Epicanthal Fold -Fading double eyelids and epicanthal folds.
8.Fading double eyelids and epicanthal folds.
Although the fading fading of double eyelid is undesirable, it may occur after some period of time. The most important thing is to analyze the causes and correct them by applying suitable methods. There are three main causes for fading. First, it is caused by weak fixation. Second, it is caused by blepharoptosis(weak eye-opening power). Third, the epicanthal fold plays an important role for the fading of the line. Unless a double eyelid surgery meets certain requirements, the double eyelid line will not be able to last for long time. If a person with severe epicanthus undergoes a double eyelid surgery only, the line of the eye would rather get loose or fade out. When severe epicanthus makes the double eyelids look unnaturally thick(sausage phenomenon), it is difficult to correct after all.
There are many differences in devolutional eyelidplasty from conventional eyelidplasty without devolutional concept. In devolutional eyelidplasty, destructive procedures on the surgical crease for stronger adhesion becomes less necessary. The epicanthus exists as a remnant fibromuscular volume on the upper medial canthal region with vertical(actually diagonal, relative meaning in relation to horizontal supratarsal crease) skin shortage and tension which causes difficulty in horizontal skin folding. It acts as a major hindrance of a double eyelid formation in Asian blepharoplasty. The fibrous tissues and malpositioned orbicularis muscle prevents the even transmission of levator muscle power toward the medial skin because the aponeurotic fibers have been detached and do not extend to the epicanthal skin area any more. The preexisting vertical skin tension acts as tensional stress on newly formed surgical crease. The epicanthal skin tension is considered as a major factor which inhibits the sustainability of surgical crease in Asian double eyelidplasty. Also, the malpositioned orbicularis muscle can be reactivated as a vertically acting inhibitor which causes active tensional stress on mid-lateral surgical crease, especially when we have performed the outfold type double eyelidplasty without epicanthoplasty.
The tensional stress on crease by vertical skin tension is the main cause of crease loss after double eyelidplasty in Asians. Contraction of malpositioned orbicularis oculi muscle in a vertical direction is also a potential lcause 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 malpositionedsoft 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 lamellais 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 the 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 incidences of mild blepharoptosis in Asian eyelids.
We think mild blepharoptosis in Asian eyelid is related with the specifics of eyelid evolution. After the evolutional process, the loading conditions of levator muscle had 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 increase loading onto the levator and Muller muscle, and act as causal factors of blepharoptosis. Patients can often experience the improvement of mild blepharoptosis after devolutional epicanthoplasty. When we evaluate blepharoptosis, we should consider the epicanthus-related factors. When we perform blepharoptosis surgery with devolutional epicanthoplasty simultaneously, correction of blepharoptosis becomescomplete and is expected to get better results.
Examples) Getting loose or fading of lines after inappropriate double eyelid surgerie
Examples) Cases where both the double eyelid surgery and epicanthoplasty are needed.
Examples) The lines after non-incisional surgery only results in in-fold type(above). After Magic epicanthoplasty and double eyelid surgery (buried suture method), it shows symmetrical in-out fold double eyelids.
Examples)Combination of Magic epicanthoplasty and revisional double eyelid srgery. If an out-fold(parallel) line is created without improving the epicanthus, the double eyelid line will look awkward and incomplete. The lines (pre revisional photo) seem very unnatural. A line created by the combined epicanthoplasty and double eyelid surgery provides a clear and natural appearance on proper physical conditions. When epicanthi are severe and the actual eyeline is covered by the eyelid skin, the structural double eyelid surgery including proper surgical technique should be performed to create beautiful and admirable eyes.
Examples) These case shows the negative effect of epicanthus in the eyes with out-fold double eyelids. There is sausage-like fullness and no continuation of line up to the medial corner of the eye(above). Magic epicanthoplasty and revisional double eyelid surgery refined the images of eye in manner of natural and distinctive appearance.
Examples) This case shows the negative effect epicanthus in the eyes after out-folder(parallel) double eyelid surgery. There is no continuation of line up to the medial corner of the eye(above). Magic epicanthoplasty refined the images of eye in manner of natural parallel line appearance(below).
