J Plast Surg Hand Surg, 2014; 48: 139–142 © 2014 Informa Healthcare ISSN: 2000-656X print / 2000-6764 online DOI: 10.3109/2000656X.2013.835264
ORIGINAL ARTICLE
Medial epicanthoplasty using the “inside-out” technique Jae Don Seo1, Ji Hoon Kim2, Chang Sik Pak2 & Chan-Yeong Heo2 Seo Jae Don Plastic Clinic, Seoul, Republic of Korea and 2Department of Plastic & Reconstructive Surgery, Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea Journal of Plastic Surgery and Hand Surgery Downloaded from informahealthcare.com by Nyu Medical Center on 06/04/15 For personal use only.
1
Abstract The epicanthal fold, a skin remnant covering the medial canthal region, is especially common in Asians. Although numerous surgical techniques for the treatment of the epicanthal fold have been developed, the results.in terms of scars and a natural look remain controversial. In this regard, the authors have developed a new method for medial epicanthoplasty. From January 2005 to December 2011, medial epicanthoplasty was performed on 1132 patients using a technique in which the skin flap inside of the medial epicanthal fold is moved outward (the “Inside-Out” technique). Preoperative and postoperative (2 months) interepicanthal distance was measured. Satisfactory results were achieved in the majority of cases. While nine patients complained of visible scarring after the operation, the scar formation spontaneously resolved within 6 months. This new “Inside-Out” technique for the treatment of the epicanthal fold is easy, simple, and delivers good aesthetic results. Key Words: Medial epicanthoplasty, epicanthal fold, double eyelid operation
Introduction The epicanthal fold, a skin remnant covering the medial canthal region, is particularly common in Asians. This fold usually arises from the bridge of the nose to the upper eyelid skin, concealing the caruncula lacrimalis. Although the concept of beauty changes over time and differs between cultures, an adequate amount of epicanthal fold may contribute to a beautiful and attractive Asian eye line. However, in severe cases, the epicanthal fold may create an impression of a wide intercanthal distance, which is cosmetically undesirable. Since the 1900s many methods for correcting the epicanthal fold have been developed. The original surgical approach was the Mustarde 4-flap method [1], which was subsequently modified by Yoon [2]. Other methods such as the V-W plasty [3], VY advancement flap [4], modified Y-V advancement flap [5–7], W-plasty [8], and various Z-plasties [9–14] have since been introduced. Although there are numerous surgical techniques for the treatment of the epicanthal fold, visible scarring and an unnatural look remain a concern. In Korea, medial epicanthoplasty (along with double eyelid operation) is one of the most popular aesthetic periorbital surgeries. Compared to other periorbital regions, the medial epicanthal region develops visible scarring after surgery, and, therefore, many patients hesitate to undergo surgery due to the potential for scarring. The goal of this study was to develop a new and easy medial epicanthoplasty method that minimizes scarring in Asian patients. Materials From January 2005 to December 2011, medial epicanthoplasty using the “Inside-Out” technique (see below) was performed in
1132 patients at a private clinic. In 896 cases, double eyelid operation was combined with epicanthoplasty, and 236 patients received epicanthoplasty alone. There were no secondary cases. The intercanthal distance was measured preoperatively and postoperatively at 2 months to determine the degree of correction. Complications such as ectropion and scars were assessed during the follow-up period. Surgical procedure Presurgical marking was performed in the sitting position, as shown in Figure 1. After pulling the skin of the medial epicanthus horizontally to the nasal side at the medial mucocutaneous junction of the caruncle (Point A), a point that represented the desired location of the new epicanthus was marked (Point A¢). Another point (Point B) was marked 3 mm above the supratarsal crease line, and the final point (point C) was marked 1.5 mm below the mucocutaneous junction of the subciliary line that passes through the vertical line of the median limbus. Finally, an incision line was curvilinearly drawn passing through the points. In severe cases, point B was located higher than 3 mm above the supratarsal crease line, according to the estimated dog-ear deformity near the newly formed medial canthus. When the design was finished a local anaesthetic solution (2% lidocaine mixed with 1:100,000 epinephrine) was infiltrated along the incision line. A minimal amount of locally applied anaesthetic solution generally creates less eyelid oedema and facilitates a more precise operation. Subsequently, an incision (C-A-A¢-B) is made using a #11 surgical blade. The skin flap on the nasal side was then elevated from the orbicularis oculi muscle using sharp scissors in the medial canthal region, and all the constriction bands from the orbicularis oculi muscle
Correspondence: Chan-Yeong Heo, MD, PhD, Assistant Professor, Department of Plastic and Reconstructive Surgery, Seoul National University Bundang Hospital, 300, Gumi-dong, Bundang-gu, Seongnam-si, Gyeonggi-do, 463-707, Republic of Korea. Tel: +82 31 787 7229. Fax: +82 31 787 4055. E-mail: [email protected] (Received 3 March 2013; accepted 12 August 2013)
