d

COSMETIC

A Four-Step Technique for Creating Individual

Double-Eyelid Crease Shapes: A Free-Style Design
Linlang Suo, M.D.
Background: Double-eyelid blepharoplasty is the most frequently performed
Jiaqi Li, M.D.
aesthetic surgery in the Asian population. However, the epicanthal fold has
Rao Fu, M.D.
been a conundrum limiting the outcomes of Asian blepharoplasty. Further-
Yun Xie, M.D. more, with the blending of Western and Asian cultures, patients have individ-
Ru-Lin Huang, Ph.D., M.D. ual standards of beauty for the upper eyelids. Here, we developed a four-step
Shanghai and Chengdu, People’s technique to form infold or outfold double-eyelid creases to satisfy individual
Republic of China patient requirements.
Methods: The medical records of patients who simultaneously underwent
double-eyelid blepharoplasty and epicanthoplasty using this four-step tech-
Downloaded from http://journals.lww.com/plasreconsurg by BhDMf5ePHKbH4TTImqenVP9XFeJftgMxF/wTW6t1GXTAbzWHqmGyDQsI/as43NY+ on 09/27/2020

nique from January of 2017 to January of 2019 were reviewed. The results
were grouped by preoperative patient requirements for eyelid crease shapes.
The rate of meeting patient expectations in each group was evaluated by two
independent observers. Preoperative and postoperative photographs were col-
lected, complications were identified, and postoperative results were assessed.
Results: In total, 285 consecutive patients were included in this study, with a
mean follow-up period of 9 months. Of the 285 patients, 207 requested infold
eyelid creases, and 190 (92 percent) procedures met patient expectations; and
78 patients requested outfold eyelid creases, and 69 (87 percent) procedures
met patient expectations. A high rate of satisfaction with the final eyelid crease
shape and resulting scarring was noted in both patient groups. The revision
rate was 3 percent. No severe complications were observed.
Conclusion: The four-step technique is a simple, flexible, and effective method
for creating infold or outfold double-eyelid creases according to individual
patient requirements and should be considered a routine method for patients
who request double eyelids. (Plast. Reconstr. Surg. 146: 756, 2020.)
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

A
medial epicanthal fold together with the
lack of a supratarsal fold (also called single
eyelid) is the most common presentation of
the upper eyelids in the Asian population.1 The
medial epicanthal fold covers the medial canthus
and lacrimal lake to different extents, visually
causing the illusion of a shorter palpebral fissure,
a widening of the intercanthal distance, and even
pseudoesotropia.2,3 Individuals with single eyelids
and no upper eyelid creases appear to have narrow
palpebral fissures and small eyes and are culturally
From the Department of Plastic and Reconstructive Surgery,
Shanghai Eighth People’s Hospital, Department of Plastic
and Reconstructive Surgery, Shanghai Ninth People's Hos-
pital, Shanghai Jiao Tong University School of Medicine;
and the Department of Dermatology, West China Hospital.
Received for publication August 16, 2019; accepted April
15, 2020.
The first two authors contributed equally to this work.
Copyright © 2020 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0000000000007185
perceived to be tired or even displeased. Along
with the increasing cultural contact between West-
ern and Asian populations, a growing number of
Asians desire double-eyelid blepharoplasty and
epicanthoplasty to achieve double eyelids and the
appearance of larger eyes.
Currently, numerous techniques for blepharo-
plasty and epicanthoplasty have been reported and
have yielded promising results.4–7 However, in clini-
cal practice, patients born with single eyelids often
exhibit medial epicanthal folds. The creation of
upper eyelid creases by blepharoplasty alone with-
out epicanthoplasty can increase the height of the
Disclosure: The authors have no financial interest
to declare in relation to the content of this article.
Related digital media are available in the full-text
version of the article on www.PRSJournal.com.

756 www.PRSJournal.com
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 Volume 146, Number 4 • Four-Step Technique for Blepharoplasty

Fig. 1. Three typical types of double-eyelid creases. (Left) Double eyelids with a moderate epicanthal fold. (Center) Infold dou-
ble-eyelid crease: minimally nasally tapered crease with a mild lateral flare. (Right) Outfold double-eyelid crease: parallel crease.
(Reprinted with permission from Elsevier from Chen PD. What is an upper lid crease? In: Asian Blepharoplasty and the Eyelid Crease.
New York: Elsevier; 2016:chap 1.)

