Transcutaneous vs. Transconjunctival? (photo)

I am a 63 year old woman with fairly good skin tone but I am developing bags under my eyes. I went for two consults and got two opinions. The first dr suggested a lower lid transcutaneous blepharoplasty at a total cost of approx. $2600. The second recommended a lower lid transconjunctival blepharoplasty at a total of $3400. How do I choose and why the difference in costs?

Doctor Answers 17

Transcutaneous vs transconjunctival blepharoplasty

{{ voteCount >= 0 ? '+' + (voteCount + 1) : (voteCount + 1) }}

Transconjunctival is the gold standard method to remove fat pads from the lower lids.  Transcutaneous incisions violate the orbicularis oculi muscle of the lower lids and lead to more complications, including scleral show, rounding, and ectropion.  It is best never to violate the muscle by a transcutaneous approach.  Transconjunctival approach is an approach performed on the inside of the lower lid whereby the fat pads are removed.  If there is excess skin on the lower lids after the fat pads have been removed, a small pinch technique of skin only can be done at the lash line and closed with tissue glue.  The fees associated with lower lid blepharoplasty reflect charges for the operating room, surgeon’s fee, and anesthesia.  Our office charges $3600 dollars for a lower blepharoplasty, which includes all 3 associated fees.

Seattle Facial Plastic Surgeon
4.8 out of 5 stars 158 reviews

In lower lid surgery which incisional approach is best?

{{ voteCount >= 0 ? '+' + (voteCount + 1) : (voteCount + 1) }}

The excess fatty tissue ("bags") and skin laxity of the lower lids can be well -managed using a variety of approaches. The transcutaneous (skin) incision has pros and cons: while a skin incision and small scar is created, visibility and manipulation of excess fat may increase and sometimes additional tissue tightening may be possible.  Likewise, the transconjunctival (behind lid) incision does not create a visible skin incision but access to fat manipulation and tissue tightening may be somewhat limited.  However, chemical peeling or laser resurfacing can usually here be done simultaneously if desired.        When there has been significant loss of skin elasticity, wrinkles are present, and  excess fat is prominent, it is sometimes wise to view lower eyelid rejuvenation as a 2-staged process. Once surgery is healed, a secondary "tweaking" procedure aimed at resurfacing (improving) the skin is often the "icing on the cake". And some lids will require more than the "routine" especially if the lateral part of the eyelid is loose or lax. This is why a careful preoperative evaluation by a well trained surgeon is so important! 

Donn R. Chatham, MD
Louisville Facial Plastic Surgeon
5.0 out of 5 stars 75 reviews

Lower eyelid bags

{{ voteCount >= 0 ? '+' + (voteCount + 1) : (voteCount + 1) }}

Your photo shows lower eyelid bags but the dark shadow does not allow much more assessment. Furthermore the photo is a still frozen in time. It does let me know how the bags change with eye movement or what the laxity of the lower eyelid is. Therefore no one can make a recommendation of any worth based solely on this photo.

Choosing between the 2 approaches to lower eyelid surgery depends on what the goals of the surgery are. If you are just going to remove some fat from inside the eyelid the transconjunctival (cut on the inner surface of the eyelid) approach is fine. If you need to remove excess eyelid skin though you will be better off with an incision just below the eyelashes on the skin. More importantly if the lid laxity is too great you need to tighten the eyelid ligaments at the outer corners of the eyes. Most women in their 60s undergoing this procedure have both excess lower eyelid skin and lax lower eyelids.

I hope you realize that this format of posting questions and receiving answers lacks the face to face direct communication required for you to make an informed decision regarding your surgery.

My response to your question/post does not represent formal medical advice or constitute a doctor patient relationship. You need to consult with i.e. personally see a board certified plastic surgeon in order to receive a formal evaluation and develop a doctor patient relationship.

