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Dr. Kwon established Evolution Theory of Asian eyelid

 

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Epicanthal Fold -The relationship between epicanthal fold and double eyelid

7. The relationship between epicanthal fold and double eyelid


The epicanthus is a characteristic of the Asians which forms small, stuffy or unfavorable eyes. The epicanthus makes the distance between the eyes seem wider than the actual distance, and lets eye form sharp or strait shape. More importantly, a double eyelid surgery without correcting the epicanthus can cause an undesirable crease, and even cause it to become loose or faded. The epicanthus is the most significant factor for determining the shape of the double eyelid, but it was not well-known. Previously plastic surgeons also thought that epicanthoplasty is just ancillary procedure, it might be natural because plastic surgeons didn't know what the epicanthus is. Additionally, massive scar formation and unsatisfied result may appear after defective previous epicanthoplasty methods. Considering previous history of Asian blepharoplasty, epicanthal folds have been an important key, but it had not been corrected properly because of defective methods based on defective understanding about epicanthus.

When women have a consultation about the double eyelid surgery, most of them ask for clearer and wider eyes such as the look of an actress. Most women say "I want to have beautiful and clear eyes", or "I want to have bigger eyes and bigger crease after surgery" during surgery consultations.

However, a double eyelid surgery without epicanthoplasty will likely make the eyes look undesirable because this will result in a wide interepicanthal distance and short eye length. If a person who has severe epicanthal folds, small eyes and a wide interepicanthal distance, take only double eyelid surgery itself, the surgery can result in a unfavorable appearance by the epicanthus covering over the epicanthal region. In case of less severe epicanthal folds, the double eyelid surgery alone can possibly make relatively desirable and favorable lines, but only an in-folder type of small double eyelid will appear after all.

Performing double eyelid surgery on Asian eyes without properly managing the epicanthal folds causes inevitably incomplete results or can be a critical reason for getting double eyelids to fade away. In fact, most of the problems after Asian double eyelid surgery are caused by the tension of the remaining epicanthus. Good candidates of Asian eyelid surgery are determined by the degree of the epicanthus. It should be explained to patient that combined epicanthoplasty and double eyelidplasty would creates a clearer and well-defined double eyelid crease by resolving epicanthus and exposing the hidden part of the inner eye better.

In case a of single eyelid, it would be better to undergo both the epicanthoplasty and the double eyelid surgery. When one has a severe epicanthuse, double eyelids must be made by combining two of these surgeries. Although it seems that only magic epicanthoplasty or only double eyeliplasty makes an some effect on eye, by considering the correlation between epicanthus and double eyelid, these two combined surgeries make harmonious surgical plans and dramatic results for beautiful Asian eye.

It is unnecessary to hesitate to have an epicanthoplasty because of the development of magic epicanthoplasty. Recently taking double eyelid surgery combined with magic epicanthoplasty has become a new paradigm of plastic eyelid surgery. 


Structural eyelidplasty in Asian eyelid : Combined Epicanthoplasty and Double Eyelidplasty as One Surgery : new paradigm in Asian double eyelid surgery​



 It could be reasoned that there is no difference in basic anatomical structure of eyelid between Asian and other ethnicities. The presence of epicanthus or absence of supratarsal crease are one of differences of phenotype by relevant environments. What we should do for Asian blepharoplasty is to understand the evolution of eyelid and reverse evoutional processes for stability of surgical crease with minimally invasive technique.​If surgeons understand evolutional relationship between the epicanthus and the supratarsal crease, epicanthoplasty should be considered the core surgery for Asian double eyelidplasty, as there is close relationship between loss of supratarsal crease and development of the epicanthus and epiblepharon. 

​Considering the relationship of the epicanthus  and double eyelid, these combined surgeries can generate a perfect plan and create dramatic results.




Examples) Combination of Magic epicanthoplasty and non-incisional double eyelid surgery 



There are many differences in devolutional eyelidplasty from conventional eyelidplasty without devolutional concept. The epicanthus and epiblepharon is same manifestation except their location. 

Both are composed of preseptal orbicularis muscle and degenerative fibrous tissues which replaced the room of atrophied orbicularis oculi muscles. There are more incidence of mild blepharoptosis in Asian eyelids. We think mild blepharoptosis in Asian eyelid is related with the eyelid evolution. After the evolutional process, the loading conditions of levator muscle had been worsened. The fibrous tissues within the epicanthus and the epiblepharon, vertical skin tension on upper eyelid, hypertrophied orbicularis oculi muscle and hypertrophied preaponeurotic fat pad add levator and muller muscle more loadings, and act as causal factors of blepharoptosis. We can experience the improvement of mild blepharoptosis after devolutional epicanthoplasty often.When we evaluate blepharoptosis, we should consider the epicanthus related factors. When we perform blepharoptosis surgery with devolutional epicanthoplasty simultaneously, correction of blepharoptosis become complete and is expected to get better result.

