Transconjunctival Blepharoplasty Vs Arcus Marginalis Release

Hello, I am a 21-year-old male who definitely wants to have my (minor) eye bags removed. I know they're caused by fat because when I squint or lay on my back they disappear. What would benefit me the most, a transconjunctival blepharoplasty or an arcus marginalis release? What are the differences between the two, and the pros and cons of either? Thank you.


Doctor Answers 17

Arcus marginalis release vs transconjunctival blepharoplasty

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Many patients have exactly what you describe, a congenital bulge under the eyes. You have astutely noted that your bulge gets better when you squint; that means the problem is due to a fat bulge. It often looks much better when this fat is removed through a transconjunctival approach.

We have abandoned the arcus marginalis release procedure entirely over 5 years ago. It involves curring and release of the arcus marginalis, in my oipinion a dangerous layer that can contract at the slightest provocation and pull down on the lower eyelid. We would rather place a separate conservative graft in the eye-cheek region than risk this complication.

Besides, why have a complicated procedure when a simple procedure (carefully done by an expert) can give predictable and lasting results?

We have several articles and chapters referenced below on the subject.

Beverly Hills Plastic Surgeon
4.9 out of 5 stars 194 reviews

For your age, arcus marginalis release may be best

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Dear Cheekpads

Generally when one refers to a transconjunctival blepharoplasty one does not just refer to an approach to the lower eyelid but rather a particular type of lower eyelid surgery. The tranconjunctival blepharoplasty is performed from behind the lower eyelid cutting accross the lower eyelid conjunctiva and the lower eyelid retractors just above the low point behind the lower eyelid on the eyelid side. This permits exposure of the three pockets of fat in the lower eyelid: lateral, central, and nasal. The lower eyelid is sculpted by removing just the right amount of fat, reducing the "bag" in the lower eyelid. This can be an excellent option for the right individual.

Increasingly however, we have come to appreciate that the lower eyelid fat is essentially an innocent bystander that becomes increasingly visible as the ligaments that when we are young hold the cheek fat high up in the lower eyelid. As these ligaments give way, the lower eyelid fat becomes increasingly exposed. Simply taking out the lower eyelid fat does nothing to help the other issue in many of these eyelids: the tear trough hollow or so-called nasojugal groove.

The arcus marginalis surgery addresses this issue by conserving the lower eyelid fat that would normally be excised during the transconjunctival lower blepharoplasty. The lower eyelid septum is a thin connective tissue plane in the lower eyelid just anterior to the lower eyelid fat. This plane thickens and inserts onto the cheek bone periosteum at the orbital rim. This condensation is called the arcus marginalis. Using the same surgical approach as the transconjunctival blepharoplasty, the surgeon can cut the septum at the orbital rim and either make a preperiosteal pocket just above the connective tissue covering of the cheek bone or a subperiosteal pocket on the bone. The lower eyelid fat can then be rotated into this pocket as a living pedicle graft to help fill the tear trough hollow. This so-called arcus marginalis release surgery improves the lower eyelid bag and at the same time provides help for the tear trougth hollow.

Which approach is right for you? Untimately, you need to be assessed by a high qualified eyelid surgeon who you trust to help you make this determination.

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

Probably need both transconjunctival blepharoplasty and Arcus marginalis release

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It is not uncommon for a 21 year old to have noticeable fat deposits in the lower lids causing a baggy appearance. As the amount of lower lid fat tends to be an inherited trait, I see them often in teenagers. Transconjunctival lower lid surgery is an approach to the fat from an incision behind the eyelid which is not visible. This is the preferred approach to orbital fat as it tends to cause less scarring and healing issues with the lower lids. Arcus marginalis release allows the fat to be repositioned in the tear trough and under the orbital line. You probably need both.

You should also consider Juvederm injection which can be effective in masking the fat. Juvederm in this location can be quite long lasting (1 year or more).

Peter T. Truong, MD
Fresno Oculoplastic Surgeon
4.9 out of 5 stars 42 reviews

The type of eyelid procedure required depends on your problem

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The type of eyelid procedure needs to be be tailored to the patient. As an expert in facial and eyelid procedures, your surgeon should be able to give you the pros and cons of each procedure. I perform the following for the following reasons.

1. Transconjuctival Blepharoplsty - This is a procedure most appropriate for very young patients ( less than 30 ) who have the problem of fat bags but not so much extra skin and wrinkles.

2. Arcus Marginalis Release - This is a procedure most appropriate for patients with deep tear trough and flat anterior cheek descent or who have a very exposed orbital line.

3. Traditional Skin Blepharoplasty - This is the most common procedure and is most appropriate for patients with more skin excess and wrinkles who are over 35 to 40 years of age. With this procedure, I can remove the skin excess as well as remove any fat bulges.

