Correction of the epicanthal fold using the VM-plasty

British Journal oj Plastic Surgery (2000), 53, 95 99 9 2000 The British Association of Plastic Surgeons DOI: I 0,1054/bj ps. 1999.3288 BRITISH JOURNAL PLASTIC SURGERY Correction of the epicanthal fold using the VM-plasty S.-D. Lin Division of Plastic and Reconstructive Surgery, Department of" Surgery, Chung-Ho Memorial Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan SUMMARY. The VM-plasty combines the principles of YV-plasty and multiple Z-plasty. It consists of three V flaps. For correction of the epicanthal fold, both A and B V-flaps were designed on the outer surface and the C V- flap was designed on the inner surface of the fold. The vertical tissue deficiency of the epicanthal fold was reconstructed with the C V-flap which brought additional tissue from the inner surface of the fold. The VM-plasty for epicanthoplasty was used alone in 8 patients, in combination with double eyelid surgery in 51 young patients and in combination with blepharoplasty and double eyelid surgery in 26 patients who had blepharochalasis. Redness of the incisions was a common complaint but this settled within 2 3 months postoperatively. The zigzag incisions of the VM-plasty were blended with the anatomic lines. 9 2000 Harcourt Publishers Ltd Keywords: epicanthal fold, surgical correction, Z-plasty, VM-plasty. The majority of medial epicanthal folds are congenital, and may persist to a variable degree until the age of 11 years. It persists beyond this age in 4.4~ of boys and 3.2% of girls in the Occidental.l It is a characteristic of the Oriental eye and the incidence ranges from 50 to 70% of population. 2'3 The palpebral fissure is short in length and narrow in height in the presence of a severe epicanthal fold. Many methods have been developed for correction of this fold, which is seen in epicanthus, telecanthus, blepharophimosis or trauma. 1,~1~ Skin resection from the upper eyelid in double eyelid surgery of the Oriental eyes worsens this condition. Therefore, in order to have better aesthetic results of double eyelid surgery, correction of the epicanthal fold is mandatory. The VM-plasty was developed by Alexander et al for correction of post-burn syndactyly. IL This procedure combines the principles of YV-plasty and multiple Z-plasty. In a comparative study of the postoperative anatomic grade and cosmetic appearance among the various methods used for correction of post-burn syndactyly, the results of VM-plasty were reported to be superior to those of graft, Z-plasty, rotational flap and YV-plasty. IL This procedure has also been extended to correct scar contracture at other free anatomic borders. ~2 Anatomic formation of both the epicanthal fold and post-burn syndactyly is a skin deficiency at the medial canthus and interdigital space respectively. 9,J~ In the present study, the VM-plasty was performed for correction of the epicanthal fold alone or simultaneously with double eyelid surgery. Surgical techniques The VM-plasty consists of creating one V-flap from the inner surface and a double V-flap from the outer surface of the epicanthal fold. The jointed point (X) of the tips of these three V-flaps is marked on the edge of the fold at the level of the mid-caruncle. Starting from the X-point, a horizontal line is drawn medially on the outer surface for the double V-flap of A and B. The angle of the A and B V-flap is about 40 ~ (Fig. 1A). By pulling the nasal skin medially to displace the inner surface, the C V-flap is designed along the upper and lower subciliary incisions (Fig. 1B). In each case, the limbs of each V-flap are equal in length. However, the size of the V flap varies in each case and is proportional to the prominence of individual fold. A wider fold requires a larger V-flap for correction. Local anaesthesia with 1% xylocaine with 1:100 000 epinephrine is used. The operation is aided by using surgical loupes (2.5 The incision is made through the skin to the orbicularis oculi muscle. Care must be taken to avoid injury to the medial canthal ligament. Neither the muscle nor the ligament is excised or shortened. After completion of the skin incision and flap dissection, release of tension crossing the medial epicanthus results in a medial triangular skin defect (Fig. 1C). Thereafter the C V-flap is advanced medially to be sutured into this defect. These sutures need not necessarily bite deeply to the periosteum. The correction is proper if suturing of the tip of the C V-flap to nasal skin maintains a firm tension on both the upper and lower palpebral borders and the caruncle is exposed fully. If this tension strength is not adequate, it could be remedied by a further medial advancement of C V-flap after a longer incision. Sutures are performed with 7-0 nylon. When dog-ears present at both upper and lower lids after completion of V-flap suturings, they are trimmed parallel to the long axis of the eyelid (Fig. 1D) A dog-ear on the upper lid is trimmed upward to blend with the pretarsal fold incision which is used for double eyelid surgery. Both epicanthoplasty and double eyelid surgery could be performed simultaneously. 95

