Transconjunctival vs. Transcutaneous Blepharoplasty

I am a 34 year old male with eye bags. I have gotten two opinions on how to treat them. Now I am confused.Is one procedure safer than the other? How long do the results last?

Doctor Answers 24

Benefits of Transconjunctival Blepharoplasty vs External Incision Blepharoplasty

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Thank you for your question.

The main benefit of Transconjunctival Blepharoplasty over traditional Blepharoplasty with External Incision is that the support of the lower eyelid is maintained. External Eyelid Incision Blepharoplasty can damage the lower Eyelid support and result in a pull down or sag of the lower eyelid. This can be a very serious complication and in fact change in Eyelid Shape is the most common complication of traditional Lower Eyelid Blepharoplasty.

Another advantage of the Transconjunctival Approach is no visible scar on the Eyelid.

If loose skin is a problem after Fat Removal a small "skin pinch" can be done through a skin only incision in the outside corner of the eye and the lid can be tightened.

Transconjunctival vs transcutaneous lower lid bleph

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For you, based on age and pix, I would say that the transconj is probably may not need any skin excision and therefore there will be no visible outside scars (not that it matters because they heal imperceptibly). The transcuteneous approach requires cutting accross the orbicularis muscle to reach the fat (bag) and it MAY weaken the lower lid and cause rounding.

Andrew Pichler, MD
Sacramento Facial Plastic Surgeon

Transconjunctival vs. Transcutaneous Blepharoplasty - which is better?

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Based on your photos, as a young individual whose predominant problem is puffiness to the lower lids, you are an ideal candidate for a transconjunctival blepharoplasty. The minimal amount of excess skin you have  will re-drape nicely after the fat is removed, and if performed by an experienced surgeon, the healing time with the transconjunctival approach will be very short with minimal discomfort. Both approaches are quite safe when applied appropriately since the chance of ectropion in someone your age is minimal. But without any excess skin there is really no reason to use the transcutaneous approach.

You want to be very careful in doing transcutaneous blepharoplasty

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In general you want to be very careful in doing transcutaneous blepharoplasty. Most patients, especially if you are 34 years old, do not need skin removal. The transconjunctival approach, with a physician who is experienced, has less chance of lower lid retraction and a more natural result. You have to be very careful and not have too much fat resected and be conservative about it. Some of the fat prolapse is because there is hollowing underneath the fat pocket. In a position like yours, you may consider a fat transfer as opposed to fat removal. I prefer Transconjunctival depending on who is doing it.

Type of Blepharoplasty Is Based On Eyelid Anatomy And Aging Concerns

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It is not question of whether there is a safety difference between transconjunctival vs transcutaneous blepharoplasty, it is a question as to which one is better for you and your eyelid anatomy and aging issues. As you can see by the answers posted here, every conceivable blepharoplasty option has been suggested. So it is not surprising that of your two consults, you have gotten two seemingly different blepharoplasty suggestions. In good hands, both options will offer improvement and it is a matter of better understanding on your part as to the subtle advantages and disadvantages of each blepharoplasty option. I would re-visit those consultations and try to get a better handle on the benefits of either approach.

Transconjunctival or Subciliary Blepharoplasty

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Frank, you live in an area with outstanding blepharoplasty surgeons who can examine you personally, talk to you at length about your specific issues, and give you world class treatment for either technique.  In the right hands, both techniques are safe and effective.  The longevity of your procedure is impossible to answer as it depends on your particular aging and sun exposure--both of which are unique to you.  I would request a consultation with either Dr. Hester, McCord, Nahai, or Codner in Atlanta.  Best wishes with your blepharoplasty. 

Luis Zapiach, MD
Paramus Plastic Surgeon

You may benefit from an Injectable Filler treatment to minimize the appearance of your lower eyelid bags.

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I read your concerns and reviewed your photos. In my practice, I hardly ever remove lower eyelid fat (lower blepharoplasty) since it may lead to a hollow appearance, and increase wrinkles in the lower eyelid skin.

You may consider a non-surgical, Injectable Filler treatment to fill the lower eyelid groove which could diminish the appearance of your bags. You should make sure your physician is experienced in the delicate art of filling lower eyelid grooves, and check many photos before proceeding.

I've attached a photo of a gentleman older than you to demonstrate non-surgical lower eyelid rejuvenation. My personal preference is to use Silikon-1000, an off-label filler, for permanent results.

I hope this is helpful for you.

Eric M. Joseph, MD
West Orange Facial Plastic Surgeon
4.9 out of 5 stars 429 reviews

Avoid the skin incision

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You will do well with transconjuctival lower blepharoplasty since you do not seem to much extra skin.  Your surgeon should prepare you though if extra skin develops after conservative removal of fal and repositioning he may need to remove a little skin.

Transcutaneous vs transconjunctival blepharoplasty--which is better?

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The simple answer is that a transcutaneous incision must be made if there is excess skin and muscle to be removed; this incision (properly performed) leaves a virtually imperceptible scar right below the eyelashes, and allows access to trim, reposition, and properly release eyelid structures, precise surgical maneuvers impossible via a transconjunctival approach. That is why this is considered the "standard" approach, and the one most commonly used by most blepharoplasty surgeons, regardless of specialty. This (transcutaneous) approach may also be necessary in an "excess fat only" patient who, in the surgeon's best opinion, has poor skin tone that will sag and deflate if fat is removed via a transconjunctival approach without some sort of skin tightening, perhaps by laser or chemical peel as other options to excision via scalpel.

If, however, the patient is young, has great skin tone (good elasticity), and only excess fat pad protrusion, the transconjunctival approach leaves no external scar, does not violate the orbital septum or lamellar structures, and reduces the (slight) risk of increased scleral show, lateral lower lid "rounding," or ectropion. That is why some surgeons who like this approach say it is "safer." In skilled hands it truly is a very safe operation, though it may lack the detail and finesse the open-incision approach allows, but with higher (still low) risk of lid malposition and corneal drying.

The best way to answer this complex question is to state that no one approach is best for all patients; each and every patient has unique age, genetics, skin/muscle elasticity, healing, and scar tendencies, and all of these need to be taken into account when recommending a procedural approach. Beware any surgeon who states "I always" or "I never" because that is just not possible for every patient.

Transconjunctival vs. transcutaneous lower blepharoplasty

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You appear to be a good candidate for the transconjunctival approach, as you do not have excess skin.

In my practice I always remove the fat transconjunctivally; I then remove skin from the outside if necessary.

This reduces the surgical injury and dramatically lowers the risk of ectropion, or pulling of the lid downward after surgery.

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.