COSMETIC

Role of the Medial Canthus Fibrous Band in

Forming Moderate and Severe Epicanthal Folds
in Asians and Its Clinical Application
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Shimeng Wang, MD
Haipeng Liu, PhD
Tian Li, PhD
Duo Zhang, PhD
Changchun, Jilin Province,
People’s Republic of China
Background: Epicanthal folds (EFs) are skin folds located at the medial canthus
in Asians. However, the anatomical structure of EFs remains unclear. The authors
discovered a fibrous band connected to the medial canthal tendon (MCT) and
referred to it as the medial canthal fibrous band (MCFB). This study aimed to
verify whether the MCFB is different from the MCT and whether its unique
anatomical relationship with the MCT plays an important role in EF formation.
Methods: Forty patients who underwent epicanthoplasty from February of 2020
to October of 2021 were included. EFs from 11 patients underwent biopsy and
were stained with hematoxylin and eosin, Masson trichrome, and Weigert stains
to reveal their composition. Expression of collagens I and III and elastin was
determined through immunohistochemical staining, and their mean optical
density was measured. Preoperative and immediate exposed lacrimal caruncle
area (ELCA) was measured after removing the MCFB.
Results: The MCFB is a fibrous tissue located in the EF and above the MCT. The
orientation and composition of collagen fibers of the MCFB are different from
those of the MCT (P < 0.001). The MCFB also has more elastin fibers than the
MCT (P < 0.05). Immediate ELCA was significantly higher than before ELCA
(P < 0.001) once the MCFB was removed.
Conclusions: The MCFB is composed of collagen fibers different from those in
the MCT and plays a role in EF formation. Removing the MCFB during epic-
anthoplasty can result in a more attractive appearance postoperatively. (Plast.
Reconstr. Surg. 153: 1092e, 2024.)
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

A
n epicanthal fold (EF) is a semilunar skin
fold at the medial canthal region that covers
the caruncle and is common in Asians but
not in White people.1 The difference is attributed
to the different anatomy of the eyelids between
Asians and White people. It was hypothesized that
the EF forms because of excess skin in the medial
canthus or incomplete nasal development.2
However, the EF is caused not only by dermato-
logic factors but also by abnormal muscles, such
as the orbicularis oculi muscle (OOM). Kakizaki
et al.3 conducted a histologic study on 10 postmor-
tem Japanese eyelids and found that EF formation
depended mainly on the orientation of the fibers
of the septal OOM. Furthermore, Park and Hwang
revealed that after removing the skin of the EF, its
morphology was maintained by the subcutane-
ous muscles and tissue, which are composed of
muscle and fibrous tissues.4 However, the mecha-
nism of how subcutaneous muscle contributes to
the unique semilunar shape of the EF remains
unclear. As the understanding of the cause and
development of EFs has significantly progressed
with in-depth studies, surgical methods to remove
them have also improved. Currently, epicantho-
plasty methods, such as Z-plasty,1 which is widely

Disclosure statements are at the end of this article,

From the Department of Plastic and Reconstructive Surgery,
following the correspondence information.
The First Hospital of Jilin University.
Received for publication August 31, 2022; accepted
February 24, 2023.
The last two authors contributed equally to this study. Related digital media are available in the full-text
Copyright © 2023 by the American Society of Plastic Surgeons version of the article on www.PRSJournal.com.
DOI: 10.1097/PRS.0000000000010724

1092e www.PRSJournal.com
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 Volume 153, Number 6 • MCFB’s Role in Forming Epicanthal Folds
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Fig. 1. A photograph of the MCFB during epicanthoplasty. After
peeling the skin of the EF, we found a fibrous band (MCFB)
(arrow) above the MCT located at the medial canthus.