eyes but not the length of the eyes, which may result
in a round and unnatural appearance. Further-
more, each patient’s cultural idea of eyelid beauty
also influences the desire for a double-eyelid shape:
some patients prefer a Western appearance and
desire to have a wider palpebral fissure with a paral-
lel supratarsal crease (outfold type), whereas some
patients prefer a soft and Asian face and desire to
have a wider palpebral fissure with a minimal nasally
tapered crease (in-fold type) (Fig. 1). Although sev-
eral techniques have been published for creating
in-fold or out-fold double-eyelid creases,8–10 none
of these methods can create different crease types
according to individual patient requirements.
Anatomically, the main difference between the
in-fold and out-fold types of double eyelids is the
height of the medial crease: for the in-fold type dou-
ble-eyelid crease, the height of the central crease is
greater than the height of the medial crease (Fig. 2,
above), whereas for the outfold-type double-eyelid
crease, the height of the central crease is close to
or equal to the height of the medial crease (Fig. 2,
below). Therefore, we developed a simple but flexi-
ble technique for customizing the in-fold or out-fold
crease for patients with single eyelids in combina-
tion with the creation of an epicanthal fold. This
technique simultaneously combines modified Z-epi-
canthoplasty with double-eyelid blepharoplasty and
yields an upper eyelid crease shape and minimal
scarring in the medial epicanthal region through a
one-stage operation. This method had a high satis-
faction rate in this 285-patient retrospective study.
PATIENTS AND METHODS
This was a retrospective study of all patients
who underwent primary double-eyelid blepha-
roplasty with modified Z-epicanthoplasty from
January of 2017 to January of 2019 performed by
the senior author (R.-L.H.). The inclusion crite-
ria were as follows: (1) primary single eyelids or
inconspicuous double eyelids with an epican-
thal fold and (2) a follow-up period of at least 6
months. The exclusion criteria were as follows:
(1) blepharoptosis and (2) an inverted epicanthal
fold. The case notes, including the detailed oper-
ation reports and patient satisfaction regarding
the final shape and appearance of the scar, were
reviewed. Photographic documentation was used
by two independent observers to evaluate the
postoperative shape of the double-eyelid crease,
as shown in Figure 1. All postoperative complica-
tions and reoperations were evaluated.
Operative Techniques
Step 1: Preoperative Design
Before making the preoperative markings,
the patient was instructed to open or close his or

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 Plastic and Reconstructive Surgery • October 2020
Fig. 2. The difference between the infold-type double-eyelid
crease and the outfold-type double-eyelid crease. (Above) For the
in-fold double-eyelid crease, the height of the central crease (H1)
is greater than the height of the medial crease (H2). (Below) For the
out-fold double-eyelid crease, the height of the central crease (H1)
is close to or equal to the height of the medial crease (H2).
her eyes (Fig. 3, above, left). [See Video 1 (online),
which demonstrates the general protocol of the
four-step technique for creating different double-
eyelid crease shapes.] The design of the supratarsal
fold morphology was based on the patient’s wishes.
Briefly, the supratarsal fold is located 5.5 to 7.5 mm
above the ciliary margin (Fig. 3, above, left). The
marking for the double-eyelid incision was placed
just inferior to this fold. Then, the epicanthoplasty
markings were designed, as shown in Figure 3, above,
left. Point A was marked on the medialmost point of
the lacrimal lake. Point B was marked on the point
of confluence of the epicanthal fold with the lower
eyelid skin. Point C was marked on the surface of
the epicanthal fold as a surface representation of
point A. The epicanthal fold was retracted to show
the lacrimal lake. Point D was placed along the line
for the double-eyelid incision. Then, lines AB and
BC were drawn. A second line was drawn from point
C to point D as an extension of the double-eyelid
incision, which runs parallel to the ciliary margin.
Step 2: Inferior Myocutaneous Flap
Dissection and Orbital Septum Debulking
Local anesthetic was administered subcutane-
ously after placing the markings to avoid distor-
tion. An incision was made using a no. 11 blade
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Copyright © 2020 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
along the designed supratarsal fold. Fine capillary
bleeding was controlled using a bipolar cautery.
Then, a skin orbicularis flap (inferior myocuta-
neous flap) was dissected inferiorly using scissors
along the superior tarsal border to the root of the
lashes. A small strip of sub–orbicularis oculi fat
and orbicularis tissue was removed according to
the thickness of the inferior myocutaneous flap.
The orbital septum was opened along the supe-
rior incision line, and the preaponeurotic fat pads
were removed according to the fullness of the
preseptal area. A small myocutaneous strip was
trimmed along the superior skin incision above
the superior tarsal border.
Step 3: Epicanthal Fold Flap Dissection
The incision for the modified Z-epicantho-
plasty started from point D. The incision DCB
was made deep through the muscle, reaching the
medial canthal ligament. The incision BA was a
straight line. The remaining adhesion of the flap
to the medial canthal ligament was then released
using scissors. Subcutaneously, the malpositioned
medial orbicularis oculi muscle in the medial
canthal ligament was subcutaneously detached
and repositioned until the flap could be rotated
above the canthal ligament level without the aid
of sutures (Fig. 3, below, left). Then, the flap AB′D
was elevated and then gently lifted up. This step
ensured tension-free flap rotation and closure.
Step 4: Wound Closure and Double-Eyelid
Shape Adjustment
Step 4 is the step in this technique that is key
to obtaining the final results. The morphology of
the double eyelid is determined by two factors: the
height of the central crease and the height of the
medial crease. The height of the central crease is
determined by the height of the superior myocu-
taneous flap, and the height of the medial crease
is determined by the size of the epicanthal fold
flap.
Before the sutures were placed, the epicanthal
fold flap was grasped and rotated upward from the
canthal ligament level until it overlapped with the
upper skin edge. The rotation angle depends on
the tension of the upper skin edge, but it is usually
45 degrees. Then, the AB′D epicanthal fold flap
was trimmed to form the patient’s desired double-
eyelid type. [See Video 2 (online), which demon-
strates step 4 for creating an in-fold double-eyelid
crease or an out-fold double-eyelid crease.] If the
patient preferred an in-fold–type double-eyelid
crease, the line AB′ was trimmed to approximately
1 mm in width (Fig. 3, above, center); if the patient
preferred an out-fold–type double-eyelid crease,
 Volume 146, Number 4 • Four-Step Technique for Blepharoplasty