140 J. D. Seo et al.
A′
A
B A′
A
Journal of Plastic Surgery and Hand Surgery Downloaded from informahealthcare.com by Nyu Medical Center on 06/04/15 For personal use only.
C
Figure 1. Preoperative design. Top left: Point A represents the medial mucocutaneous junction of the caruncle. Top right: Point A¢ represents the desired location of the new medial epicanthus and is marked on the skin covering the epicanthal fold vertically overlying Point A. Bottom left: Point B was marked 3 mm above the supratarsal crease line, and point C was marked 1.5 mm below the mucocutaneous junction of the subciliary line that passes through the vertical line of the median limbus. An incision line was curvilinearly drawn passing through the points.
were thoroughly exposed. After the skin flap was released and dissected through the incision line, point A was sutured to point A¢ using 6-0 Vicryl. The triangular flap, which existed between points A and B inside the epicanthal fold, was moved “outside” superiorly along the line between A¢ and B (Figure 2). This movement of the triangular flap is the key process of the “Inside-Out” technique, which ensures a tension-free closure of the surgical incision line. The wound was irrigated and carefully checked for hemostasis. Points A and A¢ were sutured together using 6-0 Vicryl and 7-0 black silk sutures, and the rest of the wound was closed from the lateral to the medial sides. The remnant triangular skin flap was excised with sharp scissors
B
Figure 3. After skin closure, the alignment of the fissure is more superior, medial, and posterior. The and posterior vector is responsible for the changes axis, shortened intercanthal distance, and a more dorsum appearance.
medial palpebral superior, medial, in the horizontal prominent nasal
(Figure 3). Finally, an antibiotic ointment was topically applied. Mild compression on the wound was also immediately applied for 30 min after the surgery to minimize oedema and the chance of bruising. All the sutures were removed on the 7th day. Results Among the 1132 patients treated with the “Inside-Out” technique, 1097 were female, 35 were male, and the mean age was 26.2 years. The patients were classified into mild, moderate, and severe groups. The interepicanthal distance of the mild, moderate, and severe groups was < 38 mm (213 patients), 38–43 mm (901 patients), and > 43 mm (12 patients), respectively. The decrease in the interepicanthal distance following surgery ranged from 2.5–9.8 mm (mean = 4.6 mm). The patients were followed for a mean of 4.6 months (range = 2–8 months; Table I) During the follow-up period, three patients complained of an unnatural appearance, but no other revision surgical procedures
A′
Table I. Patient characteristics and summary of the results. A′
Subject Study period Number of patients
A
C
Figure 2. The skin flap on the nasal side was elevated, and the fibres of the orbicularis oculi muscle were released using scissors. Note that, after proper subcutaneous dissection, the triangular skin flap was spontaneously rotated from its initial position (“inside”) superiorly (“out”). The A and A¢ points were sutured together, the rest of the wound was closed from the lateral to medial sides, and the remnant triangular skin flap was excised with sharp scissors.
