Choosing Your Lower Eyelid Surgery Approach: A Guide to Transconjunctival and Transcutaneous Techniques

By Dr Scott J Turner, Specialist Plastic Surgeon | Sydney & Brisbane

Lower eyelid surgery, known as lower blepharoplasty, addresses concerns such as under-eye bags, puffiness, and excess skin that can affect facial appearance. When considering this procedure, understanding the available surgical techniques helps you make an informed decision about your care.

Dr Scott J Turner, Specialist Plastic Surgeon (FRACS), performs both transconjunctival and transcutaneous lower blepharoplasty at his Sydney clinics. This guide explains the differences between these approaches, their respective benefits, and the factors that influence which technique may be most appropriate for your individual circumstances.

Understanding Lower Eyelid Anatomy and Ageing

Before exploring surgical techniques, understanding the anatomical changes that occur around the lower eyelids provides helpful context.

The lower eyelid comprises several distinct layers: the skin (the thinnest in the body), the orbicularis oculi muscle (responsible for eyelid closure), the orbital septum (a thin membrane separating the eyelid from orbital contents), and the orbital fat pads (three distinct compartments that cushion the eye within the socket).

As we age, several changes typically occur:

Skin Changes: The eyelid skin loses elasticity, leading to wrinkles and excess skin. Sun exposure, smoking, and genetic factors influence the rate and extent of these changes.

Fat Pad Prolapse: The orbital septum weakens over time, allowing the underlying fat pads to protrude forward. This creates the characteristic “bags” beneath the eyes that many patients wish to address.

Tear Trough Development: Volume loss along the inferior orbital rim creates a groove extending from the inner corner of the eye towards the cheek—commonly called the tear trough deformity.

Muscle Changes: The orbicularis muscle may become lax, leading to lower eyelid laxity and reduced overall eyelid support.

Understanding these changes helps explain why different surgical approaches may be recommended for different patients.

The Two Surgical Approaches Explained

Transconjunctival Lower Blepharoplasty

The transconjunctival approach involves creating an incision on the inner surface of the lower eyelid, through the conjunctiva (the thin membrane lining the inside of the eyelid). This internal incision provides access to the orbital fat pads without disturbing the external skin or orbicularis muscle.

Key characteristics of this approach:

• The incision is made approximately 2 to 7.5 millimetres below the tarsus (the firm plate that gives the eyelid its structure)
• No external skin incision is required
• Direct access to the three orbital fat compartments is achieved
• The orbicularis muscle and skin remain undisturbed
• Sutures are often unnecessary, as the conjunctival edges typically heal without formal closure

This technique is particularly well-suited for addressing fat prolapse when excess skin is not a significant concern.

Transcutaneous Lower Blepharoplasty

The transcutaneous approach involves an external incision placed 1 to 2 millimetres below the eyelash line (a subciliary incision). This provides comprehensive access to all layers of the lower eyelid, including the skin, muscle, and orbital fat compartments.

Key characteristics of this approach:

• An external incision follows the natural contour just below the lashes
• Direct visualisation of skin, muscle, septum, and fat is possible
• Excess skin can be directly excised
• The orbicularis muscle can be tightened if indicated
• Canthal procedures (to address eyelid laxity) can be incorporated through the same incision
• The incision, when well-placed and properly healed, typically becomes inconspicuous along the natural lower eyelid crease.

This approach offers the versatility to address multiple concerns simultaneously, including significant skin excess and muscle laxity.

Modern Approaches to Fat Management

Contemporary lower blepharoplasty emphasises preservation and repositioning of orbital fat rather than aggressive removal. Rather than simply excising prolapsed fat, modern techniques often involve repositioning this tissue to fill the tear trough groove, creating a smoother transition between the lower eyelid and cheek while avoiding the hollowed appearance that can result from excessive fat removal.

When fat removal is indicated, a conservative approach is typically preferred. Dr Turner assesses each patient’s fat pad prominence and determines the appropriate balance between removal and preservation during the pre-operative consultation.

