Incisional Double-Eyelid Blepharoplasty Corrects Upper Eyelid Epiblepharon Concomitant with Thick Excess Skin: A Report of Two Cases

Incisional Double-Eyelid Blepharoplasty Corrects Upper Eyelid Epiblepharon Concomitant with Thick Excess Skin: A Report of Two Cases | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Incisional Double-Eyelid Blepharoplasty Corrects Upper Eyelid Epiblepharon Concomitant with Thick Excess Skin: A Report of Two Cases Shinjiro Kono, Motohiro Kamei This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8860349/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Epiblepharon is characterized by a fold of skin that stretches horizontally across the upper or lower eyelid, and is usually associated with inversion of the eyelashes. Upper eyelid epiblepharon is relatively rare and is treated with double-eyelid surgery using a buried suture or an incisional method. To date, no reports have described the detailed course of treatment for epiblepharon, characterized by excess skin on the upper eyelids, that simultaneously achieves aesthetic improvement and corrects eyelash inversion. Case presentation: We present the treatment outcomes of two cases of epiblepharon of the upper eyelid with excess skin in a 16-year-old and a 35-year-old female, both treated with incisional double-eyelid surgery combined with skin excision. In both patients, eyelash inversion was corrected, double eyelids were formed, and aesthetic improvements were made. Conclusions By accurately performing appropriate skin excision and placing sutures for double-eyelid creation, a functionally and aesthetically satisfactory surgical outcome can be achieved in patients with upper eyelid epiblepharon. epiblepharon upper eyelid excess skin incisional double-eyelid blepharoplasty case report Figures Figure 1 Figure 2 Figure 3 Background Epiblepharon is characterized by a fold of skin that stretches horizontally across the upper or lower eyelid, and is usually associated with eyelash inversion [ 1 – 4 ]. It occurs more commonly in the lower lid, and epiblepharon of the upper eyelid is relatively rare [ 4 – 7 ]. Epiblepharon of the upper eyelid is treated with double-eyelid surgery using the buried suture or incisional method [ 4 – 11 ]. Buried suture techniques are commonly used to correct upper eyelid epiblepharons in cases with minimal tissue under the skin of the upper eyelid or in cases where correction of eyelash inversion can be easily achieved solely through the formation of a double eyelid crease [ 4 – 7 ]. If the disappearance of the double eyelid or poor correction of inversion is expected with the buried suture method, incisional double-eyelid surgery is indicated [ 8 – 11 ]. Furthermore, if the epicanthal folds are prominent, epicanthoplasty is sometimes performed either simultaneously or as an isolated procedure [ 8 , 10 ]. There have been several reports on the use of the buried suture method or epicanthoplasty for epiblepharon of the upper eyelid, with most reports focusing on surgery performed during childhood [ 4 – 11 ]; however, none of the reports have detailed the course of treatment for epiblepharon with excess skin on the upper eyelid after childhood to achieve both functional improvement and aesthetic improvement. By creating double eyelids with an appropriate amount of skin excision, unpleasant symptoms caused by the eyelashes are eliminated, visual function is improved, and satisfactory cosmetic results are achieved. In this report, we present the treatment outcomes of two cases of epiblepharon with excess skin—a 16-year-old female and a 35-year-old female—who underwent incisional double-eyelid surgery combined with skin excision. Written informed consent was obtained from the patients for publication of this case report and any accompanying images. Case Presentation Case 1 (Fig. 1 ) A 16-year-old girl presented with a foreign body sensation in the upper eyelid caused by eyelash inversion. The patient had no previous history of eyelid surgery. She attempted self-correction using eyelash glue; however, she subsequently developed dermatitis, making correction difficult. She sought surgical treatment to achieve a definitive resolution. Visual dysfunction due to thick excess skin was noted, in addition to eyelash inversion of the upper eyelid and corneal epithelial damage, leading to a diagnosis of upper eyelid epiblepharon with excess skin. Since the buried method was expected to result in postoperative under-correction and recurrence, incisional double-eyelid blepharoplasty with excess skin removal was planned and performed at the Aichi Medical University Day Surgery Center for Ophthalmology. A parallel incision was created 7 mm from the eyelid margin (Fig. 1 a). The excess