This document describes the Park Z-epicanthoplasty technique for modifying the epicanthal fold in Asian patients undergoing double eyelid surgery. Key points: - The epicanthal fold is a skin flap covering part or all of the lacrimal lake. It is a distinguishing feature in many East Asian populations. - The Park Z-epicanthoplasty involves making incisions within the eyelid skin to elevate and transpose the epicanthal flap, avoiding tension and visible scarring compared to other techniques. - It is most useful for type II and III epicanthal folds in patients seeking a higher or outer-type double eyelid. Careful preoperative marking and precision inc

1. Park Z-Epicanthoplasty
Jung I. Park, MD, PhD
a,
*, Min S. Park, MD
b
The epicanthal fold is a skin flap over the lacri-
mal lake in the medial corner of the eye. This fold
is the medial extension of the upper eyelid skin
and either covers a portion or the entirety of the
lacrimal lake. The fold then blends in with the
skin of the medial canthus or the medial aspect
of the lower eyelid. The epicanthal folds make
the medial aspect of the palpebral fissure round
and give the impression of the telecanthus. The
epicanthal fold is a unique feature among people
from East Asia (ie, China, Japan, and Korea). This
fold and single eyelid are the two anatomic char-
acteristics that distinguish the people from East
Asia from the rest of the world. Because of histor-
ical population movements, some Southeast
Asians also share this characteristic.
All embryos from Asian or non-Asian descent
have epicanthal folds at 3 to 6 months gestation.
This fold is preserved in only 2% to 5% of the gen-
eral population among non-Asians. The incidence
of the epicanthal fold in the Asian population
ranges between 40% and 90% [1–4]. The single eye-
lid is another unique feature of the upper eyelid in
East Asians. The eyelid without supratarsal crease is
described as the single eyelid, as opposed to the
double eyelid that has a skin fold over the
supratarsal crease in the open eye. Liu and Hsu
[1] identified the epicanthal fold in all single eyelid
individuals studied.
The epicanthal fold is found more frequently in
the population with the inner-type double eyelid
as opposed to the outer-type [1]. The inner-type
of double eyelid has a low-lying eyelid crease ap-
proximately 3 to 5 mm above the ciliary margin.
The double eyelid is obscured with upward gaze
as the overlying skin fold makes contact with the
eyelashes. The double eyelid fold in this case fol-
lows the curve of the epicanthal fold. The outer
type of the double eyelid exhibits a double fold
that runs parallel to the ciliary margin, indistin-
guishable from the non-Asian double eyelid. The
supratarsal crease is usually located 7 to 10 mm
above the ciliary margin.
The medial canthal area has distinctive anatomic
variations in terms of the presence or absence of the
epicanthal folds. Four types of medial canthal anat-
omy have been previously described [5–8]. In the
type I anatomy, there is full exposure of the lacrimal
lake, the medial most area of the palpebral fissure
forming a half-moon shaped recession. This area
is occupied by the caruncle. There is no epicanthal
fold in this type and it is seen in most eyelids
F A C I A L P L A S T I C
S U R G E R Y C L I N I C S
O F N O R T H A M E R I C A
Facial Plast Surg Clin N Am 15 (2007) 343–352
a
Department of Surgery, Northwest Campus, School of Medicine, Indiana University, 8825 Crestwood
Avenue, Munster, IN 46321, USA
b
School of Medicine, University of San Diego, 200 West Arbor Drive, Mailcode 8893, San Diego, CA 92103,
USA
* Corresponding author.
E-mail address: asiancosmeticsurgery@hotmail.com (J.I. Park).
- Preoperative consideration
- Patient preparation
- Marking
- Anesthesia
- Surgical technique
- Recovery
- Complications
- References
343
1064-7406/07/$ – see front matter ª 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.fsc.2007.04.001
facialplastic.theclinics.com