Also in devolutional eyelidplasty, destructive procedures on surgical crease for stronger adhesion is less necessary. The tensional stress on crease by vertical skin tension is main cause of crease loss after double eyelidplasty in Asians. Contraction of malpositioned orbicularis oculi muscle in vertical direction is also a potential cause of tensional stress on surgical crease. Because we have resolved the possible causes of crease loss with devolutional epicanthoplasty, aggressive adhesion which performed in conventional method is less necessary. In more cases, we can apply non-incisional method for crease formation except excessively thick skin condition with true epiblepharon.

When we should remove excessive and malpositioned soft tissues in cases of droopy eyelids with epiblepharon, conservative resection for resolving the displaced soft tissues of the anterior lamella and partial removal of preaponeurotic fat in the posterior lamella is enough without unnecessary tissue injury. The overactive resection and resultant unnecessary tissue injury only cause prolonged swelling and depression scar.

We think that we need to review conventional procedures of Asian blepharoplasty and theoretical background for adjusting to devolutional Asian blepharoplasty appropriately. If we agree with the eyelid evolution and understand about the epicanthus in relation to double eyelid better, Asian double eyelidplasty would need to be refined more in combination with epicanthoplasty under devolutional concept. 

We think that epicanthoplasty needs to be considered as a core surgery for Asian double eyelidplasty, especially when forming the parallel-type of double eyelid. Epicanthoplasty is not an ancillary surgery in Asian double eyelidplasty,but combined epicanthoplasty and double eyelidplasty deserve one complete "structural eyelidplasty" for Asians.




Examples) Example of an eye with a natural double eyelid and a slight epicanthus. The caruncle(red part) is exposed almost completely and the natural in-out fold is expressed. The eyeline is exposed fully up to the canthal angle(corner) and the eyelashes decorate eyes so beautifully. 






Examples) Magic epicanthoplasty with revisional double eyelid surgery was performed again.(below) 





Examples) Combination of Magic epicanthoplasty and incisional double eyelid surgery 





Examples) This is a case of the double eyelid surgery without the improvement of the epicanthus. 

As you can see, the epicanthal fold of left eye is more severe than the right. The right eye (actually on left from the point of view of the reader) looks unnatural because the out-fold is designed above the epicanthal fold. The line will become unclear starting from the corner of the eye. It is likely to fade away gradually. The left eye shows an in-fold type under the epicanthal fold. When there is epicanthal fold with strong tension, a double eyelid tend to be designed like the left eye where the line is lower and closer to the lashes.


















Examples) Combination of Magic epicanthoplasty and excisional method in the case of severe epicanthus. In-out folds or parallel folds are created, and the eyes have been changed into clear and vivid appearance by correcting epicanthi which makes the eyes have a fierce look. 





Examples) Combination of Magic epicanthoplasty and double eyelid surgery in the case of severe epicanthus in male patient.   

















Examples) Sausage type of double eyelids were made after not taking epicanthoplasty . Magic epicanthoplasty and revisional double eyelid surgery refined the images of eye in manner of natural and distinctive looks.






Examples) This case shows the negative effect of epicanthus on the out-fold(parallel) double eyelid . There is no continuation of line up to the medial corner of the eye(above). Magic epicanthoplasty and medial correction of double eyelid refined the images of eye in manner of natural and distinctive appearance(below). 

















Examples) Partial correction of double eyelid lines with magic epicanthoplasty in incomplete natural double eyelids with epicanthus These types of double eyelid creases are usually located at much lower position near the epicanthal region. When the Magic epicanthoplasty is performed, it is frequently necessary to correct the double eyelid lines at the same time in the epicanthal area to obtain clear double eyelids. 





Examples)The effect of Magic epicanthoplasty to the double eyelid line. This is only after the magic epicanthoplasty is performed without correcting the line. Some people just prefer in-folder lines.













Examples) Buried suture method (non-incisional double eyelid surgery) with magic epicanthoplasty was performed to correct the lines. It shows slight out-fold (parallel) lines after surgery. the line. Some people just prefer in-folder lines. 



















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