For Me, is It Transconjunctival Blepharoplasty OR the One with External Incision That is Preferred? (photo)

Good day Doctors, I am a healthy 25 year old woman, considering the blepharoplasty to get rid of the eye bags. Whether the external approach will be needed or not is what I need to know your opinion about... Is it possible that the skin will be lax after the removal of the fat by the transconjunctival approach ?? or is it unjustified fear and my youth will make the result just wonderful without me going for the blepharoplasty with the external incision approach? Thank you

Doctor Answers 15

Excellent photos

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First, let me commend you on your choice of posted photos. It is excellent and gives us great information.

There are a few points to make here:

1.  Your lower lid blepharoplasty should be done via a transconjunctival approach. You are quite young and as such need NO skin removal, and doing a skin approach to the fat would present a higher risk of lower lid retraction.

2. I would not remove any fat from the lower eyelid, but rather reposition the fat into the hollowness at  the junction of the eyelid and cheek [tear trough]. This will minimize the risk of eyelid hollowness as you age.

3. You would benefit from fat injections to the your midface/cheek just below your eyelid. Your have a prominent eye [seen well in the profile view you have posted] and an underprojected cheek which creates a "negative vector" for the eyelid. Adding volume to your cheek would improve the support of the eyelid.

4. You have mild upper eyelid ptosis [droopy upper eyelid] and an internal [no skin incision] ptosis repair would improve the appearance of the upper eyelids dramatically and give you a more alert/awake look.  I have posted the before and after photos of a very similar patient below that had that upper eyelid ptosis repair performed.

Hope this helps.

Seattle Oculoplastic Surgeon
5.0 out of 5 stars 41 reviews

Lower lid blepharoplasty

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At 25 I doubt that you have excess skin.  With the fat pockets protruding you may be a good candidate for a transconjunctival approach.

A transcutaneous lower eyelid incision would be a big mistake for you.

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You have a very big eye and poor lower eyelid support.  The lower eyelid rides below the limbus with inferior scleral show.  Transcutaneous lower eyelid surgery will weaken the lower eyelid position and lead to eyelid complications.  You do have a bit of herniated lower eyelid fat.  This is classically what tranconjunctival lower eyelid surgery is performed for or more recently arcus marginalis release.  With the benefit of a personal examination, it is also possible that you might not need a surgery and might only require lower eyelid filler with Restylane.

Kenneth D. Steinsapir, MD
Beverly Hills Oculoplastic Surgeon
4.9 out of 5 stars 26 reviews

Lower eyelids

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Hello.  Based on your photos , a transconjuctival approach would be great for the fat. You don't seem to have excess skin which would usually occur in older patients.  Good luck

TC approach

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At your age, there is usually no excess skin thus a transconjunctival approach with NO external skin incision works very well.

Transconjunctival or external lower blepharoplasty approach

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Your pictures do show that you have some protrusion of fat under your eyes that causes some puffiness.  It does not appear that you have an issue with excess skin, which would be unusual at age 25.  I would recommend the transconjunctival approach, as this should easily address the issue with the fat.  

Michael I. Echavez, MD
San Francisco Facial Plastic Surgeon
4.5 out of 5 stars 18 reviews

Transconj VS subciliary approach

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Hello 'theyellow', thanks for your question.  Being young and healthy with a firm tarsal sling for lower eyelid support and no loose skin based on your photos, I think you are a great candidate for the transconjuctival approach lower blepharoplasty.  Your main concern is redundant periorbital fat herniation leading to the fullness below your eyes, which this approach should take care of.  I reserve the subciliary (external) approach for older people who tend to have excess skin, muscle, and fat that needs removal, as well as a loose tarsal sling mechanism that needs tightening.  Either approach leads to a nice aesthetic eyelid rejuvenation, but in your case, the transconj approach will serve you best. Be sure you seek a board-certified plastic surgeon to help you achieve your goals and good luck! -Dr.92660

I expect excellent rebound from your skin

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You are only 25 years old so I would expect excellent rebound from your skin.  Part of why your lower eyelid fat is accentuated is because you have a lack of volume below the eyelid in the midface. Judgement is best made based on an in-person consultation, but it appears that you could benefit from either a transconjunctival (no external incision) blepharoplasty with a small amount of fat removal and/or filler/fat placed in the tear trough and at the infraorbital rim. I would not opt for external skin removal.

Or Me, is It Transconjunctival Blepharoplasty OR the One with External Incision That is Preferred?

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Based upon your age the posted photos I chose transcend. approach for you. So ALL of the expert posters choose the TRANSCONJ. OPTION 

Transconjunctival Subcilliary Blepharoplasty Nasal Jugal Groove

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What you are percieving as puffyness is actually a combination of 2 abnormalities.  The first is the protrusion of the orbital septum and fat which is made worse on upward gaze. The second cause is a deep nasal jugal groove, the hollow area below the puffy.  Each of these abnormailties can be addressed transconjunctivally.  I prefer to reposition the fat that is protruding into the hollow space elliminating the shadow and maintaining a full, more youthful appearence rahter than removing the fat which can make the lid look shallow and gaunt.

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.