Blepharoplasty (Lower) - Transcutaneous Vs Transconjunctival on Effectiveness (Problem Returning)

I'm 38, have good skin etc so am primarily interested in the Transconjunctival procedure. I have been told the only reason this would be unsuitable is that generally the effects of Transconjunctival Blepharoplasty are quite temporary, that the fat will herniate back from the eye socket and re-populate the lower eyelid area (being that muscle tightening performed in the Transcutaneous approach isn't done to prevent re-herniation). Is this a pitfall of Transconjunctival Blepharoplasty?

Doctor Answers 4

Transcutaneous versus transconjunctival lower blepharoplasty

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If the skin below your eyes does not have much in the way of wrinkles, then a transconjunctival lower blepharoplasty would be an excellent approach to deal with any protruding fat that you have.  There is not a higher incidence of having fat re-herniate with this technique.  The transcutaneous approach can have a higher incidence of problems with the lower lid position because the muscle is disrupted.  

San Francisco Facial Plastic Surgeon
4.5 out of 5 stars 18 reviews

Blepharoplasty (Lower) - Transcutaneous Vs Transconjunctival on Effectiveness (Problem Returning)

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I have not encountered this issue before. Typically, a transconjunctival approach is very effective for treatment of lower eyelid bags. If you're unsure about the advice you've been given you should seek a second opinion. Choose an experienced Facial Plastic Surgeon or Oculoplastic Surgeon. I hope this information is helpful.

Stephen Weber MD, FACS

Weber Facial Plastic Surgery

FIND NEW DR. byVillar

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Most of us were taught that baggy eyes were the result of the orbital septum and lid muscles weakened with age, allowing orbital fat to herniate out of the socket. WRONG.

UCLA researchers have found (2008) that fat expansion in the eye socket is the primary culprit.

"However, our study showed there is actually an increase in fat with age, and it is more likely that the fat increase causes the baggy eyelids rather than a weakened ligament," Darcy said. "There have been no studies to show that the orbital septum weakens."

Currently, many plastic surgeons performing procedures to treat baggy eyelids do not remove any fat at all. They reposition the fat or conduct more invasive tightening of the muscle that surrounds the eye, or they tighten the actual ligament that holds the eyeball in place. These procedures are performed despite there being no data indicating that these structures change with age.


"Our findings may change the way some plastic surgeons treat baggy eyes," said study co-author Dr. Timothy Miller, professor and chief of plastic surgery at the Geffen School. "Our study showed that a component of a patient's blepharoplasty procedure should almost routinely involve fat excision rather than these procedures."

Open blepharoplasty is for patients with redundant inelastic skin that has to be removed as well as the fat.  Transconjunctival blepharoplasty is for baggy eyes that do not have significant excess skin.  The longevity of the results relates to how fast the fat continues to increase, not the type of surgery performed.  Seek second opinions.  Best wishes. Knowledge is power.  Luis F. Villar MD FACS

Luis Villar, MD, FACS
West Palm Beach Plastic Surgeon
4.4 out of 5 stars 11 reviews

It's not the muscle that's the pitfall

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The main pitfall that I see with the transconjunctival approach is that most people doing this are removing fat from the orbit, when it really ought not to be removed.  This creates a significant risk of leaving a hollow appearance to the eyelids.  Fat can be repositioned with the transconjunctival approach too, although this can be a bit more challenging than simply removing it.  I also find that many times the lateral fat pocket is not well addressed with the transconjunctival approach, and this is what "repopulates" the lower eyelid and creates a persistent bulge.  While it is appealing to avoid the scar and the other risks of a transcutaneous procedure, the two approaches are not mutually exclusive, and I find that the indications for a transconjunctival blepharoplasty are very few and very specific.

Joseph L. Grzeskiewicz, MD
San Diego Plastic Surgeon

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.