Would I be a candidate for transconjuctival lower bleph? (Photo)

I want to explore options outside of fillers, and surgery seems like the best option.. But I'm not sure that I am a candidate for surgery. What are my options outside of fillers?

Doctor Answers 21

Your eye bags are not too large, but you do recognize that transconjunctival blepharoplasty doesn't require filler maintenance

Thank you for your question. You submitted a single photo of a close-up of your eyes, and ask if you are a candidate for lower eyelid blepharoplasty.

I can give you my perspective of how I counsel patients like yourself who come into our practice. I’m a Board-certified cosmetic surgeon and Fellowship-trained oculofacial plastic and reconstructive surgeon. I have been in practice in Manhattan and Long Island for over 20 years. This type of question shows how the world continues to evolve in our field. Not so long ago, the question was always asked if fillers can be an alternative to blepharoplasty. It’s understandable why you’re asking this question because a lot of people would suggest to do fillers.I’ll give you an understanding of my thought process and how I counsel my patients about the role of fillers versus surgery, and in the whole context of your appearance.

Let’s start with anatomic definition, because often people are eager to jump into solutions. Often, the solutions offered are based on the bias of the practitioner, so if you go to someone who just does skin, they may say, “do laser,” and if you go to someone who only does injectables and non-surgical, they’ll say,  you need to just do injectables,” so I can understand why you get confused. You have puffiness under your eye which is called lower eyelid fat prolapse. This means fat normally around your eyes has pushed forward, causing puffiness. Prior to fillers, transconjunctival blepharoplasty would be my recommendation which is a definitive approach. Although your puffiness may not be that significant, you’re already seeing t if you do a procedure like a lower lid blepharoplasty is definitive so you don’t need repeat filler treatments.  I have often observed people developed something called filler fatigue - they go for injectables in an area that particularly is challenging. The under eye area requires a lot of finesse to get a beautiful result with fillers, and dealing with the downsides of bruising and swelling can make someone think twice about doing it again.

In a situation like yours, I would typically recommend lower eyelid blepharoplasty. To help with the dark circles and the skin color and quality, I would use platelet-rich plasma (PRP) and I might even consider laser depending on what I see in a 3-dimensional examination.

That said, when I talk to my patients about lower eyelid blepharoplasty, they are often concerned about the paradox of hollowness, which is the valley next to the puffiness. I often show them from a side and three quarters view that there’s actually volume loss below the rim of the bone called the orbit. So there may be a value to fillers, but not exactly the same place. Fillers can be useful at the eyelid-cheek junction or in the cheek area to help blend, but that’s more of further enhancement of the global area, and not specifically for the under eye puffiness.

The art of doing lower eyelid blepharoplasty in a situation like yours is knowing how much to sculpt, maximizing the outcome or contour so it looks natural and doesn’t look like you had surgery. From the photo alone, I suggest you are probably a candidate for lower eyelid blepharoplasty.

I recommend you meet with a qualified, experienced cosmetic surgeon who does a lot of eyelid surgery and learn about your options. From my perspective, you would be someone I’d generally do a transconjunctival blepharoplasty, with platelet-rich plasma (PRP) derived from your own blood to stimulate the skin quality, growth factors that generate collagen, blood supply, and maybe a fractionated laser. Get a few opinions and go with a doctor you’re comfortable with. I hope that was helpful, I wish you the best of luck and thank you for your question.

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New York Oculoplastic Surgeon
4.3 out of 5 stars 72 reviews

Fillers versus blepharoplasty

It is difficult to tell from your pictures, but from what you submitted it looks like blepharoplasty surgery might not be the best option.  My recommendation would be filler under the eyes. You have volume loss in your mid-face, which is creating the appearance of a bag. Products such as Restylane, Radiesse, or Juvederm (depending upon the volume loss) could give you a beautiful result.  With advanced facial fillers, I think you will get a very natural and predictable response. This is an “off-label” treatment, however, so make sure you go to a provider who is well versed in treating the area around the eyes.  An oculofacial plastic surgeon who's also a skilled injector would probably be best.