skin was quantified using the pinch technique (Fig. 1 b). An upper incision line was created approximately 14 mm below the eyebrows (Fig. 1 c), and a skin excision area was designed. Skin incisions were made following the design, and excess skin, including the orbicularis oculi muscle, was excised (Fig. 1 d, 1 e). To avoid interference with the outward rotation of the eyelashes, a portion of the orbicularis oculi muscle at the eyelid margin was excised (Fig. 1 f). For double-eyelid formation, sutures were passed through the tarsal plate to the subcutaneous tissue of the eyelid margin at six equidistant points (Fig. 1 g- 1 i). During the eyelid opening, excess skin was prevented from overlapping with the double-eyelid line, and the double eyelid was neatly formed (Fig. 1 j). The skin was sutured, and the surgery was completed (Fig. 1 k, 1 l). Postoperatively, the eyelash inversion was corrected, and the swelling gradually subsided. At the 1-month follow-up, the double eyelid appeared more defined, and she found it easier to lift her eyelids compared to before the surgery (Fig. 1 m.1n). After 9 months, the double-eyelid line became slightly lower than anticipated; however, the eyelashes did not contact the cornea, and no corneal epithelial damage was observed (Fig. 1 o). The patient was satisfied with both the aesthetic and functional outcomes. Although further skin excision could be performed to make the double-eyelid line more distinct for aesthetic purposes, the patient did not request additional surgery because the primary objectives of correcting eyelash inversion and improving eyelid heaviness were achieved. Case 2 (Figures 2 and 3) A 35-year-old woman regularly plucked her upper eyelashes because they curled into her eyes. She was referred to our hospital for surgical treatment and diagnosed with epiblepharon of the upper eyelid with excess skin. During the examination, excess skin laxity with lateral hooding and corneal epithelial damage due to eyelash inversion were observed. She had no previous history of eyelid surgery. The surgery was completed using the same procedure as in case 1. After removing the excess skin, six double-eyelid sutures were placed, and a double-eyelid crease line was designed 7 mm from the eyelid margin (Fig. 2 a, 2 b). Because the excess lateral skin was excised more widely compared to the medial skin, the distance between the eyebrows and the double eyelid after excess skin excision was 15 mm over the medial canthus and 14 mm over the lateral canthus (Fig. 2 c, 2 d). Immediately after the surgery, eyelash inversion was corrected, and no corneal epithelial damage was observed thereafter (Fig. 2 e- 2 i, 3 a- 3 d). One year after surgery, the double eyelid was formed as anticipated and maintained (Fig. 2 i). The visual function and appearance were improved, and the patient was satisfied with the surgical outcome. Discussion and Conclusions We treated two cases of upper eyelid epiblepharon with excess skin and eyelash inversion. After surgery, eyelash inversion was corrected, and the eyelids were lifted sufficiently, allowing for good vision. In cases of upper eyelid epiblepharon where excess skin is minimal and the upper eyelid is thin during early childhood, the buried suture method is effective. In recent years, technical refinements aimed at maintaining double eyelids have been reported [4.7]. However, no studies have focused on the treatment outcomes of epiblepharon in patients with thick excess skin after childhood. Although incisional double-eyelid surgery carries the risk of postoperative eyelid margin scarring, it allows for the reliable placement of multiple sutures to form a double fold, making it effective for maintaining the double crease and correcting eyelash inversion [ 4 , 8 , 11 ]. In the two cases presented here, the double-eyelid line was designed to be slightly higher. Sutures were accurately passed through the tarsal plate and subcutaneous tissue to create the double eyelid line, and excess skin quantified by the pinch technique was excised. This corrected eyelash inversion resulted in satisfactory postoperative outcomes, both aesthetically and functionally. The epicanthal fold was inconspicuous, and epicanthoplasty was unnecessary. For those born with single eyelids, considering the tendency for the double-eyelid width to revert due to original eyelid weight and thickness after surgery, creating a double-eyelid width of 7 mm or more is desirable. Few studies have examined the practical widths regarding the distance between the eyebrow and the eyelid margin or the double eyelid width in blepharoplasty; one recent report recommends a ratio of approximately 1:2 between the distance from the eyebrow to the double-eyelid crease and the