Age (years) Interepicanthal distance Post-operative decrease in the interepicanthal distance Follow-up period (months)
Result January 2005 to December 2011 1132 Male 35 Female 1097 26.2 Mild Moderate Severe (< 38 mm) (38–43 mm) (> 43 mm) (n = 213) (n = 901) (n = 12) 2.5–5.0 mm 4.0–7.4 mm 8.0–9.8 mm
Range: 2.5–9.8 mm; Mean: 4.6 mm 2–8
Journal of Plastic Surgery and Hand Surgery Downloaded from informahealthcare.com by Nyu Medical Center on 06/04/15 For personal use only.
Medial epicanthoplasty using the “inside-out” technique
141
Figure 4. A 25-year-old woman before she underwent “InsideOut” epicanthoplasty with a double eyelid operation.
Figure 6. A 23-year-old woman before she underwent “InsideOut” epicanthoplasty alone.
were performed. Nine patients complained of visible scarring at the incision line 2 months after the surgery, but no further complaints were reported during the 6-month postoperative period. No lacrimal duct injury or ectropion were observed (Figures 4,5,6,7). Discussion The epicanthal fold found in Asian populations is a fold of skin that covers the medial canthus, which often occurs on both sides. The presence of epicanthal folds and the absence of supratarsal creases are unique and predominant features among Asians, and aesthetic eyelid operation is one of the most popular cosmetic procedures performed. The epicanthal folds tend to widen the interepicanthal distance and narrow the palpebral fissure. While the cause of epicanthal folds remain unclear, the epicanthus may result from an arrest in periorbital development, an excessive development of skin at the root of the nose, an abnormally poor development of the bones of the skull and nose, an excess of orbicularis muscle and fibrofatty tissues underlying the fold, and abnormal tension forces on the skin by the orbicularis muscle. Some epicanthal folds may disappear during the development of these structures [15,16], whereas others persist. There are four types of epicanthal folds depending on the origin of fold [17]. Epicanthus tarsalis, the most common type, is an epicanthal fold the arises from the skin over the tarsus, whereas epicanthus palpebralis, the second most common type, is a fold arising from the upper palpebral skin above the level of the tarsus. A fold that extends from the eyebrow to the lower eyelid is termed epicanthus superciliaris and in epicanthus inversus, the least common variation, the fold originates from the lower eyelid [18]. In a recent study of Asian subjects, Park et al. [18] reported that the epicanthus was observed in ~ 42.2% of all Asian eyelids, with epicanthus tarsalis being the most common. Many surgical approaches to correct the epicanthal fold have been introduced. The classical method reported by Mustarde [1] uses four flaps to adjust the epicanthal folds. This method is very
effective for correcting even severe folds and helps to easily expose the structures of the medial canthal region. However, this method is limited by an unnatural look and visible scar formation. Other methods such as the Z-epicanthoplasty [9–13], inverted Y-V advancement [7], root-Z epicanthoplasty [14], periciliary Y-V epicanthoplasty [19], and No-scar epicanthoplasty [20] all have merits and demerits. The most effective methods are either too difficult to perform or the scar is impossible to mask, while other methods can conceal visible scars but have minimal corrective potential. However, medial epicanthoplasty ensures a balance between the corrective potential and visible scar formation. The “Inside-Out” medial epicanthoplasty yields effective postoperative results, as well as a high patient satisfaction, by striking a balance between the amount of correction and risk of scarring. This technique efficiently releases skin tension and provides adequate skin excision without the danger of visible scarring. Using this procedure, the medial canthal point shifts from point A to A¢ and the vector of this movement is directed superiorly, medially, and posteriorly. The superior vector changes the axis of the eyelids more horizontally and the medial vector is responsible for the shortened intercanthal distance. The posterior vector makes the nasal dorsum appear more prominent. The various techniques described above are associated with postoperative scar formation. This scar formation of the medial canthal region is influenced by several factors, including racial and individual diathesis, the thickness and tension of the skin, and the scar direction [19]. Scars of the medial canthal area tend to be more prominent in Asians than in Caucasians, and different scar reactions can occur in each individual, despite being on the same area of the skin. Scar formation also has a close relationship with the skin thickness of the incision site. Incisions on thin, vs thick, skin have some advantages, elicit a less inflammatory reaction, and resultant scars can be less hypertrophic and invisible. For these reasons, the possibility of hypertrophic scarring is low when the thick nasal skin is not invaded [14].