Joseph A. Eviatar, MD, FACS
New York Oculoplastic Surgeon
4.7 out of 5 stars 66 reviews

Fillers versus surgery...

The ideal treatment would be to do both lower blepharoplasty (transconjuctival), and filler or fat injection to the crease underneath the fat. It is important to not overresect the fat or some hollowing could occur. Proper reduction of fat along with filling the crease will give the smoothest, most natural result.

Andrew Miller, MD
Edison Facial Plastic Surgeon
4.8 out of 5 stars 206 reviews

Transconjunctival blepharoplasty

The short answer is yes, you would be a candidate for transconjunctival lower lid blepharoplasty. An alternative - if you have not ruled it out yet - would be a combination of filler to enhance the cheek volume and laser to gently tighten the skin over the fat pads. If you opt for the surgery, be cautious as surgery is not reversible. You appear to be a young person with hopefully many years on the planet! You don't want to have a gaunt appearance - overzealous use of surgery can leave you with problems and fewer options down the road. best wishes with your decision.

Sara A. Kaltreider, MD
Charlottesville Oculoplastic Surgeon
5.0 out of 5 stars 7 reviews

Would I be a candidate for transconjuctival lower bleph?

You can do well with either option but transconjunctival lower blepharoplasty with fat repositioning is usually the best long term option. See video and link below.

Mehryar (Ray) Taban, MD, FACS
Beverly Hills Oculoplastic Surgeon
4.9 out of 5 stars 74 reviews

Lower eyelid surgery or fillers

For young patients with excess eye fat, most plastic surgeons would perform lower eyelid via transconjunctival approach. However, lower eyelid surgery alone may not be sufficient in some cases. Volume enhancement is often required, either with fat transfer or facial filler injections. If you haven't already, then speak with a facial plastic surgeon to review options.Best,Dr. Chaboki

Houtan Chaboki, MD
Washington DC Facial Plastic Surgeon
4.9 out of 5 stars 85 reviews

Transconjunctival blepharoplasty

Hello,Thank you for your question. The TC bleh might very well be the answer but I would be careful. From you photos it appears that you might have some sagging of the underlying muscle which can really only be addressed from a standard blepharoplasty technique. The 'trap' is believing that 'excess skin' is the only determinant of whether or not to have TC procedure. You need the opinion of a plastic surgeon with at least 15 years of experience in this area. Hope this helps.Leland Deane MD FACSManhattan, Garden City, and Babylon

Leland Deane, MD
Long Island Plastic Surgeon
5.0 out of 5 stars 32 reviews

Inferior Blepharoplasty with Fat Transposition

Dear patient, from your photos, I see definitely you got some bags under your eyes, and you are definitely a candidate for inferior blepharoplasty with fat transposition. I always recommend to do fat transposition with inferior blepharoplasty (take the under-eye fat and transposition it in the same surgery to cheek) to avoid hollow eyes after taking out the fat. Please check certified doctors who do inferior blepharoplasty with fat transposition since it is the best option for your case. Best regards.

Nabil Fakih, MD
Lebanon Facial Plastic Surgeon
5.0 out of 5 stars 3 reviews

Would I be a candidate for transconjuctival lower bleph?

An exam is needed for a definitive answer but from that photo it appears you would have only a slight improvement at best from transconjuctival lower bleph. You would have a much more attractive result by adding volume below the bulge. If your aversion to fillers is because you don't want to have to repeat injections every few months I suggest fat transfer. Properly performed transferred fat will last for decades. Please see examples.

Curtis Perry, MD
Downey Facial Plastic Surgeon
4.8 out of 5 stars 19 reviews

Trans conjunctival approach for lower blepharoplasty

From the one limited photograph, it appears that there is herniated fat in the lower lids. A trans conjunctival approach conservative fat pad removal can accomplish rejuvenating the lower lids with all of the incisions placed on the inside of the lower lids. No external incision is required. For more information and many examples, please see the link and the video below

William Portuese, MD
Seattle Facial Plastic Surgeon
4.8 out of 5 stars 145 reviews

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