Lower bleph - which is a better option - having fat removed from inside lid or removed from under eyelash line?

Question

I have read of two different ways to remove the fat pads from under the eye, one goes from inside the lid the other externally. what is the difference and why chose one over the other - any insight to advantages, disadvantages or reason why to chose one over the other would be greatly appreciated

David Tauber, MD · Answer

A blepharoplasty is done to remove or re-position the tissue around the eyes to improve the way they look. This can involve removing excess eyelid skin, removing or re-positioning the underlying orbital fat, and possibly tightening or re-positioning the lid margin. 
There are two approaches to a blepharoplasty:
Through the lid. Sometimes called a skin or skin-muscle flap. The skin and possibly the underlying muscle are elevated from the lid margin down. A cut or three small cuts are made through the lid to gain access to the protruding fat and then the excess skin, and possibly muscle, is cut away. This approach damages all three layers of the eyelid, has a longer recovery, and has a higher risk of lid pulldown (ectropion) as the lid scars. Behind the lid. Called trans-conjunctival. Access to the herniated fat is through a thin layer of tissue called the conjunctiva which is located between the eyelid and the eyeball. Excess skin, if present, can be addressed through a skin pinch below the eyelashes or, in mild cases, laser. This approach does not damage the support layers of the eyelid - decreasing the risk of lid pull-down - and results in a shorter recovery for most patients.I prefer a trans-conjunctival approach with a skin pinch because of its lower risk and faster recovery. For more information on blepahroplasty see the link below. 
A detailed examination and discussion will help delineate the best surgical option. Consultation with a plastic surgeon would be the next best step.

Stephen T. Greenberg, MD, FACS · Answer

Thank you for your question.
You are correct in that there are two different incision approaches when it comes to a lower blepharoplasty: transconjuctival and subciliary.  The choice of approach is highly dependent upon the patient's pre-op lower lid anatomy, most critically whether or not the patient has excess skin of the lower lid that will require excision.  
A transconjuctival incision is one that is made on the inside of the lower eyelid.  The primary advantage of this approach is that there are no external incisions, and therefore there is no risk of visible scarring, making this approach the patient favorite!  This approach is best suited for patients with primarily 'puffiness' of the lower lid, the result of an overdevelopment or pseudoherniation of fat.  Because this approach does not allow for removal of skin, this is not ideal for patients who have more than minimal skin laxity.
In contrast, a subciliary incision is an external incision that rests just below the lower lid lash line.  Due to its position, it tends to be very well hidden but there is always the possibility of a visible scar.  This approach allows the surgeon to address both the 'puffiness' and lax skin of the lower lids.
It would be important and recommended that you seek a consultation with a board certified plastic surgeon who is well-experienced in lower blepharoplasty procedures.  A consultation would be necessary to determine your candidacy for a lower blepharoplasty and to elucidate which approach would be of most benefit for you.  In my practice, I do prefer utilizing the transconjuctival approach, however, in some patients a subciliary incision will be required to address any more than mild skin laxity.
I hope you find this helpful and I wish you all the best!

Andrew Miller, MD · Answer

The internal bleph approach is safer and gives a great result. The only reason to use an external incision is if there is a lot of extra skin to remove or if the lower eyelid needs to be tightened. Be sure to see an eyelid specialist for consultation.

Jeffrey B. Wise, MD, FACS · Answer

This is complicated topic based on a number of factors.  I have personally performed several thousand eyelid procedures (I have three today!)  Transconjunctival eyelid procedures are best for patients (sometimes younger) with limited skin laxity and mostly puffiness (pseudoherniation of fat). Advantage of this procedure is no external incision.  Disadvantage is that nothing is done to address the skin (although laser can be performed in the right candidate).Transdermal (subcilliary) eyelid procedures are excellent for addressing skin laxity and puffiness.  Even eyelid position can be adjusted if need be.  The results can be extremely dramatic and all aspects of lower eyelid aging can be addressed.  Disadvantages of this procedure include the incision.  That said, it is extraordinarily subtle and is nearly invisible after healing.Best of luck!

Richard G. Reish, MD, FACS · Answer

Hello and thank you for your question. The best advice you can receive is from an in-person consultation. If fat needs to be removed or transposed, I prefer to do this through a transconjunctival incision (inside the eyelid), as this does not violate the orbital septum.  I think this is a safer approach in my hands and less risk for ectropion.  If skin also needs to be removed, this can be performed through a subciliary incision.
Make sure you specifically look at before and after pictures of
real patients who have had this surgery performed by your surgeon and evaluate
their results.  The most important aspect is to find a surgeon you are
comfortable with. I recommend that you seek consultation with a qualified
board-certified plastic surgeon who can evaluate you in person.
Best wishes and good luck.
Richard G. Reish, M.D.
Harvard-trained plastic surgeon

Randy Proffitt, MD · Answer

I prefer inside of the eyelid or what is known as a transconjuctival blepharoplasty. There is a good reason to use this method.  The risk of scarring of the eyelid that can pull the eyelid margin down is almost 0 with this technique.  Period.  Unless you have so much loose skin like a hound dog of the lower eyelid, the skin can be tightened sufficiently by either a small skin excision, laser resurfacing, or chemical peel of the lower eyelid skin.