performed in Asia, focus on the use of skin flap
technology to redistribute skin tension in the
medial epicanthal area. However, challenges asso-
ciated with the current epicanthoplasty methods,
including undercorrection, canalicular injury, and
dissatisfaction with the correction effect, remain.5,6
The removal of fibrous and muscle tissue in
front of the medial canthus tendon (MCT) results
in an attractive canthus postoperatively with no
apparent complications7; however, the tissue
composition of the removed tissues has not been
examined. In this study, during epicanthoplasty,
we observed a dense band of fibrous tissue in the
medial canthus after the skin was peeled, which
we referred to as the medial canthus fibrous band
(MCFB) (Fig. 1). We hypothesized that the fibrous
and muscular tissues we removed in the previous
study may contain the MCFB. This study aimed to
verify whether the MCFB is a different fibrous tis-
sue from the MCT and whether their anatomical
relationship plays an important role in EF forma-
tion. To our knowledge, there is no description of
the anatomical structure of the fibrous tissue in
EFs or their collagen composition. Thus, through
further understanding of the anatomical struc-
ture of the MCFB, the anatomy and causes of EF
formation could be further elucidated. The find-
ings of our study can help reduce complications
associated with epicanthoplasty, including postop-
erative dissatisfaction and undercorrection.
MATERIALS AND METHODS
Biopsies during Epicanthoplasty
Forty patients who underwent MCFB resec-
tion during epicanthoplasty between February of
2020 and October of 2021 were included in the
study. (See Table, Supplemental Digital Content
Copyright © 2023 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
1, which shows patients’ demographics, http://
links.lww.com/PRS/G686.) Among them, EFs from
11 patients (10 women and one man; average
age, 24.3 years) underwent biopsy. After exclud-
ing three patients who were lost to follow-up, 37
women followed up between 3 and 13 months
were included in the final analyses. Based on the
lacrimal lake area, the EF was divided into three
degrees; the moderate and severe degrees were
examined in this study.8 Patients with pathologic
eye diseases (ie, inverted EFs, blepharophimosis,
ptosis, and epicanthus inversus syndrome; history
of epicanthoplasty; and no follow-up after sur-
gery) were excluded. We followed the principles
of the Declaration of Helsinki for the intraop-
erative sampling of EFs. This study was approved
by the ethical review committee of our hospital
(approval no. 2022-341).
The procedure for removing the EF, includ-
ing the MCFB from the MCT, is shown in Figure 2.
The MCT is shown in Figure 2, right.
Histochemistry and Immunohistochemistry
EF specimens were sampled and fixed in 4%
neutral buffered formalin. Following the routine
histologic process, the samples were embedded
in paraffin, sectioned at 5 μm; and stained with
hematoxylin and eosin, Masson trichrome, and
Weigert stains. A vertical section at the level of the
palpebral fissure was made, and the stained slides
were observed under a microscope. A description
of the tissue in the slice is shown in Figure 2, below.
The tissue sections were immunohistologically
stained using collagens I and III (Abcam) and
elastin (Abcam) as the primary antibodies. The
tissue sections were incubated with primary anti-
bodies (1:200) for 1 hour and subsequently incu-
bated with biotinylated goat anti-rabbit antibodies
for 30 minutes. The corresponding specific bind-
ing was visualized by the enzymatic conversion of
the chromogenic substrate 3,3ʹ-diaminobenzidine
into a brown precipitate by a horseradish per-
oxidase–diaminobenzidine staining kit (R&D
Systems, Inc., Minneapolis, MN). After staining,
the sections were mounted, cleared, placed on
a coverslip, and examined using a confocal laser
scanning microscope (Olympus, Japan).
Immediate Exposed Lacrimal Caruncle Area
Measurement
The method through which the MCFB was
resected intraoperatively is shown in Figure 3.
After incising the muscle connected to the MCFB,
photographs were taken, and the immediate
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Fig. 2. Photographs of the biopsy step and simulation diagram. (Above, left) Point Aʹ was designed as the new
medial canthus, and point B was the point where the EF joins the lower eyelid skin. (Above, right) Point A was
approximately 2 mm lateral to the original medial canthus. The EF, including the MCFB, is excised. The MCT
(yellow arrow) is exposed after removal. (Below) Medical illustration of biopsy specimens. The red-yellow dotted
box indicates the amount of EF tissue we removed.