Fig. 3. Photographic diagram of the technique for creating different double-eyelid shapes. (Above, left) Preoperative design of
this technique: the green line represents the incision for the double-eyelid blepharoplasty; the blue line represents the incision for
epicanthoplasty. (Below, left) Dissection of the inferior myocutaneous flap and epicanthal fold flap AB′D; the epicanthal fold flap
AB′D was placed underneath the skin. (Above, center) Demonstration of the size and location of the epicanthal flap AB′D to form an
in-fold double-eyelid crease. (Below, center) Demonstration of the size and location of the epicanthal flap AB′D to form an out-fold
double-eyelid crease. (Right) Demonstration of the shape of an in-fold double-eyelid crease after interrupted tension-free sutures.

the width of the flap (line AB′) was trimmed to
approximately the same height as the double-eye-
lid crease (Fig. 3, below, center). Then, an incision
was made on the upper skin edge along the line
AB′, and the length of the incision was equal to
the length of the line AB′. The triangular section
of redundant skin above the incision was removed
to allow the epicanthal fold flap to fill the new
position.
The first suture started from the center crease.
Nonabsorbable 8-0 silk sutures or 7-0 Prolene (Eth-
icon, Inc., Somerville, N.J.) sutures were used to
engage the lower skin edge and its subcutaneous
tissue, engage the levator aponeurosis along the
superior tarsal border, and then engage the upper
skin edge and its subcutaneous tissue in turn at
the center of the double-eyelid incision; these
structures were tied with an interrupted suture.
Then, the patient was instructed to open his or
her eyes with a neutral gaze to check the height
and morphology of the crease. If the height of the
crease was too low or too high, a strip of myocuta-
neous tissue could be removed from the superior
or inferior myocutaneous flap, respectively.
The second suture was placed at the medial
canthus to fix the epicanthal fold flap in the new
position with tension-free sutures. The patient was
instructed to open his or her eyes with a neutral