Figure 5. A 25-year-old woman at 6 months after she underwent “Inside-Out” epicanthoplasty with a double eyelid operation.
Figure 7. A 23-year-old woman at 1 month after she underwent “Inside-Out” epicanthoplasty alone.
Journal of Plastic Surgery and Hand Surgery Downloaded from informahealthcare.com by Nyu Medical Center on 06/04/15 For personal use only.
142 J. D. Seo et al. In our study, of the 1132, only nine patients complained of visible scar formation and only three complained of visible scars. The authors believe that hypertrophic scarring of the medial canthal area is mostly due to the tension or incision of the nasal skin, and, since the “Inside-Out” method removes an adequate amount of skin, without tension or invading the dorsum of the nose, scars are rarely visible. In addition, the “Inside-Out” technique provides a natural appearance of the medial canthal region because it does not disrupt the normal anatomy of the medial canthal region. There has been a misunderstanding that Asians consider the Caucasian look as attractive and beautiful. Although Asian aesthetic periorbital surgeries focus on achieving the characteristics of Caucasian eyelids [21], including the presence of a superior palpebral fold, less fat on the eyelids, and the absence of the epicanthal fold, this does not mean that the Asian eyelid should completely resemble Caucasian eyelid. Ignoring the inherent interethnic differences would result in an undesirable and often unnatural look. For these reasons, we propose that the goal of the surgery should not be targeted at removing the entire epicanthal fold. Rather, it should help enhance the overall aesthetics of the periorbital area. In line with this, in most cases, the operation was performed for purely aesthetic purposes. That is, the amount/type of epicanthus of patients undergoing this type of operation fairly fell within the normal range of the Korean population. The patients wished to lengthen the palpebral fissure, produce the image of a larger and open eye, without losing a natural look. As such, the operation technique should not emphasize the amount of epicanthal fold that can be corrected or the diverse types it can correct, but instead aim at minimizing scar formation and maintaining a natural appearance. Conclusion The novel “Inside-Out” medial epicanthoplasty has several advantages over other surgical methods. First, there are few conspicuous scars following surgery. Second, the surgical procedure does not interfere with or hinder the original shape of the eyes and, therefore, results in a more natural look. Third, the method can be applied to any type of epicanthal fold. Finally, the amount of skin excision can be controlled depending on the patient’s condition. No complications and conspicuous scar formation were observed in the current cases and the overall patient satisfaction was very high.
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper. References [1] Mustarde JC. Epicanthus and telecanthus. Br J Plast Surg 1963; 16:346–56. [2] Yoon KC. Modification of Mustarde technique for correction of epicanthus in Asian patients. Plast Reconstr Surg 1993;97:245. [3] Uchida J. A surgical procedure for blepharoptosis vera and pseudoblepharoptosis in Orientals. Br J Plast Surg 1962;15: 271–6. [4] Verwey A. Over hat maskergelast en zijn behandeling. Ned Tijdschr Geneeskd 1909;1:1596. [5] Hughes WL. Surgical treatment of congenital phimosis: The V-Y operation. Arch Opthalmol 1955;54:586. [6] Kao YS, Lin CH, Fang RH. Epicanthoplasty with modified Y-V advancement procedure. Plast Reconstr Surg 1998;102:1835. [7] Cho BC, Lee KY. Medial epicanthoplasty combined with plication of the medial canthal tendon in Asian eyelids. Plast Reconstr Surg 2002;110:293–300. [8] Mulliken JB, Hoopes JE. W-epicanthoplasty. Plast Reconstr Surg 1975;55:435. [9] Blair VP, Brown JP, Hamm WG. Surgery of the inner canthus and related structures. Am J Opthalmal 1932;15:498. [10] Fuente del Campo AFD. Surgical treatment of the epicanthal fold. Plast Reconstr Surg 1983;73:566. [11] Park