exposed lacrimal caruncle area (Immed-ELCA) was compared with the preoperative ELCA (Pre-
was measured by ImageJ software (version 1.0; ELCA). Based on the basic similarity of the
National Institutes of Health). The Immed-ELCA corneal diameter of Chinese adults, which is

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 Volume 153, Number 6 • MCFB’s Role in Forming Epicanthal Folds
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Fig. 3. Photographs of epicanthoplasty using MCFB removal technique. (Above, left) Preoperative image of the EF. The lacrimal
caruncle is almost covered by the EF. (Above, right) The MCFB (black arrow) can be seen after peeling off the EF skin. (Center, left)
After the MCFB is stripped, the MCT can be seen (black arrow). (Center, right) The MCT could be seen clearly. (Below, left) After
removal of the MCFB, the lacrimal caruncle is immediately exposed. The EF is corrected, and the EF shape disappears. (Below, right)
Postoperative appearance.

approximately 11.5 mm,9 it was used as a ruler in
ImageJ software to measure ELCA.
Statistical Analyses
All values were expressed as mean ± standard
error. Image-Pro Plus software (Media Cyberntics,
Inc., Version 6.0.0260 for Windows) was used to
test the integral optical density value and area
of interest of the tissue sections. The mean opti-
cal density (MOD) was calculated using integral
optical density/area of interest. The MOD value
(optical density values per pixel) represented
the protein level of collagens I and III and elas-
tin. One-way analysis of variance was performed
at different tissue sites, including the MCFB, in
the EF samples. The SNK‐q test was performed to
assess the mean between groups after immunohis-
tochemistry. The Wilcoxon signed rank test was
performed to assess Immed-ELCA and Pre-ELCA.
P < 0.05 was considered significant, and all com-
putations were performed using SPSS Windows
Release 26.0 software (SPSS, Inc., Chicago, IL).
RESULTS
Hematoxylin and Eosin Staining
The cut tissue was flattened, and the orienta-
tion of the tissue was marked. During staining, the

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interior of the EF was composed of muscles and
fibers. (See Figure, Supplemental Digital Content 2,
which shows hematoxylin and eosin staining. The
white and black arrows indicates fibrous and muscle
tissue, respectively, http://links.lww.com/PRS/G687.)
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Masson Trichrome and Weigert Staining
The fibers in the subcutaneous side of the EF
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displayed different orientations at different sec-
tions (Fig. 4). The MCFB was a fibrous band that
closely adhered to the skin. Two fibrous sections
were completely different from those in the MCFB
Fig. 4. Graph showing Masson trichrome staining. Three images
were taken from different parts of the same slice. The yellow
dotted area is the MCFB. The black arrow (center) indicates the
FS, and the black arrow (below) indicates the MCT. The blue dot-
ted area is soft-tissue separation between the nasal side of the
MCFB and MCT. There is a cross-section of the OOM (center; white
arrow) in the separation.
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Plastic and Reconstructive Surgery • June 2024
in terms of orientation and composition; these
two fibrous areas were identified as the fusion site
(FS) of the MCFB and MCT. The location of the
FS was determined using Masson trichrome stain,
which was consistent with our observations intra-
operatively. During epicanthoplasty, the FS, which
is a tight adhesion between the initial portion of
the MCFB near the lacrimal lake and the MCT,
was observed to be tightly connected to the MCT,
rendering it visually indistinguishable. Thus, a
small apex of the MCT was cut and embedded.
The FS also displayed a similar orientation of col-
lagen with that of the MCT but different from that
of the MCFB. Lastly, there was a gap of soft tis-
sue that was composed of muscles and connective
tissues between the nasal side of the MCFB and
MCT that was observed in vivo using Masson stain-
ing. [See Video (online), which demonstrates the
MCFB during epicanthoplasty.]
Weigert staining of the tissue samples showed
that the distribution of elastin fibers was more
abundant and neatly arranged in the FS than in
the MCFB and MCT, and that the elastin distribu-
tion was higher in the MCFB than in the MCT.
(See Figure, Supplemental Digital Content 3,
which shows Weigert staining, http://links.lww.
com/PRS/G688.)
