Double eyelid blepharoplasty incorporatingepicanthoplasty using Y-V advancement procedure

F.C. Li *, L.H. Ma

Department of Plastic Surgery, Chao Yang Hospital, Affiliate of Capital University of Medicine and Science,8, Bai Jia Zhuang Road, Chao Yang District, Beijing 100020, PR China

Received 27 June 2006; accepted 17 May 2007

Journal of Plastic, Reconstructive & Aesthetic Surgery (2008) 61, 901e905

KEYWORDSEpicanthal fold;Double eyelidblepharoplasty;Surgical correction;Y-V-plasty

Summary Ethnic characteristics of the Asian upper eyelid include the lack of a superior pal-pebral fold, excessive fat, laxity of pretarsal skin, and medial epicanthal fold. Historically,these features have characterised a unique beauty in Asians. With the increase of culturalexchange, the sense of beauty has changed greatly among Asians and most Asians regard eyeswith double eyelids as beautiful. Therefore, surgical creation of a superior palpebral fold (so-called double eyelidplasty) has become the most common cosmetic operation in Asia. How-ever, the presence of an epicanthal fold weakens the aesthetic results of the operation.The size of the epicanthal fold in Asians, whilst varying widely among individuals, is usuallyrelatively small, and thus aesthetically successful effacement rarely requires more complexprocedures as performed in the West. The incision for epicanthoplasty should thereforebe as simple as possible and be confined to the eyelid area. From October 2001 to May2006, Y-V advancement procedure for epicanthoplasty was used in combination with doubleeyelid surgery in 92 cases. Most of the patients attained satisfactory results. There werefew complications in our series. A hypertrophic scar was recorded in three early cases andfaded within 2 to 3 months with satisfactory results. This procedure is simple and more suitablefor people of oriental origin.ª 2007 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published byElsevier Ltd. All rights reserved.

It is reported that 50% of all Asians lack a supratarsalfold,1,2 and double eyelid blepharoplasty is the most com-mon cosmetic operation for Asians. The epicanthal fold(the so-called Mongolian fold), another ethnic characteris-tic of Asians, covers the upper eyelashes and the true uppereyelid margin medially and gives the appearance of short

* Corresponding author. Tel.: þ86 10 85231722.E-mail address: lifcmd@yahoo.com.cn (F.C. Li).

1748-6815/$-seefrontmatterª2007BritishAssociationofPlastic,Reconstrdoi:10.1016/j.bjps.2007.05.008

eyelashes and narrow palpebral fissure. This aestheticallydispleasing appearance is aggravated with a double eyelid-plasty without some kind of epicanthoplasty. Without re-moval of the epicanthal fold prior to or during doubleeyelid blepharoplasty, the final outcome is unnatural andunattractive.3 The Asian epicanthal fold is different fromthat encountered in whites, in which a vertical shortageof skin is problematic, whereas the epicanthal fold in theAsian eyelid is usually associated with skin redundancy of

uctiveandAestheticSurgeons.PublishedbyElsevierLtd.All rightsreserved.

902 F.C. Li, L.H. Ma

the entire upper lid. When the upper eyelid skin is relaxedand hanging over the eyelashes, the skin of the medial can-thal fold is also relaxed. Once the redundant upper eyelidskin in the pretarsal area is resected during the double eye-lid surgery, some of the laxity in the medial canthal area islost. The lax skin in this area is then pulled towards the pre-tarsal fold laterally, creating a sharp skin ridge similar tothat of traumatic web formation. Because of the increasein height of the palpebral fissure by tightening and elevat-ing the pretarsal skin, and the lack of simultaneous horizon-tal increase in length, the palpebral fissure appears bothnarrower and higher. This creates an eye that looks rounderand even produces a startled appearance.4 Therefore, inorder to get better aesthetic results from double eyelid sur-gery, correction of the epicanthal fold is essential.

The purpose of this study was to present double eyelidblepharoplasty incorporating epicanthoplasty using Y-Vadvancement procedure with satisfactory results, minimalscarring and simplicity of design.

Materials

From October 2001 to May 2006, we performed Y-V epican-thoplasty during a double eyelid operation in 92 cases. Agesranged from 18 to 36 years, with an average of 23.2 years.The follow-up period ranged from 1 to 20 months.

