Blepharoplasty Transconjunctival vs Skin Pinch/Incision? (photos)

Transconjunctival lower blepharoplasty plus laser resurfacing would address both the fatty contour and tighten the loose skin under the eyes without removal of skin and risk of lower eyelid retraction.  See example in the link below

There are many issues influencing the best approach to your concerns that requires a in-person consultation. The need for skin tightening with a pinch or laser debatable. Fractional laser can improve the skin quality and brightness. The contours require the surgical manipulation of the fat layer. Of course the skin management could also be done under local anesthetic as a secondary procedure if necessary.

Given the time that you have invested with multiple
physicians I am certain that the review of allergies and salt intake have been
discussed. Hopefully you are free of these
influential factors. If you are not
these elements will affect your overall surgical outcome as they will influence
your eyes even after a perfect surgery.
This being said I would recommend a trans-conjunctival procedure (bilateral lower eyelid fat transposition) with
the possibility of bilateral lower lid laser.
Soft tissue removal on a young individual with good skin elasticity is
not ideal. Taking advantage of the inherent
youthful elasticity and the ability to produce new collagen are what make a
laser treatment in this region complementary. Transposition of the orbital fat (moving it from the area of the fullness to the region of deficiency will correct the lower eyelid contour with local, "privileged" fat that is resistant to metabolic change. Better stated, the fat survival is higher and lasts longer than other means of volume replacement.

Be healthy and be well,

James M. Ridgway, MD, FACS

I would suggest that, prior to surgery, you have your tear troughs corrected with a filler injection.  I think this would make a big difference for you.  I like Restylane Silk for this area.Then, if you still feel there is puffy fat, go ahead and do the transconjunctival fat removal procedure.  It looks like you have very minimal skin excess - so needing a pinch would be unlikely.  In general, though, pinch blepharoplasty has a low risk of lid position issues, less than a standard transcutaneous blepharoplasty.

I'm looking forward to seeing other answers to this particular question. My approach would not be a lower bleph - but fat grafting to the tear trough and central malar region to raise the lid-cheek junction and conceal the hollowing below your lower eyelid. HA fillers like Juvederm or Voluma will provide a temporary fix. Seek experienced plastic surgeons in your area for an in-person consultation.

Thank you for sharing your questions and photographs. The lower eyelid is perhaps the most difficult area of the face to treat, which is why you will get so many different treatment recommendations. If you ask ten physicians you'll likely get ten different answers.  Blepharoplasty, whether transconjunctival (with a pinch) or traditional transcutaneous approach, would generally consist of removing fat and/or skin, which are permanent interventions and ignore the main problem which is volume deficiency over the bony rim of the eye.  Keep in mind that most skin pinch techniques remove several millimeters of skin, which you likely don't need. Generally speaking, the best options for young patients are the most conservative ones, such as fat injections or hyaluronic acid filler injections. Thanks again for sharing your questions and photographs.Good luck,Dr. Harmych

I do not think lasers alone would satisfy your objectives.  I would recommend a blepharoplasty withan incision below the lash line or a subciliary incision.  Through this approach, the fat could alsobe addressed with one approach.  

It's a good question. Patients with excess lower eyelid fat and excess skin, do well with a transconjunctival fat removal and a small pinch of lower eyelid skin. Most patients in their 30s do not have significant excess skin, and do very well by just removing the fat. Some lower eyelid skin tightening can be obtained by using a laser.It sounds like you're on the right track. It's wise to obtain multiple consultations.Good luck with the procedure.

First, surgical advice online bypasses a very critical thing called an actual consultation which means talking without to listen and hear your concerns and explore the history of things you have tried.  Then a detailed examination determines the basis for your issues.  So I am going to have you do your own examination right now.  Put your finger on top of your bag.  I suspect what you are feeling is not a soft pillow of herniated fat.  The hard structure you are feeling is your bony orbital rim.  This is not operated on or fixed with either a skin pinch or a tranconjunctival lower blepharoplasty.  That does not stop a whole lot of surgeons because when you are a hammer, the world looks like a nail.  Standard eyelid surgery is highly disappointing for addressing these situations.  You best option for quite sometime (the next decade or so) is to have a very experienced injector fill this area with hyaluronic acid filler.  The best filler for this in my opinion is Restylane.  Do not let anyone inject a so-called smooth filler like Juvederm or Belotero in this issue.  You can read my free ebook cited below about more information about these types of issues.

At age 32 you may not have enough extra skin to do a pinch.  That is often determined at surgery.  It can increase the risk of ectropion if too much skin is excised.  Laser resurfacing is a good option in younger patients to improve the texture of the skin.  A bigger issue is fat removal vs repositioning.  I am a big believer in keeping the fat and moving it down into the tear trough to prevent any hollowing.  Too often we see deep tear trough after fat removal which then has to be filled.