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

It's very important to understand that both approaches (subciliary and transconjunctival) carry risks. Although there are certain patients that I would not perform a transcutaneous approach on, the photos do not seem to suggest that you are in this category. Patients with absent mid-facial support (negative vector) are poor candidates for a subciliary transcutaneous approach. In my opinion and in my practice, I ma able to obtain better elevation of the upper cheek with a transcutaneous approach. It is more technically demanding, but the results speak for themselves.

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.

A transconjunctival approach to a blepharoplasty is able to remove or reposition fat but by itself does not remove skin. This procedure can be combined with a laser resurfacing to tighten the skin or a skin pinch to remove a small amount of skin. A transcutaneous approach to a blepharoplasty is performed usually when more skin needs to be removed. The fat pockets are accessed via this skin incision. There is more manipulation of the tissues and slightly greater scarring and risk of ectropion with this approach. I will often perform a muscle suspension to better support the lower eyelid muscles to minimize the chance of any eyelid malposition or ectropion during healing.

Your photos do not show excess skin but you do have excess fat. There is no need for fat repositioning. And there is no need for muscle tightening from what I can see. I would recommend a transconjunctival lower lid blepharoplasty. The recovery is very quick.

Andrew Campbell, M.D.
Facial Rejuvenation Specialist
Quintessa

Based on your limited photos, you appear to have bulging fat in your under eye area, and I do not see excessive wrinkled skin. In that regard, if you are looking to have your bags removed, a transconjunctival approach would lead to no external scar. I hope this helps. Sincerely, Dr Joseph

Many do transconj, many to transcutaneous. I do both depending upon the person and their needs You could likely benefit from transconj with lsaer as there seems to be limited skin outside to remove. But, trust the surgeon to make a good decision.

Based on moderate tear trough deformity and mild fat deposits transconjuctival lower blepharoplasty would be a good choice. A Surgeon would decide based on preoperative-intraoperative findings whether small skin excision is needed as well.

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.

In our practice for over 30 we have only performed fat removal through a trans conjunctival approach, which is clearly the best approach to address your issues. It avoids external scarring, and weakness of the eyelid muscle and amongst many other issues. You appear to be too young to need a skin pinch. We also do not do fat repositioning, just a conservative fat removal under a brief general anesthesia and outpatient procedure.