[Revision Double Eyelid Surgery, Duhan Plastic Surgery] - [Inner Canthoplasty, Outer Canthoplasty]

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When there is an epicanthal fold

Sometimes the double eyelid line does not carry all the way through and disappears in the middle.

If the inner line of the double eyelid disappears, it can give a somewhat constricted feeling.

Epicanthal fold removal is also called inner canthoplasty.

If a double eyelid is created by combining double eyelid surgery and inner canthoplasty,

the double eyelid line can continue to the end, creating a natural-looking double eyelid line.

What is epicanthal fold removal surgery?

When the space between the two eyes appears wide, or when too much skin at the inner corner of the eye covers the eyeball, the skin that covers the eyeball on the inner side of the eye is called the epicanthal fold.

Epicanthal fold removal surgery (inner canthoplasty) refers to surgery that removes the skin at the inner corner of the eye to normalize the distance between the eyes and open up the constricted-looking inner eye area.

An epicanthal fold (medial canthal skin fold) is diagnosed when the distance between the eyes is 40 mm or more, or when the skin on the inner side of the eye covers the white of the eye, creating a constricted feeling.

Eyes with an epicanthal fold usually have an inner corner that is not sharp and looks rounded or has a steep downward angle.

What are the principles of epicanthal fold removal (inner canthoplasty)?

There should be no scarring. The incision line should be hidden inside the eyelid boundary so that scarring is almost absent.
The shape should look natural. The inner corner of the eye should be designed horizontally so that the inner canthoplasty looks natural.
It should not recur. The inner corner should be secured and sutured to the ligament so that it does not return to its original position.

Why scars do not occur in our epicanthal fold removal (inner canthoplasty)

When skin is incised, scarring inevitably occurs.

The same applies to the epicanthal fold, because surgery is performed with an incision, so scarring is an unavoidable issue.

If surgery is performed in a way that leaves the scar exposed on the surface, the scar can look unsightly no matter how carefully it is sutured.

However, if the scar line is hidden at the very edge of the eye corner so that it is covered, the scar becomes barely noticeable.

In other words, because the scar is not exposed on the surface, it does not show.

What are the indications for epicanthal fold removal (inner canthoplasty)?

① When the distance between the eyes appears wide Surgery is generally indicated when the distance between the inner corners of the eyes is over 40 mm. The normal distance between the eyes is about 36–37 mm, but if the distance is normal and there is still an epicanthal fold, it is better not to perform surgery. If done incorrectly, the distance between the eyes can become too narrow, making the eyes look crowded.

② When you want to create out-fold double eyelids If there is an epicanthal fold, an in-fold double eyelid is created, so epicanthal fold removal is needed to create an out-fold double eyelid.

Comparison between exposed scars from epicanthal fold removal (inner canthoplasty) and our clinic’s inner canthoplasty

The principles of epicanthal fold removal (inner canthoplasty) are: minimal scarring, low recurrence, and a method that can be performed together with double eyelid surgery.

At our clinic, we mainly perform surgery using the Furukwa and Y-V methods.

The advantages are that the scar is less visible, the result looks natural, and when combined with double eyelid surgery, the epicanthal fold can be removed naturally along the extension of the double eyelid.

What are the various methods of epicanthal fold removal (inner canthoplasty) and the shapes of scars?

Various methods have been developed and used, but only a few are actually used.

The principles of epicanthal fold removal (inner canthoplasty) are: minimal scarring, low recurrence, and a method that can be performed together with double eyelid surgery.

At our clinic, we mainly use the Furukwa method shown in the lower right.

Its advantages are that the scar is almost invisible, the shape looks natural, and when combined with double eyelid surgery, the epicanthal fold can be removed naturally along the extension of the double eyelid.

What is the procedure for epicanthal fold removal (inner canthoplasty)?

▶ Steps 1 to 3: Pull the skin toward the nose -> Design the planned incision line -> Administer local anesthesia.

① Pull the skin toward the nose to make it taut.
② While the skin is pulled tight, design the area with special ink. The shape of the design varies depending on the surgical method, so there is no fixed shape.
③ Under sedation anesthesia, local anesthesia is administered to the designed area.

▶ Steps 4 to 6: Incise along the planned incision line -> Lift the skin and separate it from the muscle -> Reposition the lifted skin.

④ Make a precise incision with a scalpel along the design line.
⑤ Lift the skin away from the muscle.
⑥ Reposition the skin tissue so that the epicanthal fold is pulled toward the nose. At this time, an appropriate amount of excess skin tissue is removed.

▶ Step 7: Suture the skin.

| ⑦ The skin is sutured with fine thread. A bandage does not need to be applied immediately after surgery, and the stitches are removed after 5 to 6 days. |

Examples of epicanthal fold removal (inner canthoplasty)

How is care after epicanthal fold removal (inner canthoplasty)?

