Two approaches, one operation
Lower blepharoplasty is performed using one of two main approaches. The transconjunctival approach goes through the inside of the eyelid (the conjunctiva — the clear membrane lining the inside of the lid). The transcutaneous approach goes through a fine external incision placed just beneath the lash line.
Patients sometimes assume one approach is uniformly better than the other. It is not. Each suits a different anatomical situation, and the appropriate approach is set by the examination, not by patient preference.
This article walks through what each approach does, what determines which is appropriate, and what patients should understand before consultation.
What the transconjunctival approach involves
The transconjunctival approach involves a small incision inside the lower lid, in the conjunctiva. Through this incision, the orbital fat pads — the small pockets of fat behind the orbital septum that can bulge forward and create the appearance of under-eye bags — can be addressed. The fat can be removed where appropriate, or repositioned to smooth the transition between the lower lid and the upper cheek.
The key advantage of this approach is the lack of an external skin incision. There is no visible scar. Patients with younger skin and good skin tone — particularly those whose main concern is bulging fat pads rather than excess skin — are often appropriate candidates.
The key limitation is that the transconjunctival approach does not address skin laxity. If the lower-lid skin is loose, wrinkled, or sitting in folds, transconjunctival surgery alone will not change that. Excess skin requires a different approach (or an addition to the transconjunctival approach).
For some patients with mild skin laxity, the transconjunctival approach is combined with a skin-only resurfacing technique (such as a chemical peel or laser resurfacing) addressed separately. This can be an option where the skin needs some addressing but a full transcutaneous approach would be over-treatment.
What the transcutaneous approach involves
The transcutaneous approach involves a fine incision placed just beneath the lower lash line — a "subciliary" incision. Through this incision, the practitioner can:
- Address the orbital fat (remove or reposition, as with the transconjunctival approach)
- Trim excess skin
- Tighten the lateral canthal tendon if appropriate
- Repair muscle laxity that contributes to lower-lid malposition
The advantage of this approach is the ability to address skin laxity, which is the limiting factor for the transconjunctival approach. Patients with significant lower-lid skin laxity — typically older patients, or younger patients with a hereditary tendency to early lid laxity — are generally appropriate candidates.
The trade-off is the external scar. A subciliary incision usually heals to a thin, well-concealed line, but it is technically a visible scar. Most patients find the scar is not visible to anyone but themselves on close inspection in good light.
What determines which approach is appropriate
The decision is made at examination, not at the booking conversation. The factors that matter:
Skin laxity
The primary factor. Patients with minimal lower-lid skin laxity (the skin springs back quickly when gently pinched) can often have the transconjunctival approach. Patients with significant laxity (the skin remains in folds or returns slowly after pinching) usually need the transcutaneous approach.
Fat herniation
The location and extent of bulging fat pads. Both approaches can address fat herniation, but the surgical access is slightly different.
Lateral canthal tendon function
The lateral canthal tendon is the anchor at the outer corner of the eyelid. If it is loose, lower-lid surgery without supporting the tendon (via a canthopexy added at the same operation) can pull the lid down and create a sad or rounded appearance during healing. The transcutaneous approach provides more straightforward access for adding a canthopexy when indicated.
Patient priorities
Some patients place a high priority on no external scar and are willing to accept the limitations of the transconjunctival approach. Others place a higher priority on addressing the visible skin laxity and are willing to accept the small scar of the transcutaneous approach. The clinical recommendation is what is appropriate for the anatomy; the patient's priorities inform the conversation about whether that recommendation aligns with what they want.
Combined considerations
For some patients, neither approach alone is appropriate. The combined approach — transconjunctival fat work plus skin-only trimming or resurfacing — can address both the fat and the skin without committing to a full transcutaneous incision.
What recovery looks like
Recovery from lower blepharoplasty is broadly similar between the two approaches:
Week 1: Bruising and swelling around the eyes. Cool compresses, prescribed ointment, and head elevation help minimise swelling. Reading and screen time should be limited. Sleeping with the head elevated helps reduce overnight swelling.
Week 1–2: Most patients return to office-based work after 7 to 10 days. Bruising usually fades over 2 weeks. Sutures (when used) are removed at around day 5 to 7.
Week 2–4: Mild exercise can typically resume after 2 weeks. Bruising is fully resolved. Some residual swelling continues to settle.
Weeks 4–12: The final result becomes clearer as swelling fully resolves. Scar maturation continues (for the transcutaneous approach). The scar fades over several months.
The transcutaneous approach tends to involve slightly longer visible bruising in the first week because the external incision adds to the bruising in the lid area. The transconjunctival approach often has less visible bruising at this stage because there is no skin incision.
Risks specific to lower blepharoplasty
Beyond the general risks of surgery, lower blepharoplasty carries:
- Lagophthalmos — incomplete eyelid closure, more associated with upper blepharoplasty but possible with lower
- Ectropion — outward eversion of the lower lid, more associated with the transcutaneous approach if canthal tone is not addressed when needed
- Chemosis — swelling of the conjunctiva, more associated with the transconjunctival approach
- Dry eyes — common in the first weeks; patients with pre-existing dry-eye disease are at higher risk
- Lower-lid retraction — the lid sitting lower than its normal position, a serious complication that is uncommon but possible
- Asymmetry — slight differences between sides are common; significant asymmetry is uncommon
- Scarring — for the transcutaneous approach, a fine subciliary scar; for the transconjunctival approach, no external scar
- Need for revision surgery — uncommon but possible
All risks are discussed in detail at consultation.
Costs and Medicare
Medicare rebates and private health insurance rebates do not apply to procedures performed at Dr Konrat's practice. Both transconjunctival and transcutaneous lower blepharoplasty are classified as cosmetic procedures and no rebate is available.
A personalised fee estimate is provided after consultation. Fees vary depending on whether canthopexy or other adjunct procedures are included and whether upper blepharoplasty is being done at the same time.
When the consultation is the right next step
The consultation is the right step when:
- You have a clear sense of what lower-lid change you are considering
- You have a GP referral
- You are comfortable with the framework (two-consultation rule, seven-day cooling-off period)
- You are open to the examination determining which approach is appropriate, rather than arriving committed to one approach
If you are considering lower blepharoplasty in Sydney, the blepharoplasty practice page covers the broader operation, the complication taxonomy, and what the first consultation involves.