Causes, Prevention, and Treatment
E picanthic fold is the semi-lunar skin fold located at the medial canthus. It is a common lid condition obscuring the view of the medial canthus. It is mainly bilateral but can be unilateral too and usually appears along the upper eyelids but can also appear along the lower eyelids. It is normal in Asians, but in non-Asians, it is an abnormal condition.
Epicanthal folds are formed due to the excess growth and development of the skin over the nasal bridge.
There are 4 types of epicanthic folds.
1. Epicanthus tarsalis: The most common upper eyelid type.
2. Epicanthus inversus: The most common lower eyelid type.
3. Epicanthus palpebralis: Includes both lower and upper eyelids.
4. Epicanthus superciliaris: arises from the brown and goes down to the lacrimal sac. (1)
The severity of the condition depends on the degree of lacrimal caruncle (the pink nodule at the medial corner of the eye) obscuration. Severe epicanthic folds cover nearly all he caruncle, moderate cover more than half, and mild cover less than third.
Figure 1 – Epicanthic folds are a natural facial feature in East Asian populations but are considered a cosmetic flaw as they make the face seem ‘weary and tired’ (M.Mikamo, pioneer of East Asian aesthetic surgery).
Why Do Epicanthic Folds Affect Facial Aesthetic?
The nasal bridge is usually associated with epicanthic folds. People with prominent epicanthic folds tend to have lower nasal bridges than people with higher nasal bridges. They are also associated with ancestry, certain health issues, ageing, and congenital anomalies such as Down’s syndrome.
Epicanthoplasty is usually used to remove epicanthic folds. It is one of the most challenging procedures since it may affect the lacrimal canals, which are responsible for draining tears. The procedure usually leaves scars and should be followed by other corrective techniques.
What Causes Epicanthic Folds?
Epicanthic folds form due to the excess growth and development of the skin over the lower-based nose bridges. Many factors affect the formation of epicanthic folds including age, ancestry, and certain health problems.
Epicanthic folds usually disappear during gestation before the fetus is 6 months old. However, some babies are born with them and they may persist/reappear during the development stages of children. They usually disappear completely when the nasal bridge develops completely. (2)
Epicanthic folds are common in certain ethnicities including Asians, Native Americans, and the Malagasy. It is a characteristic feature of certain populations. Nearly 90% of East and Southeast Asians. (3)
Certain Medical Conditions
Epicanthic folds are sometimes one of the features of certain medical conditions, especially congenital anomalies. These medical conditions are characterized by the failure of maturation of the nasal bridge, which allows the epicanthi folds to grow and appear. 60% of Down syndrome people have epicanthic folds. In addition, Williams syndrome, Noonan syndrome, Blepharophimosis syndrome, Phenylketonuria (PKU), Rubinstein-Taybi syndrome, Turner syndrome, and Zellweger syndrome individuals also have epicanthic folds. (4)
Fetal Alcohol Syndrome
Fetal alcohol syndrome happens due to the consumption of alcohol by pregnant women. It is characterized by brain damages and growth problems. Its features vary from one child to another, but the damages are not reversible.
Children with fetal alcohol syndrome usually have prominent epicanthic folds. (5)
How To Prevent Epicanthic Folds?
Some causes of epicanthic folds are inevitable such as Down syndrome and aging. However, other causes such as fetal alcohol syndrome can be avoided. Also, since it’s more predominant in certain Asian ethnic groups, it is determined by facial genetics and there are no reasonable ways to prevent them.
Women who have prominent epicanthic folds, but they cannot get rid of them surgically can hide them via the use of makeup. Many epicanthic fold makeup ideas can hide your epicanthic folds completely.
Avoid Alcohol During Pregnancy
Consuming alcohol during pregnancy causes severe damages to your child’s brain, growth, and development including epicanthic folds. Avoid drinking too much alcohol during pregnancy to prevent Fetal Alcohol Syndrome from happening in the first place.
Figure 1 – A 24-year-old woman with epicanthal folds. A, Preoperative view. B, Four months after periciliary Y-V epic-anthoplasty.
How To Treat Epicanthic Folds?