distance from the double-eyelid crease to the eyelid margin, as aesthetically desirable; this ratio was also appropriate in our cases [ 12 ]. Further skin excision carries the risk of creating an unnatural appearance due to an excessively wide double eyelid crease. It is preferable to limit excision to the point where only a slight amount of excess skin overlaps the double eyelid line. The incision scars were hidden by the double eyelids. The scar area, where the lateral skin is widely removed, can sometimes be visible, which may be a concern. However, the scarring becomes less noticeable over time in most cases when the sutures are accurately placed. In our two cases, the incision scars did not pose a problem. This study has some limitations that warrant discussion. First, the follow-up period was 9 months to 1 year; therefore, longer-term follow-up is desirable to confirm the degree of eyelash correction and the maintenance of double eyelid formation. Second, skin thickness and texture also influence the degree of postoperative double eyelid formation, necessitating further analysis. In conclusion, we report two cases of upper eyelid epiblepharon in patients with thick excess skin. By accurately performing appropriate skin excision and placing sutures for double eyelid creation, a functionally and aesthetically satisfactory surgical outcome can be achieved. Our technique can be applied to double eyelid formation for various types of eyelids. Declarations Statement of ethics The authors adhered to the tenets of the 1964 Declaration of Helsinki. Written informed consent was obtained from the patient in Case1 and her mother, and from the patient in Case 2 for publication of this case report and any accompanying images. We asked the institutional review board of Aichi Medical University Hospital and confirmed that the ethics approval for this report was not necessary on the basis of the ethical guidelines for medical and health research involving human subjects established by the Japanese Ministry of Education, Culture, Sports, Science, and Technology and the Ministry of Health, Labor, and Welfare. Consent for publication Written informed consent was obtained from the patient and the mother for publication of this case report and any accompanying images. Availability of data and materials The data that support the findings of this study are not publicly available due to privacy reasons but are available from the corresponding author, S.K. on reasonable request. Competing interests The authors declare that there is no conflict of interest. Funding sources This research did not receive any specific grants from funding agencies in the public, commercial, or not-for-profit sectors. Author Contributions All authors contributed to the conception and design of this study. The material preparation, data collection, and analysis were performed by S. K. S. K. and K. M. conducted the literature search. The first draft of the manuscript was written by S. K., and M. K. commented on the previous versions of the manuscript. All the authors have read and approved the final version of the manuscript. Acknowledgements None. Authors' information Not applicable. References Valencia MRP, Takahashi Y, Nakakura S, Kakizaki H. Sex-specific difference in age distribution of congenital lower eyelid epiblepharon in a Japanese population. Jpn J Ophthalmol. 2019;63:425–8. Ahn HB, Seo JW, Yoo JH, Jeong WJ, Park WC, Rho SH. Epiblepharon related to high body mass index in Korean children. J Pediatr Ophthalmol Strabismus. 2011;48:57–60. Huang S, Han Y, Zeng X, Qi X, Li X, Li J, et al. Congenital epiblepharon in Chinese school-age children: a cross-sectional study. J AAPOS. 2024;28:103938. Choi SW, Goldberg RA, Lew H. Blepharoplasty with a buried double twisted suture technique to correct upper eyelid epiblepharon. Plast Reconstr Surg Glob Open. 2016;4:e685. Kim JS, Jin SW, Hur MC, Kwon YH, Ryu WY, Jeong WJ, et al. The clinical characteristics and surgical outcomes of epiblepharon in Korean children: a 9-year experience. J Ophthalmol. 2014;2014:156501. Sundar G, Young SM, Tara S, Tan AM, Amrith S. Epiblepharon in East Asian patients: the Singapore experience. Ophthalmology. 2010;117:184–9. Lew H, Yu SB, Yun YS, Lee SY. Correction of epiblepharon of the upper eyelid by the buried suture technique: correlation with morphological features of the upper eyelid. Ophthalmologica. 2008;222:100–4. Mimura M, Sato Y, Fujita Y, Korn BS, Kikkawa DO, Oku H, et al. Adjustable medial epicanthoplasty using a rotational flap for epiblepharon repair. J Craniofac Surg. 2022;33:1218–21. Lee KM, Choung HK, Kim NJ, Lee MJ, Lee KW, Khwarg SI. Prognosis of upper eyelid epiblepharon repair in down syndrome. Am J Ophthalmol. 