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Dr. Kwon established Evolution Theory of Asian eyelid

 

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Epicanthal Fold

home link home > Epicanthal Folds

 

01What is the epicanthus?
( = Epicanthal fold, Epicanthic fold, Mongolian fold)

 

Fig. Various types of epicanthus

The epicanthus exists as a normal characteristic in Asian ethnicity, and it is peculiar to East Asians.
The epicanthus exists as a normal characteristic in Asian ethnicity, and it is peculiar to East Asians. The true incidence of the Asian epicanthus is uncertain. But at least most people have the epicanthi of varying degree with absence or incomplete presence of supratarsal crease. Dr. Kwon reasoned that the epicanthus is a manifestation of the eyelid evolution by hypertrophy of the orbicularis oculi muscle. The affected areas of eyelid can be divided into three parts in aspect of their evolutional processes. The manifestations of the eyelid evolution consists of 1) The epicanthus with vertical skin shortage and tension on upper medial eyelid, 2) The epiblepharon with loss of crease on the rest upper eyelid.
3) Skin fold on lower eyelid.

 

Fig. (Left) Three parts of the eyelid which are affected in evolutional processes. (Right) The epiblepharon is formed after the epicanthus formation for additional veiling of the eye.
Severe epicanthus-related skin fold on lower eyelid is developed after epicanthus formation
but before complete loss of supratarsal crease in the eyelid evolution. ​ ​

The main part of the eyelid evolution is the bulging epicanthus of upper medial eyelid. The upper medial eyelid bulged with soft tissue toward eyelash, directing inferomedially to the medial canthal ligament along the rudimentary supratarsal crease. Under the skin of epicanthus, there are dense fibrous tissues and various amounts of orbicularis oculi muscle fibers. The second part is the skin fold on lower eyelid inferior to medial canthal ligament. Skin fold and related wrinkles on lower eyelid are formed by pulling-up traction mechanism. The last part is the epiblepharon lateral to the point S ,which formed after loss of mid-lateral supratarsal crease and displacement of orbicularis muscle like the epicanthus.

Examples) Typical Asian eye with a single eyelid accompanied with severe epicanthus


The epicanthus is a resultant manifestation by atrophy and fibrous degeneration of hypertrophied orbicularis oculi muscle after the active processes of the eyelid evolution. Von ammon first used the term 'epicanthus' in 1860. For exact understanding about the evolution of eyelid, we need to define correctly the term “epicanthus” which means epicanthus itself with or without skin fold on lower eyelid equivocally. So far the epicanthus means“ a vertical fold of skin over the angle o fthe inner canthus”. The expression word-‘fold’-is not good. And the commonly used term ‘epicanthal fold’ is inappropriate to describe the condition of Asian epicanthus. It may mislead plastic surgeons to understand epicanthus as a fold. When we describe skin fold on lower eyelid-‘Epicanthus-related skin fold of lower eyelid’-is a more appropriate term considering its location.The epicanthus-related skin fold on lower eyelid is just skin fold by traction force which resulted from pulling-up of origin point during contraction of preseptal orbiculraris muscle. Formation of prominent fold on the lower eyelid is an ancillary manifestation which is formed between formation of epicanthus and complete loss of supratarsal crease over time.

 


Fig. (Left) A Caucasian eyelid on strong frowning who has hypertrophied orbicularis muscle., Notice angular point (point S) on which sheer stress is concentrated.
(Middle left) Asian single eyelid on strong frowning (Middle right) Relaxed eyelid with drawing of supratarsal crease. (Right) Open eyelid with crease formation by stick.

Von ammon first used the term 'epicanthus' in 1860. For exact understanding about the evolution of eyelid, we need to define correctly the term “epicanthus” which means epicanthus itself with or without skin fold on lower eyelid equivocally. So far the epicanthus means“a vertical fold of skin over the angle ofthe inner canthus”. The expression word-‘fold’-is not good. And the commonly used term ‘epicanthal fold’ is inappropriate to describe the condition of Asian epicanthus. It may mislead plastic surgeons to understand epicanthus as a fold.

When we describe skin fold on lower eyelid-‘Epicanthus-related skin fold of lower eyelid’-is a more appropriate term considering its location.The epicanthus-related skin fold on lower eyelid is just skin fold by traction force which resulted from pulling-up of origin point during contraction of preseptal orbiculraris muscle. Formation of prominent fold on the lower eyelid is an ancillary manifestation which is formed between formation of epicanthus and complete loss of supratarsal crease over time. Formation of epiblepharon is consequent to loss of mid-lateral crease and displacement of orbicularis muscle. The epiblepharon is a continuous structure with epicanthus in the upper eyelid and consists of the same composition as the epicanthus. The epicanthus and epiblepharon are purposeful structures of the evolutional process for eye protection, but the skin fold on lower eyelid is an unnecessary by-product. If we include the epicanthus itself and skin fold on lower eyelid into the meaning of ‘epicanthus’, the epiblepharon should be included also in the evolutional aspect.

