it is characterized by a horizontal skin fold across the edge of the eyelid , occurring more often in the lower lid [ 15 ] . the two known causes of lower eyelid epiblepharon are inadequate lower lid retractor development , marked by the absence of adhesion to the skin , and a pretarsal orbicularis muscle inserted too closely to the lid margin ; subsequently , the muscle and skin anterior to the tarsal plate are pushed forward over the tarsal plate , resulting in muscle and skin hypertrophy . in contrast , the causes of congenital entropion , which differs from epiblepharon , are a lack of a tarsus , hypertrophy of the pretarsal orbicularis muscle in the eyelid , and an aponeurosis retractor attachment rupture [ 6 , 7 ] . with redundant lower eyelid skin and insufficient adhesion of the orbicularis oculi muscle to the tarsal plate this skin causes the cilia to be inverted toward the eyeballs , which may touch and irritate the cornea , particularly in the downward gaze [ 1 , 2 ] . associated symptoms of this condition include ocular irritation ( e.g. , epiphora , photophobia , eye rubbing , increased discharge , frequent blinking , and foreign body sensation ) and corneal erosion , both of which can result in vision impairment [ 8 , 9 ] . in most cases , symptoms are not serious and are outgrown with facial bone growth and the accompanying skin and muscle extension . however , in serious cases or when the condition persists , surgical correction is often necessary [ 10 , 11 ] . compared to caucasians , asians generally have nasal bones that tend to rise at a later age , and it has been reported that 12.6% of asian children aged 7 to 14 years old have epiblepharon . the condition does not always correct itself with age , and surgical correction should be performed once symptoms appear . despite numerous studies examining the prevalence of epiblepharon in asian populations [ 1214 ] , no large - scale , long - term studies on epiblepharon in korean infants and children have been previously performed . here , we report on the prevalence , symptoms and surgical success , recurrence , and complication rates observed in korean children undergoing epiblepharon surgical correction . among our patients , 768 patients were diagnosed with epiblepharon , underwent corrective surgery between january 2005 and december 2013 , and were followed for at least 6 months following surgery . patient medical records were retrospectively reviewed for the age , gender , chief complaint , presence of keratitis , location of epiblepharon , concomitant disorders , postoperative location of epiblepharon , complications , and recurrence rate . epiblepharon was classified by the location into the upper lid and the lower lid groups . additionally lower cilia - touching lesions were classified into nasal , center , and temporal groups , according to the corneal region involved . surgery was performed when significant corneal damage occurred , as confirmed by slit lamp examination or serious irritation complaints . the surgeries were performed by the same surgeon and involved skin resection and full - thickness rotating suturing in the lower lid corrections and simple - interrupted buried suturing in the upper lid corrections . skin resection and full - thickness rotating suture placement on the lower lid involved marking a skin incision line with the aid of bishop forceps . after an incision was made with a number 15 bard - parker blade , skin and subcutaneous tissue resection was performed with stevens scissors . part of the orbicularis oculi was also removed using electrocautery to minimize bleeding . after exposing the tarsal plate , one or two simple - interrupted buried sutures ( 6 - 0 nylon ) were placed in the subcutaneous tissues of the incision 's upper end and on the lower end of the tarsal plate , with the resected skin inserted into the incision . for the remaining skin , a continuous suture ( 6 - 0 fast absorbing plain gut ) was placed . the simple - interrupted buried suture was also placed for the upper lid correction , paying close attention to bilateral lid symmetry . four points were marked with a marking pen where the double fold was to be formed and the stitches were to be placed ( figure 2 ) . epinephrine mixed with 2% lidocaine was injected into the subcutaneous space and the upper subconjunctival layers . several 2 - 3  mm incisions were then made with a number 11 blade for the suture entry . the upper lid was everted and a single - interrupted buried suture ( 4 - 0 vicryl ) was placed on the 4 marked points . all postoperative follow - up exams were performed in an outpatient setting in which the position of the cilia and cilia - corneal touch were