Which would you recommend Transconjunctival vs. Transcutaneous Blepharoplasty? (photos)

Either approach might work well, but in a younger patient with minimal excess skin or skin laxity, I tend to recommend a transconjunctival blepharoplasty approach. Sometimes no skin excision is needed at all, while in other cases, a small skin pinch might be needed. I will often also laser the lower eyelid area with a fractional CO2 laser at the same time (often without the skin pinch) in order to give a small amount of tightening of the skin without removing any skin or making any incisions.
For patients with a deep tear trough, this needs to be addressed in some way as well, usually either through fat repositioning, fillers, cheek augmentation, or a combination of the above. Talking with a facial plastic surgeon can be very helpful for an in-person exam and to discuss all of the options in detail.
All the best,

 Most of the surgeons here have recommended transconjunctival blepharoplasty, which is a reasonable approach for someone with isolated fat bulging, as you tend to see in younger patients such as yourself. What concerns me is that your skin may have been stretched out enough that once the fat is removed, you will have some skin excess. I think it defeats the purpose of doing a transconjunctival blepharoplasty if you ultimately have to make an external incision to remove excess skin anyway. In those cases it would have made more sense to do an external approach. This is a judgement call that a surgeon can best make by examining you. You can then discuss the best options with him or her.

From your photos provided it appears you have significant puffiness in the lower eyelids without evidence of redundant skin. For this reason, most experienced eyelid surgeons would recommend transconjunctival approach and (if needed) a skin "pinch" technique for removal of a small amount of lower eyelid skin. 

You have significant fat pads for your age.  A transconjunctival is the method of choice for most surgeons these days.  There are usually less complications with this approach.  From the inside of the lid, the fat can be repositioned inferiorly to fill in the tear trough.  You have so much fat that some may need to be removed as well. If there is excess skin,  a pinch of skin can be removed from directly under the lash line .    

I have done both for 35 years so I see adv-disadv of both. Though I normally do patients like you Transconjunctivally I think your bags are so large that when they are removed you will have excess skin and therefore need a transcutaneous approach. 

In general, transconjunctival lower blepharoplasty (to address the fat/bags) is safer and heals quicker than transcutaneous lower blepharoplasty. It does not alter the eye shape or cause lower eyelid retraction.  If there is extra loose skin that needs to be removed, then skin pinch method can be done combined with the transconjunctival approach.  See an oculoplastic surgeon.

Based on your photos, it doesnt look like there is a significant amount of excess skin present. I would definitely recommend transconjunctival lower blepharoplasty for you. We surgeons love having patients like you come in, because there is a lot of excess fatty tissue present and you will likely have a very dramatic improvement from the surgery.In transconjunctival surgery, the incision will be on the back of your eyelid so there is no visible scar and little to no risk of eyelid retraction after the surgery. I reserve transcutaneous lower eyelid surgery for patients with laxity in their lower eyelids and a lot of excess skin. 

However, you are going to have far more issues with transcutaneous lower blepharoplasty.  You have a very large eye.  You have poor support for the lower eyelid with relative lack of cheek bone projection (negative vector lower eyelid).  Transcutaneous lower eyelid surgery violated the orbicularis oculi muscle to access the fat.  In about 70% of patients this results in permanent weakening of the pretarsal orbicularis oculi muscle responsible for holding the lower eyelid against the eye.  Lateral canthoplasty or pexy is often performed to compensate for this loss of motor nerve function.  However, this procedure also pulls the lower eyelid down.  For this reason, I advise transconjunctival lower eyelid surgery with preservation of the lower eyelid fat and relocation of this material to the top of the cheek (arcus marginalia release surgery).  You may also need very gentle lateral canthal support at the time of surgery.

Hi there.  I feel that the trans-conjunctival approach to cosmetic lower eyelid blepharoplasty is very favorable. Instead of approaching the fat pads from the outside (trans-cutaneous blepharoplasty) the dissection is actually performed from behind, within the eyelid. The trans-conjunctival blepharoplasty is usually combined with an external skin pinch, to remove the redundant skin, once the fat pads are removed and deflated.  Lower lid Blepharoplasty may be performed with a combination of local anesthesia as well as light IV sedation anesthesia. General anesthesia is not necessary, although patient preference should always be taken into consideration.Hope this at least provides useful information. Good luck and best wishes. Dr. Shah

Given the youthful appearance of your skin, a
transconjunctival approach with a skin pinch excision to tighten the skin, and
fat grafting to camouflage the junction between your lid and cheek would be
appropriate. Laser skin tightening is also available if additional tightening
is needed after the initial surgery. I recommend consultation with a board
certified Plastic Surgeon. - Brian M. Derby MD on behalf of James C. Grotting MD