It is appropriate that ‘epicanthus’ means epicanthus itself excluding skin fold on lower eyelid.
The main actor of eyelid evolution is the upper medial portion of preseptal orbicularis oculi muscle.The epicanthal skin region was originally crease. The epicanthus bulged from concave crease to convex shape with concurrent loss of medial crease consequent to detachment of aponeurotic expansion.

The shape of bulging convexity is due to gravitational displacement of anterior lamella including hypertrophied preseptal orbicularis muscle. So it would be reasonable that we call the epicanthus as ‘epicanthal bulging’ instead of 'epicanthal fold.’ Nevertheless, bulging or fold only means or indicates a part of affected eyelid areas. So we think that we need to better define each part ‘epicanthus’, ‘epiblepharon’,'epicanthus-related skin fold’ separately to remove any confusion.

 

Examples) Combined magic epicanthoplasty and non-incisional double eyelid surgery


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 epicanthus 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 epicanthus The epicanthus veils various amounts of inner medial canthus, so it makes Asian eyes look stuffy aesthetically.
​ ​

 

Evolution of the Epicanthus (Kwon’s Theory)

Fig. The evolutionary process of the eyelid

Underdeveloped nasal bone, excess of horizontal medial canthal skin relative to the vertical skin shortening, excess of orbicularis muscle and abnormal skin tension are described as causes of the epicanthusby plastic surgeons previously.
There is an anthropological hypothesis that the epicanthus is an outward phenotype which is the result

of evolution for adaptation to relevant environments. Genetically, all modern humans are included into the subspecies Homo sapiens sapiens,i.e. the subspecies ofHomo sapiens. It has been reasoned that the racial differences of modern humans are just phenotypic variations. But, the developmental mechanism of Asian epicanthus was not suggested clearly.

Dr. Kwon reconsidered basically without stereotype for the epicanthus. As is the standard for all evolutionary adaptations, the human muscle system would evolve in its efforts to increase survivability. It is clear that the evolution of eyelid muscles are based upon how humans operated in the relevant environments.

Anthropologists had already presumed the strong UV, Siberian cold, yellow dust of northeast of Asia as causes of the epicanthus. There would be strong repeated contraction of upper orbicularis muscle and depressor supercilli muscle in Asian eyelid for frowning. Excessive muscle contraction would be inevitable action for protection of eyes from environmental harshness. Environmental adaptation would be a basic cause for formation of the epicanthus.

Dr. Kwon suggested Kwon's theory for the evolution of Asian eyelid.

 

Fig. The stage of the eyelid evolution according to the main action of orbicularis oculi muscle in Kwon’s theory. Loss of medial crease, formation of the epicanthus, loss of mid-lateral crease, formation of the epiblepharon occur in sequence. I. Stage of hypertrophy: The hypertrophy of orbicularis oculi muscle and depressor supercilli muscle develop by repeated frowning. The hypertrophy of orbicularis oculi muscle cause attenuation of the aponeurotic expansion which penetrate through orbicularis muscle. The aponeurotic penetrations
loosen and become sparse.

II. Stage of sheer stress: Complete detachment of aponeurotic expansions with loss of supratarsal crease takes place on point S by sheer stress. The detachment of aponeurotic fibers can occur beneath the orbicularis muscle or on the orbicularis muscle. Orbicularis oculi muscle contraction acts as sheer tensional stress with depressor supercilli muscle. The depressor supercilli muscle plays an ancillary role.

III. Stage of tensional stress: The successive loss of medial crease below point S results from displacement of preseptal orbicularis oculi muscle toward eyelash and the vicious cycle between malpositioned muscle hypertrophy and crease loss. The orbicularis oculi muscle contraction mainly act as tensional stress on remaining aponeurotic fibers and medial crease.

IV. Stage of compressional stress: Excessive contraction of orbicularis oculi muscle acts as compressional stress on overlying skin of upper medial eyelid with resultant vertical skin shortage and tension. The tight tension band develops due to vertical skin shortening of upper medial eyelid.

