When is it appropriate to do a transcutaneous approach vs transconjunctival approach for lower eyelid bleph? (Photos)

Under eye wrinkles are due to diminished skin quality, not excess skin quantity, which can be treated without skin removal, or even surgery. The transcutaneous approach carries a higher risk of complications such as ectropion, lower eyelid retraction, and entropion. Although I don't perform the transcutaneous approach, as an oculofacial plastic surgeon I often revise these surgeries performed by other surgeons. You can refer to the attached video about the transconjunctival approach, and how wrinkles can be treated with skin tightening, and collagen induction procedures.

Based on your photos, you are a good candidate for a transconjunctival approach to removing some fat. In plastic surgery, we try to give the best result with the most minimal risk. A transcutaneous procedure is not needed here because you don't have extra skin to remove. If you want the skin a little tighter, then laser can be considered. although your skin doesn't look loose. Be sure to see a facial specialist for consultation.

I agree a transconjunctival is safer with regard to lid lag and ectropion. You can still do skin removal and muscle tightening with the transconjunctival approach.