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 Plastic and Reconstructive Surgery • October 2020
Fig. 4. Flow diagram of this retrospective study.
gaze to check the shape of the double-eyelid
crease. Then, three to four interrupted sutures
were placed medially and laterally (Fig. 2, right).
Statistical Analyses
The results were divided according to the
patient eyelid shape request (in-fold type and out-
fold type). The Kruskal-Wallis test was used to ana-
lyze the distribution of the epicanthal fold severity,
and chi-square tests were used to compare the rate of
meeting patient expectations and the patient satis-
faction with the final scar and eyelid shape between
the groups. All analyses were performed with SPSS
Version 18.0 (SPSS, Inc., Chicago, Ill.), and a value
of p < 0.05 indicated statistical significance.
RESULTS
Between January of 2017 and March of 2019,
483 patients underwent primary double-eyelid
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Copyright © 2020 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
blepharoplasty; of these patients, 324 (67 percent)
underwent double-eyelid blepharoplasty with
modified Z-epicanthoplasty and were enrolled
in the study. Thirty-nine patients were excluded
because they were lost to follow-up before a mini-
mum of 6 months, leaving 285 patients for analy-
sis (Fig. 4). Of these patients, 207 (70 percent)
preoperatively requested an in-fold double-eyelid
crease shape, and 78 (30 percent) preoperatively
requested an out-fold double-eyelid crease shape
(Fig. 1). The distributions of mild, moderate,
and severe epicanthal folds in the patients who
requested in-fold and out-fold eyelid creases were
not significantly different. (See Table, Supple-
mental Digital Content 1, which shows distribu-
tions of mild, moderate, and severe epicanthal
folds in the patients who requested in-fold–type
and out-fold–type eyelid creases, http://links.lww.
com/PRS/E180.) All of the included patients were
female and Asian. The mean patient age was 24
 Volume 146, Number 4 • Four-Step Technique for Blepharoplasty

Fig. 5. (Above) A 21-year-old woman presented with single eyelids and mild epi-
canthal folds. She desired in-fold double-eyelid creases and underwent blepharo-
plasty combined with modified Z-epicanthoplasty. (Below) She is shown here at 6
months postoperatively. Note the minimal scarring in the medial canthal region.

Fig. 6. (Above) A 27-year-old woman presented with single eyelids and severe
epicanthal folds. She desired in-fold double-eyelid creases and underwent
blepharoplasty using our technique. (Below) She is shown here at 10 months
postoperatively.

years (range, 17 to 38 years). The average follow-
up period was 9 months (range, 6 to 23 months).
Photographic Analysis
Figures 5 through 8 show patients with dif-
ferent initial requests. The postoperative pho-
tographic analysis showed that among the 207
patients who requested an in-fold type of double-
eyelid crease, 190 (92 percent) achieved an in-
fold–type crease, eight (4 percent) achieved an
out-type–type crease, and only nine (4 percent)
had a mild residual epicanthal fold; among the 78
patients who requested an out-fold type of dou-
ble-eyelid crease, 69 (89 percent) obtained an out-
fold–type crease, nine (9 percent) achieved an
in-fold–type crease, and only two (3 percent) had
a mild residual epicanthus. (See Table, Supple-
mental Digital Content 2, which shows the results
regarding meeting patient expectations, http://
links.lww.com/PRS/E181.) The rate of meeting

761
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 Plastic and Reconstructive Surgery • October 2020

Fig. 7. (Above) A 24-year-old woman presented with unnatural double-eyelid

creases and moderate epicanthal folds. She desired out-fold double-eyelid
creases and underwent blepharoplasty combined with modified Z-epicantho-
plasty. (Below) She is shown here at 6 months postoperatively. Note the improve-
ment in the height of the double-eyelid creases and the exposed lacrimal
caruncle, giving a natural appearance.

Fig. 8. (Above) A 23-year-old woman presented with asymmetric eyelid creases

and moderate epicanthal folds. She desired wide out-fold double-eyelid creases.
(Below) She is shown here 14 months after surgery.

patient expectations was not significantly differ-
ent between the two groups.
Patient Satisfaction Rate
After 6 months, satisfaction was assessed by
asking the patients whether the final shape of
the double-eyelid creases met their initial request
and whether they were pleased with the scar in
the medial canthal region. Of the 207 patients
who initially requested in-fold–type double-eyelid
creases, 200 (97 percent) reported being satis-
fied or fully satisfied with the double-eyelid shape,
and 188 (91 percent) reported being satisfied or
fully satisfied with the scar in the medial epican-
thal region. Seven patients (3 percent) reported
being unsatisfied with the final shape. Of these
patients, three complained that the final shape
was not the expected shape, and four complained

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 Volume 146, Number 4 • Four-Step Technique for Blepharoplasty

Table 1. Postoperative Complications in the Table 2. Postoperative Revisions in the In-Fold–Type