V. Stage of traction and tensional stress: Contraction of orbicularis oculi muscle acts as tensional stress on remaining supratarsal crease resulting in successive loss of supratarsal crease on the upper eyelid superiorly and/or act as traction force causing skin tent toward point P on the lower eyelid inferiorly. During and after formation of a tight tension band by vertical skin shortage, the orbicularis oculi muscle contraction causes a prominent skin fold on the lower eyelid by pulling-up the muscle point of origin like setting up a tent pole during contraction. The preseptal orbicularis muscle pulled up its origin superolaterally with skin tent on lower eyelid during contraction.

VI. Stage of degeneration: The atrophy of orbicularis oculi muscle and accompanying degenerative fibrosis develop, leaving the epicanthus with incomplete crease or epicanthus without crease.
The hypertrophied orbicularis oculi muscle becomes atrophied and replaced by fibrosis, but there remains vertical skin shortage and tension left on upper eyelid and skin fold and wrinkles on lower eyelid. Also there has been left centripetal fibrosis toward point p under the skin of lower eyelid.

 

Kwon’s Classification of the epicanthus in relation to supratarsal crease.

 

Fig. Classification of the epicanthus in relation to supratarsal crease.

Type I : Attenuated original crease without epicanthus (exopthalmic Asian eyelid)
Type II : Minimal epicanthus without crease. (without epibepharon)
Type III : Epicanthus with attenuated original crease
Type IV : Epicanthus with lowered infold crease
Type V : Epicanthus without crease (epicanthus and epiblepharon).

The epicanthus is a remnant manifestation of eyelid evolution which resulted from hypertrophy of upper orbicularis muscle and related aponeurotic attenuation. . Increased blood supply induced by hypertrophied orbicularis muscle and climate factors would cause hypertrophy and pseudoherniation of preaponeurotic fat. Displacement of orbicularis muscle and fat pad would affect the levator muscle and Muller’s muscle.

A relatively longer medial canthal ligament and underdeveloped nasal bone would be additional evolutional manifestations by hypertrophy of the orbicularis oculi and excessive tension. Under this theory, the main purposes of Asian epicanthoplasty would be the anatomical restoration of medial canthus and eyelid soft tissues which are basicfor double eyelid formation in Asian eyelids.We could apply the devolutional concept which reverses evolutionary processes in Asian epicanthoplasty.

Example) Magic epicanthoplasty


Example) Magic epicanthoplasty combined with a non- incisional double eyelid surgery


Example) Magic epicanthoplasty combined with a incisional double eyelid surgery


What is epicanthoplasty (correction of epicanthal folds)?

 

Epicanthoplasty is the name of the surgery that corrects epicanthal folds that cover the inner corner of Asian eyes, so that your eyes look more open and become more refined and bigger. For those who have a wide distance between eyes or has small eyes, or looks severe because of inclination of the inner corner of your eyes by a epicanthal fold, the epicanthoplasty is helpful. When it is performed with a double eyelid surgery at the same time, the horizontal length of eyes can be extended and the interepicanthal distance will also be narrowed effectively. Also, attractive and refined double eyelids will be created by improvement of the epicanthal folds.

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 tend 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 surgeons 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 helpful in Asian double eyelidplasty, there has not been clear understanding about epicanthal fold, 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. Currently using methods are combined technics 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. 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 outfold type(parallel type). But, there has not yet been a potent epicanthoplasty method which deserves universal solution for Asian double eyelidplasty. So we developed Kwon's method based on devolutional concept.


 

02What is Kwon's method (Devolution epicanthoplasty, Magic epicanthoplasty)?

 


Magic epicanthoplasty(Kwon’s method) is a unique method for correcting epicanthal folds of Asian eyelid, and is the surgery to be first founded by Dr. Kwon. Kwon’s method is based on the devolutional concept that restores original pericanthal structure for stable double eyelid formation without anatomical distortion. It can be accomplished by just rearranging the soft tissue without risk of severe complication or noticeable scar. Unlike conventional methods, Magic epicanthoplasty primarily releases the malpositioned soft tissues and fibrosis, then leads to the restoration of the medial canthus naturally without the removal of the skin or muscle.



Magic epicanthoplasty(Kwon’s method) is a universal method for various Asian epicanthus, and is the basal surgery for double eyelidplasty for Asian.



 

 

The clinical significance of epicanthal fold is mainly related with double eyelidplasty in Asians. Epicanthal fold is worsened when performing double eyelidplasty without epicanthoplasty as double eyelid aggravates tension on epicanthal skin. And aesthetic results of double eyelidplasty without epicanthoplasty tend to be unnatural or unattractive. When performing out-fold type eyelidplasty without epicanthoplasty, prolonged swelling retention(so-called sausage phenomenon) occurs due to blockage of lymphatic flow by vertical tension and fading away of double eyelids are frequently noted. Unless the epicanthoplasty releases skin tension and remove potential inhibition factors of crease loss, the surgical crease will not look natural or not be able to last in any enduring fashion .