Immunohistochemical Staining of Collagen and
Elastin
The collagen compositions of the MCFB and
MCT are shown in Figure 5, left. [See Figure,
Supplemental Digital Content 4, which shows col-
lagen I (above and second row) and collagen III
(third row and below) immunohistochemical stain-
ing images, http://links.lww.com/PRS/G689.] The
MOD of collagen I in the MCFB (0.116 ± 0.003)
was significantly lower than that in the FS (0.145
± 0.003) and MCT (0.143 ± 0.004) (P < 0.001).
However, the MOD of collagen I between the FS
and MCT was not significantly different, and the
MOD of collagen III in the FS (0.162 ± 0.003) was
higher than that in the MCT (0.135 ± 0.007) (P
< 0.05) and MCFB (0.098 ± 0.002) (P < 0.001).
Moreover, the MOD of collagen III in the MCT
was lower than that in the MCFB (P < 0.001).
Immunohistochemical analysis of elastin
showed a similar trend with Weigert staining. The
MOD of elastin was the highest in the FS (0.188
± 0.010) followed by the MCFB (0.141 ± 0.010)
and MCT (0.103 ± 0.006); the difference was sta-
tistically significant (P < 0.05) (Fig. 5, right). (See
Figure, Supplemental Digital Content 5, which
shows elastin immunohistochemistry, http://links.
lww.com/PRS/G690.)
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Fig. 5. Graph showing collagen composition results (left) and elastin results (right).
Fig. 6. Graph showing the analysis results of Immed-ELCA and
Pre-ELCA measurements.
Immed-ELCA Measurement
In 37 patients, the Immed-ELCA (3.349 ±
0.120 mm2) was significantly larger than the Pre-
ELCA measurement (0.274 ± 0.065 mm2) (P <
0.001) (Fig. 6).
Copyright © 2023 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
DISCUSSION
During epicanthoplasty, a dense band of
fibrous tissue in the medial canthus was found,
which we defined to be the MCFB. We found
that the MCFB is a thickened fibrous tissue of the
septal OOM located above the MCT. The MCFB
is composed of collagen, and the orientation of
its fibers is different from that of the MCT. The
MCFB also contains more elastin than the MCT.
Furthermore, the MCFB plays an important role
in EF formation.
The EF is a common eyelid characteristic in
Asians, especially in those with single eyelids; its
incidence rate can be as high as 70%.6 Severe EF
usually affects the facial appearance by increasing
intercanthal distance. For Asian aesthetics, the
optimal ratio of inner canthal distance to fissure
length is close to 1.10 Epicanthoplasty accompa-
nied by double eyelid surgery is a conventional
and highly acceptable cosmetic operation for
Asians. Since the conceptualization of the EF in
1831,11 epicanthoplasty has become more diverse.
Moreover, with the popularization of surgical tech-
niques, concerns regarding the complications of
epicanthoplasty have gradually shifted from acces-
sory injuries, such as canalicular injuries, to post-
operative scar formation, undercorrection, and
unsatisfactory postoperative results. To reduce
postoperative complications and ensure a more
attractive appearance postoperatively, the anat-
omy and cause of EFs are increasingly studied in
the reconstructive and cosmetic fields.
A single-eyelid appearance in Asians with
EFs is different from that of a double-eyelid
appearance in White people without EFs and is
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attributable to the differences in the anatomical
structures of the eyelids between these two pop-
ulations. Several studies have speculated about
the causes of EF formation, with explanations
including “Z-shaped kinking of the orbicularis
muscle fibers,” excess OOM located in the medial
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canthus region, and medial levator aponeuro-
sis being hardly reached.12,13 However, Kakaizaki
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et al. reported that EFs are mainly caused by the
intermuscular fibers of the preseptal muscle,
which is oblique. Moreover, OOM does not dis-
play “Z-shaped kinking” or hypertrophy.3 Park
and Hwang4 showed that the OOM under the
EF is mainly composed of septal OOM. Our pre-
vious study7 revealed that the difference in the
anatomical structure of the medial canthal area
between Asians and White people is attributable
to the malposition of the OOM under the EF in
addition to its shape being consistent with that of
EFs. (See Figure, Supplemental Digital Content
6, which shows a photograph of an EF that still
shows a fold shape after peeling the skin, http://
links.lww.com/PRS/G691.) Thus, canthal skin is
not the main cause of EF formation; if the fibro-
muscular tissue under the skin is not removed,
epicanthoplasty would not produce satisfactory
results. Furthermore, we demonstrated that the
removal of muscles contributes to forming an
attractive appearance postoperatively.7 In-depth
in vivo anatomical observation revealed a fibrous
band of tissue located between the skin and MCT
in the EF, which was referred to as the MCFB. The
MCFB can be found in all moderate and severe
cases of EF with varying width and sizes.