5. Nonsurgical Blepharoplasty - This is a procedure I am performing more commonly. I do this procedure with fillers (Radiesse, Juvederm, or Sculptra). By filling in the malar cheek and camouflaging the orbital bone line, any extra lines get plumped out, the fat bags get camouflaged, and the orbital line is erased.

Phillip Chang, MD
Leesburg Plastic Surgeon
4.6 out of 5 stars 10 reviews

Arcus marginalis release (fat transfer) with tranconjunctival ("no visible incision") blepharoplasty

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These are not mutually exclusive options. The transconjunctival bleph is an approach and not an endpoint. It essentially means that your incision is made on the internal lining (conjuntiva) of the eyelid rather than the skin surface. Once open, you can use this approach to remove fat, release the arcus, perform an orbital fracture repair or muscle surgery, etc.

The arcus release allows the fat to escape the contents of the orbit (softening the appearance of the bags). Many surgeons than sew or fix this fat into the nasojugal fold (tear trough) to more softly contour the transition from the eyelid to the cheek.

So to answer your question, both may be needed.

Otto Joseph Placik, MD
Chicago Plastic Surgeon
4.9 out of 5 stars 86 reviews

Transconjunctival blepharoplasty vs arcus marginalis release

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Generally a 21 year old in my practice can be treated with fillers at your tear trough or transconjunctival fat removal and or with transposition of fat.  I am convinced that a traditional lower lid blepharoplasty which interrupts nerves critical to lower lids function will be replaced by techniques which address budging fat from a transconjuctival approach and skin problems can be corrected with resurfacing or pinch skin only blepharoplasty.  Best to let someone see you and talk to you about your best options.  Good luck

Craig Harrison, MD, PA
Tyler Plastic Surgeon

Transconjunctival blepharoplasty and the arcus marginalis

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Transconjunctival blepharoplasty is a technique for exposing the eyelid fat pockets and arcus marginalis without using a skin incision. This technique uses an incision created on the inside of the eyelid through the conjunctiva ( the conjunctiva is the tissue covering the inner surface of the eyelid). Fat is exposed and removed when the eyelid is puffy or fat is re-positioned when the eyelid is hollow. If additional fat is needed to correct eyelid hollowness, then the arcus marginalis can be released. 

The arcus marginalis is a structure that is attached to the eye socket (orbit) bone and helps keep the fat in the eye socket from moving forward. Since we all have fat in our orbit to protect and support the eye, this is a great source for extra fat when needed. When the arcus marginalis is released (incised) fat moves forward and helps to improve hollowness. In the the overwhelming majority of patients no difference in the eyeball position or function occurs.

Adam J. Cohen, MD
Glenview Oculoplastic Surgeon

Transconjunctival blepharoplasty vs arcus marginalis release

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The arcus marginalis is usually only released when there are certain preexisting aging conditions of the eyelids where the lower lids have drooped down. The primary goal of lower blepharoplasty surgery is to have the fat pads removed from the lower lids through a transconjunctival approach, which removes the puffy or double bubble look of the lower lids.

William Portuese, MD
Seattle Facial Plastic Surgeon
4.8 out of 5 stars 158 reviews

Blepharoplasty vs. arcus marginalis release

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Transconjunctival blepharoplasty is performed solely to remove excess or herniated fat that creates the bulging or puffiness of the lower eyelids. If there is excess skin of the lower eyelids, an external skin incision approach is indicated. In my opinion, transconjunctival blepharoplasty is usually indicated in the younger population where there is no skin to remove. However, in a middle aged individual who has multiple rhytids (wrinkles) of the lower lids and puffy fat herniation present with no excess skin to be trimmed, a transconjunctival blepharoplasty can be performed with laser resurfacing of the skin of the lower eyelids. However, there is greater post-op downtime after laser resurfacing.

Many factors to consider when deciding which surgery is appropriate

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Transconjunctival refers to the type of incision, I assume you are referring to then excising the fat vs an arcus marginalis release where one opens the covering of the bone or perisoteum releasing the area below the fat pad or repositioning the fat pad to that area. Many factors come into play when deciding which surgery is right for you, do you have a midface that is not very prominent (called a negative vector), do you have prominent eyes and others anatomic findings. With that said I more commonly avoid removing fat from someone of your age running the risk of looking hollow in a few years. I would sooner reposition the existing fat or fill the area under the fat for now. There are some patients your age that could benefit from fat debulking. It would all depend on your anatomy.

Robert Schwarcz, MD
New York Oculoplastic Surgeon
4.5 out of 5 stars 23 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.