In the early days of epicanthoplasty surgery, numerous surgical methods were introduced to correct the redundant skin fold which were based on the concept of local flaps. However, their disadvantages such as difficulty in design and resultant prominent scars had limited their use. Recently new epicanthoplasty methods have been introduced to correct Asian anatomical differences such as excessive skin, abnormal skin tension, a malpositioned orbicularis muscle, fibroadipose tissue, elongated medial canthal ligament, etc. However, none of them could be a treatment of choice as they lacked exact understanding regarding the malposition of upper orbicularis muscle and vertical skin tension in relation to the double eyelid. The surgical methods based on defective/inadequate understanding of the true nature of the epicanthus could not be sufficiently effective for Asian eyelidplasty.

Epicanthoplasty using devolutional method(Kwon's method) was developed on the basis of our understanding of epicanthal formation and causal relationship with double eyelid. This method is also called the magic epicanthoplasty. With good reports and reputations by people who have already undertaken this, it is becoming a term that is commonly used in Korea and in many other countries.

What we do in combined devolution epicanthoplasty and double eyelidplasty in sequence.


1. Design both epicanthoplasty and double eyelid surgery simultaneously

2. Mark the marginal transverse incision along the skin tension line of original canthal margin on lower eyelid

3. Incision for epicanthoplasty and double eyelidplasty

4. Elevation of composite flap including skin and fibrosis on lower eyelid

5. Subcutaneous dissection on upper eyelid

6. Shaving excessive fibrous tissues under upper epicanthal skin flap, if necessary.

7. Detachment and superomedial reposition of preseptal orbicularis oculi muscle

8. Additional releasing of fibrosis on lower eyelid for restoration of canthal shape, if necessary

9. Correction of medial canthal ligament, if necessary

10. Advancement of skin flap to add vertical skin length for tensionless crease, if necessary

11. Confirming absence of vertical tension and smooth skin folding along the designed crease by simulation of crease folding.

12. Anchoring canthal skin on turning axis of medial canthal tendon as first anchoring of double eyelid with anchoring of nasal skin flap simultaneously.

13. Anchoring suture for crease formation (double eyelidplasty)

14. Skin closure

To perform magic epicanthoplasty, a surgeon needs plentiful experiences and extreme carefulness to acomplish optimal results. Teuim plastic surgical clinic have more than 5000 cases of magic epicanthoplasty alone or combined double eyelid surgeries.



Example) Magic epicanthoplasty in Asian single eyelid


Example)Magic epicanthoplasty in Asian with double eyelid



Example) Combination of the Magic epicanthoplasty with the non-incisional double eyelid surgery


Example) Combination of the Magic epicanthoplasty with the incisional double eyelid surgery


Example) Combination of the Magic epicanthoplasty with the ptosis correction surgery


Example) Combination of the Magic epicanthoplasty with revisional double eyelid surgery


 

03Actual shape of the medial canthus and differences of eyelid in Asians


The eyelashes are the true boundaries of the palpebral fissure. The eyelashs of a Caucasian is exposed completely and the eyes look clear. Also, the eye looks bigger with the parallel supratarsal crease of eyelid. In contrast, the eye of Asian without supratarsal crease is veiled by various amount of skin drooping and the eyeline where the lashes grow is hidden beneath the soft tissues called epiblepharon. The more the eyelid tissuues droops down, the smaller and the puffier the eyes look.


Example) Caucasian's canthal angle


Example) This picture shows a case of asymmetric shapes of the canthal angles and caruncles(the red tissue at inner corner)


The canthus of Caucasian is exposed completely, whereas the inner part of medial canthus of Asian eye is veiled by the epicanthus. The shapes of the canthal angle are quite various, but generally Asian canthal angles are rounder and shorter than those of the Caucasians. There are various distortions of canthal shape in Asian medial canthus which have been affected in the eyelid evolution. Devolutional epicanthoplasty can restore original shape of medial canthus and reveal it completely. Epicanthoplasty also restore length of palphebral fissure and refine nasocanthal contour.


Examples) This picture shows cases of asymmetric shapes of the medial canthal area by the epicanthi. After devoution epicanthoplasty they look symmetric.


