Epicanthoplasty

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Article initiated by:

Christine Wang MS, MD, Hui Yu Juan, BS

All contributors:

Hui Yu Juan, BS, Adam R. Sweeney, MD, Michael T Yen, MD, Cat Nguyen Burkat, MD FACS, Christine Wang MS, MD

Assigned editor:

Adam R. Sweeney, MD

Review:

Assigned status Update Pending

 by Adam R. Sweeney, MD on April 14, 2024.

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Contributing Editors:	add

The epicanthoplasty addresses the epicanthal folds commonly found in Asian eyelids. In medical literature, there are a variety of surgical techniques that have been reported and could be considered to achieve customized aesthetic results.

Surgical Procedure: Epicanthoplasty CPT 67950

Surgical Procedure:

Epicanthoplasty CPT 67950

Background

Epicanthal fold is an uneven distribution of skin, comprising of the orbicularis oculus and medial canthal structures,  that partially covers the medial corner of the eye.This fold is seen in 2% to 5% among non-Asians, while among the Asian population, ranges between 40% and 90%.The epicanthal fold is more common in those with inner-type double eyelid as opposed to the outer-type.

Epicanthoplasty is a voluntary aesthetic procedure that eliminates the epicanthal folds to lengthen the inner part of the eye.It is commonly performed in conjunction with Asian double eyelidplasty because the epicanthus can limit the cosmetic outcome of eyelidplasty. For example, if a patient prefers achieving a medially converging, natural, shallow crease, the added tension from a surgically-induced double eyelid would aggravate the vertical tension to the epicanthal skin and potentially make the palpebral fissure appear narrower as well as more hooded.

Additionally, there can be prolonged swelling retention due to the blockage of lymphatic flow by vertical tension. Unless epicanthoplasty is performed to release skin tension, the surgical crease will not look natural or last over time.

The surgery may be performed simultaneously with a double eyelid surgery, or may be performed first and the eyelid positioning re-evaluated after.

Indications

Epicanthoplasty is a voluntary cosmetic procedure that eliminates the epicanthal folds to lengthen the inner part of the eye and create a bigger, brighter eye appearance. It may be performed in conjunction with double eyelid surgery to mitigate further exaggerating prominent epicanthal folds from the tension created medially during eyelid surgery.

Preoperative Evaluation

Severity of epicanthus, determined by the covered extent of lacrimal lake and the width of the epicanthal fold (the distance between the edge of the skinfold and the medial-most point of the lacrimal lake).

• Mild if less than half of the lacrimal lake is covered and the width of the epicanthal fold is <2 mm.

• Moderate if more than half but not the entire lacrimal lake is covered and the width of the epicanthal fold is 2–4 mm.
• Severe if lacrimal lake is completely covered by the fold that curves laterally to fuse with the lower eyelid and the width of epicanthal fold is >4 mm.

Surgical Preparation

This procedure is performed with patient in the supine position. Broad-spectrum antibiotics, 1.5 to 2 mg alprazolam (Xanax), and propoxyphene napsylate–acetaminophen, 100/650 mg (Darvocet N-100) may be administered. The patient is then put under sedation. The skin should undergo sterile preparation before the markings. An extra-fine marking pen would be selected to avoid asymmetric markings between the eyes. Two percent lidocaine with 1:200,000 epinephrine solution buffered with sodium bicarbonate in 1:10 ratio is used for local anesthesia, which is administered to the eyelid after markings are made.

Surgical Techniques

A large array of epicanthoplasty designs have been described in literature. The following are a few common procedures that have been historically described.

1. V-W plasty: A vertical W-shaped wound is created medial to medial canthus, with the central point of the W then split as a V towards the medial canthus.
   1. Disadvantages: Requires multiple incisions, scar exposure, and more hypertrophic scars.
2. Horizontal incision method: A horizontal incision is made from the most medial part of lacrimal lake to the point on epicanthal point perpendicular to the starting point. The extra skin fold gathered from the prior incision is removed.
   1. Disadvantages: Releases the epicanthal tension only in the muscular layer and not the skin layer, and higher rate of epicanthal recurrence.
3. Z-plasty: A Z-shaped incision is made to create two triangular skin flaps, one containing most of the skin from epicanthal fold and one with the skin from the medial canthal area. Two flaps are subsequently transposed with excess skim trimmed off.
   1. Disadvantages:  Redundancy of the pretarsal skin can develop near the medial canthus, convergence of a pretarsal double fold toward the lacrimal lake. Difficulty in design, prominent scarring of the medial canthal and nasal area, recurrence due to excessive tension force, and rigidity of application.
4. V-Y advancement: A horizontal incision is made from edge of epicanthal fold at level of mid-caruncle to outer surface of epicanthal fold, then the nasal skin is pulled medially to expose the lacrimal fold. The excess orbicularis oculi muscle and adhesion bands are removed to advance V flap to repair the defect.
   1. Disadvantages: Cosmetic outcome limited by space between the lateral canthus and the lateral bony orbital wall. Difficulty in design, prominent scarring of the medial canthal and nasal area, recurrence due to excessive tension force, and rigidity of application.
5. Subcutaneous epicanthoplasty: Performed in conjunction with blepharoplasty, the orbicularis muscle and underlying fibrofatty tissue in the epicanthal fold is excised and debulked through the medial edge of an eyelid crease incision. The skin is then tacked down with absorbable sutures.
   1. Disadvantages: Typically only able to soften but not completely eliminate the epicanthal fold.

Postoperative care

Postoperative care is surgeon dependent, however generally is as follows: Semi-reclined positioning immediately postoperatively. Moist gauze is place over the eyelid followed by an ice pack. The ice pack is tied around the head or looped around the ear to keep the ice pack in place. Rest for 30 minutes to an hour before discharge. Usually, an additional dose of narcotic medication is sufficient for pain control. Postoperatively, only several more dosages of pain medications are necessary. After discharge, patient may take antibiotics for 2 days. The ice pack is applied in 30-minute intervals on and off for the first 2 to 3 days. After which, hot compresses may be used to increase blood flow to incisional areas and decrease erythema. The patient is allowed to see and ambulate as needed after discharge. First postoperative visit should be scheduled in a week after surgery. During the first week after discharge, patients may return to work with shaded glasses. For patients who wear contact lenses, regular glasses are recommended to hide the unnatural appearance during the recovery period. Vigorous exercises are usually allowed after 2 weeks.

Postoperative Complications

Unnatural appearance and visible medial scar formation are undesirable outcomes. Complications can arise from poor procedural design and lack of precision in dissection. Incomplete flap elevation causes blunting of the medial canthal area and persistence of the epicanthal fold. Permanent anchoring suture on the superficial layer may result in suture migration, erythema, granuloma formation, suture abscess, and visible scarring. Skin closure under tension is the most common cause of thick scar formation, which can be caused by incomplete flap elevation. Temporary epiphora caused by obstruction of the lacrimal sac from swelling is common, but it usually self resolves within a couple of weeks. The vicinity of lacrimal sac makes it possible to be damaged as well. Moreover, asymmetry between the eyes is also frequently seen.