JI. Z-epicanthoplasty in Asian eyelids. Plast Reconstr Surg 1996;98:602. [12] Rogman M. Nouveau procede operatoire pour corriger l’epicanthus. Ann Ocul 1904;131:464. [13] Park JI. Modified Z-epicanthoplasty in the Asian eyelid. Arch Facial Plast Surg 2000;2:43. [14] Yoo WM. Root Z-epicanthoplasty in Asian eyelids. Plast Reconstr Surg 2002;109:2067. [15] Rubenzik R. Surgical revision of the oriental lid. Ann Ophthalmol 1977;9:1189. [16] Farkas LG, Cheung G. Orbital measurements in the presence of epicanthi in healthy North American Caucasians. Ophthalmologica 1979;179:309. [17] Duke-Elder WS. Textbook of Ophthalmology. St. Louis, MO: Mosby; 1952. p 4653. [18] Park DH, Choi WS, Yoon SH, Song CH. Anthropometry of Asian eyelids by age. Plast Reconstr Surg 2008;121:1405–13. [19] Lee YJ, Baek RM, Song YT, et al. Periciliary Y-V epicanthoplasty. Ann Plast Surg 2006;56:274. [20] Yen MT, Jordan DR, Anderson RL. No-scar Asian epicanthoplasty: a subcutaneous approach. Ophthal Plast Reconstr Surg 2002;18:40. [21] Blake CR, Lai WW, Edward DP. Racial and ethnic differences in ocular anatomy. Int Ophthalmol Clin 2003;43:9.
ORIGINAL ARTICLE
Medial epicanthoplasty using the “inside-out” technique Jae Don Seo1, Ji Hoon Kim2, Chang Sik Pak2 & Chan-Yeong Heo2 Seo Jae Don Plastic Clinic, Seoul, Republic of Korea and 2Department of Plastic & Reconstructive Surgery, Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea Journal of Plastic Surgery and Hand Surgery Downloaded from informahealthcare.com by Nyu Medical Center on 06/04/15 For personal use only.
1
Abstract The epicanthal fold, a skin remnant covering the medial canthal region, is especially common in Asians. Although numerous surgical techniques for the treatment of the epicanthal fold have been developed, the results.in terms of scars and a natural look remain controversial. In this regard, the authors have developed a new method for medial epicanthoplasty. From January 2005 to December 2011, medial epicanthoplasty was performed on 1132 patients using a technique in which the skin flap inside of the medial epicanthal fold is moved outward (the “Inside-Out” technique). Preoperative and postoperative (2 months) interepicanthal distance was measured. Satisfactory results were achieved in the majority of cases. While nine patients complained of visible scarring after the operation, the scar formation spontaneously resolved within 6 months. This new “Inside-Out” technique for the treatment of the epicanthal fold is easy, simple, and delivers good aesthetic results. Key Words: Medial epicanthoplasty, epicanthal fold, double eyelid operation
Introduction The epicanthal fold, a skin remnant covering the medial canthal region, is particularly common in Asians. This fold usually arises from the bridge of the nose to the upper eyelid skin, concealing the caruncula lacrimalis. Although the concept of beauty changes over time and differs between cultures, an adequate amount of epicanthal fold may contribute to a beautiful and attractive Asian eye line. However, in severe cases, the epicanthal fold may create an impression of a wide intercanthal distance, which is cosmetically undesirable. Since the 1900s many methods for correcting the epicanthal fold have been developed. The original surgical approach was the Mustarde 4-flap method [1], which was subsequently modified by Yoon [2]. Other methods such as the V-W plasty [3], VY advancement flap [4], modified Y-V advancement flap [5–7], W-plasty [8], and various Z-plasties [9–14] have since been introduced. Although there are numerous surgical techniques for the treatment of the epicanthal fold, visible scarring and an unnatural look remain a concern. In Korea, medial epicanthoplasty (along with double eyelid operation) is one of the most popular aesthetic periorbital surgeries. Compared to other periorbital regions, the medial epicanthal region develops visible scarring after surgery, and, therefore, many patients hesitate to undergo surgery due to the potential for scarring. The goal of this study was to develop a new and easy medial epicanthoplasty method that minimizes scarring in Asian patients. Materials From January 2005 to December 2011, medial epicanthoplasty using the “Inside-Out” technique (see below) was performed in
