Transconjunctival vs. Transcutaneous Lower Blepharoplasty: Which Technique Is Right For You?

Lower eyelid blepharoplasty is a surgical procedure designed to rejuvenate the appearance of ageing lower eyelids by addressing issues such as fat protrusion, excess skin, and wrinkles. As a patient considering this procedure, understanding the different surgical approaches and their implications is essential for making an informed decision.

Dr. Scott J Turner, Specialist Plastic Surgeon in Sydney, offers both transconjunctival and transcutaneous lower blepharoplasty at his Manly and Double Bay clinics. This comprehensive guide will help you understand the differences, benefits, and considerations of each technique.

Understanding the Two Approaches

Transconjunctival Lower Blepharoplasty

The transconjunctival approach involves making an incision on the inner surface of the lower eyelid through the conjunctiva. This technique:

• Provides direct access to the orbital fat pads without disturbing the skin or underlying muscle
• Allows surgeons to remove or reposition fat without creating any visible external scars
• Preserves the natural structure and function of the eyelid

During the procedure, Dr. Turner may create a pocket by making a periosteal incision through the arcus marginalis just below the inferior orbital rim. This technique allows for fat transposition to address tear trough deformities and infraorbital hollowing.

Transcutaneous Lower Blepharoplasty

The transcutaneous approach involves making an external incision just below the eyelash line (subciliary incision). This technique:

• Provides direct access to the orbital fat pads, excess skin, and underlying muscle
• Allows for removal of redundant skin and tightening of the orbicularis oculi muscle
• Can be easily combined with lateral canthopexy or canthoplasty to address canthal laxity

After the skin incision, dissection is carried out between the orbicularis oculi muscle and orbital septum toward the inferior orbital rim. The orbital septum is then opened to expose the three orbital fat pads, which can be either resected or fashioned into fat pedicles for transferring to the tear trough area.

Patient Selection and Ideal Candidates

Who Should Consider Transconjunctival Blepharoplasty?

The transconjunctival approach is best suited for:

• Younger patients (typically 30s to early 40s) with prominent fat herniation but minimal skin excess or laxity
• Patients who prioritize avoiding visible scarring and prefer a faster recovery time
• Individuals with a history of hypertrophic scarring
• Patients with pre-existing pseudoproptosis who are at higher risk for lower eyelid retraction

Who Should Consider Transcutaneous Blepharoplasty?

The transcutaneous approach is generally recommended for:

• Older patients (typically over 50s) who present with significant skin laxity, deep wrinkles, or visible skin sagging in addition to fat prolapse
• Patients with excessive skin redundancy or significant dermatochalasis
• Individuals requiring canthal procedures to correct lid laxity
• Patients seeking more comprehensive rejuvenation of the lower eyelid and midface regions

Comparing Recovery and Downtime

Recovery After Transconjunctival Blepharoplasty

Patients undergoing transconjunctival blepharoplasty typically experience:

• A shorter and more comfortable recovery period (3-7 days)
• Less pronounced bruising and swelling due to reduced trauma to surrounding tissues
• Minimal discomfort, with most patients requiring only over-the-counter pain medication
• No external incision to heal, requiring only cold compresses for the first two days

Most patients can return to work within a week, though some lingering bruising and swelling may be present. The procedure can be performed using local anesthesia with light IV sedation, allowing patients to go home soon after surgery.

Recovery After Transcutaneous Blepharoplasty

Recovery following transcutaneous blepharoplasty is typically longer:

• Patients generally need 10-14 days before returning to normal activities
• More pronounced swelling and bruising due to increased trauma to the eyelid tissues
• The external incision requires time to heal, with temporary swelling lasting up to a month
• Some patients may experience temporary dryness, tearfulness, and chemosis (conjunctival swelling)

Pain management may require stronger analgesics in the first few days, with cold compresses followed by warm compresses after 72 hours to reduce swelling and improve comfort.

Risks and Complications: Comparing Both Approaches

Category	Transconjunctival Approach	Transcutaneous Approach
Eyelid Position and Structure	• Minimal risk of lid malposition (<1%) • Preserves the natural structure of the orbicularis oculi muscle • Very low risk of ectropion (0.1%)	• Higher risk of lower eyelid retraction (15–20%) • 1% risk of ectropion (outward turning of the eyelid) • May affect the natural contour of the eyelid
Scarring Considerations	• No visible external scarring • Incision heals inside the eyelid without visible trace	• External incision below the eyelash line • 3–5% risk of hypertrophic scarring • 2% risk of stitch-track scarring
Tissue Impact and Function	• Minimal impact on tear production and ocular surface • Preserves eyelid function and natural blink mechanism	• Some patients (16.7%) experience temporary dryness • Potential for temporary incomplete eyelid closure • Temporary reduced blink efficiency during recovery
Aesthetic Outcomes	• Limited ability to address significant skin excess • May require additional skin procedures for complete rejuvenation • More natural-looking results with less disturbance to eyelid structure	• Effectively addresses both fat and skin concerns • Small risk (2–5%) of hollowed appearance • Potential for minor asymmetry (1–3%)

Complications Common to Both Approaches

Both approaches may involve:

• Hematoma and Bruising: Temporary bruising, though typically more pronounced with the transcutaneous approach
• Infection: Low rates (0.2%) with both approaches due to the eyelid’s robust blood supply
• Temporary Vision Changes: Some patients may experience blurred vision or light sensitivity for a few days

With proper patient selection and surgical technique, Dr. Turner minimizes these risks for all patients.

Current Trends in Lower Blepharoplasty

Lower eyelid blepharoplasty has evolved significantly over time, with current trends following a tissue-preserving philosophy rather than the traditional reductive approach. Modern techniques often emphasize fat repositioning or transposition rather than simple excision to address volume loss associated with facial aging.

There has been a notable shift in preference toward transconjunctival approaches among plastic surgeons in recent years, reflecting growing recognition of the approach’s benefits, including lower complication rates and more natural-looking results.

Both approaches now commonly incorporate fat repositioning techniques to address tear trough deformities and restore volume in areas of hollowing, representing a significant evolution from earlier techniques that focused primarily on fat and skin removal.

Making Your Choice: Factors to Consider

When deciding between transconjunctival and transcutaneous lower blepharoplasty, consider these factors:

1. Your anatomical needs: Do you have primarily fat prolapse, or significant skin excess?
2. Age and skin condition: Younger patients with good skin elasticity are often better candidates for the transconjunctival approach.
3. Recovery time availability: Can you accommodate a longer recovery period if needed?
4. Your priorities: Is minimizing visible scarring your primary concern, or is addressing significant skin laxity more important?
5. Additional procedures: Are you considering other facial rejuvenation procedures that might be better combined with a particular approach?

Conclusion

Both transconjunctival and transcutaneous lower blepharoplasty approaches have their place in modern plastic surgery. The choice between these techniques should be guided by careful consideration of your unique characteristics, aesthetic goals, and risk factors.

During your consultation with Dr. Scott J Turner, he will assess multiple factors beyond these considerations, including your overall health status, medical history, weight stability, and your understanding of potential risks and benefits.

By understanding the differences between these techniques, you can have a more informed discussion with Dr. Turner to determine which approach will help you achieve your desired results with the least risk and downtime.

To schedule a consultation at Dr. Turner’s Manly or Double Bay clinics, please contact us today.