2. with a natural double fold. Some individuals of
East Asian descent, however, have both the double
eyelid fold and the epicanthal fold.
Type II medial canthal anatomy has an epican-
thal fold that partially covers the lacrimal lake.
The epicanthal fold joins the skin at the margin
of the lacrimal lake (Fig. 1A). In type III anatomy,
the lacrimal lake and caruncle are covered almost
completely by the epicanthal fold. As the fold rea-
ches the lower eyelid and passes the lacrimal lake,
it curves laterally to blend in with the lower eyelid
skin (Fig. 1B). As opposed to type II anatomy, types
I and III show round medial palpebral fissures. In
type I, the boundary of the palpebral fissure is the
fully exposed lacrimal lake, whereas the curved epi-
canthal fold forms the medial boundary of the fis-
sure in type III.
Type IV is a rare anomaly of the reversed epican-
thal fold where the epicanthal fold originates from
the lower eyelid and blends with the upper eyelid
skin [5–8]. The epicanthal fold in its natural shape
gently slopes in a smooth curve that blends well
with the upper eyelid and medial canthal area. It
is considered a mark of beauty among Asians, along
with the single eyelid or inner-type double eyelid.
The presence of the epicanthal fold becomes an is-
sue only when it is surgically altered in the process
of creating a double eyelid fold.
The double eyelid operation consists of attaching
the pretarsal skin to the levator aponeurosis. As the
eye opens, the pretarsal skin is lifted because of the
pull of the levator palpebral muscle. The skin of
the medial epicanthal fold is drawn up as the suture
used to create the supratarsal crease lifts the pretar-
sal skin of the medial aspect of the upper eyelid. As
the upper eyelid skin rises, the curve of the epican-
thal fold changes from a gently sloping, horizontal
orientation to an unsightly, tight vertical orienta-
tion (Fig. 2A, B). A higher supratarsal crease results
in a steeper displacement of the epicanthal fold.
When the double eyelid operation is aimed at the
creation of a conservative inner-type double fold,
the epicanthal fold remains soft and harmonious
with the surrounding structures (Fig. 3).
Numerous procedures to eliminate medial epi-
canthal folds have been described. Despite an
Fig. 1. (A) Type II medial canthal fold. (B) Type III medial canthal fold.
Fig. 2. (A) Type II epicanthal fold in a single eyelid. (B) As the upper eyelid skin is lifted to create the supratarsal
crease, tension develops on the epicanthal fold.
Park & Park344

3. abundance of available procedures, most surgeons
are reluctant to perform medial epicanthoplasty
for Asian eyelid cosmetic surgery because of the fre-
quent development of unsightly scars. Visible scars
form because of its proximity to the nasal skin. It is
almost impossible to hide even fine scars medial to
the medial canthus. Excision of the epicanthal skin,
W-plasties, V-Y advancements, Z-plasties, and so
forth have been attempted [8–10]. The Park Z-epi-
canthoplasty differs from the previously described
procedures by placement of the incision within, as
opposed to adjacent to, the eyelid skin. The epican-
thal flap is completely elevated from the medial
canthus by an incision adjacent to the medial
most edge of the palpebral fissure–lacrimal lake.
The flap is transposed away from the lacrimal lake
without tethering. The Park Z-epicanthoplasty was
first described in 1996, with a modification pub-
lished in 2000 [5,6].
Preoperative consideration
The Park Z-epicanthoplasty is most beneficial in
type III epicanthal folds and is also widely used
for type II epicanthal folds. It is most useful for in-
dividuals seeking higher double folds and outer-
parallel–type double eyelid folds. Because of the
lack of vertical tightening, inner-type double folds
tend to maintain a smooth transition from the dou-
ble eyelid to the epicanthal fold without epicantho-
plasty (see Fig. 3). Individuals with even the
slightest possibility of hypertrophic scar formation
should not be considered as a candidate for epican-
thoplasty. Although the Park Z-epicanthoplasty re-
sults in far less scarring, patients should always be
counseled of the potential for visible scar formation
before surgery. This technique is often performed at
the time of the double eyelid procedure. Less fre-
quently, it is performed on patients with distorted
epicanthal folds from previous double eyelid
procedures.
Patient preparation
The patient is premedicated with oral administra-
tion of broad-spectrum antibiotics, 1.5 to 2 mg
alprazolam (Xanax), and propoxyphene napsy-
late–acetaminophen, 100/650 mg (Darvocet
N-100). Sedation should result in relaxation or light
sleep. Patient cooperation is necessary to evaluate
changes in the transposed flap with the formation
of the double eyelid as the patient opens their
eyes. Most inks used for ultra-fine marking are par-
tially or completely erased with water. Sterile prep-
aration of the skin is done before skin marking.
Every effort should be made to preserve the skin
markings during infiltration of local anesthetic. Re-
drawing of the lines following infiltration of the
Fig. 3. Harmonious type II epicanthal fold after a con-
servative inner-type double eyelid operation.
Fig. 4. (A) The Park Z-epicanthoplasty design. Point A is the surface representation of point D. The epicanthal
fold meets the skin of the lower eyelid at point B. (B) Point D is the medial most point of the lacrimal lake.
(C) Triangle EAC is removed. (D) Flap EABD is lifted. (E) The flap is rotated and sutured. (F) Long-term scar.
The lines AD-C and AD-B become invisible with time.
Park Z-Epicanthoplasty 345