1132 patients at a private clinic. In 896 cases, double eyelid operation was combined with epicanthoplasty, and 236 patients received epicanthoplasty alone. There were no secondary cases. The intercanthal distance was measured preoperatively and postoperatively at 2 months to determine the degree of correction. Complications such as ectropion and scars were assessed during the follow-up period. Surgical procedure Presurgical marking was performed in the sitting position, as shown in Figure 1. After pulling the skin of the medial epicanthus horizontally to the nasal side at the medial mucocutaneous junction of the caruncle (Point A), a point that represented the desired location of the new epicanthus was marked (Point A¢). Another point (Point B) was marked 3 mm above the supratarsal crease line, and the final point (point C) was marked 1.5 mm below the mucocutaneous junction of the subciliary line that passes through the vertical line of the median limbus. Finally, an incision line was curvilinearly drawn passing through the points. In severe cases, point B was located higher than 3 mm above the supratarsal crease line, according to the estimated dog-ear deformity near the newly formed medial canthus. When the design was finished a local anaesthetic solution (2% lidocaine mixed with 1:100,000 epinephrine) was infiltrated along the incision line. A minimal amount of locally applied anaesthetic solution generally creates less eyelid oedema and facilitates a more precise operation. Subsequently, an incision (C-A-A¢-B) is made using a #11 surgical blade. The skin flap on the nasal side was then elevated from the orbicularis oculi muscle using sharp scissors in the medial canthal region, and all the constriction bands from the orbicularis oculi muscle
Correspondence: Chan-Yeong Heo, MD, PhD, Assistant Professor, Department of Plastic and Reconstructive Surgery, Seoul National University Bundang Hospital, 300, Gumi-dong, Bundang-gu, Seongnam-si, Gyeonggi-do, 463-707, Republic of Korea. Tel: +82 31 787 7229. Fax: +82 31 787 4055. E-mail: [email protected] (Received 3 March 2013; accepted 12 August 2013)
140 J. D. Seo et al.
A′
A
B A′
A
Journal of Plastic Surgery and Hand Surgery Downloaded from informahealthcare.com by Nyu Medical Center on 06/04/15 For personal use only.
C
Figure 1. Preoperative design. Top left: Point A represents the medial mucocutaneous junction of the caruncle. Top right: Point A¢ represents the desired location of the new medial epicanthus and is marked on the skin covering the epicanthal fold vertically overlying Point A. Bottom left: Point B was marked 3 mm above the supratarsal crease line, and point C was marked 1.5 mm below the mucocutaneous junction of the subciliary line that passes through the vertical line of the median limbus. An incision line was curvilinearly drawn passing through the points.
were thoroughly exposed. After the skin flap was released and dissected through the incision line, point A was sutured to point A¢ using 6-0 Vicryl. The triangular flap, which existed between points A and B inside the epicanthal fold, was moved “outside” superiorly along the line between A¢ and B (Figure 2). This movement of the triangular flap is the key process of the “Inside-Out” technique, which ensures a tension-free closure of the surgical incision line. The wound was irrigated and carefully checked for hemostasis. Points A and A¢ were sutured together using 6-0 Vicryl and 7-0 black silk sutures, and the rest of the wound was closed from the lateral to the medial sides. The remnant triangular skin flap was excised with sharp scissors
B
Figure 3. After skin closure, the alignment of the fissure is more superior, medial, and posterior. The and posterior vector is responsible for the changes axis, shortened intercanthal distance, and a more dorsum appearance.
