Epicanthoplasty

What it treats

• The epicanthal fold forms where the upper preseptal orbicularis oculi muscle connects to the lower preseptal muscle; this connection was present in all 15 hemifaces with a fold and absent in hemifaces without one, in a cadaver study of 16 Korean adults PMID 27171956.
• The fold is classified by type and severity: the medial canthus fibrous band is larger in severe folds than moderate folds (P<.01), and the epicanthus tarsalis type has a longer lower-eyelid flap dimension than the palpebralis type at matched severity (P<.01), measured from surgical video review of 40 patients PMID 38198214.
• A systematic literature review (46 articles after screening) found Z-plasty described most often among correction methods (21 of 48 methods, 43.8%), followed by advancement flaps (29.2%) and excision (14.6%); skin redraping was described least often (8.3%) but has grown in use since 2007 PMID 27192634.
• Epicanthus surgery was first developed in the West for congenital conditions such as Down syndrome; procedures aimed at cosmetic alteration of the Asian eyelid emerged over roughly the past 150 years, and since 1989 the epicanthus surgery literature has been written predominantly by authors of East Asian descent PMID 38281686.

How it is done

Technique families

• Techniques fall into two flap types: advancement (V-Y, W-plasty) and transposition (Z-plasty); releasing vertical tension by subcutaneous dissection and orbicularis myectomy, rather than the flap shape itself, is described as the key surgical step PMID 27096377.
• Lessa S's 1984 Z-epicanthoplasty marked the new canthus using the Mustardé technique, then performed a double Z-plasty, in 31 patients with excellent results PMID 6393744. del Campo AF described a separate surgical technique for the epicanthal fold the same year PMID 6709736.
• Park JI's Z-epicanthoplasty, from 160 cases published in 1996, placed the incision within the eyelid skin rather than adjacent to it, reducing scarring compared with the more complex W-plasty PMID 8773682. The Park Z-epicanthoplasty is described as most useful for type III folds and widely used for type II folds PMID 17658430, with a root modification published in 2003 PMID 12794505.
• Fuente del Campo's 1997 technique used an asymmetric Z-plasty with a flap raised from the posterior surface of the epicanthal fold itself, requiring no geometric planning PMID 9354596.
• Oh YW's skin redraping (tension-free epicanthoplasty) method, from 215 Asian patients published in 2007, needs only skin elevation and trimming, without flap design, anchoring, plication, or subdermal fixation; no patient complained of visible scarring and none needed revision PMID 17230110.
• A 2025 technical-refinement paper describes skin redraping as the currently preferred method for many Asian surgeons because of its inconspicuous incisions, while noting the technique is difficult to execute given the three-dimensional anatomy of the epicanthus PMID 38742871.
• A modified Z-epicanthoplasty with accurate flap design was used in 163 patients from 2006-2010, followed 4 months to 4 years, with no recurrence, though 3 patients needed a second procedure for asymmetric caruncle exposure PMID 21607535.
• A three-dimensional Z-epicanthoplasty rotates excess horizontal skin into the sagittal plane to preserve medial canthal depth and hide the scar from the coronal view; in 138 patients followed 6-36 months, medial canthal depth was preserved without lower-lid distortion PMID 35703205.
• U-flap epicanthoplasty rotates a flap from the medial canthal skin upward along the palpebral fold line; in 118 Chinese patients, average intercanthal distance decreased 4.36±0.32mm, satisfaction was 97.5%, and 3 patients had hypertrophic scarring that resolved with triamcinolone injections PMID 27286852.