4. anesthetics can cause significant asymmetry be-
cause of tissue distortion.
Marking
Conventional surgical marking pens are often too
thick to be used for Z-epicanthoplasty marking.
A broken cotton tip applicator can be used to apply
methylene blue. This method, however, has a ten-
dency to bleed along fine wrinkles resulting in
some blurring. It is critical to use an extra-fine mark-
ing pen to minimize the potential for asymmetric
incisions between the eyes.
Marking is made with the patient in a sitting po-
sition following the sterile preparation of the face.
A small dot is placed on the surface of the epican-
thal fold with the eyes in the primary gaze position.
This dot, designated as point A, serves as the surface
representation of the medial most point of the lac-
rimal lake (Figs. 4A and 5). Point B is placed where
the epicanthal fold joins the skin of the medial can-
thus in type II or the skin of the lower eyelid in type
III anatomy (see Fig. 4A; Fig. 6). Although point B
is easily identifiable in most cases, there are occa-
sions when the confluence is not well defined. In
these instances, the surgeon must choose an arbi-
trary point close to both the lacrimal lake and the
point of closure following a tension-free, flap rota-
tion. Point D is at the medial most point of the lac-
rimal lake (Figs. 4B and 7). When points A and D
are viewed from the front, these two points should
align as one point.
The lines AB and DB should also be the same line
when viewed from the front. When flap ABD is ele-
vated and transposed to the recipient triangle, the
incisions AB and DB should close without any ten-
sion (Fig. 4C–E). The double eyelid incision line
continues medially until it joins point A. The upper
eyelid and nasal skin is stretched in a medial and
superomedial direction with the eyes closed. This
maneuver tightly spreads the medial epicanthal
fold and makes additional markings more precise
(see Fig. 7). Point E is made on the line for the dou-
ble eyelid incision. A second line is drawn from
point E as an extension of the double eyelid inci-
sion running parallel to the ciliary margin (see
Fig. 4A).
An oblique line drawn from point A at about
a 45-degree angle from the horizontal plane in
a superior medial direction is drawn toward the
glabella. Point C is the intersection of the second
line from point E and the oblique line from point
A. The line EA tends to converge toward the lacri-
mal lake in a primary gaze position. The line EC
runs parallel to the ciliary margin. A slender trian-
gle is formed by the points E, A, and C (see
Fig. 4A).
Fig. 5. Dot is a surface representation of the medial
end of the lacrimal lake.
Fig. 7. The eyelid is stretched medially to show point
D. The lines AB and DB are visible.
Fig. 6. Marking of point B and line AB is shown. Point
C is also marked.
Park & Park346