Examples)Relativley round and short shape of canthal angles were exposed fully after epicanthoplasty


Examples) Canthal angles were not exposed fully after epicanthoplasty


Examples) The inclined eyeline of lower eyelid improved to horizontal eyeline after epicanthoplasty


There is a red flesh, called a caruncle of eye, hidden under the epicanthal folds. In Caucasian, most of these parts are exposed, while it is partially veiled in Asians. Considering the overall shapes of eyes, it is better to be exposed harmoniously. To make big and beautiful eyes, the inner corner of the eyes should be exposed. The inner eyes of most celebrities’ are exposed and they have weak epicanthal folds. Shapes of the caruncle, the inner corner of the eyes are different in each one, so the degree of the exposure must be considered carefully before the surgery. Magic epicanthoplasty considers factors such as the condition around the eyes, the exposure of red flesh(called caruncle), the inner-gathering of eyes and so on. So, the results are great while still maintaining natural, oriental attractiveness. There are many other basic factors we must take a close look such as the skeletal structure around the eyes, double eyelids, relation with the nose, and so on.



Some people worry about whether the eyes will look too close together after magic epicanthoplasty, but one of the most importantly considered points when performing magic epicanthoplasty is the intercanthal distance. It is generally said that it is ideally good when the distance between two eyes is the same as the intercanthal distance. For Korean women, the length of the interepicanthal distance is ideal and looks good when it is about 33-35mm long, but most of them have it over 37mm., There are a few that have a length under 33mm. There’s no need to worry about it in most case.



 

04Is epicanthus (Mongolian folds) abnormal? No


Caucasians, unlike the eyes of Asians, have no epicanthus. Instead, they have a double eyelid in shape of out-folder(parallel line), and the eyeline is exposed completely from the inner corner of the eyes. That is the reason why their eyes seem refined, more open, and vivid. This is merely a racial and genetic difference. However, the epicanthi are not to be thought as strange or unusual because these are the usual and dominant structures for Koreans or other related races. Although epicanthi are not medical issues, the surgery may be needed in order to enhance the beauty of Asian eyes.

 

Examples) Very severe types of epicanthi


 

05Effects of the epicanthus on Asian eyes

 

An eyeline of a Caucasian is exposed almost completely, whereas that of Asians is veiled by the hanging down of the skin (in cases where the person does not have a double eyelid.). Drooping skin on the eyes starts from the epicanthus. For Asians, the epicanthi are the conclusive factor that making eyes look small, narrow, and bluff. There is not much to be said about who the good candidates are (whether the epicanthus is severe or not) for plastic surgery of Asian eyelid.

In cases of non-severe epicanthi the results of the surgery will turn out to be more attractive and refined, while, in cases of severe epicanthi, the double eyelids can hardly be made and even start to slightly fade away after some time, or have some problems due to the tension of the epicanthus. When correction of the epicanthus with proper epicanthoplasty is done along with exposing your eyelines completely, clear and shining eyes can be achieved while maintaining oriental beauty.


Examples) In-out fold double eyelids in Asians after double eyelid surgery combined with magic epicanthoplasty


Examples) Out-fold(parallel line) double eyelids in Asians after double eyelid surgery combined with Magic epicanthoplasty


06What is the visual effect of epicanthal folds?

 

They look as if the width of eyes is small before epicanthoplasty.


The distance between eyes look wide and unclear before the surgery because the corner of the eye is not exposed.


Asymmetries caused by different shapes of the epicanthus in each eye


Pseudoesotropia. Looks as if the eyes are squinting due to the coverage of the corner of the eye.. The caruncle and inner white part of the eye (called sclera) is covered, making the eye look small.


Showing sharp images caused by inclined epicanthus.


Reinforcing effect of Magic epicanthoplasty over love-bands(a thickened portion on lower eyelid margin). They become prominent after Magic epicanthoplasty even without any procedure.


Epicanthus accompany fine wrinkles and pigmentations under the eyes. Magic epicanthoplasty improve these manifestations by releasing fibrosis.


When a double eyelid is accompanied with the severe epicanthus, it shows an in-fold crease, showing the outside line only because the medial crease is inhibited by the epicanthus. After Magic epicanthoplasty, the shapes have converted to in-out- or out-fold types of double eyelid.


Unnatural out-fold crease and acutely bended double eyelid crease which were caused by the epicanthus is improved.


The prickling of eyelashes into the eyeballs is improved which was originally caused by the inversion(rolling-in) of the eyelid accompanied by the epicanthus.


Improvement for dark circles may be visible. This ancillary effect can be achieved by releasing fibrosis of lower eyelid.


A softer eye image is expressed by converting the inner corner of the eye horizontally.


 

07The 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.


Examples) These are the cases which show tension of epicanthus in the eyes with out-fold double eyelid. Clear lines were made by the combination of Magic epicanthoplasty and medial correction of double eyelid.


 

08Fading 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).


 

09Why 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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