Surgical intervention is rare in people who have epicanthic folds since the condition resolves spontaneously in almost all cases due to the development of a nasal bridge. However, several surgical procedures are available if the epicanthic folds intervened with vision.
If you have a mild degree of epicanthic folds, this operation may be the best choice for your condition. It is a simple procedure that is usually done for cosmetic purposes in non-Asian people.
The Five-Flap Technique
This technique is for difficult conditions and broad epicanthic folds. It depends on removing the excess muscles and deep tissues under the medial epicanthic folds. Studies show that this procedure is the best in people whose epicanthic folds are considered a deformity. It also requires about a year of regular follow-up and the results are satisfying in nearly all patients. (6)
People with moderate epicanthus can benefit from this procedure, especially if their vision is not fully affected by the epicanthic folds yet. It is an effective procedure that has been used for decades to obliterate the epicanthus. It is even simpler than the ‘V’ Operation. (7)
This procedure has been modified several times to provide the best results. It is used for the most complex conditions because it is difficult and requires a professional plastic surgeon who specializes in this type of surgery. The principle of this technique is the formation of the new epicanthus. It is suitable for all types of epicanthic folds and the results are good and satisfying in most cases. (8)
Pang’s Eyelid Crease Technique
This procedure is common among Asians to correct any problems with their creases and increase their quality regarding their shapes, height, depth, and softness. The procedure can increase the thickness of the fibrous tracts of the eyelids. The procedure depends on creating adhesion between the skin and the superior tarsal border. Epicanthic folds are usually corrected along with the rest of the creases. It is mainly used for cosmetic purposes. (9)
They are usually used to address the severity of the condition and figure out how it will be solved surgically. Some cases respond to the injection of Hyaluronic Acid (HA), but most cases need surgical corrections. The use of dermal fillers usually follows surgical procedures to improve the condition and remove any scars that may result due to the blepharoplasty. (10)
Figure 2 – Twin sisters had atypical monolids: single eyelid and III type of medial epicanthus(top); one of the sisters had an epicanthoplasty with double-eyelid (middle left), the other hadn’t(middle right). After ﬁnding the results her sister achieved, the other also demanded the same operation.
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1. Nguyen, A., & Kwon, B. (2015). Reconsideration of the Epicanthus: Evolution of the Eyelid and the Devolutional Concept of Asian Blepharoplasty. Seminars in Plastic Surgery, 29(03), 171–183. doi:10.1055/s-0035-1556849
2. Ma, H., Chen, Y., Cai, X., Tang, Z., Nie, C., & Lu, R. (2019). Effect of aging in periocular appearances by comparison of anthropometry between early and middle adulthoods in the Chinese Han population. Journal of Plastic, Reconstructive & Aesthetic Surgery. doi:10.1016/j.bjps.2019.07.030
3. Suhk, J., Nguyen, A., & Kiranantawat, K. (2015). The Asian Eyelid: Relevant Anatomy. Seminars in Plastic Surgery, 29(03), 158–164. doi:10.1055/s-0035-1556852
4. Akhtar F, Bokhari SRA. Down Syndrome (Trisomy 21) [Updated 2019 Apr 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-.
5. Fetal alcohol syndrome. (2002). Paediatrics & child health, 7(3), 161–195. https://doi.org/10.1093/pch/7.3.161
6. Anderson, R. L. (1989). The Five-Flap Technique for Blepharophimosis. Archives of Ophthalmology, 107(3), 448. doi:10.1001/archopht.1989.01070010458045
7. MACK, M. H. (1964). Y-V OPERATION FOR, EPICANTHUS. Plastic and Reconstructive Surgery, 34(2), 182–185. doi:10.1097/00006534-196408000-00010
8. Lessa, S., & Sebastiá, R. (1984). Z-epicanthoplasty. Aesthetic Plastic Surgery, 8(3), 159–163. doi:10.1007/bf01597520
9. Patel BC, Malhotra R. Upper Eyelid Blepharoplasty. [Updated 2020 May 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-.
10. Cazzaniga, A., Ballin, A., & Brandt, F. (2008). Hyaluronic acid gel fillers in the management of facial aging. Clinical Interventions in Aging, Volume 3, 153–159. doi:10.2147/cia.s2135