What Are the Risks of Transconjunctival Lower Eyelid Surgery with Skin Pinch?

I saw a plastic surgeon today (will see others as well) and he recommended a fat melting blepharoplasty or transconjunctival. What are the risks of transconjuntival lower eyelid surgery with perhaps a skin pinch should the protruding skin not retract back nicely and either sag or wrinkle?

Doctor Answers 14

Lower Eyelid Surgery

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For blepharoplasty patients with true lower lid skin excess or redundancy, some skin must be removed to restore a youthful appearance. This is performed through a subciliary incision, which is an incision placed immediately below the lower lid lashes. This incision is hidden by the lower lid eyelashes and is almost always imperceptible once it has healed.

As with upper lid, skin excision of the lower lid should be very conservative, amounting to only that amount of skin that is necessary to improve the lower lid skin contour. The muscle layer below must remain completely undisturbed, as it provides horizontal support for the lower lid and helps to maintain the lid position flush against the surface of the eye. Excessive removal of lower lid skin may lead to a complication called ectropion, where the lower lid is pulled down and away from the surface of the eye. This complication often requires additional surgery to correct it, and must therefore great care must be taken to avoid it.

In eyelid surgery patients that do not have adequate lower lid tone or support, and in any patient felt to be at some risk of ectropion, a lateral canthopexy is performed to protect against that potential problem. The lateral canthus (the lateral corner of the eye) contains a tendon that attaches the lower lid tissues to the orbital rim laterally, and this tendon serves as a 'clothesline' that maintains lower lid position. A lateral canthopexy consists of an anchoring or supporting suture that tightens that tendon and thus the lower lid as well. When desired, a lateral canthopexy can also elevate the position of the lower lid. In patients who desire it, this procedure can produce a more 'almond' shape to the eyes.

Lower Eyelid Fat Pads or "Bags"

A very common aging change in the lower eyelids is the development of 'bags', which are in most cases due to an outward bulging of the fat pads behind the lower lids. These 'bags' of fat can be improved by conservative removal through an invisible incision on the inside of the lower lid (trans-conjunctival approach) in patients that do not require skin excision, or through the under-eyelash (sub-ciliary approach) in patients that are having some excess lower lid skin removed.

As with skin removal, I believe that the reduction (NOT total removal) of lower lid fat pads should be conservative. Excessive removal of lower lid fat pads results in a hollowed-out appearance that makes blepharoplasty patients look tired or even ill. I see quite a number of eyelid surgery patients who require structural fat grafting of the lower lids to improve that very problem following an over-aggressive lower blepharoplasty in the past.

In some case lower lid 'bags' can be improved by repairing or reinforcing the soft tissues that normally hold them back. Additionally, excessive lower lid fat can sometimes be mobilized and transposed inferiorly to fill in periorbital hollows or depressions such as the 'tear trough' at the medial junction of the lower lid and cheek.

Some eyelid 'bags' involve redundant muscle tissue which must be removed and/or repositioned, usually in patients who are in their sixties or older. This is performed through an under-eyelid (sub-ciliary) incision which is extended laterally into the 'crow's feet' area.

Raleigh-Durham Plastic Surgeon
4.8 out of 5 stars 123 reviews

Fat melting is not really approved nor do I advise

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From what I understand, fat melting is not really approved nor do I advise. Transconjunctival is removal of the fat.  You have to make sure that you actually need to have lower lid fat removed and make sure that not too much of it is removed. You don’t want to end up having a hollowed out look.  The skin pinch is sometimes done to remove excess skin; but again, you have to make sure it’s really necessary.

Risks of Transconjunctival Lower Eyelid Surgery (Blepharoplasty) with skin pinch.

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 The Transconjunctival Lower Blepharoplasty IMHO, is the gold standard for removing excess fat bags from the lower eyelids and was the topic of a research paper I wrote in 1991 on the subject of lower Blepharoplasty.  If your surgeon is experienced in this technique, it offers distinct advantages over the older transcutaneous method including less incidence of lower eyelid malposition.  A conservative (must be conservative IMHO) skin pinch can be done but so can a lower eyelid 30 % TCA peel that leaves no telltale scar. 

 There is a risk that the cornea could be damaged but I use an inner mucosal flap, from the lower eyelid, to protect the corneas while performing the Blepharoplasty.  Corneal shields are another solution but can, IMO, actually scratch the cornea themselves and as such I discontinued their use over 15 years ago during this procedure.

