The surgical procedure was performed under local anesthesia, with the patient in the supine position. The surgical method was a modification of the conventional reconstruction technique used after medial epicanthoplasty. As illustrated in Fig. 1, the approach resembled traditional V-Y advancement reconstruction, including the determination of points a, a’, b, and c. Point a represented the most medial end of the currently exposed medial canthus, while point a’ was the anticipated final position to which the V flap would be advanced to cover the red caruncle. Points b and c were respectively located at the vertices of the upper and lower portions of the V flap, the points where the upper and lower eyelids intersected with an imaginary vertical tangent line drawn from the lateral border of the exposed caruncle, and the points just above and below the eyelash line. Initially, as depicted in Fig. 1, incisions were made along the lines connecting points a to b and b to c. The V-Y advancement skin-muscle flap was then elevated along the medial canthal margin. When elevating the V flap, a portion of the pretarsal orbicularis oculi muscle was included. Dissection continued in the same layer medially and towards the upper and lower regions. To tighten the lax medial canthal tendon (MCT), the underlying pretarsal orbicularis oculi muscle and MCT were sutured using a horizontal mattress technique with buried sutures in the upper and lower sections, respectively, using 6-0 nylon (Fig. 2). Although anatomical variations exist among patients, point b’ in Fig. 2 generally corresponds to point b in Fig. 1 and is located approximately 1 mm above it. Similarly, point c’ corresponds to point c and is situated approximately 1 mm below it. Point a1 is approximately 1 to 2 mm medial to and 1 mm above point a, while point a2 is 2 mm below a1. Next, point a of the upper area of the V flap and point a’ of the lower area were advanced, and a buried suture was placed using 7-0 monofilament polydioxanone suture material (Fig. 1). The positions of points a and a’ should be adjusted based on the individual’s anatomy. Finally, skin closure was achieved with 7-0 silk sutures to complete the Y flap (Fig. 1). Notably, the locations and measurements of landmarks in this surgical technique may require modification based on the patient’s features.

An 85-year-old man presented with drooping of the right medial canthus and exposure of the right caruncle. He had no history of eye surgery, and the changes in his eye were attributed to the aging process, without any specific ocular conditions. Due to the excessive exposure of the caruncle and asymmetry of the medial canthal area, surgical intervention was undertaken to correct the overexposure and improve symmetry. The surgical technique described was applied to the right side of the affected area. The stitches at the sutured area were removed 7 days after the surgery. Throughout 4 months of follow-up, the patient was satisfied with the postoperative cosmetic improvement, and no complications were noted during wound healing. No noteworthy deformity or recurrence was observed during the follow-up period (Fig. 3).

A 71-year-old woman presented with widening of both medial canthals. She had no specific medical conditions affecting her eyes and no history of eye surgery, and she exhibited age-related changes to both eyes. The patient had noticed bilateral caruncle exposure and horizontal elongation of the medial canthus over many years. No other ophthalmic symptoms were noted; however, the patient did exhibit left-sided blepharoptosis, which was also addressed during surgery. The surgical technique to correct the medial canthal widening was performed bilaterally. Furthermore, left levator advancement was conducted to correct the left blepharoptosis concurrently with the medial canthal procedure. Postoperatively, the previously elongated bilateral medial canthus appeared horizontally shortened in comparison to the medial end of the eyebrow, with an increased inner canthal distance. The patient was satisfied with the cosmetic outcome (Fig. 4). Over 6 months of follow-up, no complications arose during the wound healing process, and no specific scar management products were required. No postoperative deformity or recurrence was observed.