Steven Wallach, MD · Answer

The thinking is to not damage the muscle around the eye, so may will do a transconj fat removal and if skin is an issue, a skin pinch can be performed.

Wayne F. Larrabee, MD · Answer

We use both approaches and tailor the approach to the individual patient. For the usually younger patient with primarily excess fatty tissue the transconjunctival approach is idea.  It can be combined with some type of resurfacing (laser or chemical peel) for those with minimal excess skin but photoaged or wrinkled skin.  For those patients with more added skin a "skin pinch" can be added to the fat removal.  By doing this "inside-outside" approach the intervening layers including the muscle is left intact and the chances of a lid malposition are minimized.  For patients with more lid laxity and excess skin an external incision usually with some type of lid tightening is preferred.  See a surgeon who is expert in all of the techniques so he or she can select the best approach for you.

William B. Rosenblatt, MD · Answer

Almost all lower lids can be done via an inside incision, if there is excess skin, using a small pinch it can be removed. This technique decreases the chance of ectropion ( lower lid pull down) and scleral show. It is preferred by the experts.

Amiya Prasad, MD - Account Suspended · Answer

Thank you for your question. You submitted a question without an image asking about the difference between transcutaneous and transconjunctival blepharoplasty, and the advantages and disadvantages of both.
I can share with you my direct experience with these procedures. A little background: 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. What you’re describing are options for lower eyelid blepharoplasty, which is a significant part of my daily practice. 
To understand the difference of these procedures, you have to first understand why the procedures are done. Lower eyelid surgery is usually done to address puffy under eye bags, skin that appears to be loose and wrinkled, and sagging of the lower eyelid from its normal, more desirable position. 
When people do their research and learn about what their options are, they come across the choices many doctors tend to gravitate towards. Transcutaneous blepharoplasty is the approach where an incision is made from beneath the eyelashes to go to the fat pockets, do whatever is necessary to remove them, redrape the skin, then trim if necessary or desired by the doctor to tighten the skin. A transconjunctival blepharoplasty is done from the inside of the eyelid to address lower eyelid fat prolapse where the fat from behind the eyelid pushes forward and creates this bulge.
From the time I trained in oculofacial surgery to the present day, things have continuously evolved in our field, not only from a surgical point of view, but also from a tissue remodeling, rejuvenating point of view, from the perspective lasers, radiofrequency, platelet-rich plasma (PRP), regenerative medicine, etc. 
With these surgeries, we’re trying to rejuvenate the lower eyelid. As an eyelid specialist, I’m in a position to deal with a lot of complications of patients who come from around the world who had eyelid surgery that resulted in problems like ectropion where the eyelid turns out, or eyelid retraction where the eyelid is pulled down. 
From a purely anatomic perspective, you are able to achieve comparable results with either procedure. The overwhelming majority of my patients I perform lower eyelid blepharoplasty for, I use the transconjunctival approach. When we think about the anatomy of the lower eyelid, one of the things people see in others who had eyelid surgery is very rounded lower eyelids. The eyelid goes from being an almond shape to rounded. Very often, that occurs from a transcutaneous blepharoplasty where the procedure was done from the outside. A well-meaning doctor will do the surgery, trim some skin and will cause some pulling and tension.
When I do transconjunctival blepharoplasty, I’m preserving all of the support structures that maintain eyelid shape. It’s minimally invasive even though it’s more technically advanced, and allows us to address the fat pockets without compromising the integrity of the lower eyelid. 
A lot of doctors were trained in lower eyelid surgery only from the external approach. That’s what they’re comfortable with, that’s what they’ve always done, and essentially play the odds that most of the time, and get acceptable and reasonable results, but periodically, they end up with complications. From my perspective as an eyelid expert and specialist who can do all these different variations of surgeries in the lower eyelid, I feel I want to offer my patient the most safe and predictable procedure that can get the best results. 
People often ask about the relative excess skin that can occur after lower eyelid surgery done from the inside because we’re not taking away skin, which is one of the biggest misperceptions about lower eyelid skin. Generally, lower eyelid skin is not in excess, but actually an issue of skin quality, not skin quantity. It’s a very difficult concept to understand because patients will pull their skin out and say, “Doc, what about this extra skin?” If you take away skin, you may end up with the eyelid pulling down. 
There’s going to be the occasional patient who does need skin removal, but that can be addressed by doing a straightforward skin pinch or skin excision where we don’t have to undermine and separate the skin flap. That’s getting more technical than is necessary, but the key is to have a nice, natural look. 
When I want to address skin quality, I do things such as fractional CO2 laser, Erbium laser, platelet-rich plasma (PRP), or radiofrequency such as Pellevé. All of these things can help skin quality without compromising the integrity of the eyelid position. 
It is rare for me to do a transcutaneous blepharoplasty rather than a transconjunctival blepharoplasty. I think the transconjunctival blepharoplasty has significant advantages in many ways, and can be customized with other procedures to get the optimal outcome. I hope that was helpful, I wish you the best of luck, and thank you for your question.

Lower bleph - which is a better option - having fat removed from inside lid or removed from under eyelash line?

Answers (10)

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