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Blepharoplasty & risks

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All surgery carries some risk; eyelid surgery included. Whether the incision is made in the skin below the lid/lashes or in the conjunctival trough behind the lid margin, there are certain risks that may include unwanted bleeding, scarring, and even problems associated with loss of vision and/or cornea injuries.  But when patients are carefully selected and prepared for surgery (ie, no aspirin containing products for example, and no physical activity post operatively for awhile) this greatly reduces risks. Blepharoplasty is a very delicately performed procedure, and it is important to discuss details with the surgeon whether this is a facial plastic or plastic surgeon or oculoplastic surgeon.  In most cases, the transconjunctival approach to removal or repositioning of lower eyelid fat ('bags") is a nice procedure, and can be combined with outer skin resurfacing (chemical peels or lasers) at the same time. This can lead to a very refreshed appearance with high patient satisfaction!

Donn R. Chatham, MD
Louisville Facial Plastic Surgeon
5.0 out of 5 stars 74 reviews

Transconjunctiva lower eyelid blepharoplasty

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The risks from this approach are similar to the more traditional trans cutaneous approach.  These include: bleeding, infection, lower eyelid malposition, and eye muscle injury.  Many surgeons feel that this approach is slightly less risky for lower eyelid malposition in that the approach does not interrupt some of the suspensory structures that are involved in the trans cutaneous approach.  I do probably 80% of my lower eyelid surgeries using the transconjunctival  approach, and have been very satisfied with the surgical outcomes.  Good luck!  I hope you get a wonderful result.

Jenifer L. Henderson, MD
Silverdale Facial Plastic Surgeon

What Are the Risks of Transconjunctival Lower Eyelid Surgery with Skin Pinch?

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The risks of this operation are the same as with any blepharoplasty: the risks of the anesthetic, bleeding, infection, dry or teary eyes, injury to the muscles that move your eyes and injury to the eye itself, up to and including blindness. There are also the aesthetic complications: too much, too little, unevenness, etc.

I have done this operation for at least a half-dozen years and have found it to work well. It is nearly impossible to produce the most common complication of all: ectropion, or pulling down of the lower lid.

This is because the operation leaves untouched virtually all the structures that support the lid against the effects of healing and gravity.

I am a big fan of this operation.

Good luck!


Transconjunctival blepharoplasty.

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There should be almost no risk if you go to an experienced plastic surgeon who has done these for many years.

Toby Mayer, MD
Beverly Hills Facial Plastic Surgeon
4.8 out of 5 stars 36 reviews


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Transconjunctival blepheroplasty with or with out a skin pinch is a good and accepted technique. Although it was the rage a few years ago less are done today. All of the usual complications can occur. These are primarily over or under skin removal or too much fat removal.

David A. Bray, Sr., MD
Los Angeles Facial Plastic Surgeon

Transconjunctival lower eyelid rejuvenation

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Transconjunctival lower eyelid blepharoplasty, or eyelid rejuvenation surgery, removes the lower eyelid fat that is responsible for creating the bulges or puffiness of the lower eyelid regions. It is performed through either several small or one continous incision underneath your lower eyelid, thus avoiding any external incisions. It preserves a natural anatomic structure called the septum frmo being violated, thus potentially reducing any postoperative complications such as excessive scarring, or lower eyelid malposition. It can be very effectively combined with a small external skin pinch to remove either skin or a combination of skin and muscle to create a natural youthful result. This is my preferred technique of lower eyelid rejuvenation.

Jeffrey D. Hoefflin, MD
Los Angeles Plastic Surgeon

Honestly it is very difficult to usefully answer this question for you.

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A photograph would be very helpful to meaningfully answer this question.  The particular risk of the surgery really relate to your precise anatomy.  For example, if your issues are such that a filler service is all you actually need then having unnecessary surgery is a complication.  The skin pinch can sometimes be a skin muscle pinch.  The key really relates to the execution of surgery.  General plastic surgeons and facial plastic surgeons do offer these procedures as do oculoplastic surgeons.  The trend has been preservation of fat by moving it from the lower eyelid to the top of the cheek, called an arcus marginalis release.  This reduces the risk of making the lower eyelid too hollow by removing excessive lower eyelid fat.

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