Thank you for your question.
You submitted a question without an image but you are asking essentially what’s the
difference between a transcutaneous, transconjunctival blepharoplasty and what are the advantages
and disadvantages of both.
Well, I can certainly share with you my direct experience doing these procedures.
A little bit of background, I’m a Board-certified cosmetic surgeon and Fellowship-trained oculofacial
plastic and reconstructive surgeon.
I have been in practice in Manhattan and Long Island for over 20 years.
And essentially, what you’re describing are options for lower eyelid blepharoplasty
which is a significant part of my daily practice.
So, what you want to first understand the difference of these procedures, you still
have to first have the understanding why the procedures are being done.
Usually, lower eyelid surgery is done to address puffy under eye bags, skin that appears to
be loose and wrinkles, as well as sagging of the lower eyelid from its normal, more
desirable position.
So when people do their research and learn about what their options are, they come across
the choices that many doctors tend to gravitate towards.
One, the transcutaneous blepharoplasty is the approach where an incision is made from
beneath the eyelashes to go to the fat pockets and do whatever is necessary and then redrape
the skin and trim if necessary or desired by the doctor to tighten the skin.
A transconjunctival blepharoplasty is done from the inside of the eyelid to essentially
address lower eyelid fat prolapse.
And that means the fat from behind the eyelid pushes forward and creates this bulge.
Now I can tell you from my personal evolution in terms of from the time I trained from oculofacial
surgery to the present day is that things have continuously evolved in our field, not
only from a surgical point of view but also from a tissue remodeling or rejuvenating point
of view, from the perspective lasers, radiofrequency, platelet-rich plasma (PRP), regenerative medicine
etc.
So when you think about these surgeries, you have to really think about what are we trying
to do.
We’re trying to rejuvenate the lower eyelid.
Now, as a specialist, I have also been in a position that deals with a lot of complications
of patients who come from around the world because they had eyelid surgery that resulted
in problems like ectropion where the eyelid turns out or eyelid retraction where the eyelid
is pulled down.
Now, from a purely anatomic perspective, you are able to achieve comparable results with
either procedure but in my mind, the overwhelming majority of patients who I perform lower eyelid
blepharoplasty for, I use the transconjunctival approach.
And why is that?
Well, when we think about the anatomy of the lower eyelid, one of the things that people
have been aware of when they see people who have had eyelid surgery is that they often
feel that people they have seen have very rounded lower eyelids where the eyelid is
kind of went from being an almond shape but is now rounded.
Well, very often, that occurs from a transcutaneous blepharoplasty where the procedure was done
from the outside.
A well-meaning doctor will do the surgery, trim some skin and will cause some pulling
and tension.
When I do transconjunctival blepharoplasty, I’m essentially preserving all of the support
structures that maintain eyelid shape.
Basically, it’s as minimally invasive even though it’s more technically advanced but
minimally invasive and allows us to address the fat pockets and not compromise the integrity
of the lower eyelid.
Now, I can speak for hours about the anatomic issues from a technical standpoint but understanding
basically the culture of plastic surgical training, you would probably get a different
perspective.
Essentially, a lot of doctors, when they were training, trained essentially lower eyelid
surgery from the external approach.
That’s what they’re comfortable with, that’s what they’ve always done and essentially
they play mostly the odds that most of the time, they get acceptable and reasonable results.
Periodically, they end up with complications.
And so, from my perspective, as an expert, as a specialist who can do all these different
types, all these variations of surgeries in the lower eyelid, essentially I feel like
I want to offer my patient the most safe and predictable procedure that can get the best
results.
Now, people often ask what about the relative excess skin that can occur after lower eyelid
surgery done from the inside because we’re not taking away skin and this is one of the
biggest misperceptions about lower eyelid skin.
Generally speaking, lower eyelid skin is not in excess.
It’s actually an issue about skin quality and not skin quantity.
And it’s a very difficult concept to understand because patients will pull their skin out
and say, “Doc, what about this extra skin?”
No, if you take away skin, you may end up with the eyelid pulling down.
Now, there’s going to be the occasional patient that does need skin removal but that
can be addressed by doing a straightforward skin pinch skin excision.
We don’t have to necessarily undermine and separate the skin flap.
Now again, that’s getting more technical than is necessary.
But the key is to have a nice natural look.
When I want to address skin quality, I do things such as fractional CO2 laser, Erbium
laser, platelet-rich plasma (PRP), radiofrequency such as use Pelleve.
All of these things can help skin quality without compromising the integrity of the
eyelid position.
So from my perspective, it is essentially rare for me to do a transcutaneous blepharoplasty
rather than a transconjunctival blepharoplasty.
I think the transconjunctival blepharoplasty has significant advantages in many ways and
can be customized with other procedures to get the optimal outcome.
So I hope that was helpful, I wish you the best of luck and thank you for your question.