Results and evidence

• In 92 eyes (46 Korean patients), root Z-plasty (64 eyes), Y-V plasty (13 eyes), and Mustardé's technique or its one-armed modification (15 eyes) were compared; horizontal fissure width increased 1.74mm (8.4%), 1.64mm (8.9%), and 1.89mm (12.9%) respectively at 6 months (P<.001, P=.041, P=.027); root Z-plasty scored a higher appearance grade than the other two methods (P<.001), with scarring graded good for root Z-plasty versus fair for the others PMID 26155997.
• In 106 patients (212 eyes), modified Z-plasty scored significantly better for scarring than modified skin redraping in mild, moderate and severe epicanthus palpebralis (P=.034, .028, .013); redraping scored better for smoothness in mild epicanthus tarsalis (P=.025) and was more effective at shortening intercanthal distance in the palpebralis type PMID 30068494.
• A 2026 meta-analysis of 14 studies (1,539 patients, all published in Chinese) comparing skin redraping with Z-plasty found no significant difference in intercanthal-distance reduction (mean difference 0.56mm, 95% CI -1.20 to 2.33, P=.53, I2=98%); Z-plasty scored a better 6-month Vancouver Scar Scale result (mean difference 0.44, 95% CI 0.31-0.57, P<.00001), higher patient satisfaction (odds ratio 0.39, 95% CI 0.18-0.84, P=.02), and lower recurrence, though the recurrence comparison drew on only 3 studies (odds ratio 13.73, 95% CI 2.53-74.49, P=.002); complication rates were similar between the two methods (odds ratio 1.45, 95% CI 0.65-3.23, P=.36) PMID 42065185.
• In 135 patients treated with an integrated four-step upper blepharoplasty and dual-plane epicanthoplasty, palpebral fissure distance (relative to iris diameter) increased 8.1% and intercanthal distance shortened 3.5% at a mean 12.9-month follow-up; patient-satisfaction score averaged 62.9 of 70 (89.8%), and 90.6% and 85.4% of patients rated upper-lid and inner-canthal scarring as barely visible PMID 34806289.
• In 252 patients treated with a scarless technique combined with double eyelid surgery, intercanthal distance fell from 36.5±2.6mm to 32.7±2.3mm at 3 months (P<.05), with slight retraction to 33.0±2.4mm by 6 months, and mean satisfaction was 4.2 of 5 PMID 27704196.

Risks and complications

• A systematic review of 34 eyelid-procedure studies (3,650 patients), covering blepharoplasty, epicanthoplasty and other eyelid surgery, found hypertrophic scarring in 36 patients and no keloid formation after any cosmetic (nonburn) eyelid procedure PMID 36797842.
• Among 138 formal blepharoplasty complaints analyzed over 7 years, epicanthoplasty drew more complaints of "noticeable scarring" than primary double eyelid surgery did PMID 39998431.
• A historical review notes that overcorrection has followed excessive use of epicanthoplasty, creating demand for restoration and reconstruction methods PMID 27192634.
• Reverse Z-plasty was used to revise overcorrected folds in 548 patients; only 6% needed a further scar revision, and in a subgroup of 60 patients with revisional epicanthoplasty alone, intercanthal-distance-lengthening ratios ranged 2.9%-31.1% (average 8.6%) PMID 33675227.
• In 512 patients treated for severe epicanthal scarring after earlier epicanthoplasty (mean age 31.3 years, 15.4% having already had one reconstruction attempt), scar excision with reverse redraping increased mean intercanthal distance from 32.8mm to 36.6mm PMID 29610952.
• In 324 patients unsatisfied with a prior epicanthoplasty, a modified reverse skin redraping technique increased mean intercanthal distance from 33.6mm to 36.9mm; minor complications occurred in 4.6% and were resolved with minor revision, with no severe complications requiring reoperation PMID 28177970.

Recovery

• Scar assessment in adjunct-treatment trials is typically staged at 1, 3, and 6 months, with the largest gains in scar score seen by the 3-month mark PMID 31568286.
• Early postoperative botulinum toxin type A, injected at days 6-7, improved Vancouver Scar Scale scores in a 43-patient split-face trial (30 completed), with about 86.7% of patients satisfied with the scar and epicanthoplasty outcome by 6 months PMID 31568286.
• A second, independent split-face trial of 21 patients (20 completed) found botulinum toxin type A improved scar width (0.37±0.18mm versus 0.68±0.42mm with saline) and multiple scar-scale scores at 6 months, with no adverse effects PMID 39681687.
• In a trial of 1540nm non-ablative fractional laser added to silicone sheeting versus silicone alone (70 enrolled, 64 completed), the combined treatment improved scar pliability at 6 months over silicone alone; the silicone-alone protocol was 12 hours of sheeting daily plus gel twice daily for 5 months after the scab fell off PMID 35364722.
• A novel triangular-resection design used in 421 patients from 2010-2017 aimed to avoid the wide undermining associated with hypertrophic scar and webbing; no scarring or webbing complication was reported, and revision was performed in 18 cases where patients wanted additional correction PMID 36882913.
• Most technique-outcome studies follow patients 6 to 36 months to judge final scar appearance, since early scarring typically fades over that period PMID 35703205 PMID 27286852.

