Transconjunctival eye surgery vs the outside excision - which should I go for?

I have been to see 2 doctors about my lower eye bags, i am a 40 year old male bags caused by the fat sticking out. Both said i only need mild fat removal, but 1 of them said a bit of excess skin also needed to be removed. The doc that said skin removal is not needed uses the transconjunctival as oppose to the exterior cut that the other doc prefers. Which technique is likely to give the best, safest, longest lasting results ? I was very comfortable with both docs, they are both highly experienced

Doctor Answers 10

Transconjunctival eye surgery vs the outside excision - which should I go for?

Both procedures are acceptable and is simply a matter of surgeons choice.

However I used a trans-conjunctival approach almost exclusively because there is less risk of ectropion or change in eyelid shape.  Even with a trans-conjunctival approach if minor skin excision is required it can be done through a pinch technique with a small incision on the lateral or side portion of the eyelid.  For more information please read the following link:

Transconjunctival approach is safer for the lower eyelids

Given the well-documented data showing that the transconjunctival approach is safer than the transcutaneous (subciliary) approach, it's hard to recommend anything but the transconj approach for the majority of patients. It carries a much lower risk of lid rounding and ectropion (where the eyelid ends up hanging out away from the eyeball). If there also is excess loose skin this is dealt with via a simple "skin pinch" excision just below the lash line at the same time as the transconjunctival treatment of the bags. 

All the best,


Pearson Facial Plastic Surgery®

David C. Pearson, MD
Jacksonville Facial Plastic Surgeon
5.0 out of 5 stars 24 reviews

Lower eyelid surgery candidate

In our practice, the trans-conjunctival approach for lower eyelid surgery has been the gold standard for over 25 years for the fat bag removal in the lower lids. If patients have excess skin after the fat has been moved, a small incision placed at the eyelash line is performed and a small amount of excess skin is removed and closed with tissue glue. It's very important not to violate the muscle on the lower lids which can create scleral show and  and unnatural appearance.  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 143 reviews

Transconjunctival eye surgery vs the outside excision - which should I go for?

Like many, I have stopped using transcutaneous approach for lower blephs for at least 20 years.  I prefer a tranconjunctival approach and if necessary add a skin pinch skin removal (avoiding going through all the layers of the lower lid and reducing risks) to remove excess skin.  IMO it is by far the safest approach.  Regards,

Jon A Perlman MD FACS 

Certified, American Board of Plastic Surgery 

Extreme Makeover Surgeon ABC TV

Best of Los Angeles Award 2015, 2016 

Beverly Hills, Ca 

Jon A. Perlman, MD
Beverly Hills Plastic Surgeon
5.0 out of 5 stars 30 reviews

Lower lids

davedavies, see an experienced facial specialist that does "only faces" and is familiar with a "SOOF lift blepharoplasty" which in my opinion is the safest most effective procedure for the lower lids. This procedure is done using a transconjunctival approach. See the video and good luck!

M. Sean Freeman, MD
Charlotte Facial Plastic Surgeon
4.7 out of 5 stars 48 reviews

There is no question that trancutaneous lower eyelid surgery has many more complications.

Ideally the surgeon proposing transconjunctival lower eyelid is not throwing the lower eyelid fat away but transposing it as an arcus marginalis release surgery to reduce volume in the eyelid and help the lack of volume at the top of the cheek.  

Transcutaneous lower eyelid surgery weakens the motor function of the lower eyelid and for that reason is associated with many, many post surgical complications.

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

Transconjunctival eye surgery vs the outside excision

Definitely go with the transconjunctival approach for reduction of the fat pads. It is the lowest risk approach for that. If it is necessary to remove skin that can be done with a skin pinch technique after the fat has been reduced.

Ronald V. DeMars, MD
Portland Plastic Surgeon
5.0 out of 5 stars 27 reviews

Transconjunctival eye surgery vs the outside excision - which should I go for?

Hello davedavies - Thanks for your question. I will often remove fat using the transconjunctival approach and then remove skin with a small skin pinch or skin flap using a subciliary incision. If there isn't enough skin for a surgical removal of excess skin, laser resurfacing is a great option to shrink wrap crepey skin. As you are only 40 years old, I doubt you have much excess skin, so a transconjunctival fat removal alone is the safest option. If you end up with a little bit of excess skin that doesn't tighten after surgery, a laser resurfacing procedure would work nicely. 

I hope this helps. 

Good luck, 

Dr. Shah

Manish H. Shah, MD, FACS
Denver Plastic Surgeon
4.8 out of 5 stars 55 reviews

Lower lid blepharoplasty

A transconjunctival approach has fewer possible complications and that is why many people have switched to this technique.  It also avoids an external incision if there is little or no skin. The main issue with the skin approach is that there is a greater risk of post-op ectropion.  However when done correctly and without removal of too much skin you should be fine. 

The other consideration is whether you should be having a fat repositioning surgery.  I do most of mine this way as I think preserving the fat  but moving it inferiorly gives a better cosmetic result and avoids any hollowing as you age.       

John J. Martin, Jr., MD
Coral Gables Oculoplastic Surgeon
5.0 out of 5 stars 27 reviews

Transconjunctival vs transcutaneous lower eyelid surgery

Removal of fat from the lower eyelids can be performed through an incision under the eyelash line (transcutaneous approach) or on the back of the eyelid (transconjunctival approach). Both are reasonable surgeries and each surgeon will have his or her own personal preferences. I prefer tranconjunctival surgery whenever possible and generally only use the transcutaneous approach when there is a lot of excess skin on the lower eyelids, but this is just my personal preference. 

Instead of deciding between one approach or the other, I would recommend seeing each doctor again and having surgery with whoever you feel the most comfortable with.

Mitesh Kapadia, MD, PhD
Boston Oculoplastic Surgeon
5.0 out of 5 stars 165 reviews

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.