5. There are two critical design issues in the Park Z-
epicanthoplasty. Point A must be marked precisely
as the surface representation of point D. It is better
to err with a more lateral placement of point A in
relation to point D. If point A is placed medial to
point D, the skin of point A must be stretched lat-
erally under tension for adequate skin approxima-
tion. Skin closure under tension often results in
a wide, unattractive scar. Point C must also be
clearly defined. The more medial this point is
from the tarsal margin, the more the scar is visible.
Placing points A and C too lateral can cause resid-
ual redundancy of the epicanthal fold. Of the two
errors, it is far more important to avoid a visible
scar.
Anesthesia
Two percent lidocaine with 1:200,000 epinephrine
solution buffered with sodium bicarbonate in 1:10
ratio is used for local anesthesia. The eyelid is infil-
trated with local anesthetics after all markings are
complete. The surgeon should make a conscious
effort to avoid blurring or washing away any ink.
Distortion of the marks may result in asymmetry
of the eyelids following the procedure. The area ad-
jacent to point D should be infiltrated carefully and
thoroughly. If the medial canthal ligament in this
area is not properly anesthetized, the patient may
complain of pain during the dissection.
Surgical technique
Because the area for the epicanthoplasty is small
and the markings may be easily erased by blood
and manipulation, the Z-epicanthoplasty incision
is made before the incision for the double eyelid
procedure. This area also requires more precision
than the double eyelid procedure. Incisions
through EAB, EC, AC, and BD are made through
the skin and muscle (Fig. 8A). The skin and a por-
tion of the underlying muscle are removed from the
triangle EAC and discarded (Figs. 4C and 8B). If ex-
cision of any upper eyelid skin is required for the
double eyelid operation, the triangle EAC is incor-
porated with the skin island excision (Fig. 8C, D).
Fig. 8. (A) Incision is made for the double eyelid operation and Z-epicanthoplasty. The skin island is shown in the
triangle EAB. (B) A tiny triangle EAC is removed. Removal of a slightly larger triangle may cause a scar in this
critical area. If one decides not to remove the triangle, the excess skin may adapt fairly well without causing
excessive redundancy. (C, D) When a strip of pretarsal skin is removed, the triangle is incorporated with the pre-
tarsal skin excision.
Park Z-Epicanthoplasty 347

6. The incision through DB should be made as a per-
fectly, straight line (Fig. 9A). If the incision is not
straight, it tends to curve laterally toward the lower
eyelid skin. This creates a gap between the lines AB
and DB, necessitating a closure under tension with
eventual visible scar formation. Line DB is incised
deeply using a #15 Bard-Parker blade with the
cutting edge toward the surgeon (Fig. 9B). Acciden-
tal injury may occur if the cutting side of the blade is
directed toward the eye. The tip of the blade is
aimed at point D. Steady, firm pressure is then ap-
plied to the knife handle so that the tip of the blade
cuts through point D, follows line DB, and ad-
vances deep over the surface of the medial canthal
Fig. 9. (A) Skin is stretched medially to demonstrate
the straight line DB. (B) The tip of the #15 Bard-
Parker blade touches the medial canthal ligament
(point D). Line DB is incised by pushing the blade
gently but firmly toward point B. (C) Complete tran-
section of line DB exposes the area over the medial
canthal ligament.
Fig. 10. (A, B) Line DB is transected and the base of the flap ABD is completely freed from the medial canthal
ligament. The tip of the flap is lifted under tension using a pair of forceps while the flap is freed. Often a sudden
release of the flap can be felt.
Park & Park348

7. ligament (Fig. 9C). To ensure a straight incision, the
epicanthal skin should be stretched tightly in all di-
rections (see Fig. 9A). This step of the operation is
crucial to free flap EABD completely without tether-
ing to the underlying ligament. To further ensure
complete release of the flap, the tip of the flap
EABD is grasped and lifted under slight tension
with a fine pair of toothed forceps at point B. Any
residual attachment of the flap is severed from the
medial canthal ligament with the knife blade or te-
notomy scissors (Fig. 10B). As soon as detachment
is successful, a sudden release is felt by the surgeon
holding the flap. The flap is then rotated to the re-
cipient triangle EAC (Figs. 4D, E and 11A). Point
B moves to point C. Line EAB effaces line AC. At
the same time, the opposite side of incision AB ef-
faces the remaining side of incision DB. When the
design is correct and the flap elevation is complete,
the incisions should be in complete approximation
without any help of suture placement. The final clo-
sure follows the points E, C, AD, and B (Fig. 4F).
Because of the development of a tension-free
flap, a deep fixation suture is unnecessary
(Fig. 11A–C). If a more distinctive medial crease is
desired, an anchoring suture may be placed be-
tween the rotated flap EAB and the deep, soft tissue
under the incision EC on the nasal side. A 7-0 clear
nylon suture with buried knot may be used for this
purpose. The knot should be deeply buried to pre-
vent superficial migration, which may result in
persistent redness, nodules, granulomas, or suture
Fig. 12. One week post–Park Z-epicanthoplasty.
Fig. 11. (A) The flap is freed until it rests comfortably in the recipient triangle without fixation suture. (B) The
incision lines are in perfect approximation without fixation. (C) The rotated epicanthal flaps are kept in place
without suture fixation.
Park Z-Epicanthoplasty 349

