The epicanthal fold is a skin fold over the lacrimal lake resulting from the certain anatomical structures including orbicularis oculi muscle, medial palpebral tendon and adjacent structures in the medial canthal area [1,2]. This fold is the medial extension of the upper eyelid skin and covers a portion of the lacrimal lake. The eyes with epicanthal fold are usually unattractive aesthetically and cause some restrictions when performing double eyelidplasty and other ancillary procedures [3]. It has been investigated that the incidence of epicanthal fold is 50-90% in Korean and Japanese populations [4]. Medial canthal area exhibits distinctive anatomic variations according to the presence or absence of the folds, and classified into four types (Table 1) [5].

Although an epicanthal fold is not a pathologic condition, numerous procedures have been introduced to correct this structure. Prominent epicanthal folds can be worsened when performing double eyelidplasty only without medial epicanthoplasty, because double eyelidplasty causes more tension on the epicanthal fold and results in an unpleasant round medial canthus [6]. Surgical techniques to improve epicanthal fold are mostly based on the concept of local flaps, besides they were developed and transformed to overcome drawbacks of previously conducted procedures. These techniques include the Mustarde four-flap [7], V-M plasty [8], V-W plasty (Uchida procedure) [9], modified V-Y flap [10], and various Z-epicanthoplasty techniques [11]. However, there are potential disadvantages with these techniques such as unnatural ciliary position of the lower eyelids, prominent scarring caused by excessive tension and limitations to obtain pretarsal fold running parallel to the upper eyelid margin. Medial epicanthoplasty using the skin redraping method was introduced to overcome previously mentioned problems [12]. Nevertheless, there were still disadvantages including medial canthal contracture due to superficial dissection and volume deficiency of the lower eyelid.

We propose a modification of the skin redraping method. There are supplementary points and procedures compared with the conventional technique, for instance, the designation of subciliary and supratarsal fold line, intramuscular dissection and preseptal orbicularis myotomy without muscle resection.

Medial epicanthoplasties using modified skin redraping method were performed on 386 patients from December of 2011 to February of 2013. There were 43 male and 343 female patients. The average age was 24 years (range from 16 to 52 years). The follow-up period was 3 months to 12 months, with an average of 7.5 months. Patients were evaluated to identify the presence of entropion or ectropion, exophthalmos or enophthalmos, and a medical history of keloid or hypertrophic scar. All of the epicanthal folds in above group belonged to type II or III, according to the Park’s classification (Table 1) [5]. 56 patients underwent only epicanthoplasty. 330 patients underwent simultaneous double eyelidplasty.

A total of 386 patients underwent operative procedures employing the described surgical techniques; 330 of this group went through with simultaneous double eyelidplasty. Most of the patients obtained aesthetically satisfactory results being followed up from 3 months to 12 months postoperatively (Fig. 5, 6).

The mean follow-up period was 7.5 months. There was no recurrence of the epicanthal folds and wound related complications. Patients were followed up with interviews and photographs were taken at the same time. There was not any patient who complained about visible scarring at the medial epicanthal area. Tenderness and swelling in a small number of patients usually lasted up to 1-2 months and disappeared without revision or additional procedures.

The medial epicanthal fold is defined as a semilunar fold of skin that runs downward from the upper eyelid at the side of the nose with its concavity directed to the inner canthus. These epicanthal folds result in a round-looking inner eye and make the palpebral fissure narrower. It has been suggested that epicanthoplasty should be focused on several anatomic manifestations; the arrest in generation of the open epicanthus, the excessive development of skin on the root of the nose, a redundant attachment of orbicularis muscle and fibrofatty tissues beneath the fold, and abnormal forces of the orbicularis muscle resulting in tension on the skin [12].

The epicanthal fold, in addition to the eyelid with single fold, is a distinctive feature of East Asian populations, which are regarded as less attractive appearance. Epicanthoplasty can create a sharp medial corner of the epicanthus and widen the palpebral fissure which allows the eyes look more open. Many epicanthoplasty methods had been introduced to correct epicanthi fold, such as elliptical excision, Z-plasty [4-6], W-plasty [8], horizontal Y-V advancement [2] and other modified techniques [3,10,11]. Certain methods, however, created deficiency of the skin tissue and prominent scarring in the medial canthal area, which does not contribute to the attractive appearance.

Medial epicanthoplasty using the skin redraping method was established by Oh YW in 2007 [12]. This technique went after “tension free epicanthoplasty” because a prominent scar of the medial canthal area after epicanthoplasty could be caused by excessive tension and rigidity. Two independent procedures were performed at both muscle and skin tissues. First, preseptal orbicularis muscle was released. Second, tension on the skin was released by dissecting the adhesion between skin and orbicularis muscle. Nevertheless, there were several limitations including postoperative contracture and pigmentation due to superficial dissection on the subdermal plane, and downward direction of the cilia of the lower eyelid.

The authors’ modifications were focused on those drawbacks of the conventional skin redraping method. First, intramuscular dissection is safer than raising subdermal flap superficially, which can cause postoperative contracture, hypertrophic scar, long lasting edema, and pigmentation. We can raise the lower flap in various surgical planes. Musculocutaneaous flap has limitation of moving, so may have some limitations in redraping, and can result in tension on the suture site consequently. On the contrast, pure skin only flap has good mobility, however has some limitations that we described above. Second, preseptal orbicularis muscles and medial raphe should be released by myotomy, not myectomy of muscular tissues for prevention of volume deficiency of lower lid. Third, removal of the minimal amount of remnant skin and dog ear tissue is recommended for reduction of tension. If adequately dissected, some remnant tissues are noted in lower lateral part. Trimming out is not recommended, but they should be sutured to medial side to augment and reduce tension in medial side. Fourth, Y-shape incision involving subciliary line of the lower eyelid and supratarsal fold line of the upper eyelid allows operator to mobilize the position of medial canthus horizontally and vertically. Appropriately designed supratarsal fold line can be extended to the double fold line for concomitant eyelidplasty. The other purpose of extending incision to upper eyelid is the prevention of dog ear deformity. With conventional redraping method, dog ear deformity can be easily met at the end of trimming site in upper lid. The lower part tissue should be preserved to maintain configuration and volume of lower cilia, but more active trimming the upper part is recommended to achieve ‘deep set eyes’. Aforementioned modifications helped lower cilia to preserve their original position and direction avoiding downward distortion and even ectropion.

One of the most common and painful result is excessive vertical, horizontal enlargement and resulting caruncle exposure. The cause of this event is overestimation, over-excision of soft tissues and tension. In addition, excessive release should be avoided because it may result in too strong and sharp appearance.

Care must be taken to prevent complications. Medial epicanthus is close to the lacrimal canaliculi, and anatomical structures should be considered during the procedure. Temporary epiphora caused by partial obstruction of the lacrimal canaliculi from swelling can occur. These can be resolved without additional treatments. There are possibilities of certain degree of asymmetry.

Medial epicanthoplasty using a modified skin redraping method was performed to upgrade the conventional method. Authors’ procedures including Y-shape incision, intramuscular dissection, releasing with myotomy of medial raphe and minimal skin resection helped preserving original ciliary position and maximizing natural appearance. As a conclusion, medial epicanthoplasty using a modified redraping method is very effective method to correct medial epicanthal fold.