① After surgery, visit the clinic the next day for disinfection of the surgical site and observation of the progress.
② The stitches are removed on the fifth day after surgery.
③ Swelling after surgery is minimal, and the period for complete settling is about 1 to 3 months. During this period, the surgical site should not be rubbed strongly.
④ For about 3 months, a slight scar may be visible along the inner corner of the eye, which is a normal process. After 3 months, it becomes almost unnoticeable.
⑤ When washing the face, be careful not to rub the surgical site. If the site is rubbed strongly, the scar may become messy or widen, so caution is needed.

What are the precautions for epicanthal fold removal (inner canthoplasty)?

It should only be performed when it suits your own eye shape. During consultation, you should discuss with the specialist and carefully consider whether epicanthal fold removal is truly necessary before deciding on surgery.
With any method of epicanthal fold removal, it is difficult to perform surgery without leaving any scar at all. It is better to operate in a way that leaves as little scarring as possible, and it is advisable to hide the scar inside. Because the scar is not visible on the surface, there is almost no visible trace of the surgery.

When should epicanthal fold removal (inner canthoplasty) not be performed?

If the distance between the eyes is less than 40 mm, the normal distance is usually about 36–37 mm. If it is less than 40 mm, epicanthal fold removal should not be performed. If inner canthoplasty is done on eyes with a normal distance, the side effect of making the eyes look crowded can occur, so caution is needed.
If the distance between the eyes is wide but the inner corner has a sharp shape, epicanthal fold removal should not be performed. The purpose of epicanthal fold surgery is to open up and soften eyes whose inner shape is round, but if the eye already appears sharply open, surgery may make the eyes look even more severe, so caution is needed.

A double eyelid line that has had unnecessary inner canthoplasty

Various problems can arise from unnecessary inner canthoplasty.

Inner canthoplasty should only be performed when it is truly needed in eyes with an epicanthal fold,

and unnecessary or excessive inner canthoplasty can cause

overexposure of the inner mucosa,

a severe out-fold line,

eyes that appear too narrow or too sharp.

Unnecessary inner canthoplasty often makes the impression look worse, so care is needed.

What is inner canthoplasty restoration?

It refers to surgery that reverses an inner canthoplasty that was performed even though it was not indicated, in order to restore the original eye shape.

Why is inner canthoplasty restoration done?

If inner canthoplasty was done out of necessity, you should consider whether it now needs to be restored.

It happens when surgery is recommended unconditionally without considering the post-surgical eye shape.

If inner canthoplasty is performed without indication, various problems may occur.

Problems that occur after unnecessary inner canthoplasty surgery

○ The distance between the eyes becomes shorter than normal, making the eyes look crowded.
○ If inner canthoplasty is done when the inner corner is already sharp, the eye shape becomes sharper and looks more severe.
○ The inner mucosa becomes overly exposed, making it look unpleasant.
○ After inner canthoplasty, the inner line becomes thicker, and if an in-fold line was desired, it may become an unwanted out-fold line.
○ A double eyelid revision surgery was performed to reduce the inner line, but when combined with inner canthoplasty, the line did not decrease or became even larger.

How is inner canthoplasty restoration performed?

The method applied varies depending on the shape of the individual’s eyes and the available tissue.

For restoration, the design is made opposite to the original inner canthoplasty, and restoration is performed using a V-Y advancement flap method or a Z-plasty method.

Restoration surgery leaves more scars than inner canthoplasty surgery, so this must be taken into account before proceeding.

Examples of inner canthoplasty restoration

It is important to avoid creating a situation that would require inner canthoplasty restoration in the first place.

Having inner canthoplasty make your impression worse and then undergoing restoration surgery to undo it is a waste of both time and money.

You should carefully judge and decide whether the surgery is truly necessary for you.

What is Director Shin Duhan’s method for inner canthoplasty restoration at our clinic?

Based on more than 20 years of rich clinical experience and expertise, if inner canthoplasty has been done too extensively and restoration is desired, it may be possible to perform it in one session if the current double eyelid is natural and there is enough excess skin in the front area. However, if there is not enough excess skin and the double eyelid looks awkward and large, staged reconstructive surgery may be needed.

In general, if the thickness (width) of the double eyelid is around 6 mm or larger than that, and if the fixation position of the double eyelid is very high, it is expected to take a long time before it looks natural.

Reconstruction can be performed according to the shape of your own eyes.

It takes about 1 to 3 months for swelling to subside and for the result to settle.

Even if you undergo epicanthal reconstruction surgery, it cannot become exactly the same as your previous eyes. Also, during reconstruction surgery, the skin around the eyes must be gathered toward the eye area, so care must be taken to prevent the scar from spreading below the inner corner of the eye.