medial palpebral superior, medial, in the horizontal prominent nasal
(Figure 3). Finally, an antibiotic ointment was topically applied. Mild compression on the wound was also immediately applied for 30 min after the surgery to minimize oedema and the chance of bruising. All the sutures were removed on the 7th day. Results Among the 1132 patients treated with the “Inside-Out” technique, 1097 were female, 35 were male, and the mean age was 26.2 years. The patients were classified into mild, moderate, and severe groups. The interepicanthal distance of the mild, moderate, and severe groups was < 38 mm (213 patients), 38–43 mm (901 patients), and > 43 mm (12 patients), respectively. The decrease in the interepicanthal distance following surgery ranged from 2.5–9.8 mm (mean = 4.6 mm). The patients were followed for a mean of 4.6 months (range = 2–8 months; Table I) During the follow-up period, three patients complained of an unnatural appearance, but no other revision surgical procedures
A′
Table I. Patient characteristics and summary of the results. A′
Subject Study period Number of patients
A
C
Figure 2. The skin flap on the nasal side was elevated, and the fibres of the orbicularis oculi muscle were released using scissors. Note that, after proper subcutaneous dissection, the triangular skin flap was spontaneously rotated from its initial position (“inside”) superiorly (“out”). The A and A¢ points were sutured together, the rest of the wound was closed from the lateral to medial sides, and the remnant triangular skin flap was excised with sharp scissors.
Age (years) Interepicanthal distance Post-operative decrease in the interepicanthal distance Follow-up period (months)
Result January 2005 to December 2011 1132 Male 35 Female 1097 26.2 Mild Moderate Severe (< 38 mm) (38–43 mm) (> 43 mm) (n = 213) (n = 901) (n = 12) 2.5–5.0 mm 4.0–7.4 mm 8.0–9.8 mm
Range: 2.5–9.8 mm; Mean: 4.6 mm 2–8
Journal of Plastic Surgery and Hand Surgery Downloaded from informahealthcare.com by Nyu Medical Center on 06/04/15 For personal use only.
Medial epicanthoplasty using the “inside-out” technique
141
Figure 4. A 25-year-old woman before she underwent “InsideOut” epicanthoplasty with a double eyelid operation.
Figure 6. A 23-year-old woman before she underwent “InsideOut” epicanthoplasty alone.
were performed. Nine patients complained of visible scarring at the incision line 2 months after the surgery, but no further complaints were reported during the 6-month postoperative period. No lacrimal duct injury or ectropion were observed (Figures 4,5,6,7). Discussion The epicanthal fold found in Asian populations is a fold of skin that covers the medial canthus, which often occurs on both sides. The presence of epicanthal folds and the absence of supratarsal creases are unique and predominant features among Asians, and aesthetic eyelid operation is one of the most popular cosmetic procedures performed. The epicanthal folds tend to widen the interepicanthal distance and narrow the palpebral fissure. While the cause of epicanthal folds remain unclear, the epicanthus may result from an arrest in periorbital development, an excessive development of skin at the root of the nose, an abnormally poor development of the bones of the skull and nose, an excess of orbicularis muscle and fibrofatty tissues underlying the fold, and abnormal tension forces on the skin by the orbicularis muscle. Some epicanthal folds may disappear during the development of these structures [15,16], whereas others persist. There are four types of epicanthal folds depending on the origin of fold [17]. Epicanthus tarsalis, the most common type, is an epicanthal fold the arises from the skin over the tarsus, whereas epicanthus palpebralis, the second most common type, is a fold arising from the upper palpebral skin above the level of the tarsus. A fold that extends from the eyebrow to the lower eyelid is termed epicanthus superciliaris and in epicanthus inversus, the least common variation, the fold originates from the lower eyelid [18]. In a recent study of Asian subjects, Park et al. [18] reported that the epicanthus was observed in ~ 42.2% of all Asian eyelids, with epicanthus tarsalis being the most common. Many surgical approaches to correct the epicanthal fold have been introduced. The classical method reported by Mustarde [1] uses four flaps to adjust the epicanthal folds. This method is very
