Is Transconjunctival Blepharoplasty Better Than Transcutaneous?

Now for the correct answer. ;-)

The transconj approach was designed specifically to address the higher rate of ectropion with the subciliary or transcutaneous approach. It was not designed simply to hide a scar.

It is also woefully incorrect to claim that transconjunctival approaches are "for younger people who have a significant congenital fat excess of the lower eyelids." Nonsense.

The advantage of the transconj approach is that it allows for fat contouring without disrupting the structures of the middle lamella of the eyelid, thereby reducing the chance of lid problems (by an order of magnitude). Excess skin is also (and nearly always) treated simultaneously with a "skin pinch" which also avoid that middle lamella.

Sure there are some surgeons who get good results with either approach. But if you want to minimize the chance of ectropion and lid malposition, it's generally lower with the transconjunctival.

All the best,

--DCP

There are pro's and con's to each approach. The transcon procedure makes the incision inside the lower eyelid, where the fat pads can be accessed. Genreally this technique is used to remove the fat pads that cause bags under the eyes. It does not tighten loose skin but a peel can be done for that. If there is skin laxity, then an external approach is usually better. It is true that the external approach has a higher likelihood of ectropion - pulling down of the eyelid due to scar - but this is very uncommon with good technique and judgment. Also, the trend is to preserve the fat around the eye and reposition it to correct the bags, so the transcon approach is less commonly done now.

The less disruption that occurs to the lower eyelid the better.  The goal of lower eyelid surgery is generally to improve and contour fullness from anterior orbital fat that projects into the lower eyelid.  In addition other goals may include reducing lower eyelid skin lines, lifting the midface, and tightening the lower eyelid margin.  

Transcutaneous lower eyelid surgery is performed through an incision placed just below the lower eyelid lashes.  A cut is make through the skin muscle to expose lower eyelid fat.  Unfortunately, this approach damages the nerves that innervate the muscle at the edge of the lower eyelid and can lead to ectropion, the outward roll of the lower eyelid.  Scar can also develop in the skin because of damage to the eyelid due to disrupting many eyelid layers.  

This can cause permanent damage to the shape of the eyelid contour.  This problems are generally avoid by using a transconjunctival approach to the lower eyelid fat.  Less damaging methods of reducing eyelid wrinkles include skin pinch and chemical peels.  For younger patients, we now often do fillers as a very viable alternative to lower eyelid surgery.

Yes, transconjunctival blepharoplasty is much better than transcontinuous. There is no violation of the lower lid muscles and much less chance of altering eye shape through transconjunctival approach. When performed correctly, it is very rare to see any ectropion or scleral show after transconjunctival blepharoplasty.

There are many ways of performing a blepharoplasty, there are indications for each of them, but most important it is the experience of your surgeon. The traditional teaching is that with a external approach you will have more chances of ectropion ( pulling of your lid), you can have also problems with the transconjunctival approach, in my opinion the most important factor its the experience of your surgeon. With the external approach the surgeon should be able to improve certain problems, which are very difficult to fix with the internal approach, specially the eyelid/cheek junction line. Check pictures of the surgeons you visit, specially the lateral view.

Good luck

There is no one treatment that will fit every patients need. The job of a good surgeon is to choose the best treatment for each patient. Transconjunctival is indicated in younger patients.

Transconjunctival blepharoplasty places the lid incision on the inside to better hide the scar yet still allow access to the fat causing the lower lid fullness. The transconjunctival approach is limited in that it will not address skin excess or laxity that has developed through aging. It is a perfect procedure in younger individuals will great skin tone and inherited prominent fatty lower lids. In the past the procedure was combined with laser and peels on the lower lids to help with the skin excess. However, pigmentation issues and lid pulling start to surface. If transconjunctival lower lid rejuvenation is right for you, great. If skin excess and muscle laxity is present your result will fall short and the lash line approach will be the correct choice, despite the risk of change in lid shape and ectropian (lid pulling). These are risks, though they should seldom occur in experienced hands.
Best of luck,
peterejohnsonmd

The two approaches to the lower lid are different in what they can do and the risks they expose you to.  While the external approach may have more potential for ectropion, a proper preop evaluation of your lid laxity would indicate certain maneuvers to prevent that ie canthopexy.  The transconjunctival approach is best for dealing with fat only and carries an increases risk of damage to the muscles that move your eyes.  

It is not a question of whether one approach to eyelid rejuvenation is superior to another but which of the two procedures is best for a given problem. If the issue is lower lid "bags" but the overlying lid skin is taught then the transconjunctival approach is most appropriate.  With this technique the surgeon can remove fat causing the "bags' by working through the inside of the lower lid leaving no visible scar on the exterior. 

However, if the lower lid problem also involves the presence of loose wrinkled skin then there is no way of avoiding a transcutaneous approach without compromising the result. If the surgeon is careful this skin can be removed with little risk of causing ectropion or change in the shape of the eye. Then the surgeon can also remove the "bags" through this same transcutaneous incision or elect to do so transconjunctivally thereby combining the two techniques.

Transconjunctival blepharoplasty has less chance of ectropion, but it also has limitations in correcting the skin and muscle components of the lower eyelid. However, the skin and muscle can be address with other less invasive procedures including peels and muscle tightening.

When using a traditional subciliary incision all of the components (fat, muscle, and skin) can be addressed through the same incision. The traditional approach also allows for more aggressive tightening of the eyelid Canthopexy or canthoplasty) if indicated. A careful exam by an experience eyelid plastic surgeon will be helpful in deciding which approach is best for you.