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.

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.

Based on your photos and your age, I would recommend a transconjunctival approach-which leaves to external scars.  I would not remove any fat but rather reposition the fat by tightening the orbital septum.  Fat removal in this area has been shown to actually make patients look older and more gaunt. You want to preserve as much fat as possible in order to maintain a youthful appearance.

I recommend consulting with at least one more board certified plastic surgeon in your area before making your decision.

Best wishes,

Dr. Bruno

There are many approaches to treating lower eyelid bags. In young patients like yourself this problem can often be treated entirely via volume enhancement of the cheek/lower eyelid (using fat grafting or facial filler such as restylane for example). Depending on how prominent the lower eyelid fat pads are I may recommend concurrent conservative removal of some of the fat via a transconjuctival approach, but this is less common.

I find that if the cheek volume loss isn't addressed the result will be more of a hollowed out look, which isn't as natural appearing.

Both of these techniques are great depending on individual patient characteristics.  I would recommend getting additional opinions from board certified plastic surgeons in your area.  Typically young patients with isolated "puffiness" of the lower eyelids can be appropriately managed with conservative fat resection via the transconjuctival approach.  If other issues exist, then the transcutaneous approach can be used.

If you simply have an excess of fatty tissue, the transconjunctival bleph. works great...as long as the fat is removed evenly, and not too much is removed.  Looking at your photos, it seems like this could certainly work well for you.

If there is some excess skin, the TC bleph can be combined with a simple skin pinch technique, for a nice result.

Your surgeon can help you with this decision.  All the best,