Examples)This case shows the negative effect of epicanthal folds. There is asymmetric natutal double eyelid line on the medial corner of the eye(above). Magic epicanthoplasty and double eyelid surgery refined the images of eye in manner of symmetric out-fold(parallel line) appearance(below).
9.Why does devolution epicanthoplasty and combined double eyelidplasty become the new paradigm for Asian blepharoplasty?
Double eyelidplasty is the most frequent cosmetic procedure for Asians, and the epicanthus was a conundrum which limit cosmetic result of double eyelidplasty. Double eyelidplasty without epicanthoplasty tends to be unattractive or unnatural.
Aesthetically, the epicanthal fold is worsened when performing double eyelidplasty without epicanthoplasty, because double eyelid formation aggravates vertical tension on epicanthal skin. It has been a long-standing dilemma for plastic surgeonsin regards to which procedure to choose, i.e. infold type double eyelidplasty with a less satisfactory result or outfold type double eyelidplasty with concomitant epicanthoplasty, taking risk of hypertrophic scar in Asian eyelid. When the epicanthal fold is severe, the surgical incision of skin flap also become longer, and a scar could be easily visible in conventional method, which based on the concept of local skin flap and lacked a consideration of upper orbicularis muscle and vertical epicanthal tension.
Although it has been reasoned that combined epicanthoplasty is necessary in Asian double eyelidplasty, there had not been clear understanding about epicanthal fold(2004), resulting in controversies for solution. There have been so many epicanthoplasty methods developed in its early days, which are mostly based on skin flap concept. Current methods are combined techniques including skin excision, Z-plasty, myotomy or myectomy of preseptal orbicularis muscle, skin redraping, plication of medial canthal ligament and so on.
The development of incomplete methods were unavoidable without understanding about true nature of the epicanthus. 10 years ago (2004), only a few patients knew about the epicanthoplasty. During consultations on double eyelid surgeries, it took a long time for us to explain and make the patients understand about the necessity, effectiveness, and usefulness of the magic epicanthoplasty and the important relationship between the double eyelids with the epicanthus. Until now, many people are regarding epicanthoplasy as a kind of meagerly effective surgery for just the lengthening of eyes by cutting a little amount of skin of the epicanthal area, similar to the lateral canthoplasty. As the clinical significance of the epicanthus is mainly related with Asian double eyelidplasty, essential epicanthoplasty should be a key to plastic surgeons for choice of all the type of double eyelid including high outfoldtype(parallel type). But, there has not been a potent epicanthoplasty method which deserves universal solution for Asian double eyelidplasty in early 2000.
We proposed that the epicanthus developed in the eyelid evolutionary process. Under this theory of eyelid evolution, we developed a new method for Asian eyelidplasty. Through more than 5000 cases of patients who already underwent devolutional eyelidplasty, our method has proved to be a very satisfactory and universally applicable method for Asian eyelid. The surgical outcomes are very natural. We could lessen the rate of sausage phenomenon, loss of surgical crease and hypertrophic scar obviously. We think that many recent anatomical studies and clinical experiences support our theory. Magic epicanthoplasty is a surgery based on the devolutional concept that reverses evolutionary processes, so it is the universal solution for the various Asian epicanthi.
Through high satisfaction and consistent natural result by people who already underwent, the Magic epicanthoplasty has converted negative recognition of epicanthoplasty positively. Now, through the development of the Magic epicanthoplasty, it is unnecessary to hesitate epicanthoplasty due to scar or ineffectiveness. Considering the relationship of a epicanthal fold and a double eyelid, these combined surgeries can generate a perfect plan and create best results. Now, devolution epicanthoplasty plus double eyelidplasty, these two combined surgery is becomong the firm basic concept(Structural eyelidplasty concept in Asian eyelid : Combined Epicanthoplasty and Double Eyelidplasty as One Surgery) for the Asian blepharoplasty. We believe that the magic epicanthoplasty developed in Teuim plastic surgery can help Asian people who want to have a wide and beautiful expression of eyes.
Examples) Scar revision on the eyes with severe scar caused by conventional epicanthoplasty
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