Medial and Lateral Epicanthoplasty

52.1 Introduction

The epicanthoplasty can elongate the length of the eyes, increase the eye size, and improve the aesthetic results of the double-eyelid formation. Epicanthoplasty along with double-eyelid formation is frequently performed on Asians bearing epicanthal folds. Despite the existence of epicanthal fold correction methods frequently practiced on Asians, including the split V-W plasty of Uchida, the V-Y plasty, the modified Mustarde technique, the simple Z plasty, and the complex Z plasty, these correction methods accommodate numerous problems such as the complexity of surgical techniques, the high possibility for generation of scars caused by the tone of the medial canthus flap, and the reoccurrence of the preoperational state. Several techniques have been introduced that remarkably reduce the tension along the skin suture line such as adding plication of the medial epicanthal tendon with medial epicanthoplasty.

52.2Anatomy and Classification of Epicanthus

The anatomical structure of an Asian’s eye is quite different from that of a Westerner’s (Fig. 52.1). The eyes of Asians do not have the pretarsal skin attached to the levator palpebrae muscle, so they lack supratarsal

D.H. Park

Plastic and Reconstructive Surgery, Catholic University of Daegu, Daegu Catholic Medical Center, 3056-6 Daemyung 4-dong, Namgu, Daegu 705-034, Korea

e-mail: dhpark@cu.ac.kr

folds. While they not only have excessive fat distributed between the orbicularis oculi muscle and the levator muscle, they also have relatively thick palpebral skins and orbicularis oculi muscles. Their orbits are comparatively small so that the orbital margin is more protruded than that of Westerners. Asians also have epicanthic folds that cover up the lacrimal lakes causing the medial canthal area to display fullness. The epicanthal fold indicates the fold initiating from the upper portion of the orbit and covering the medial canthus while being connected to the skin of the nasal bridge. Many muscle and tendon are attached at medial canthal area (Figs. 52.2 and 52.3) and there is fibromuscular tissue below the skin in medial canthal area (Fig. 52.4).

The ideal eyelid for oriental is: The intercanthal distance is 3.0–3.6 cm. The distance ratio between intercanthal distance and horizontal palpebral fissure is 0.90–1.15. The degree of the slant of palpebral fissure is 5–10°. Epicanthus is absent (Fig. 52.5).

There are the epicanthus palpebralis, the epicanthus tarsalis, the epicanthus superciliaris, and the epicanthus inversus [1]. Among these types, the epicanthus tarsalis is displayed most frequently.

52.3 Technique

52.3.1 Medial Epicanthoplasty

The indications of medial epicanthoplasty in Orientals are as follows:

1.Easily visible and severe medial epicanthus.

2.The distance ratio between the intercanthal distance and horizontal fissure of eyelid is larger than 1.3.

3.The distance ratio between horizontal fissure and vertical fissure of eyelid is <3.

4.The distance ratio between midpoint of pupil to medial epicanthus and midpoint of pupil to lateral epicanthus is <1.

The classification of epicanthoplasty includes elliptical excision, using Z-plasty, using Y-V advancement, and using W-plasty.

52.3.1.1Elliptical excision: Von Ammon, Arlt, Hiraga, and Watanabe methods

(a)Von Ammon’s method is glabellar resection from radix region [2].

(b)Arlt’s method is elliptical resection of skin close to medial epicanthus. But this method makes

a

b

remarkable scar. A modified method is used (Figs. 52.6–52.8).

(c)Hiraga’s method is transverse incision and trimming of dog-ear.

(d)Watanabe’s method is modification of Higara’s method to prevent acute angle formation.

52.3.1.2 Z-Plasty Method

Methods using Z-plasty are:

(a)Single Z-plasty:

Rogman’s method: Dictates that the flap, accommodating a pedicle directed toward the superior,

Fig. 52.8 Modified Arlt’s method (periciliary approach)

should be positioned not toward the nose but toward the eyes, i.e., toward the lateral direction. The result is a cosmetic surgery method combining Z plasty and VY plasty, while tugging the old toward the medial, i.e., nasal side, with VY plasty. However, the postoperative suture carries the disadvantage of being able to generate a new fold quite easily.

Sheehan’s method: Draws a Z on the inferior area of the epicanthic fold and designs the postoperative central angle that is positioned lower than the medial canthus, such that the direction of the suture, postoperatively, would be ideal.

Imre’s method: Unlike those of Rogman and Sheehan, has the flap carrying the pedicle on the superior area toward the medial, i.e. nasal side, with the position of Z centered. The resulting disadvantages involve creating unnatural central angles and having difficulty in controlling the supratarsal fold.

Park’s Z-plasty method: After marking for Z-epicanthoplasty incisions are made at the outer epicanthus (dotted lines) and the inner epicanthus is marked. After triangular excision, flap elevation is performed. However Park’s method although effective makes visible scar. In order to make less scar a modified Park’s method (half Z-plasty) is sometimes used (Figs. 52.9 and 52.10).

(b)Methods using double or multiple Z-plasty are various: Blair, Converse (Fig. 52.11) [3], and Mustarde and Spaeth [4].

Blair’s method: Consists of two combinations of the Z plasty. Although it is highly effective as it greatly enhances the vertical direction and abolishes the fold better compared to a single Z plasty method, the zigzag-shaped scar on the medial canthal area is quite noticeable and a sutured line is generated horizontally from the medial canthus causing it to lack aesthetics. In addition, huge dogears, caused by the rotation of flaps, are sometimes created.

Double opposing Z plasty (Converse): Has two general 60° Z plasty types. When comparing this to the singular Z plasty, its effect on eliminating the fold is great, it is suitable for applying on traumatic epicanthic folds, and the transference of the flap is smoother than in Blair’s method. However, even though there is no scar generating horizontally from the medial canthus, the zigzagshaped scar is frequently and, unfortunately, noticeable. This also has the disadvantage of displaying too much of the medial canthus. Mustarde’s method: Adaptable to severe states of

Fig. 52.9 Modified Park’s method (half Z-plasty). From top to bottom: Marking for incision, incision by design, flap elevation, dog-ear removal, postoperative

a

Fig. 52.11 Converse’s method. (a) Design. (b) Postoperative

b

b

epicanthus or epicanthic folds with severe scars and is quite efficient in eliminating the folds such that it easily displays the medial canthus into the open, bringing great results. The medial canthal ligament is also shortened and fixed so that there are few cases of reoccurrence after the operation. However, there is the disadvantage of noticeable

zigzag scars. In order to improve this, the flap on the superior area of the medial canthal line must be detracted and the epicanthic fold may be corrected by solely using the inferior flap [5]. Mustarde’s method can be modified by using a Z-plasty on its lower part [6]. The upper part is trimmed by dog-ear excision (Fig. 52.12).