In-Fold–Type and Out-Fold–Type Operations and Out-Fold–Type Operations
Complications No. of Patients Revisions No. of Patients
In-fold In-fold
 Hematoma 1  Asymmetrical or unnatural crease 3
 Asymmetric or unnatural crease 4  Excessive scarring 2
 Chemosis 16  Undercorrected epicanthus 1
 Ocular irritation 4 Out-fold
 Xerophthalmia 2  Asymmetric or unnatural crease 1
 Undercorrected epicanthus 9  Excessive scarring 2
 Visible scar 19  Undercorrected epicanthus 0
Out-fold
 Hematoma 0
 Asymmetric or unnatural crease 2 unnatural double-eyelid creases, and one was per-
 Chemosis 11
 Ocular irritation 3 formed to correct an undercorrected epicanthal
 Xerophthalmia 4 fold. The rates of postoperative complications and
 Undercorrected epicanthus 2 revision are listed in Tables 1 and 2, respectively.
 Visible scar 7

that the double-eyelid creases were asymmetric or
unnatural. (See Table, Supplemental Digital Con-
tent 3, which shows the rate of satisfaction with the
final eyelid crease shape, http://links.lww.com/PRS/
E182.) Nineteen patients (9 percent) complained
that the scars in the medial epicanthus were too vis-
ible. Of the 78 patients who requested out-fold–type
double-eyelid creases, 73 (94 percent) reported
being satisfied or fully satisfied with the final shape,
and 71 (91 percent) reported being satisfied or
fully satisfied with the residual scar. Five patients
(6 percent) were unsatisfied with the final shape.
Of these patients, three complained that the final
shape was not the expected shape, and two com-
plained that the double-eyelid creases were asym-
metric or unnatural. Seven patients (9 percent)
were unsatisfied with the residual scar. (See Table,
Supplemental Digital Content 4, which shows the
rate of satisfaction with the scar in the medial epi-
canthal area, http://links.lww.com/PRS/E183.) The
rates of patient satisfaction with the eyelid shape
and scar were not significantly different between
the two groups.
Postoperative Complications
Severe postoperative complications were rare.
There were no cases of hematoma, blepharopto-
sis, upper lid retraction, or wound infection in any
patient, except for a small hematoma in one eye-
lid in one patient, which resolved spontaneously.
Mild complications, such as postoperative chemo-
sis, xerophthalmia, and ocular irritation, recovered
well within 4 to 8 weeks with conservative treat-
ment. The total revision rate was 3 percent (nine
of 285). Of these procedures, four were performed
to remove excessive scar tissue in the medial epi-
canthus, four were performed to fix asymmetric or
DISCUSSION
With the blending of Asian and Western
cultures, the concept of upper eyelid beauty in
Asian people has changed: some patients prefer
eyes that appear larger with in-fold double-eyelid
creases, whereas some patients prefer eyes that
appear larger with out-fold double-eyelid creases.
To satisfy individual patient requirements for dif-
ferent upper eyelid appearances, we developed
a technique that combines blepharoplasty and
modified Z-epicanthoplasty to create in-fold or
out-fold double eyelids in a single-stage opera-
tion. In this retrospective study, the simple four-
step technique was generally effective and had a
high satisfaction rate in patients with both single
eyelids and epicanthal folds.
Many different surgical techniques have been
developed to create in-fold– or out-fold–type eyelid
creases. Wang et al.9 and Zhao et al.8 described their
modified Z-plasty techniques for creating in-fold–
type or out-fold–type eyelid creases, respectively.
The researchers followed a similar Z-epicantho-
plasty protocol to treat epicanthal folds but yielded
different eyelid crease shapes. The inconsistent
results were attributable to the complex preop-
erative incision designs and flap rotations. Our
modified Z-epicanthoplasty adopted the principle
of root Z-epicanthoplasty but simplified the preop-
erative design and made it relatively easy to adjust
the shape of the eyelid creases. The root Z-epic-
anthoplasty preoperatively dictates the size and
rotation direction of the two flaps. It is difficult to
adjust the shape of creases after elevation of the
flaps. Following our modified Z-epicanthoplasty,
only four points are needed to mark the epicanthal
fold flap. The size and rotation angle of the epi-
canthal fold flap could be freely adjusted during
the operation according to the patient’s individual