96 British Journal of Plastic Surgery,X D Figure l (A, B) The design of the VM-plasty. (C) Skin incision of the VM-plasty releases the vertical tension of the medial canthus and results in a triangular defect. (D) Suture lines are along the anatomic lines. Results VM-plasty for epicanthoplasty was used most often in combination with the double eyelid surgery (51 cases). The epicanthoplasty was performed first, followed immediately or several months later by the double eyelid surgery. The second most common cases (26 cases) were blepharochalasis for blepharoplasty and double eyelid surgery. The VM-plasty could be routinely applied for these cases whenever a medial epicanthal fold presented. After epicanthoplasty, the vertical and horizontal palpebral fissures of these cases become higher and longer than those before surgery respectively. The shape of the postoperative eyes assumed an almond-like appearance (Figs 2-5). If the medial epicanthal fold was not corrected along with the double eyelid surgery, this fold became more prominent and the patient sometimes complained of tightness in the medial canthus. The VMplasty could be used to correct this fold and the symptom was released (Fig. 6). An epicanthal fold resulting from burn scar contracture or trauma could also be corrected with this VM-plasty (Fig. 7). Redness of the VM-plasty scar was a common complaint. This red discoloration usually faded within 2-3 months. In one case, the patient disrupted the wound on the second day resulting in obvious scarring which settled in the subsequent months (Fig. 6). In this series, there was no persistent unsightly scarring. Discussion The presence of the epicanthal fold obscures the medial angle of the eye giving the eye a semilunar medial end instead of an almond-like appearance. This eye has a short horizontal palpebral fissure and a narrow vertical palpebral fissure.1 One explanation for the formation of this fold is that there is a tissue deft- ciency in the vertical plane as opposed to the horizontal plane. 9 In conventional double eyelid surgery, the pretarsal skin is resected and the vertical tension in the medial canthal area is increased, making the fold more prominent and the eye rounder and shorter looking than before] 3,14 Patients are dissatisfied with this startled appearance and in double eyelid surgery, epicanthoplasty is mandatory whenever there is an epicanthal fold. The goals of correction of the epicanthal fold include redistribution of the fold skin to lengthen the vertical plane, 4 steps to prevent recurrence of this fold 16 and minimisation of scar formation on the nasal skin. 15 The Z-plasty and its modifications release the shortage of the skin on the vertical plane but leave a vertical line crossing the medial canthus. Recurrence of this fold may sometimes occur. ~6 In VM-plasty for epicanthoplasty, the vertical skin deficiency is released and reconstructed with the C V-flap. The incisions are broken into a zigzag line and thus there is no vertical line across the medial canthus. Recurrence of the fold is effectively avoided. In surgery of the oriental eyelid, hypertrophic scarring is a common problem especially when the scars are located beyond the eyelid itself. 15 The incision for epicanthoplasty should therefore be as simple as possible and be confined to the eyelid area. The four-flap technique of Mustard6 and its modifications have complex incisions and some of which extend beyond the eyelid/,17 When these methods are used in the Oriental case, occurrence of scarring must be properly treated. 15,18 In VM-plasty for epicanthoplasty, the suture lines blend with or along the upper and lower palpebral fold and are made within the upper and lower eyelids. The redness noted in the majority of cases subsequently faded within 2-3 months with occlusive therapy with DuoDerm (ConvaTec, Bristol- Myers Squibb Company) and no triamcinolone (Kenacort was used in this series. These final scars

Correction of the epicanthal fold using the VM-plasty 97 Figure 2-- (A) Preoperative view of a young girl for double eyelid surgery. (B) Markings of the A and B V-flaps on the outer surface of the epicanthal fold. (C) Nasal skin pulled medially to show the C V-flap on the inner surface of the epicanthal fold, its limbs located along the upper and lower eyelid border. (D) The VMplasty for epicanthoplasty and the double eyelid surgery performed at the same time. (E) Postoperative view at 4 months with no visible scarring. Figure 3~(A) Preoperative view of a young girl with prominent medial epicanthal folds. (B) Postoperative view 2 weeks alter the double eyelid surgery. In this case, epicanthoplasty with the VM-ptasty and the doable eyeiid surgery were performed separately. The interval between these two operations was 4 months. were well h i d d e n in a n a t o m i c lines a n d were aesthetically invisible. The C V-flap harvested from the i n n e r surface o f the fold is a d v a n c e d medially to the nasal skin defect resulting from release of vertical skin deficiency o f this fold. This C V-flap brings a d d i t i o n a l skin tissue to the vertical plane a n d thus corrects the e p i c a n t h a l fold anatomically. It also pulis back the laterally displaced

98 British Journal o f Plastic Surgery Figure 4--(A) Preoperative view of a young woman for double eyelid surgery. (B) Postoperative view at 3 weeks with eyes looking larger than before. Figure 5 (A) Preoperative view of a 42-year old woman with blepharochalasis. (B) Postoperative view 2 months after VM-plasty for epicanthoplasty, upper eyelid blepharoplasty and double eyelid surgery. Figure 6--(A) Young woman dissatisfied after double eyelid surgery without epicanthoplasty. She looked tired and felt a tight sensation with her eye open. Prominent epicanthal folds visible. (B) VM-plasty was performed to correct this fold. Rubbing the eye by patient herself caused wound dehiscence of the left eye. This unrepaired wound resulted in visible scar 1 month postoperatively. (C) Postoperative view at 4 months there was no obvious scar.