effective for correcting even severe folds and helps to easily expose the structures of the medial canthal region. However, this method is limited by an unnatural look and visible scar formation. Other methods such as the Z-epicanthoplasty [9–13], inverted Y-V advancement [7], root-Z epicanthoplasty [14], periciliary Y-V epicanthoplasty [19], and No-scar epicanthoplasty [20] all have merits and demerits. The most effective methods are either too difficult to perform or the scar is impossible to mask, while other methods can conceal visible scars but have minimal corrective potential. However, medial epicanthoplasty ensures a balance between the corrective potential and visible scar formation. The “Inside-Out” medial epicanthoplasty yields effective postoperative results, as well as a high patient satisfaction, by striking a balance between the amount of correction and risk of scarring. This technique efficiently releases skin tension and provides adequate skin excision without the danger of visible scarring. Using this procedure, the medial canthal point shifts from point A to A¢ and the vector of this movement is directed superiorly, medially, and posteriorly. The superior vector changes the axis of the eyelids more horizontally and the medial vector is responsible for the shortened intercanthal distance. The posterior vector makes the nasal dorsum appear more prominent. The various techniques described above are associated with postoperative scar formation. This scar formation of the medial canthal region is influenced by several factors, including racial and individual diathesis, the thickness and tension of the skin, and the scar direction [19]. Scars of the medial canthal area tend to be more prominent in Asians than in Caucasians, and different scar reactions can occur in each individual, despite being on the same area of the skin. Scar formation also has a close relationship with the skin thickness of the incision site. Incisions on thin, vs thick, skin have some advantages, elicit a less inflammatory reaction, and resultant scars can be less hypertrophic and invisible. For these reasons, the possibility of hypertrophic scarring is low when the thick nasal skin is not invaded [14].
Figure 5. A 25-year-old woman at 6 months after she underwent “Inside-Out” epicanthoplasty with a double eyelid operation.
Figure 7. A 23-year-old woman at 1 month after she underwent “Inside-Out” epicanthoplasty alone.
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142 J. D. Seo et al. In our study, of the 1132, only nine patients complained of visible scar formation and only three complained of visible scars. The authors believe that hypertrophic scarring of the medial canthal area is mostly due to the tension or incision of the nasal skin, and, since the “Inside-Out” method removes an adequate amount of skin, without tension or invading the dorsum of the nose, scars are rarely visible. In addition, the “Inside-Out” technique provides a natural appearance of the medial canthal region because it does not disrupt the normal anatomy of the medial canthal region. There has been a misunderstanding that Asians consider the Caucasian look as attractive and beautiful. Although Asian aesthetic periorbital surgeries focus on achieving the characteristics of Caucasian eyelids [21], including the presence of a superior palpebral fold, less fat on the eyelids, and the absence of the epicanthal fold, this does not mean that the Asian eyelid should completely resemble Caucasian eyelid. Ignoring the inherent interethnic differences would result in an undesirable and often unnatural look. For these reasons, we propose that the goal of the surgery should not be targeted at removing the entire epicanthal fold. Rather, it should help enhance the overall aesthetics of the periorbital area. In line with this, in most cases, the operation was performed for purely aesthetic purposes. That is, the amount/type of epicanthus of patients undergoing this type of operation fairly fell within the normal range of the Korean population. The patients wished to lengthen the palpebral fissure, produce the image of a larger and open eye, without losing a natural look. As such, the operation technique should not emphasize the amount of epicanthal fold that can be corrected or the diverse types it can correct, but instead aim at minimizing scar formation and maintaining a natural appearance. Conclusion The novel “Inside-Out” medial epicanthoplasty has several advantages over other surgical methods. First, there are few conspicuous scars following surgery. Second, the surgical procedure does not interfere with or hinder the original shape of the eyes and, therefore, results in a more natural look. Third, the method can be applied to any type of epicanthal fold. Finally, the amount of skin excision can be controlled depending on the patient’s condition. No complications and conspicuous scar formation were observed in the current cases and the overall patient satisfaction was very high.
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