763
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 Plastic and Reconstructive Surgery • October 2020
requests. Generally, the shape of the double-eyelid
crease is determined by the height of the central
crease and the height of the medial crease. If the
height of the medial crease is close to or equal to
the height of the central crease, the eyelid crease
will have an out-fold shape; if the height of the
medial crease is close to zero, the eyelid crease
will have an in-fold shape. In the four-step tech-
nique, the design of the epicanthal fold flap and
adjustments to the size of the epicanthal fold flap
are the most critical steps. With a free-style design,
the location of the epicanthal fold flap is simply
decided by points B and C, and the shape of the
double-eyelid crease is simply decided by adjust-
ing the size of the epicanthal fold flap. Compared
with the other techniques for blepharoplasty and
epicanthoplasty, this four-step technique is easy to
learn, shortens the operative duration, and yields
a high patient satisfaction rate. Furthermore, the
independent observers reported that the four-step
technique is a flexible and reliable technique for
creating individual eyelid shapes.
The medial canthal area is a unique region in
the context of blepharoplasty. Typically, hypertro-
phic scarring is more obvious in the upper medial
canthal region than it is for periocular wounds in
other parts of the eye after blepharoplasty. Many
surgeons prefer to perform double-eyelid bleph-
aroplasty alone to avoid visible scarring in the
medial canthal area, leaving partial or incomplete
double-eyelid creases. The modified Z-epicantho-
plasty we developed here not only removed the
epicanthal fold and enlarged the appearance of
the eyes but also left invisible scars in the patients
in this case series. This modified Z-epicanthoplasty
is a version of the root Z-epicanthoplasty11 and
uses the recent understanding of the anatomical
characteristics of the medial epicanthal fold; the
medial epicanthal fold is composed of a double-
layer skin fold and the oblique preseptal orbicu-
laris muscle.12–14 Therefore, surgical manipulation
of the abnormally distributed skin by Z-epican-
thoplasty and detachment of the malpositioned
medial orbicularis oculi muscle by subcutaneous
dissection not only allows the surgery to be per-
formed in an effective and anatomically logical
manner but also reduces the tension that results
in hypertrophic scarring in the early postoperative
period. Our methods shared similar principles
with the methods used by Jin et al. to treat wound
tension in the medial canthal area and yield simi-
lar invisible scars for epicanthoplasty.15
The prevalence of epicanthal folds in the gen-
eral population has not been reported. However,
single-eyelid patients usually possess epicanthal
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Copyright © 2020 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
folds.1 Some surgeons prefer to simultaneously per-
form double-eyelid blepharoplasty and epicantho-
plasty in these patients.16–18 However, these patients
are usually persuaded to have in-fold eyelids because
the in-fold crease requires a lower tension suture
and leaves a smaller scar in the medial epicanthus
than the out-fold crease.9 The four-step technique
described here combines traditional double-eyelid
blepharoplasty and a modified Z-epicanthoplasty,
which offers a wide visual field during the operation
and allows for the release of redundant fibromuscu-
lar tissue around the medial canthal ligament. More
importantly, the patient-reported results showed no
significant difference in the scar in the medial epi-
canthal area between the two patient groups.
Postoperative complications and revision
operations were rare in this series. However, the
most common patient-reported event was hyper-
trophic scarring of the medial incision in the
first 3 postoperative months. Hypertrophic scar-
ring–related complications, such as an unnatural
creases, a sense of tightness, and xerophthalmia,
have also been reported by some patients. Most
of the hypertrophic scarring gradually atrophied
within 6 postoperative months, leaving minor
scars on the medial canthus. Our previous study
showed that an early postoperative injection of
botulinum toxin type A at the medial epicanthal
area efficiently reduced hypertrophic scarring by
reducing the soft-tissue tension caused by orbicu-
laris oculi muscle and depressor supercilii muscle
contraction and subsequently improved the out-
comes of epicanthoplasty.19
CONCLUSIONS
This four-step technique offers a simple, flex-
ible, and effective method for simultaneously
creating in-fold or out-fold double-eyelid creases
according to individual patient requirements and
achieved a high satisfaction rate in this series. We
hope that the results of this study lead to the incor-
poration of this technique as a routine method for
blepharoplasty and epicanthoplasty.
Ru-Lin Huang, Ph.D., M.D.
Department of Plastic and Reconstructive Surgery
Shanghai Ninth People’s Hospital
Shanghai Jiao Tong University School of Medicine
639 Zhizaoju Road
200011 Shanghai, People’s Republic of China
huangrulin@sjtu.edu.cn
PATIENT CONSENT
Patients provided written consent for the use of their
images.
 Volume 146, Number 4 • Four-Step Technique for Blepharoplasty
ACKNOWLEDGMENTS
This research was supported by grants from the
National Natural Science Foundation of China (grant
no. 81871571), the Shanghai Pujiang Program (grant
no. 2019PJD023), and the Two-hundred Talent of
Shanghai Jiao Tong University School of Medicine
(grant no. 20191916). The authors thank Wenjin
Wang, Ph.D., M.D., for a critical reading of this article.
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