In some cases, additional volume restoration using fat grafting may be recommended. Fat harvested from another body site can be injected in small quantities to address residual hollowing or asymmetry.

Determining Which Approach Is Appropriate

The choice between transconjunctival and transcutaneous techniques depends primarily on your individual anatomy and the specific concerns you wish to address. Neither method is universally superior—instead, each offers distinct advantages for appropriate candidates.

When Transconjunctival Blepharoplasty May Be Recommended

The transconjunctival approach is generally more suitable for:

Patients with primarily fat prolapse: When the primary concern is prominent under-eye bags caused by protruding fat, but the skin retains good elasticity without significant excess.

Younger patients: Individuals in their 30s to early 40s often present with fat prolapse before significant skin laxity develops.

Those with good skin quality: When the skin is expected to contract adequately following fat reduction or repositioning.

Patients concerned about visible scarring: The absence of an external incision appeals to those particularly anxious about scarring.

Individuals with a history of problematic scarring: Those prone to hypertrophic or keloid scarring may benefit from avoiding external skin incisions.

Patients with pre-existing lid position concerns: Those with prominent eyes or pre-existing lower lid laxity may be at higher risk of lid position changes with external approaches.

This approach offers lower complication rates, faster recovery, and no external scarring. It can also be combined with laser resurfacing, conservative skin excision, and fat repositioning to extend its applicability.

When Transcutaneous Blepharoplasty May Be Recommended

The transcutaneous approach is generally more appropriate for:

Patients with significant skin excess: When redundant, loose skin contributes substantially to the aged appearance, direct skin excision becomes necessary.

Older patients: Individuals typically over 50 often present with combined concerns—fat prolapse, skin excess, and wrinkles—that benefit from comprehensive treatment.

Those requiring muscle tightening: When orbicularis muscle laxity contributes to the problem, the transcutaneous approach provides direct access for plicating the muscle.

Patients needing canthal procedures: When lower eyelid laxity requires correction through canthopexy or canthoplasty, the external approach facilitates these additional procedures.

Those seeking comprehensive lower eyelid and midface treatment: The transcutaneous approach can be extended to address midface descent and other adjacent concerns.

When expertly performed with attention to preserving orbicularis muscle function and providing proper canthal support, this approach delivers excellent, long-lasting results.

Comparing Recovery Experiences

Recovery differs between the two approaches, though both techniques typically allow a return to normal activities within 1 to 2 weeks.

Recovery Following Transconjunctival Blepharoplasty

The internal approach generally involves a shorter, more comfortable recovery period. Swelling and bruising are typically less pronounced than with external approaches, and most patients manage discomfort adequately with over-the-counter pain relief. Cold compresses help reduce swelling during the first 48 hours, and eye drops may be prescribed to maintain ocular surface comfort.

Many patients feel comfortable returning to non-strenuous work within 5 to 7 days. No external sutures require removal. Residual swelling continues to subside over weeks 2-4, during which most patients resume normal social activities.

Recovery Following Transcutaneous Blepharoplasty

The external approach generally requires a slightly more extended recovery period due to greater tissue manipulation. Swelling and bruising are typically more pronounced, peaking around days 2-3 before gradually improving. Cold compresses are applied for the first 48-72 hours, followed by warm compresses. The external incision requires careful wound care, and prescription pain medication may be needed initially.

Sutures are typically removed at the one-week follow-up appointment. Most patients take 10 to 14 days before returning to work. Bruising normally resolves within 2 to 3 weeks, while swelling continues to diminish over 6 to 8 weeks. Full scar maturation requires 6 to 12 months.

General Recovery Guidelines

Regardless of technique, Dr Turner recommends keeping the head elevated for the first week (particularly during sleep), avoiding strenuous activities and heavy lifting for at least two weeks, refraining from swimming for 2 to 3 weeks, protecting the eyes from sun exposure, and attending all scheduled follow-up appointments. Contact the clinic if unexpected symptoms develop.