2010;150:476–e4801. Johnson CC. Epicanthus and epiblepharon. Arch Ophthalmol. 1978;96:1030–3. Choo CT, Chan CM, Fong KS. Surgical management of upper lid epiblepharon. Eye (Lond). 1998;12:623–6. Chen WPD. Concept of double-eyelid segments ratio: practical application in Asian blepharoplasty. Plast Reconstr Surg Glob Open. 2024;12:e5944. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8860349","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":620944590,"identity":"5dca75c1-065d-46a5-9be7-f1c7a894c297","order_by":0,"name":"Shinjiro Kono","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABBUlEQVRIie3RsUoDMRjA8S8E7ha1aw6hfYXALXaoz5Lg4GQpHIhgwZSDdDlwjfgS+gReOEi3zh1KddI1o0MHo6TtlJ5jofkvCQc/+HIfQCx2iBEkgFAAJAzUFoD570k7wRMDWv2P+DMtDeCTHQnXey7lx8Vo1T2VhjcDeTnspAJZC2fDEKFLPaWEFnlWmbq5kVdFVtU4U5AUQUK4JIQy/qpmwhHMXxYscRMmXIQGU568vX+Jpi8f2gksPJkINxiSTTuhnuRuL0xX8xl/qnSZKRp+S09df56TNes6ktvv23v+mJba2jsT/GO/4c1uAP0t0C0XqGH7CLLb63p7G+8lsVgsdlT9ANXTXZ6r9OQ1AAAAAElFTkSuQmCC","orcid":"","institution":"Aichi Medical University Hospital","correspondingAuthor":true,"prefix":"","firstName":"Shinjiro","middleName":"","lastName":"Kono","suffix":""},{"id":620944592,"identity":"203a2f0a-f3e3-4705-b010-4144d87fd9f2","order_by":1,"name":"Motohiro Kamei","email":"","orcid":"","institution":"Aichi Medical University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Motohiro","middleName":"","lastName":"Kamei","suffix":""}],"badges":[],"createdAt":"2026-02-12 09:39:51","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8860349/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8860349/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":106876746,"identity":"a6638270-4640-46e9-99e2-07e83d21dcb4","added_by":"auto","created_at":"2026-04-14 10:37:59","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":978068,"visible":true,"origin":"","legend":"\u003cp\u003eCase 1: Surgical procedure and outcome. a) The incision line was marked to create a double-eyelid crease 7 mm from the eyelid margin. b) The excess skin was measured by pinching it, and the excision area was designed. c) The upper incision line was 14 mm below the eyebrow. d) Using a radiofrequency cutting device, excess skin, including the orbicularis oculi muscle, was excised according to the design. e) Following skin removal, the boundary between the levator aponeurosis and the orbicularis oculi muscle was clear. f) The orbicularis oculi muscle protruding from the eyelid margin was resected. g-i) Sequentially passing sutures created a double eyelid through the tarsal plate and subcutaneous tissue at the eyelid margin at six points. j) The eyelashes rotated outward, and the amount of excised skin was appropriate. k) The skin was closed, and the surgery on the right eyelid was complete. l) The completed surgery. m) Preoperatively, thick excess skin and eyelash inversion were observed. n) One month postoperatively, the excess skin is resolved, a double eyelid is formed, and the eyelashes rotate outward. o) Nine months postoperatively, the swelling has subsided, resulting in a more refined appearance. The double-eyelid width had slightly diminished, but eyelash inversion was absent, and the patient was able to enjoy styling.\u003c/p\u003e","description":"","filename":"Fig01.png","url":"https://assets-eu.researchsquare.com/files/rs-8860349/v1/135019f8f2b99599f78ffd53.png"},{"id":106876747,"identity":"3bd59e33-ae44-44e2-9ff4-2f4b67a05137","added_by":"auto","created_at":"2026-04-14 10:37:59","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":591560,"visible":true,"origin":"","legend":"\u003cp\u003eCase 2: Surgical procedure and outcome. a) As in Case 1, after making an incision along the design, the excess skin, including the orbicularis oculi muscle, was excised. b) The thread was passed from the tarsal plate to the eyelid margin to create a double eyelid. c) Double-eyelid surgery was performed on both sides, and the incisions were closed. The distance between each eyebrow and the double-eyelid crease was measured to confirm the absence of asymmetry. d) Immediately after surgery, the eyelashes rotated outward, and there was no asymmetry in the double eyelids. e) Preoperatively, excess skin and eyelash inversion are present. f) One week postoperatively, some swelling is present; however, the double eyelid is formed, and eyelashes rotate outward. g) One month postoperatively, the double-eyelid width became appropriate, and the eyelashes rotated outward. h) Six months postoperatively. i) 12 monthspostoperatively. The double-eyelid width is unchanged, and visual function is maintained.