To our knowledge, no studies have examined
the fibrous tissue inside the EF or its composi-
tion. However, through intraoperative observa-
tion, we observed that the anatomical structure
of the MCFB is different from that of the MCT,
with the former being involved in the formation
of the semilunar shape of EFs through the septal
OOM. Based on the intraoperative observations
and Masson trichrome staining, we speculated
the following reasons underlying EF forma-
tion. First, the top of the MCFB closely adheres
to the posterior wall of the EF skin. In addition,
the MCFB is connected to the surrounding sep-
tal OOM. Thus, the MCFB stretches the skin of
the EF and exerts traction. Consequently, the skin
forms a fold, wrapping the OOM and covering
the caruncle. Second, the gap between the MCFB
closer to the nasal side and the MCT is composed
of loose connective tissue that provides mobil-
ity. Furthermore, the MCFB fuses with the MCT
at the initial portion near the lacrimal lake. The
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Plastic and Reconstructive Surgery • June 2024
Fig. 7. Simulation diagram of the MCFB. The EF is a three-
dimensional structure. After removing the skin of the EF, the
MCFB adhered to the posterior wall skin of the EF. The MCFB is
fused with the MCT at the initial portion of the MCFB near the
lacrimal lake; on the nasal side, the gap between the MCFB and
MCT becomes mobile loose connective tissue.
fiber tissue component of MCFB at the other end
disappeared and transformed into muscle tissue.
At this end, skin began to flip and fold, forming
the folded shape (Fig. 7). Thus, the transition
zone of the MCFB is the site of skin fold rever-
sal. [See Figure, Supplemental Digital Content 7,
which shows that the flipped EF skin is marked
(black arrow, above) and the intersecting edge can
be seen when the skin is pulled (below, left). Fusion
(blue dotted line) of the MCFB and septal OOM is
consistent with the EF skin mark, http://links.lww.
com/PRS/G692.]
The MCFB is an independent fibrous band
formed by the thickening of the preseptal OOM on
the MCT, making it structurally different from the
MCT. The connective tissue in the ligaments and
tendons is composed of collagen I by dry weight,
whereas the rest is composed of collagen III.14
Meanwhile, other proteins regulate the assembly
of fibers. Different types of collagen composi-
tions can form tendons with different functional
properties.15 Through immunohistochemistry,
we revealed that the collagen composition of the
MCFB is different from that of the MCT. The
expression of collagens I and III in the MCFB was
significantly lower than those in the MCT and FS;
however, there was no significant difference in the
level of collagen I between the FS and MCT. Type
I collagen provides strength and forms the mac-
romolecular network.16 It has been reported that
the superficial limb of the MCT is thick and stable,
with a thickness of 4.5 ± 2.3 mm17; thus, more col-
lagen I is needed to maintain this limb. However,
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Fig. 8. Follow-up of a patient who underwent epicanthoplasty using the MCFB removal technique. (Left) Preoperative and (right)
6-month postoperative views.
the MCFB is a fibrous tissue formed by the OOM,
which is attached to the MCT, and its collagen
fibers are not as dense as those in the MCT; thus,
the fibers are not as strong and collagen I is not as
abundant in the MCFB as in the MCT. Notably, the
level of collagen III in the FS was higher than that
of the MCFB and MCT; however, further research
is needed to elucidate this observation.
