excess skin.
   
• Places a nylon suture on the site.

After this blepharoplasty, the surgeon directly removes the dog-ear on the upper lid and places a permanent nylon suture on the affected part.
 

Risks, Side Effects & Complications

There will be a scar (no matter how small) but it should heal with time. There may be moderate pain and discomfort, which the prescribed medications should take care of. The most significant discomfort occurs within 24 hours after surgery. Drug allergy effects may include itching, tightness in the throat, and wheezing, for which immediate medical attention must be sought.

Prompt medical attention must also be sought if there is severe pain that refuses to go away with medication. Other reasons to rush to the emergency room include red incisions, fever, excessive bleeding, and swelling felt more on one side than the other.
 

After Care, Recovery & Outcome

There should be minimal activity in the first 48 hours of the surgery. Pulling, pushing, and lifting should be limited. The patient should, as much as possible, elevate the bed’s head up to 45 degrees to assist with the swelling. The patient may wash the face or take a light shower after removal of the stitches. However, the bathtub or swimming pool must not be used for two to three weeks following surgery. There should be no smoking for the first two weeks after the surgery. The eye should also be protected against the sun, and the patient must not color their hair for one month following the procedure. 

The surgeon removes all sutures or stitches from 5 to 9 days following the surgical procedure. A recovery period of two weeks is recommended for proper healing. The patient will attend two follow-up appointments but subject to change as advised by the surgeon.

If performed adequately, epicanthoplasty provides a more accepted beauty standard. The patient needs to note that results vary from person to person. Epicanthoplasty is considered a challenging procedure because the epicanthal fold overlies the tear drainage canals. Scar-hiding procedures present more satisfactory results.

Often, there is no recurrence of epicanthus, and the lacrimal function remains undisturbed. Most patients register satisfactory results between the 3^rd and 6^th months following surgery, where the scar on the canthus area has healed reasonably. Surgeons use the Stony Brook Scar Evaluation Scale (SBSES) to evaluate cosmetic appearance. The SBSES is made up of five categories, ranging from 0 to 5.