\u003c/p\u003e","description":"","filename":"Fig02.png","url":"https://assets-eu.researchsquare.com/files/rs-8860349/v1/092de07410ff092af15fa295.png"},{"id":106876748,"identity":"e1c14d4f-47e6-48cc-b920-255d56f2e513","added_by":"auto","created_at":"2026-04-14 10:37:59","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":800718,"visible":true,"origin":"","legend":"\u003cp\u003eCase 2: Slit-lamp microscope photograph. a) and b) Preoperatively, the eyelashes are drooping and touching the cornea. c) and d) 12 months post-surgery, double eyelids have formed, and the eyelashes are not touching the cornea.\u003c/p\u003e","description":"","filename":"Fig03.png","url":"https://assets-eu.researchsquare.com/files/rs-8860349/v1/579ede520f02a080df7a21a3.png"},{"id":106960432,"identity":"85cca9f8-ed49-45c9-b37c-fac9ac6c93b5","added_by":"auto","created_at":"2026-04-15 09:21:03","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":4601221,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8860349/v1/698e5880-ab12-4e05-84d4-3de63eeae00d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Incisional Double-Eyelid Blepharoplasty Corrects Upper Eyelid Epiblepharon Concomitant with Thick Excess Skin: A Report of Two Cases","fulltext":[{"header":"Background","content":"\u003cp\u003eEpiblepharon is characterized by a fold of skin that stretches horizontally across the upper or lower eyelid, and is usually associated with eyelash inversion [\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. It occurs more commonly in the lower lid, and epiblepharon of the upper eyelid is relatively rare [\u003cspan additionalcitationids=\"CR5 CR6\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEpiblepharon of the upper eyelid is treated with double-eyelid surgery using the buried suture or incisional method [\u003cspan additionalcitationids=\"CR5 CR6 CR7 CR8 CR9 CR10\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Buried suture techniques are commonly used to correct upper eyelid epiblepharons in cases with minimal tissue under the skin of the upper eyelid or in cases where correction of eyelash inversion can be easily achieved solely through the formation of a double eyelid crease [\u003cspan additionalcitationids=\"CR5 CR6\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. If the disappearance of the double eyelid or poor correction of inversion is expected with the buried suture method, incisional double-eyelid surgery is indicated [\u003cspan additionalcitationids=\"CR9 CR10\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Furthermore, if the epicanthal folds are prominent, epicanthoplasty is sometimes performed either simultaneously or as an isolated procedure [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThere have been several reports on the use of the buried suture method or epicanthoplasty for epiblepharon of the upper eyelid, with most reports focusing on surgery performed during childhood [\u003cspan additionalcitationids=\"CR5 CR6 CR7 CR8 CR9 CR10\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]; however, none of the reports have detailed the course of treatment for epiblepharon with excess skin on the upper eyelid after childhood to achieve both functional improvement and aesthetic improvement. By creating double eyelids with an appropriate amount of skin excision, unpleasant symptoms caused by the eyelashes are eliminated, visual function is improved, and satisfactory cosmetic results are achieved.\u003c/p\u003e \u003cp\u003eIn this report, we present the treatment outcomes of two cases of epiblepharon with excess skin\u0026mdash;a 16-year-old female and a 35-year-old female\u0026mdash;who underwent incisional double-eyelid surgery combined with skin excision. Written informed consent was obtained from the patients for publication of this case report and any accompanying images.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eCase 1 (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/h2\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eA 16-year-old girl presented with a foreign body sensation in the upper eyelid caused by eyelash inversion. The patient had no previous history of eyelid surgery. She attempted self-correction using eyelash glue; however, she subsequently developed dermatitis, making correction difficult. She sought surgical treatment to achieve a definitive resolution. Visual dysfunction due to thick excess skin was noted, in addition to eyelash inversion of the upper eyelid and corneal epithelial damage, leading to a diagnosis of upper eyelid epiblepharon with excess skin. Since the buried method was expected to result in postoperative under-correction and recurrence, incisional double-eyelid blepharoplasty with excess skin removal was planned and performed at the Aichi Medical University Day Surgery Center for Ophthalmology.