monitored by slit lamp examinations . during the follow - up period , the patients were carefully monitored for surgical complications and epiblepharon recurrence . among the 768 epiblepharon patients included , 302 ( 39.3% ) were male and 466 ( 60.7% ) were female . the mean patient age at the time of presentation was 6.55  2.37 years ( table 1 ) . four - year - olds composed the largest patient group ( n = 107 , 13.9% ) , with the majority of patients aged between 3 and 7 years ( n = 475 , 61.8% , figure 1 and table 2 ) . at the time of presentation , 712 patients ( 92.8% ) reported epiblepharon symptoms , but 56 patients ( 7.3% ) were incidentally discovered while undergoing visual acuity and/or ophthalmologic examinations for other reasons . the most common complaints among patients were foreign body sensation due to cilia - corneal touch ( n = 209 , 27.2% ) , ocular discharge ( n = 97 , 12.6% ) , photophobia ( n = 80 , 10.4% ) , and decreased visual acuity ( n = 69 , 9.0% , table 3 ) . lower lid epiblepharon patients had cornea - cilia touch most often in the nasal area ( n = 408 , 58.6% ) , followed by the central area ( n = 264 , 37.9% ) , and , finally , the temporal area ( n = 24 , 3.4% , table 1 ) . the concomitant eye disorders were ptosis ( n = 62 , 8.1% ) , strabismus ( n = 48 , 6.3% ) , floppy eyelid syndrome ( n = 44 , 5.8% ) , trichiasis ( n = 37 , 4.8% ) , and amblyopia ( n = 10 , 1.3% , table 4 ) . epiblepharon correction surgery was performed on both the upper and lower lids of 82 patients ( 10.5% ) , on the lower lids of 629 patients ( 80.3% ) , and on the upper lids of 72 patients ( 9.2% , table 1 ) . eyelid shape and function were maintained in 740 patients ( 96.4% ) with no epiblepharon recurrence at the final follow - up examination . the remaining 28 patients ( 3.6% ) had epiblepharon recurrence involving the lower lid , 15 ( 1.9% ) of whom were operated on a second time . following the second procedure , no complications ( e.g. , ectropion , scar formation , and wound dehiscence ) the 13 patients who did not undergo a second correction procedure showed improvement without surgical intervention through the follow - up period . statistically , the recurrence rate of lower cilia - corneal touch was significantly higher in the nasal area compared to the other corneal regions ( table 5 ) . it is generally a bilateral anomaly of the lower lid and is characterized by a skin fold that runs horizontally across the eyelid edge [ 1 , 2 , 15 ] . in their study of japanese children , noda et al .   reported that 81% of epiblepharon cases involved the lower lid and that only 7% and 12% of cases involved the upper lid or both lids , respectively . fortunately , most infants outgrow epiblepharon , and symptoms spontaneously improve as facial bones , skin , and muscles grow . only approximately 2% of infants with epiblepharon show no symptomatic improvement by the time they reach school age [ 1517 ] . because epiblepharon pushes the cilia toward the cornea and/or conjunctiva , symptoms include conjunctival irritation and injury , eye rubbing , and epiphora . it has also been associated with astigmatism and decreased visual acuity [ 9 , 18 ] . in this study , the most common symptom at the time of presentation was cilia - induced corneal irritation , even in patients in whom severe epiblepharon was incidentally discovered ( 7.3% ) . epiblepharon was observed most frequently in patients aged 4 to 7 years , which was indicative of the high prevalence rate for this age group . therefore , even in infants without noticeable symptoms , careful examination is necessary to detect epiblepharon and prevent subsequent refractive error and decreased visual acuity caused by corneal irritation . epiblepharon that is mild or in an early stage may be conservatively addressed either with medication   or by retracting the skin fold downward with adhesive or cellophane tape [ 16 , 20 ] . surgical intervention criteria vary slightly between surgeons , but , in most cases , the presence of symptomatic cilia - induced corneal irritation is the decisive factor [ 12 , 21 ] . however , some controversy remains regarding this issue because even in the presence of corneal irritation , some infants and children do not complain , and more conservative therapies can be used successfully . in the current study , the severity of corneal irritation was subjectively assessed by a single surgeon to determine whether surgical intervention was needed . no objective criteria for this evaluation have been established , although such criteria would have been of great use and an interesting area for further study . nonincisional methods result in less postoperative edema , can easily be repeated , and leave minimal scars ; unfortunately , these methods result in occasional recurrence [ 25 , 26 ] . in this study , the nonincisional simple - interrupted buried suture technique was used to correct upper lid epiblepharon , and no recurrence was observed during the follow - up . the nonincisional suture technique , first presented by quickert et al . , is simple and rapid with a reported success rate of 100% . nevertheless , the disadvantages of this technique make it impractical for severe epiblepharon correction and include frequent suture infection and a recurrence rate of up to 29% . the modified hotz procedure ( i.e. , hotz - celsus procedure ) was widely used until recently . it involves lower lid redundant skin and partial orbicularis oculi resection and placing an anchoring suture of skin to the tarsal plate . it is a relatively simple procedure with a high success rate but requires an unnecessarily large skin resection , which can result in ectropion and lid retraction [ 4 , 25 , 26 ] . this procedure involves exposing the tarsal plate and burying it together with subcutaneous tissues [ 21 , 27 ] . our surgical method for lower lid epiblepharon correction involved only little skin resection , and when further correction was needed , the full - thickness rotating suture technique was used . thus , lower lid crease , scar formation , and complication rates ( e.g. , ectropion and lid retraction ) could be reduced , all while maximizing surgical success rate and minimizing recurrence rate . our recurrence and reoperation rates were highest in patients with lower lid epiblepharon with nasal cilia - cornea touch . this result was in agreement with swan , who found that , in severe epiblepharon , creasing at the nasal end of the eyelid occurs substantially more frequently . .   reported on an additional epiblepharon surgical technique that , coupled with z - epicanthoplasty , positively affected defect correction . in our study , in an attempt to overcome the defect , an additional full - thickness rotating suture was placed in cases of severe epiblepharon . therefore , further research is necessary to identify the most effective intervention method that reduces recurrence and reoperation rates by sufficiently improving cases of severe epiblepharon at high risk of recurrence . the greatest limitation of this study was the subjective assessment for the need of surgery , but the influence of this limitation was minimized by having only one evaluating surgeon . unfortunately , no objective system to evaluate cilia - induced corneal irritation symptoms and epiblepharon severity is available , and this system is a needed area of future research . to conclude , epiblepharon is frequently found in korean infants and children and should be addressed with caution and care , even in the absence of symptoms . many surgical interventions carry the risks of general anesthesia and of postoperative complications , such as postoperative scar formation and ectropion . here , we reinforce the idea that effective epiblepharon correction can be achieved with a simple surgery , alleviating symptoms and preventing keratitis - induced decreases in visual acuity . nevertheless , age and symptom severity should be considered when determining which surgical correction method to use .
purpose . to examine the demographic characteristics , clinical features , surgical outcomes , and long - term prognoses of epiblepharon in korean children 
 . 
 methods . 
 epiblepharon patients who were followed for  6 month following surgical correction between january 2005 and december 2013 . 
 the patient demographics , clinical features , concomitant disorders , surgical outcomes , and complications were retrospectively reviewed . 
 results . 
 a total of 768 epiblepharon records were included in the analysis . 
 the mean patient age was 6.55  2.37 years . at presentation , 712 patients ( 92.8% ) complained of typical epiblepharon symptoms . 
 the mean patient age at surgery was 6.95  2.52 years , with 629 patients ( 81.9% ) on the lower lid and 72 patients ( 9.4% ) on the upper lid and 82 patients ( 10.7% ) undergoing surgery on both lids . 
 the eyelid was well everted with no recurrence in 740 patients ( 96.4% ) . 
 conclusion . 
 epiblepharon frequently occurs in korean children and is correctable with a simple surgery . 
 recurrence and serious complications do not occur often , and any suspicions of epiblepharon should be investigated . 
 a thorough ocular examination can lead to a correct diagnosis and timely corrective surgery . 
 most procedures are successful and prevent secondary complications that often occur with uncorrected epiblepharon .