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How to address the epicanthal fold in the Asian eyelid: `No Scar Asian Epicanthoplasty' technique provides simple, graded procedure. (Avoids complications).
From: Ophthalmology Times | Date: 10/1/2002 | Author: Anderson, Richard L.; Jordan, David R.; Yen, Michael T.
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Formation of a "double eyelid" by creating an upper eyelid crease with aponeurotic fixation has become one of the most popular cosmetic procedures in many Asian patients.
In those individuals with epicanthal folds, however, removing the upper eyelid skin without addressing the epicanthal fold creates additional tension along the fold and accentuates its appearance.
In the past, epicanthal folds were thought to be due to excess skin, and early techniques involved excision of the fold. This almost always created secondary folds and noticeable scarring. Z-plasty transposition flaps and Y-V advancement procedures were directed toward treating what was thought to be a shortage of tissues and their resulting tension lines.
These procedures all create additional incisions and can cause prominent scarring in the medial canthal region. Unnatural folds and lines can be created by the incisions, which are visible postoperatively and may be more cosmetically unacceptable than the original epicanthal fold.
Our "No Scar Asian Epicanthoplasty" is a simple technique of removing the excessive muscle and softening or eliminating the epicanthal fold of the Asian upper eyelid without creating incisions in the medial canthal region, thus avoiding these complications.
Instead of creating complicated transposition flaps and unsightly incisions, we perform a subcutaneous epicanthoplasty in conjunction with upper eyelid blepharoplasty or ptosis repair. The upper eyelid crease incision and the epicanthal fold are marked prior to infiltration with local anesthetic. The incision should not extend into the medial canthal region or over the crest of the epicanthal fold.
Upper eyelid blepharoplasty or aponeurotic ptosis surgery is performed in the usual manner. Excision of the underlying musculature from the epicanthal fold begins at the medial end of the eyelid crease incision (Figure 1). Tension on the medial aspect of the incision in the direction of the epicanthal fold demonstrates the hypertrophic orbicularis muscle underlying and creating the epicanthal fold.
[FIGURE 1 OMITTED]
The skin of the epicanthal fold is elevated with skin hooks, and the orbicularis muscle is dissected away from the overlying skin (Figure 2). During the dissection and excision of the orbicularis muscle, the angular or infratrochlear vessels may be encountered, and meticulous cautery is essential to maintain hemostasis. Direct cauterization of the skin must be applied cautiously to prevent scarring.
[FIGURE 2 OMITTED]
The extent of the dissection and excision of the underlying hypertrophic orbicularis muscle should be graded depending on how much the epicanthal fold is to be softened. If complete elimination of the epicanthal fold is desired, deep tissue fixation at the medial edge of the blepharoplasty incision is accomplished by anchoring the skin to the deep tissues with a strong absorbable suture, such as 6-0 chromic catgut (Figure 3). One or two interrupted sutures are usually sufficient to provide adequate deep fixation and further eliminate the epicanthal fold and prevent its recurrence. The eyelid crease incision is then closed in the usual manner. Antibiotic/steroid ointment is applied to the incision, and the patient is instructed in routine postoperative wound care.
[FIGURE 3 OMITTED]
By aggressively removing the musculature underlying the epicanthal fold, with the "No Scar Asian Epicanthoplasty" the surgeon is able to avoid the use of complicated and unsightly transposition flaps. There is minimal risk of web formation or scar formation in the medial canthal region since no skin incisions are made in that area.
This technique does not create unnatural lines, folds, or scars, and it is simple to perform in conjunction with upper eyelid blepharoplasty or ptosis repair. An added benefit of this technique is that it can be graded either to soften or to eliminate the epicanthal folds depending on the amount of musculature removed.
In our experience, most Asian patients do not wish to eliminate their epicanthal folds completely and have the occidental eyelid appearance. Their expectations are to have a less noticeable epicanthal fold after creation of an upper eyelid crease rather than a more prominent epicanthal fold as occurs if nothing is done to soften the fold. This creates the cosmetically desirable "Euro-Asiatic" eyelid rather than an occidental eyelid. In summary, softening of the epicanthal fold is necessary when creating an upper eyelid crease in the Asian patient. We believe that the cosmetic correction of most Asian epicanthal folds can be performed without the use of confusing and complicated transposition flaps. Our technique is a simple, graded procedure that can be performed in conjunction with upper eyelid blepharoplasty or ptosis repair.
* Yen MT, Jordan DR, Anderson RL. No-scar Asian epicanthoplasty: a subcutaneous approach. Ophthal Plast Reconstr Surg 2002;18:40-44.
Michael T. Yen, MD, is assistant professor of ophthalmology, Cullen Eye Institute, Baylor College of Medicine, Houston, TX.
David R. Jordan, MD, is professor of ophthalmology, University of Ottawa, Ontario, Canada.
Richard L. Anderson, MD, editor of Plastics Pearls, is an ophthalmic and facial plastic surgeon. He is medical director of Center for Facial Appearances, Salt Lake City, UT