\u003c/p\u003e \u003cp\u003eA parallel incision was created 7 mm from the eyelid margin (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ea). The excess skin was quantified using the pinch technique (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eb). An upper incision line was created approximately 14 mm below the eyebrows (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ec), and a skin excision area was designed. Skin incisions were made following the design, and excess skin, including the orbicularis oculi muscle, was excised (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ed,\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ee).\u003c/p\u003e \u003cp\u003eTo avoid interference with the outward rotation of the eyelashes, a portion of the orbicularis oculi muscle at the eyelid margin was excised (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ef). For double-eyelid formation, sutures were passed through the tarsal plate to the subcutaneous tissue of the eyelid margin at six equidistant points (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eg-\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ei). During the eyelid opening, excess skin was prevented from overlapping with the double-eyelid line, and the double eyelid was neatly formed (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ej). The skin was sutured, and the surgery was completed (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ek,\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003el).\u003c/p\u003e \u003cp\u003ePostoperatively, the eyelash inversion was corrected, and the swelling gradually subsided. At the 1-month follow-up, the double eyelid appeared more defined, and she found it easier to lift her eyelids compared to before the surgery (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003em.1n). After 9 months, the double-eyelid line became slightly lower than anticipated; however, the eyelashes did not contact the cornea, and no corneal epithelial damage was observed (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eo). The patient was satisfied with both the aesthetic and functional outcomes. Although further skin excision could be performed to make the double-eyelid line more distinct for aesthetic purposes, the patient did not request additional surgery because the primary objectives of correcting eyelash inversion and improving eyelid heaviness were achieved.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eCase 2 (Figures 2 and 3)\u003c/h3\u003e\n\u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eA 35-year-old woman regularly plucked her upper eyelashes because they curled into her eyes. She was referred to our hospital for surgical treatment and diagnosed with epiblepharon of the upper eyelid with excess skin. During the examination, excess skin laxity with lateral hooding and corneal epithelial damage due to eyelash inversion were observed. She had no previous history of eyelid surgery.\u003c/p\u003e \u003cp\u003eThe surgery was completed using the same procedure as in case 1. After removing the excess skin, six double-eyelid sutures were placed, and a double-eyelid crease line was designed 7 mm from the eyelid margin (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ea,\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eb). Because the excess lateral skin was excised more widely compared to the medial skin, the distance between the eyebrows and the double eyelid after excess skin excision was 15 mm over the medial canthus and 14 mm over the lateral canthus (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ec,\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ed).\u003c/p\u003e \u003cp\u003eImmediately after the surgery, eyelash inversion was corrected, and no corneal epithelial damage was observed thereafter (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ee-\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ei,\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003ea-\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003ed). One year after surgery, the double eyelid was formed as anticipated and maintained (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ei). The visual function and appearance were improved, and the patient was satisfied with the surgical outcome.\u003c/p\u003e"},{"header":"Discussion and Conclusions","content":"\u003cp\u003eWe treated two cases of upper eyelid epiblepharon with excess skin and eyelash inversion. After surgery, eyelash inversion was corrected, and the eyelids were lifted sufficiently, allowing for good vision.