Epicanthal Fold Repair
Janice C. Liao, MD
DISEASE DESCRIPTION
An epicanthal fold is a vertical or oblique fold of skin originating from the upper or lower eyelids and extending toward and overlying the medial canthus. There are four subtypes of epicanthal folds (Figure 12.1):
Epicanthus tarsalis — The fold primarily involves the upper eyelid.
Epicanthus palpebralis — The fold involves both the upper and lower eyelids.
Epicanthus inversus — The fold primarily involves the lower eyelid.
Epicanthus supraciliaris — The fold extends from the eyebrow toward the lacrimal sac.
The severity of the epicanthal fold is considered mild if less than one-third of the caruncle is obscured, moderate if approximately one-half of the caruncle is obscured, and severe if two-thirds or more of the caruncle is obscured.
Epicanthal folds can be seen in infants of all races, with resolution in the majority of non-Asian patients by adulthood. Epicanthal folds can be found in isolation, such as epicanthus tarsalis folds in many patients of Asian descent. They can also be associated with other congenital findings or syndromes, such as congenital ptosis, Down syndrome, and blepharophimosis epicanthus inversus syndrome, among others. They can give rise to pseudoesotropia.
Anatomically, ectopic orbicularis muscle fibers and connective tissue cause vertical tension at the medial canthus, with a relative deficiency of vertical skin and relative excess of horizontal skin over the nasal bridge. The upper eyelid preseptal orbicularis and the lower eyelid preseptal orbicularis have been shown to be connected within the epicanthal fold. Histologically, the epicanthal fold is made of an outer layer of skin, a central core of muscle fibers and fibrosis, and an internal layer of skin. The orientation of the epicanthal fold is thought to be related to the orientation of the oblique preseptal orbicularis fibers.
MANAGEMENT OPTIONS
Patients should be monitored initially. Mild epicanthus is not uncommon in children and often improves with time as the midface and nose grow. Most cases of simple epicanthus do not require surgery. If the epicanthal folds do not improve sufficiently with time, surgery is appropriate.
 FIGURE 12.1. There are four subtypes of epicanthal folds. |
INDICATIONS FOR SURGERY
Surgery is indicated if the epicanthal folds persist after the face has matured, and are cosmetically bothersome. Epicanthus inversus tends to persist even after facial maturation.
SURGICAL DESCRIPTION
Preoperative Considerations
Does the patient have other eyelid abnormalities or craniofacial syndromes?
For example, if the patient has blepharophimosis epicanthus inversus syndrome, surgery should be staged, and performed after age 2.
First stage — surgical correction of epicanthus and telecanthus. For severe telecanthus, epicanthoplasty alone may not be adequate, and midline transnasal wiring may have to be performed concurrently.
Second stage — surgical correction of ptosis, based on the degree of levator function
Third stage — surgical correction of vertical skin deficiency and lateral canthus malposition
If the patient is undergoing double-eyelid blepharoplasty, performing epicanthoplasty concurrently may improve patient satisfaction.
Does the patient have a history of other eyelid or facial surgeries? Obtain prior records if available.
Has the face matured? As discussed earlier, epicanthus may significantly improve with time, and surgery should be delayed when possible until the face has had time to mature, typically no sooner than 5 years of age.
Surgical Planning
Identify the type and degree of epicanthal fold and the degree of telecanthus, if present. Determine whether the patient will be undergoing any concurrent or staged surgeries. Patients who have had prior surgery may have preexisting cicatrix and surgery or healing may be more complicated. It is important to counsel Asian patients and confirm that they fully understand that their appearance will change in an irreversible manner.
Multiple techniques have been developed to address epicanthal folds. Three common surgeries used to address a variety of epicanthal folds are reviewed later. The specific surgery depends on the severity of the epicanthal fold and the surgeon’s experience and preference. For patients undergoing Mustardé epicanthoplasty, advise the family and patient that this surgery produces higher postoperative tension than do many of the other procedures, and thus has an increased risk of complications related to the postoperative scar.
Surgery can be performed under local anesthesia with conscious sedation or with general anesthesia, depending on the age and preference of the patient.
Surgical Procedures
Mustardé epicanthoplasty — this classic technique is appropriate for epicanthus inversus when moderate to severe telecanthus is also present, because it shifts the position of the medial canthus. This is often used as part of the surgical treatment for blepharophimosis epicanthus inversus syndrome.
Mark the surgical incisions.
Mark the midline between the medial canthi with a vertical line.
Mark the new medial canthus (M2) on each side as half the distance between the midline and the center of the pupil, with the patient fixating at distance (Figure 12.2A).
Mark a horizontal line (h) (Figure 12.2A) between the location of the new medial canthus (M2) and the current medial canthus (M1).
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