Surgical techniques

At first, with the patient in a sitting position with the eyesclosed, the incision for the double eyelidplasty is markedaccording to the patient’s desire and surgeon’s aestheticsense, and the amount of skin resection on the upper eyelidis judged with the aid of the Green forceps. An incision of 6to 7 mm high at the midpupillary level which is parallelto the upper lid margin or slightly flaring laterally, is

preferred. The method of double eyelidplasty is similar tothat of Yoon’s,5 except for the epicanthoplasty.

The jointed point of the tips (point a) of the Y-V-plasty ismarked on the edge of the epicanthal fold at the level of themid-caruncle. Starting from this point, a horizontal line isdrawn medially on the outer surface of the epicanthal foldup to point b (Figure 1A). The length of the line varies in eachcase and is proportional to the prominence of the individualfold. Next, the nasal skin is pulled medially to completely ex-pose the lacrimal lake. From point a, two lines are made. Theline on the upper eyelid corresponds with the planned linefor the double eyelid fold and the line on the lower eyelid lo-cates along the lower eyelid border (Figure 1B). The lengthof the lower line can be adjusted to correct dog-ear defor-mities after approximating points a and b.

Local anaesthesia of 1% xylocaine with 1:100 000 epineph-rine is used. The incision is made through the skin andsubcutaneous tissue. Complete release of tension crossingthe medial epicanthus is performed first. Subcutaneoustissues and muscles lying between points a and b can beresected with scissors until the superficial portions of themedial canthal tendonsareexposed.Thefibrofatty tissueandmuscle that underlies the incision in the epicanthal fold isreleased. The excessive orbicularis oculi muscle is trimmed,and all adhesion bands are subsequently released. Care mustbe taken to avoid injury to the medial canthal ligament.

Release of tension crossing the medial epicanthususually results in a medial triangular skin defect; the V-flap is advanced medially to repair this defect (Figure 1C). Adeep, buried suture using 6/0 clear nylon is performed bybiting the periosteum of nasal bone or midial canthal liga-ment to the tip of the point a. After this suturing, pointsa and b are approximated without tension using 7/0 nylon.

The correction is proper if the caruncle is exposed fullyafter points a and b are approximated. If correction isinadequate, it could be remedied by a further medialadvancement of point a after a longer incision. But

Figure 1 The surgical design of Y-V advancement epicanthoplasty with double eyelidplasty simultaneously.

Double eyelid blepharoplasty incorporating epicanthoplasty using Y-V procedure 903

Figure 2 This 18-year-old girl with epicanthal folds received Y-V advancement epicanthoplasty and double eyelid surgery simul-taneously. (Left) Preoperative view. (Right) Postoperative view 1 year later.

surgeons should keep in mind that the incision should notinvade the nasal skin, because the nasal skin is a dangerousarea in terms of a hypertrophic scar. After the approxima-tion of points a and b, two small triangular areas of skin areresected. When the dog-ears were obvious on the lowereyelids, they could be trimmed parallel to the long axis ofthe eyelid. Both epicanthoplasty and double eyelid surgerywere performed simultaneously (Figure 1D).

Results

Epicanthoplasty using V-Y plasty showed good results inmost cases. There were no recurrences of the epicanthalfold and no disturbances of lacrimal function. Redness ofthe surgical scar was noted in the first 1 to 2 months,however the scar faded by 3 months in all patients. None ofthe patients required revision surgery. Most of the patientsobtained satisfactory results (Figures 2 and 3). Hypertro-phic scars were recorded in three early cases and fadedwithin 2e3 months (Figure 4). No triamcinolone or othertherapies were used in this series.

Discussion

Many methods had been designed to correct the epican-thus. Some of these procedures are too complicated andextensive for the correction of Asian epicanthal folds,ultimately resulting in an unsightly scar. Mustarde’s fourflap6 and its modification,7 VW plasty,8 V-Y advancement,9e11

VM-plasty,12 W plasty,13 square flap,14 have all been used.However, difficulty with design, prominent scarring of themedial canthal and nasal area because of excessive ten-sion, and rigidity of application are potential problems as-sociated with these procedures. The region on theepicanthus, especially in Asian patients, exhibits a biologi-cal predisposition to hypertrophic scar formation, and eventhe most meticulously performed procedure in this areamay be complicated by an aesthetically unpleasant scar,especially when the scars are located beyond the eyelid it-self. So most surgeons were reluctant to do a medial epi-canthoplasty due to the fear of leaving unsightly andlong-lasting scars in the medial canthal area.15,16

In order to avert additional scars, Lee17 used anchor epi-canthoplasty combined with outfold-type double eyelidplastyfor Asians. The disadvantages of the procedure are technicaldifficulty, for which there is a learning curve to avoidminor re-visions, andthepossibilityofactivebleeding,whichmakes theoperation more difficult and time consuming.