\u003c/p\u003e \u003cp\u003eIn cases of upper eyelid epiblepharon where excess skin is minimal and the upper eyelid is thin during early childhood, the buried suture method is effective. In recent years, technical refinements aimed at maintaining double eyelids have been reported [4.7]. However, no studies have focused on the treatment outcomes of epiblepharon in patients with thick excess skin after childhood. Although incisional double-eyelid surgery carries the risk of postoperative eyelid margin scarring, it allows for the reliable placement of multiple sutures to form a double fold, making it effective for maintaining the double crease and correcting eyelash inversion [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn the two cases presented here, the double-eyelid line was designed to be slightly higher. Sutures were accurately passed through the tarsal plate and subcutaneous tissue to create the double eyelid line, and excess skin quantified by the pinch technique was excised. This corrected eyelash inversion resulted in satisfactory postoperative outcomes, both aesthetically and functionally. The epicanthal fold was inconspicuous, and epicanthoplasty was unnecessary. For those born with single eyelids, considering the tendency for the double-eyelid width to revert due to original eyelid weight and thickness after surgery, creating a double-eyelid width of 7 mm or more is desirable. Few studies have examined the practical widths regarding the distance between the eyebrow and the eyelid margin or the double eyelid width in blepharoplasty; one recent report recommends a ratio of approximately 1:2 between the distance from the eyebrow to the double-eyelid crease and the distance from the double-eyelid crease to the eyelid margin, as aesthetically desirable; this ratio was also appropriate in our cases [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Further skin excision carries the risk of creating an unnatural appearance due to an excessively wide double eyelid crease. It is preferable to limit excision to the point where only a slight amount of excess skin overlaps the double eyelid line.\u003c/p\u003e \u003cp\u003eThe incision scars were hidden by the double eyelids. The scar area, where the lateral skin is widely removed, can sometimes be visible, which may be a concern. However, the scarring becomes less noticeable over time in most cases when the sutures are accurately placed. In our two cases, the incision scars did not pose a problem.\u003c/p\u003e \u003cp\u003eThis study has some limitations that warrant discussion. First, the follow-up period was 9 months to 1 year; therefore, longer-term follow-up is desirable to confirm the degree of eyelash correction and the maintenance of double eyelid formation. Second, skin thickness and texture also influence the degree of postoperative double eyelid formation, necessitating further analysis.\u003c/p\u003e \u003cp\u003eIn conclusion, we report two cases of upper eyelid epiblepharon in patients with thick excess skin. By accurately performing appropriate skin excision and placing sutures for double eyelid creation, a functionally and aesthetically satisfactory surgical outcome can be achieved. Our technique can be applied to double eyelid formation for various types of eyelids.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eStatement of ethics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors adhered to the tenets of the 1964 Declaration of Helsinki. Written informed consent was obtained from the patient in Case1 and her mother, and from the patient in Case 2 for publication of this case report and any accompanying images. We asked the institutional review board of Aichi Medical University Hospital and confirmed that the ethics approval for this report was not necessary on the basis of the ethical guidelines for medical and health research involving human subjects established by the Japanese Ministry of Education, Culture, Sports, Science, and Technology and the Ministry of Health, Labor, and Welfare.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient and the mother for publication of this case report and any accompanying images. \u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are not publicly available due to privacy reasons but are available from the corresponding author, S.K. on reasonable request.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that there is no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding sources\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research did not receive any specific grants from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the conception and design of this study. The material preparation, data collection, and analysis were performed by S. K. S. K. and K. M. conducted the literature search. The first draft of the manuscript was written by S. K., and M. K. commented on the previous versions of the manuscript. All the authors have read and approved the final version of the manuscript.