Understanding Potential Risks and Complications

All surgical procedures carry inherent risks. Understanding these allows for informed decision-making and realistic expectations.

Complications Associated with Transconjunctival Blepharoplasty

Lower eyelid malposition: The transconjunctival approach carries a lower risk of lower eyelid retraction and ectropion (outward turning of the eyelid) compared to transcutaneous surgery. Published studies report scleral show (visible white below the iris) rates of 0-3 per cent, with ectropion occurring in fewer than 1.6 per cent of cases.

Conjunctival swelling (chemosis): Temporary swelling of the conjunctiva may occur, typically resolving within 1 to 2 weeks.

Under-correction: Because this approach addresses fat without excising skin, some patients may require additional procedures if significant skin excess exists.

Transient discomfort: A temporary foreign-body sensation affects a small percentage of patients and usually resolves within 48 to 72 hours.

Complications Associated with Transcutaneous Blepharoplasty

Lower eyelid malposition: The transcutaneous approach carries a higher risk of lid position changes. Studies report lower eyelid retraction in 10-20% of cases, with frank ectropion affecting approximately 1% of patients.

Visible scarring: While incisions typically heal well and become inconspicuous, some patients may develop visible or hypertrophic scarring.

Temporary dry eye or tearfulness: Approximately 16 per cent of patients experience temporary changes in tear function during the healing period.

Orbicularis muscle weakness: Manipulation of the muscle during surgery may temporarily affect eyelid function.

Complications Common to Both Approaches

Haematoma and bruising: Bleeding and bruising occur with both techniques, though typically more pronounced with the transcutaneous approach.

Infection: While rare (approximately 0.2 per cent) due to the eyelid’s excellent blood supply, infection remains possible with any surgical procedure.

Temporary vision changes: Brief periods of blurred vision or light sensitivity may occur during the early recovery period.

Retrobulbar haemorrhage: This rare but serious complication (occurring in approximately 1 in 10,000 to 30,000 cases) involves bleeding behind the eye and requires immediate recognition and treatment to prevent vision loss.

Asymmetry: Some degree of asymmetry exists in all faces, and complete symmetry following surgery cannot be guaranteed.

Need for revision surgery: Published literature reports reoperation rates ranging from 0 to 9 per cent, with most studies reporting rates below 3 per cent.

Expected Outcomes and Longevity

Both transconjunctival and transcutaneous approaches achieve high satisfaction rates when appropriately selected and expertly performed. Initial improvement is visible once swelling and bruising resolve (typically 2 to 4 weeks), with final results becoming apparent between 3 and 6 months post-operatively.

The effects of lower blepharoplasty can persist for many years. However, surgery does not halt the ageing process—your face will continue to age naturally, though from an improved baseline. Factors influencing longevity include genetics, sun exposure, smoking, and weight fluctuations.

Summary

Selecting the correct technique and surgeon requires thorough consultation and careful consideration. During your appointment with Dr Scott J Turner, Specialist Plastic Surgeon (FRACS), he will assess your facial anatomy, discuss your concerns and goals, and recommend the approach best suited to your individual circumstances.

Dr Turner’s practice focuses exclusively on facial surgery, providing depth of experience in periorbital anatomy and eyelid surgery techniques. Each patient receives an individualised assessment, with treatment recommendations tailored to their unique anatomy and goals. All procedures are performed in fully accredited hospital facilities with qualified consultant anaesthetists.

With proper patient selection, meticulous surgical technique, and appropriate post-operative care, both transconjunctival and transcutaneous approaches can deliver the refreshed, well-rested appearance you desire.

Book a Consultation in Sydney or Brisbane

If you are considering lower eyelid surgery, Dr Scott J Turner offers comprehensive assessments at his Sydney and Brisbane clinics. As a Specialist Plastic Surgeon specialising in facial aesthetic surgery, Dr Turner can evaluate your individual concerns and recommend the most appropriate surgical approach.

To arrange your consultation, please contact us or telephone 1300 437 758.

Learn more about Dr Turner’s eyelid surgery procedures.