Because the scar is sutured from within the skin, it does not form.

A double eyelid line that has had outer canthoplasty

Sometimes the skin below the double eyelid line is pulled upward, causing outward turning of the eyelashes.

This can happen when scar adhesion is severe, when there is not enough skin,

or when the sutures are pulled too far upward.

The adhesion of the double eyelid should be released,

and the skin should be brought downward to correct it.

What is outer canthoplasty restoration?

These days, complaints of side effects from outer canthoplasty surgery at other hospitals are frequent.

Outer canthoplasty refers to surgery that opens the outer corner of the eye, the opposite of inner canthoplasty.

It is one of the surgeries that should absolutely not be performed among cosmetic procedures.

Even cosmetic surgery textbooks state that it is better not to do it.

Outer canthoplasty is a procedure that can cause various side effects such as exposed mucosa, outward turning of the eyelid, a severe-looking eye shape, and significant scarring.

What are the types of outer canthoplasty side effects?

Eversion and lifting of the eyelid
Distorted scar at the outer corner of the eye
Exposed mucosa and sagging eyelid
Excessive exposure of the white part below the eye
Deformation of the eye shape and twisting of the outer canthus
Dry eye and tearing

Examples of outer canthoplasty side-effect surgery at other hospitals

Please refer to the photos below. ㅠㅠ

The outer canthoplasty photos below are from people who came to our clinic to show the severity of outer canthoplasty side effects, or from people who came for surgery after having outer canthoplasty performed at another hospital.

What is Director Shin Duhan’s method for outer canthoplasty restoration at our clinic?

It has recently gained attention by compensating for the drawback of re-adhesion, which is a pre-existing outer canthoplasty side effect.

Because the tissue that tends to re-adhere is sufficiently removed through skin dissection, it does not reattach, and the procedure delicately sutures according to anatomical structure from the inner conjunctiva of the eye to the ligament-fascia layer, muscle layer, and skin layer.

Because the skin and mucosa are sutured separately, it does not form a D-shape, and there is no concern about re-adhesion.

Also, unlike other hospitals, it is not done with skin incision alone; it is firmly fixed to the periosteum so it does not come undone, and it is a safe procedure that can also be restored later if needed.

The sutured area is naturally hidden along the eye corner line to minimize visible scars, and with over 20 years of extensive double eyelid revision experience, the delicate and precise suturing leaves almost no scar.

Choices when the surgery is very complicated or difficult during consultation

When a patient visits for consultation and examination, there are cases where, from the surgeon’s perspective, the eye shape is very difficult or there is no confidence in producing a satisfactory result.

In such cases, it is not possible to simply say during consultation that one is fully confident, but on the other hand, saying that it is a bit difficult may cause trust in the clinic to drop or lead to being mistaken for an unskilled doctor.

From the surgeon’s point of view, if they honestly and firmly judge the patient’s condition and explain exactly what is difficult and that the result may be poor, some people accept it, but more people react the opposite way.

They come to think that the doctor is not skilled and has low competence.

In the end, the surgeon is pushed into a situation where, even for a very difficult operation, they must give an exaggerated consultation such as “It will definitely go well” just to avoid being called an unskilled doctor, and if the patient is misled by that exaggerated consultation and undergoes surgery, the situation can become even more bleak.

From the patient’s point of view, it is very important to distinguish between consultation explanations that are exaggerated and a surgeon who practices with conviction.

There are various outcomes in revision surgery.

Some people think that if they meet a highly skilled doctor for revision surgery, they will always get a good result.

This is a very dangerous way of thinking.

Even if a doctor is skilled, there will be cases where surgery improves things, cases where it cannot improve them, and sometimes cases where the result is unsatisfactory.

Before surgery, you should keep the three cases above in mind and receive a consultation, then make a realistic judgment by checking whether surgery is possible, how much improvement can be expected if it is possible, or whether it is impossible.

Cases where revision surgery is difficult or impossible

There are many cases where revision surgery is impossible or difficult.

These include cases with insufficient excess skin, cases where the scar line is too pronounced to release adhesions, cases where the skin and muscle are excessively thick, cases where tissues have become hard and thick after multiple revision surgeries, cases with severe sausage-like swelling where the tissue is likely to push down again even after surgery, and cases with severe ptosis.

Just as there are patients who can and cannot be saved no matter how skilled and capable the doctor is, the same applies to double eyelid revision surgery.

When the surgery is very complicated and difficult, the patient must understand the limits, but there are people who do not want to accept those limits.

If you go ahead with surgery while holding only the vague hope that somewhere there must be a hospital that will perform a perfect operation, you are setting yourself up to fall into a deeper pit.

Therefore, you must carefully judge the limits and prognosis in your current condition before deciding on surgery.

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