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eValencia MRP, Takahashi Y, Nakakura S, Kakizaki H. Sex-specific difference in age distribution of congenital lower eyelid epiblepharon in a Japanese population. Jpn J Ophthalmol. 2019;63:425\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAhn HB, Seo JW, Yoo JH, Jeong WJ, Park WC, Rho SH. Epiblepharon related to high body mass index in Korean children. J Pediatr Ophthalmol Strabismus. 2011;48:57\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHuang S, Han Y, Zeng X, Qi X, Li X, Li J, et al. Congenital epiblepharon in Chinese school-age children: a cross-sectional study. J AAPOS. 2024;28:103938.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChoi SW, Goldberg RA, Lew H. Blepharoplasty with a buried double twisted suture technique to correct upper eyelid epiblepharon. Plast Reconstr Surg Glob Open. 2016;4:e685.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim JS, Jin SW, Hur MC, Kwon YH, Ryu WY, Jeong WJ, et al. The clinical characteristics and surgical outcomes of epiblepharon in Korean children: a 9-year experience. J Ophthalmol. 2014;2014:156501.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSundar G, Young SM, Tara S, Tan AM, Amrith S. Epiblepharon in East Asian patients: the Singapore experience. Ophthalmology. 2010;117:184\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLew H, Yu SB, Yun YS, Lee SY. Correction of epiblepharon of the upper eyelid by the buried suture technique: correlation with morphological features of the upper eyelid. Ophthalmologica. 2008;222:100\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMimura M, Sato Y, Fujita Y, Korn BS, Kikkawa DO, Oku H, et al. Adjustable medial epicanthoplasty using a rotational flap for epiblepharon repair. J Craniofac Surg. 2022;33:1218\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee KM, Choung HK, Kim NJ, Lee MJ, Lee KW, Khwarg SI. Prognosis of upper eyelid epiblepharon repair in down syndrome. Am J Ophthalmol. 2010;150:476\u0026ndash;e4801.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJohnson CC. Epicanthus and epiblepharon. Arch Ophthalmol. 1978;96:1030\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChoo CT, Chan CM, Fong KS. Surgical management of upper lid epiblepharon. Eye (Lond). 1998;12:623\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen WPD. Concept of double-eyelid segments ratio: practical application in Asian blepharoplasty. Plast Reconstr Surg Glob Open. 2024;12:e5944.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"epiblepharon, upper eyelid, excess skin, incisional double-eyelid blepharoplasty, case report","lastPublishedDoi":"10.21203/rs.3.rs-8860349/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8860349/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eEpiblepharon is characterized by a fold of skin that stretches horizontally across the upper or lower eyelid, and is usually associated with inversion of the eyelashes. Upper eyelid epiblepharon is relatively rare and is treated with double-eyelid surgery using a buried suture or an incisional method. To date, no reports have described the detailed course of treatment for epiblepharon, characterized by excess skin on the upper eyelids, that simultaneously achieves aesthetic improvement and corrects eyelash inversion.\u003c/p\u003e\u003ch2\u003eCase presentation:\u003c/h2\u003e \u003cp\u003eWe present the treatment outcomes of two cases of epiblepharon of the upper eyelid with excess skin in a 16-year-old and a 35-year-old female, both treated with incisional double-eyelid surgery combined with skin excision. In both patients, eyelash inversion was corrected, double eyelids were formed, and aesthetic improvements were made.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eBy accurately performing appropriate skin excision and placing sutures for double-eyelid creation, a functionally and aesthetically satisfactory surgical outcome can be achieved in patients with upper eyelid epiblepharon.\u003c/p\u003e","manuscriptTitle":"Incisional Double-Eyelid Blepharoplasty Corrects Upper Eyelid Epiblepharon Concomitant with Thick Excess Skin: A Report of Two Cases","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-14 10:37:55","doi":"10.21203/rs.3.rs-8860349/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"80402338-adb6-4147-a01c-ae03fa4816a2","owner":[],"postedDate":"April 14th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-04-14T10:37:55+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-14 10:37:55","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8860349","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8860349","identity":"rs-8860349","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}