Correction of the epicanthal fold using the V M - p l a s t y 99 Figure 7 (A) Preoperative view. Facial burn resulted in formation of bilateral medial epicanthal folds and ectropion of both lower eyelids. (B) Postoperative view 1 year after VM-plasty for correction of the epicanthal folds and skin graft for reconstruction of the bilateral ectropion. medial canthus and lengthens the horizontal palpebral fissure. The medial canthus is changed from a round shape to a pleasing almond-like shape with an exposed caruncle. There are many methods for correction of the epicanthal fold in Occidental people in whom there is already a pretarsal fold, but the necessary incisions may overly complicate the double eyelid surgery for the Oriental. In order to prevent this morbidity conventional epicanthoplasty and double eyelid surgery have often been performed separately.2,z~ Park described double eyelid surgery in combination with Z-epicanthoplasty in which the pretarsal fold was extended along with the transposition flap into the nasal skin. 14 Flowers designed an independent VWplasty on the nasal skin for correction of the epicanthal fold during double eyelid surgery. L~,I9 In the majority of the present cases, VM-plasty for epicanthoplasty is performed in combination with the double eyelid surgery. Epicanthoplasty is done first and the upper eyelid incision of the B V-flap can be extended upward to blend with the pretarsal fold incision for double eyelid surgery. This results in a long, natural double eyelid and the eye looks larger than before (Fig. 4). The eyes change markedly to a pleasing appearance when the medial epicanthal fold is simultaneously corrected by VM-plasty along with the double eyelid surgery in one stage. 5. Mack MH. Y-V operation for epicanthus. Plast Reconstr Surg 1964; 34:182 5. 6. Kao YS, Lin CH, Fang RH. Epicanthoplasty with modified Y-V advancement procedure. Plast Reconstr Surg 1998; 102: 1835-41. 7. Mulliken JB, Hoopes JE. W-epicanthoplasty. Plast Reconstr Surg 1975; 55:435 8. 8. del Campo AE Surgical treatment of the epicanthal fold. Plast Reconstr Surg 1984; 73: 566-70. 9. Lessa S, Sebasti5 R. Z-epicanthoplasty. Aesthetic Plast Surg 1984; 8:159 63. 10. McCord CD Jr. The correction of telecanthus and epicanthal folds. Ophthalmic Surg 1980; 11: 446-54. 11. Alexander JW, MacMillan BG, Martel L. Correction of postburn syndactyly: an analysis of children with introduction of the VM-plasty and postoperative pressure inserts. Plast Reconstr Surg 1982; 70: 345-54. 12. Lin SD, Yang CC, Lai CS, Chou C-K. Expanding use of VMplasty in correction of scar contracture. J Plast Reconstr Surg Ass ROC 1992; 1:13-19. 13. Flowers RS. Upper blepharoplasty by eyelid invagination: anchor blepharoplasty. Clin Plast Surg 1993; 20:193 207. 14. Park JI. Z-epicanthoplasty in Asian eyelids. Plast Reconstr Surg 1996; 98:602 9. 15. Hin LC. Unfavorable results in Oriental blepharoplasty. Ann Plast Surg 1985; 14:523 34. 16. Mustard6 JC. The treatment of ptosis and epicanthal folds. Br J Plast Surg 1959; 12:252 8. 17. Yoon KC. Modification of the Mustard6 technique for correction of epicanthus in Asian patients. Plast Reconstr Surg 1993; 92:1182-6. 18. Matsunaga RS. Westernization of the Asian eyelid. Arch Otolaryngol 1985; 111: 149-53. 19. Flowers RS. Surgical treatment of the epicanthal tbld (discussion). Plast Reconstr Surg 1984; 73: 571. References 1. Mustard6 JC. Epicanthus and telecanthus. Br J Plast Surg 1963; 16:346 56. 2. Fernandez LR. Double eyelid operation in the Oriental in Hawaii. Plast Reconstr Surg 1960; 25:257 64. 3. Ohmori K. Esthetic surgery in the Asian patient. In: McCarthy JC (ed.), Plastic Surgery. Philadelphia: Saunders, 1990; 2415 35. 4. Blair VR Brown JB, Harem WG. Correction of ptosis and of epicanthus. Arch Ophthalmol 1932; 7:831-46. The Author Sin-Daw Lin MD, Professor and Chief Division of Plastic and Reconstructive Surgery, Chung-Ho Memorial Hospital, Kaohsiung Medical University, 100 ShihChuan 1st Road, Kaohsiung 807, Taiwan. Paper received 31 March 1999. Accepted 8 November 1999, after revision.