The presence of epicanthal folds is a unique appearance in the eyelids of Asians. Various medial epicanthoplasty techniques have been discussed to achieve a better aesthetic result. Owing to the complexity of the surgery, a design based on anatomic variations of the epicanthal fold is imperative. From September 2006 to November 2010, the author performed medial epicanthoplasty procedures on 86 Asian patients. The whole procedure, including discrepant Z skin incision, myotomy and the plication of the medial canthal ligament (MCL), was performed layer by layer. The inner canthal distance (ICD) was measured and calculated by software ImageJ before and 3 months after surgery. All patients were satisfied with the long-term results and there were no recurrences of the epicanthal fold. The shortening ratios of the ICD ranged from 7.2% to 13.7% (average 10.78%) in the group without the plication of the MCL (57/86). In addition, the ICD shortening ratio ranged from 9.1% to 17.7% (average 15.66%) in the group with the MCL plication (29/86). The technique we described is aimed to correct layered structures including skin, muscle and the MCL of the medial epicanthus. Satisfactory results were ideally achieved with finer scar and natural cosmetic appearance in this series.