When the tissue samples were stained with
Weigert stain, we found that the distribution of
elastin fibers in the FS was higher than that in
the MCFB and MCT. Similarly, through immu-
nohistochemical analysis, the expression of elas-
tin in the FS was significantly higher than that in
the MCFB and MCT, which was consistent with
the traction mechanical model of EF under nor-
mal conditions. The MCT plays a vital role in the
fixation of the inner canthus skin at the lacrimal
crest and lacrimal lake and in the plate morphol-
ogy of the upper and lower eyelids. Thus, the FS
bears the muscle traction force from the MCFB,
which then bears the traction force of the septal
OOM. Elastin provides retraction and resilience
for tendons and elastic recoil and tensile capacity
for connective tissue.18 In our model, the MCT is
the tendon that maintains static fixation and does
not change shape even when there is a change
in external force. In contrast, the FS and MCFB
are structurally different from the MCT, as their
shapes change following traction from the EF.
When the EF is pulled, the MFCB may transform
into different shapes and states. Furthermore,
because the amount and mechanical properties of
elastin fibers decrease with age,19 the mechanical
function of the MCFB also decreases. Therefore,
we speculated that the degree of EF will diminish
or even disappear as Asians age, which is related
to the decrease in elastic fibers in the MCFB. Our
findings further verify that the MCFB is the main
contributor for maintaining EF tension.
The MCFB is the tension conductor from
the muscle to the skin in the medial canthal
Copyright © 2023 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
area; thus, removing the MCFB from the MCT
is crucial during epicanthoplasty. Figure 3 dem-
onstrates the removal of the MCFB. After MCFB
removal, the original medial canthus was exposed
without removing the skin or fixing sutures, and
the exposed area of the lacrimal lake and lacri-
mal caruncle increased, similar to the anatomy
of the inner canthus in White people. For epic-
anthoplasty, the postoperative exposure of the
lacrimal caruncle improves the appearance of
eyes. The purpose of EF correction surgery is to
shorten the distance between the inner canthus
and remove the EF to expose the lacrimal car-
uncle. Moreover, the two most common and chal-
lenging postoperative complications are residual
scars in the inner canthus and recurrence of the
EF. In our surgical experience, we believe that
removing all muscles connected to the MCFB and
leaving only the skin to ensure that the skin and
the inside of the MCT adheres closely are keys to
a successful operation. As the muscles in EF lose
the anchor point (MCFB) between the skin and
the MCT, muscle tension in the inner canthus
region can disappear, resulting in two benefits: a
smaller postoperative scar and reduced probabil-
ity of recurrence. Conventionally, local tension is
an important factor that can result in scars, and
removal of the MCFB will reduce muscle and skin
tension in the inner canthus area; therefore, post-
operative scars are not obvious in patients that
we have followed. As for EF recurrence, because
there is no muscle tension or EF muscle mor-
phology because of the absence of the MCFB, its
probability is greatly reduced. During follow-up,
no patient who underwent this technique experi-
enced recurrence. Therefore, the key to reducing
postoperative scarring and recurrence of epican-
thoplasty is to completely remove the MCFB. The
postoperative outcomes of this epicanthoplasty
technique are as follows: (1) attractive inner can-
thus; (2) no apparent postoperative scar; and (3)
no recurrence (Fig. 8).
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CONCLUSIONS
The MCFB is an independent fibrous struc-
ture comprised of collagen fibers different from
those of the MCT and is located below the skin of
the EF. The MCFB plays an important role in the
formation of the EF. Thus, completely removing
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the MCFB can reduce postoperative scarring and
recurrence of EFs.
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Tian Li, PhD
Department of Plastic and Reconstructive Surgery
The First Hospital of Jilin University
No. 1 Xinmin Street
Changchun 130021, Jilin Province,
People’s Republic of China
litian@jlu.edu.cn
Duo Zhang, PhD
Department of Plastic and Reconstructive Surgery
The First Hospital of Jilin University
No. 1 Xinmin Street
Changchun 130021, Jilin Province,
People’s Republic of China
zhangduo@jlu.edu.cn
DISCLOSURE
The authors have no financial interest to declare in
relation to the content of this article.
PATIENT CONSENT
Patients provided written informed consent for the
use of their images.
ACKNOWLEDGMENTS
This study was supported by the Doctor of
Excellence Program (DEP), The First Hospital of Jilin
University (JDYYDEP-2023031), and the National
Institutes of Jilin Sunbird Regeneration Medical
Engineering Co., Ltd.
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