Transconjunctival vs. Transcutaneous Blepharoplasty

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.

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.

Hello,For a person of your age the primary goal is to remove fat from the lower eyelid that is causing the puffiness. There are two basic ways to get to this fat, one is through the inside of the lower eyelid, the second is through the skin of the lower eyelid. The difference between these approaches is important. If the incision is made on the inside of the eyelid the muscle that surrounds and supports the eyelid is not injured in any way.This helps to prevent any change in the position of the lower eyelid as you are healing from surgery. In your case you probably would not need to have any excess skin removed from the lower eyelid. If skin were needed to be removed that would occur through a second incision on the outside of the eyelid just below the eyelashes. This would still allow the underlying muscle to remain intact. As you can tell I would favor the trans-conjunctival (inside of the eyelid) approach.