According to Park’s4 experiences, unsatisfactory resultsof medial epicanthoplasty often relate to the following fac-tors: (1) complex incisions in diverse directions; (2) inabilityto incorporate the medial canthal incisions with the rest ofthe incision for the double-lid procedure; (3) lack of clearlandmarks and reference points. The medial epicanthalfold is the main ethnic characteristic of the Asian uppereyelid. Approximately 90% of Asians exhibit an epicanthus;the size of the fold, while varying widely among individuals,is usually relatively small, and thus aesthetically successfuleffacement only rarely requires the more complex

Figure 3 (Left) Preoperative view of a 20-year-old girl awaiting double eyelid surgery and Y-V advancement epicanthoplasty.(Right) Postoperative view at 3 months with eyes looking larger than before.

904 F.C. Li, L.H. Ma

Figure 4 A 26-year-old woman with mild epicanthal folds. (A) Preoperative view. (B) Two months after operation, hypertrophicscar developed. (C) Six months after operation, the scar faded with satisfactory results. A small curtain over the medial aspect onthe left eye may be the result of inadequate resection of excessive skin.

procedures. So the method of epicanthoplasty for Asiansshould have following characteristics: simplicity in designand ease of performance. The incision for epicanthoplastyshould be confined to the eyelid area and blend with thedouble eyelidplasty incision.

The design of our procedure is simple and landmarks areobvious, so it is easy to understand and reproduce. The lowerlimb of skin incision of Y-V epicanthoplasty is put along theciliary margins of the lower eyelid thin skin, so there is lesschance of leaving hypertrophic and visible scars. Moreover,horizontal scars along the ciliary margins of the lower eyelidskin are less noticeable. The upper limb of the incision iscontinuous with the incision of the double-fold blepharo-plasty. These final scars were well hidden in anatomic linesand were aesthetically invisible. The inner V-flap is advancedmedially to repair skin defects resulting from the release ofthe epicanthal fold. It also pulls back the laterally displacedmedial canthus and lengthens the horizontal palpebralfissure. The medial canthus is changed from a round shapeto a pleasing almond-like shape with an exposed caruncle.

Hughes10 applied Y-V advancement on the medial can-thus to treat blepharophimosis. However, these proceduresare inappropriate for correction the Asian epicanthal foldbecause of the resultant unsightly scar extending to the na-sal skin. In order to avert scarring, Kao9 and Lee12 used per-ciliary Y-V advancement procedure to correct epicanthalfold This technique averts scarring above and/or belowthe medial canthus by placing less noticeable supracilliaryand subciliary incisions. When the medial epicanthoplastyis performed simultaneously with double eyelid surgery,two incision lines meet each other very closely at the

medial upper eyelid after medial epicanthoplasty and inci-sional upper blepharoplasty. If the skin between the two in-cisions has not been maintained with adequate skintension, the problem of postoperative skin bulging occurseasily. In our procedure, the upper line of Y-V epicantho-plasty is continuous with the incision of double fold bleph-aroplasty, so we can avoid this problem.

There always exists horizontal tension after full releaseof the epicanthal fold, so it is necessary to perform a deep,buried suture biting the periosteum of nasal bone or midialcanthal ligament to the tip of point a. This manœuvre canreduce the tension between point a and point b, which canprevent hypertrophic scar formation. In our early cases, wedid not pay attention to this manœuvre, and three patientsdeveloped a hypertrophic scar, but this situation did nothappen when the deep suturing was used.

The epicanthal fold is not a pathologic condition as inthe Caucasian population but a normal ethnic characteristicin the Asian population. In Asians a little epicanthal fold isacceptable, so the incision should not invade the nasal skin,though the caruncle was not exposed fully.

References

1. Fernandez LR. Double eyelid operation in the Oriental inHawaii. Plast Reconstr Surg 1960;25:257e64.

2. Flowers RS. Upper blepharoplasty by eyelid invagination:anchor blepharoplasty. Clin Plast Surg 1993;20:193e207.

3. Cho BC, Lee KY. Medial epicanthoplasty combined with plica-tion of the medial canthal tendon in Asian eyelids. Plast Re-constr Surg 2002;110:293e300.