Aaron Stone, MD
Los Angeles Plastic Surgeon

Lower lid blepharoplasty approach

{{ voteCount >= 0 ? '+' + (voteCount + 1) : (voteCount + 1) }}

Hi Carole. Either approach to your lower lids will result in an improvement.  Your photo does  not allow me to evaluate the skin changes - are there fine lines, wrinkles, capillaries etc.  Another factor that helps us to determine the best approch is the reslience of the lower lid when it is pulled away from the eye ball - the snap test.  If  the skin is smooth and the lower lid snaps back as soon as it is released then the transconjunctival approach would be my choice.  Very little bruising associated with this approcah.  If there are multiple fine lines with a good snap test then I would suggest laser resurfacing in addition to the transconjunticval approach.  If you have a  poor snap test then I would recommend a transcutaneous approach with a tightening procedure for the lower lid - a canthopexy.  Hope this helps.  Good luck! 

Joseph N. Togba, MD
Oakland Plastic Surgeon

Transconjunctival vs. Transcutaneous Blepharoplasty

{{ voteCount >= 0 ? '+' + (voteCount + 1) : (voteCount + 1) }}

Both transconjunctival and a transcutaneous approach to your lower blepharoplasty will provide improvement. The difference between the two is in how much improvement you will get and at what risk and cost to do so. At your age with more loose lower eyelid skin, a transcutaneous approach would give a better result but at a higher cost and with the potential risk of lower eyelid malposition afterwards and a longer period of swelling and bruising. You need to consider each of their advantages and disadvantages carefully. What is best may be different for each patient.  

Blepharoplasty at 61

{{ voteCount >= 0 ? '+' + (voteCount + 1) : (voteCount + 1) }}

Given the extent of anticipated skin laxity with decreased lower lid tone and skin excess, in my practice I would suggest a subcilliary / transcutaneous approach with tarsoraphy and tarsal suspension. I believe transconjuctival approach even with skin pinch will be insufficient correction of lid laxity and extent of redundant skin excision would be more difficult to judge with this technique vs. trascutaneous. I would also suggest searching for the surgeon with most experience in this procedure rather than the lowest cost, although the highest cost does not necessarily correlate with the highest skill.

Edwin Ishoo, MD
Cambridge Facial Plastic Surgeon

Transcutaneous vs. Transconjunctival?

{{ voteCount >= 0 ? '+' + (voteCount + 1) : (voteCount + 1) }}

 First let me start out by saying that I published a scientific paper, in the early 1990's, comparing the results and potential complications of a transcutaneous versus transconjunctival lower Blepharoplsty (eyelid surgery).  The paper concluded that the transconjunctival lower eyelid surgery yielded superior results with less comlications and IMHO has been the gold standard in lower eyelid surgery since the 1990's.  Price differences reflect many things.  Level of experience of the plastic and cosmetic surgeon and level of difficluty being the most common.

Francis R. Palmer, III, MD
Beverly Hills Facial Plastic Surgeon
4.7 out of 5 stars 28 reviews

Transcutaneous lower lid rejuvenation

{{ voteCount >= 0 ? '+' + (voteCount + 1) : (voteCount + 1) }}

Your best option is a transcutaneous blepharoplasty, as at age 61, there will be an issue of skin excess as well as fat which is addressed through the transconjunctival approach. Choose a surgeon you can trust and understand, with board certification. Cost is a variable, though important, if you are unhappy with your experience or results.

Best of luck,

Peter E. Johnson, MD
Chicago Plastic Surgeon
4.0 out of 5 stars 44 reviews

Transcutaneous blepharoplasty would be a better option

{{ voteCount >= 0 ? '+' + (voteCount + 1) : (voteCount + 1) }}

Based on your photo, it appears you have significant orbiculars oculi laxity.  You would benefit from tightening of this muscle and suspension of it from your orbital rim (orbicularis suspension).  Your may also need lower lid tightening as well.  A formal consultation is required to see what would be best for you.  Warmest regards.

Dr. Pippin

Gregory Pippin, MD
Metairie Facial Plastic Surgeon


{{ voteCount >= 0 ? '+' + (voteCount + 1) : (voteCount + 1) }}

Fees vary from doctor to doctor. As for the technique, it depends upon what is needed.  If you have loose skin, then some skin can be removed transcutaneously. If not only going transconjunctival is fine.  I usually do a transconjunctival for fat removal, and if skin is needed to be removed I often do a skin pinch and try not to violate the muscle.  Often I combine it with a canthopexy to support the lower lid.

Steven Wallach, MD
New York Plastic Surgeon
4.2 out of 5 stars 30 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.