The treatment of a clinically prominent medial fold of the upper lid often elicits a spontaneous reaction from clinicians that an epicanthoplasty is necessary. This idea has reached an almost epidemic proportion from patients searching for information on the Internet, and seeing informational pages on different websites that profess their expertise in these corrections. Johnson wrote the first paper on epicanthus, and there have been several early papers describing the treatment for truly pathological epicanthus.
I have often been insistent on the notion that the term epicanthal folds refers to a distinct entity seen as a pathological condition in association with blepharophimosis syndrome and other congenital disorders, often with ptosis, telecanthus and euryblepharon. As such, the papers (including Mustarde’s) originally written for correction of these conditions were as much for correction of telecanthus (through intercanthal wiring), treatment of congenital ptosis and reduction/elimination of the epicanthus. The findings of epicanthus tarsalis were generalized to normal Asians who are single-lidded (with no upper lid crease) who happen to have a fold similarly located. Here is where I have a problem. First of all, there are many normal Asians who present with a mild medial upper lid fold (consider that there are probably at least 3 billion Asians on earth); secondly, the folds we see in these normal healthy Asians are smaller in extent compared to the ones we occasionally see in the rare congenital blepharophimosis syndrome; and thirdly, they are not really obscuring the caruncle. So we have a dilemma: do we call someone who is ‘pre-diabetic’ a diabetic? Is someone who has a medial upper lid fold considered as having an ‘abnormal epicanthus’, or merely a single-lidded person with a heavier fold of skin medially that may have a resemblance to that seen in blepharophimosis, but lacks any blockage of view of the caruncle, and without ptosis or telecanthus, or euryblepharon of the lower lids?
We see the drastic techniques for the treatment of congenital epicanthus being modified to treat these more benign medial upper lid folds (common in normal Asians) but we have retained the term epicanthoplasty, as a distinct add-on selection choice on the plastic surgery menu. So now, medial canthal skin manipulations through complex stick-man figures, flap transpositions and many variants of these same ideas of Mustarde are being published, followed and performed, for very simple prominent medial upper lid folds (folds that this author feels can be eliminated as part of the Asian blepharoplasty, with some simple techniques applicable to the medial end of the incisions, which we will go over very soon in this chapter).
I feel this is a wrong direction to go for many reasons. There is an expansion of unnecessary complexity added to the medial canthal region where there is not much pathology. Medial canthal skin near the nasal bridge is being worked on in normal otherwise-attractive facies. Often the surgical results in epicanthoplasty (as practiced now on normal single-lidded Asians) shows an exaggerated show of the caruncles, and there is a higher than expected problem of delayed skin healing (and perhaps complications) through maneuvers over these anatomic regions as practiced by aesthetic surgeons dealing with eyelids. It is common to see residual scars – or at least, I do. That is why in the first edition of this book ( Asian Blepharoplasty – A Surgical Atlas , Butterworth–Heinemann; 1995) I stated that a prominent medial upper lid fold in a single-lidded individual can be simply excised through the main body of steps involved in Asian blepharoplasty, with the crease shape designed to merge medially into the remnant of the medial fold, and gives a very natural nasally tapered crease similar to what we see in those Asian individuals born with a nasally tapered crease shape. This is very apparent to those of us who work with Asian patients. Their caruncles are seen easily, or only half-shielded, they do not have telecanthus, and their palpebral dimensions to inter-canthal distance, as well as proportion to the width of face, falls within the ideal ratios after simple Asian blepharoplasty.
To this day I feel that the term epicanthal fold has been massively mis-applied, commercially exploited and epicanthoplasty unnecessarily recommended. There is confusion among those who are shopping for surgeries/surgeons as well as pressure among surgeons who follow the trend. I often see less-than-satisfied Korean-American patients coming in for revision consultation, who did not know what they had undergone overseas, and who show me a medical invoice itemizing at least three charges: double-eyelid crease procedure, ptosis repair and epicanthoplasty. Perhaps this is the trend, a trend that is not beneficial to doctors and their patients. (The overuse of ptosis correction in non-ptotic Asian patients who simply have a prominent eyelid fold over their upper lid margin is another issue that has similar repercussions.)
Solutions for Reduction of Medial Upper Lid Fold in Relation to Crease Shape Design
In my practice the majority of single-eyelid patients who may have a narrowed palpebral fissure medially may simply have a prominent medial upper lid fold of skin (a term I favor). In recommending crease shape, I often will show these patients illustrations of a natural nasally tapered crease so they have an idea.
(1) If they understand and choose a nasally tapered crease (NTC), during the procedure the medial end of the crease design may include a greater degree of excision of skin tissues between the crease line (lower line of incision) and the upper line of incision; for example, while normally there may be only 1–1.5 mm of skin marked for excision there, I may design and include 2.5–3.0 mm ( Figure 25-1 A ). Their medial upper lid fold mostly consists of skin and a few strands of pretarsal orbicularis oculi fibers, and can be easily excised through the lower skin incision line (crease line). Residual skin still present on the end of the lower line of incision can be carefully undermined and trimmed ( Figure 25-2 B ) so the closure fits in nicely under the natural lid fold that you have just constructed as a nasally tapered crease. One seldom sees a prominence of orbicularis oculi as one does in blepharophimosis syndrome, nor does one see an elongation of the superficial portion of the upper limb of the medial canthal tendon. The reduction of medial upper lid fold is performed within and is included in the Asian blepharoplasty that I perform.