Double eyelid blepharoplasty incorporating epicanthoplasty using Y-V procedure 905

4. Park JI. Z-epicanthoplasty in Asian eyelids. Plast Reconstr Surg1996;98:602e9.

5. Yoon KC, Park S. Systematic approach and selective tissue re-moval in blepharoplasty for young Asians. Plast Reconstr Surg1998;102:502e8.

6. Mustarde JC. Epicanthus and telecanthus. Br J Plast Surg 1963;16:346e56.

7. Yoon K. Modification of Mustarde technique for correction of ep-icanthus in Asian patients. Plast Reconstr Surg 1993;92:1182e6.

8. Uchida J. A surgical procedure for blepharoptosis and pseudo-blepharoptosis in Orientals. Br J Plast Surg 1962;15:271e6.

9. Kao YS, Lin CH, Fang RH. Epicanthoplasty with modified Y-Vadvancement procedure. Plast Reconstr Surg 1998;102:1835e41.

10. Hughes WL. Surgical treatment of congenital palpebral phimo-sis: the Y-V operation. AMA Arch Ophthalmol 1955;55:586e90.

SURGICAL TIP

Fat transfer using an epidural needle*

We introduce a novel method of lipoinjection using anepidural needle, replacing the usual blunt Colemancannula for the purpose of added length (Figure 1).

A lady with a breast contour deformity was admitted fora fat transfer to fill in that defect. In the course of theoperation, we attempted to use a typical infiltrationcannula to inject fat into the recipient site from the peri-areolar incision made. However, we found it too short, anddecided to use an epidural needle, which is 1.5 cm longer.This negated the need for another incision closer to the re-cipient site.

The typical lipoinjection cannula is blunt, reducing therisk of damage to underlying structures such as nerves andvessels, and decreases the likelihood of intra-vascularemboli.1

However, sharp cannulae can be employed to breakdown adhesions, e.g. prior to filling a defect undera scar.2 They also give the surgeon better control

Figure 1 The blunt Coleman needle (above) is comparedto the sharp epidural needle (below).

11. Lee YJ, Baek RM, Song YT. Periciliary Y-V epicanthoplasty. AnnPlast Surg 2006;56:274e8.

12. Lin SD. Correction of the epicanthal fold using the VM-plasty.Br J Plast Surg 2000;53:95e9.

13. Mulliken JB, Hoopes JE. W-epicanthoplasty. Plast ReconstrSurg 1975;55:435e8.

14. Wu WH, Xu JF, Shi S. Correction of severe epicanthus using thesquare-flap method. Chin J Plast Surg Burns 1994;10:358e60.

15. Hin LC. Unfavourable results in Oriental blepharoplasty. AnnPlast Surg 1985;14:523e34.

16. Matsunaga RS. Westernization of the Asian eyelid. Arch Otolar-yngol 1985;111:149e53.

17. Lee Y, Lee E, Park WJ. Anchor epicanthoplasty combined without-fold type double eyelidplasty for Asians: do we have tomake an additional scar to correct the Asian epicanthal fold?Plast Reconstr Surg 2000;105:1872e80.

lipoinjecting into the immediate subdermal plane, in fi-brous tissue and in scarred tissue.2

The epidural needle is sharp and can fulfil thepurposes stated above. This process still enabled fatdeposition in small aliquots during needle withdrawal,which Coleman states, is imperative.1,2 This allowsgreater surface area of contact between the fat graftand the vascularised recipient tissues, therefore in-creases the viability of the transplanted fat. It also im-proves the integration of the fat with host tissues, anddiscourages migration.

In our case, the added length of the epidural needlesaved us from making an incision closer to the recipientsite. On this patient, the scar would have been all themore noticeable, as it would have been on the uppermedial quadrant of her breast. The epidural needle iseasily accessible in most theatres and has been shownhere to be an innovative instrument in lipoinjection.

References

1. Coleman SR, Saboeiro AP. Fat grafting to the breast revisited:safety and efficacy. Plast Reconstr Surg 2007 Mar;119:775e85.

2. Coleman SR. Structural fat grafting: more than a permanentfiller. Plast Reconstr Surg 2006 Sept;118:108se20s.

Corrine J. WongBhagwat Mathur

Venkat RamakrishnanSt. Andrew’s Centre,Broomfield Hospital,

Chelmsford, Essex, UKE-mail address: Corrine_wong@hotmail.com

*This paper has not been presented previously. We haveno financial support or benefits by writing this article.

ª 2008 British Association of Plastic, Reconstructive andAesthetic Surgeons. Published by Elsevier Ltd. All rightsreserved.

doi:10.1016/j.bjps.2007.12.072