With double eyelid surgery

• Epicanthoplasty is described as part of a single, inseparable procedure with double eyelid surgery when forming a parallel-type crease, since an unaddressed epicanthal fold leaves the eye looking round and the fissure short even after a well-formed crease PMID 26306084.
• A concomitant Z-epicanthoplasty and double eyelidplasty was performed in 230 of 236 total cases in one series (6 were epicanthoplasty-only); 67 patients followed 4-23 months (average 7 months) showed natural double-eyelid contours, with mild early scar proliferation fading to a gray-white line; the procedure was not indicated for the inversus type of epicanthus, and older age was a relative contraindication PMID 16980849.
• Epicanthoplasty is also combined with ptosis correction: in 99 patients undergoing both procedures together, intercanthal-distance change depended on the epicanthoplasty method used (elliptical excision 3.1mm, half-Z 4mm, periciliary 5.3mm, V-W 5.4mm), with periciliary or V-W recommended for severe folds; no revisions were needed PMID 24076697.

Current questions

• Whether Z-plasty or skin redraping gives better outcomes remains unsettled: the 2026 meta-analysis favored Z-plasty for scar score, satisfaction, and recurrence, but drew entirely on Chinese-language studies with high heterogeneity (I2=98%) and called for multicenter randomized trials PMID 42065185.
• The medial canthus fibrous band's role in fold severity was only quantified in 2024, and its effect on technique selection has not been tested prospectively PMID 38198214.
• Restoration techniques for overcorrected or scarred folds (reverse Z-plasty, reverse skin redraping, scar excision) form a growing subfield as primary epicanthoplasty volume rises, reflecting real but uncertain rates of overcorrection PMID 33675227 PMID 28177970 PMID 29610952.
• Two independent split-face randomized trials support botulinum toxin type A as a scar-prevention adjunct, but each enrolled fewer than 45 patients PMID 31568286 PMID 39681687.
• A 2025 review of 85 publications found no single epicanthoplasty technique proven superior for all cases; skin redraping is favored by current trend, a conclusion the review states is not supported by randomized or prospective comparative data PMID 41367314.

Terms

• Epicanthal fold: a skin fold covering the inner corner of the eye, formed by a connection between the upper and lower preseptal orbicularis oculi muscle PMID 27171956.
• Epicanthus palpebralis / tarsalis: subtypes of epicanthal fold classified by anatomic extent PMID 38198214.
• Z-plasty (Park Z-epicanthoplasty): a transposition-flap technique placing the scar within the eyelid skin PMID 8773682.
• Skin redraping method: a tension-free technique using skin elevation and trimming without a transposition flap PMID 17230110.
• Mustardé technique: a canthus-marking method combined with a double Z-plasty for epicanthus correction PMID 6393744.
• Medial canthus fibrous band (MCFB): fibrous tissue underlying the fold whose size correlates with fold severity PMID 38198214.
• Intercanthal distance (ICD): the horizontal distance between the inner corners of the two eyes, the main outcome measure for epicanthoplasty PMID 26155997.
• Vancouver Scar Scale: a validated scar-grading tool used in epicanthoplasty scar trials PMID 31568286.
• V-Y advancement / W-plasty: advancement-flap technique families for epicanthal fold correction PMID 27096377.
• Reverse Z-plasty: a revision technique that restores an overcorrected epicanthal fold PMID 33675227.

Papers