8. abscess and eventual unsightly scarring in this crit-
ical area. If flap EABD is much longer than recipient
triangle EAC, the lower edge of the flap may be
trimmed conservatively in a triangular shape. Sutur-
ing point A and point D is a technical challenge be-
cause of both the close proximity of point D to the
eye and the lack of substantial tissue at the medial
canthus. The suture through the medial canthal lig-
ament often breaks through. As an alternative,
a deep suture may be placed through the skin
slightly lateral (outside) to point A and point D.
There is a discrepancy in the thickness of the skin
at points A and D. Although the subcutaneous fat
is abundant under point A, there is virtually no un-
derlying tissue under point D. Approximation of
two tissues with different thicknesses results in
step formation at the closure line. It is often neces-
sary to remove fat tissue under point A to even the
thickness between the two points. Skin closure for
Z-epicanthoplasty may be done with 6-0 black ny-
lon or 6-0 fast absorbing gut. Using 6-0 fast absorb-
ing gut for closure between points A and D may
help avoid painful suture removal adjacent to the
eye and accidental displacement of nylon into the
conjunctiva. Keys to success for the Park Z-epican-
thoplasty are the exact placement of point A, com-
plete detachment of the flap at point D, and
conservative excision of triangle EAC.
Recovery
The patient is taken to the recovery room and
placed in a semi-reclining position. Moist 4 Â 4
gauze is place over the eyelid followed by an ice
pack. A surgeon’s mask over the ice pack tied
around the head or looped around the ear of the pa-
tient secures the ice pack in position. The patient is
Fig. 13. Preoperative and postoperative views of Park Z-epicanthoplasty.
Fig. 14. Preoperative and postoperative views of Park Z-epicanthoplasty.
Park & Park350

9. required to rest for 30 minutes to an hour before
discharge. Patients often begin to complain of
pain toward the end of the procedure. Usually, an
additional dose of narcotic medication is sufficient
for pain control. Postoperatively, only several more
dosages of pain medications are necessary. Antibi-
otics are administered for 2 days following the sur-
gery. The ice pack is applied in 30-minute intervals
on and off for the first 2 to 3 days. The patient is
allowed to see and ambulate as needed after
discharge. The first postoperative visit is recommen-
ded 7 days after surgery (Fig. 12). Vigorous physical
activities, such as heavy weight lifting, are allowed
after 2 weeks. Skin thickness, extent of surgery,
and patient age determines the degree of postoper-
ative edema. Edema is generally less in patients with
thinner eyelid skin. Patients may return to work
with shaded glasses during the first week of surgery.
Patients who wear contact lenses may be
encouraged to wear regular glasses to camouflage
the unnatural appearance during the recovery
period.
Complications
Complications are often related to poor design and
lack of precision in dissection. Incomplete flap ele-
vation causes blunting of the medial canthal area
and persistence of the epicanthal fold. The superfi-
cial placement of permanent anchoring suture may
result in suture migration, redness, granuloma for-
mation, suture abscess, and eventual visible scar-
ring. Skin closure under tension is the most
common cause of thick scar formation. Incomplete
flap elevation at point D also causes a closure under
tension and thick scar formation. Temporary epi-
phora caused by obstruction of the lacrimal canna-
liculi from swelling is common. This often resolves
within a week or two without treatment. Although
it has not been an issue for the authors, it is possible
inadvertently to damage the lacrimal cannaliculi or
lacrimal sac. Some degree of asymmetry is frequent
and patients should be warned of this possibility.
Fortunately, a minor degree of asymmetry is well ac-
cepted by most patients.
Fig. 15. Preoperative and postoperative views of Park Z-epicanthoplasty.
Fig. 16. (A) Double eyelid with epicanthal fold. (B) One year post–double eyelid operation with Park Z-
epicanthoplasty.
Park Z-Epicanthoplasty 351

10. A case review of the Park Z-epicanthoplasty is
shown in Figs. 13 to 16.
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Park & Park352