Lower eyelid surgery at RNWOOD: transcutaneous and transconjunctival approaches compared
At RNWOOD Plastic Surgery, Dr. Ryu performs lower blepharoplasty through two different approaches: transcutaneous, through the skin below the lashes, and transconjunctival, through the inner surface of the lower eyelid.
The appropriate approach is recommended after an in-person examination, as Dr. Ryu assesses the eyelid skin laxity, protruding fat and the surrounding tissue together, and decides the most suitable method of surgery to address the patient's concerns.
How do the two approaches compare?
| Point | Transcutaneous | Transconjunctival |
|---|---|---|
| Where the incision is made | Along the lower lash line | Through the inner surface of the eyelid |
| Scarring | Visible incision line beneath the lashes during the healing process | Avoids an external skin incision and hides the scar |
| Shared risks | Bleeding, hematoma, infection, swelling, bruising, dry eye, changes in eyelid position, asymmetry, rare complications affecting vision | The same |
Why is the choice made after examination?
The main difference between the transcutaneous and transconjunctival approaches to lower blepharoplasty lies in whether skin laxity is present.
The transcutaneous approach involves an incision along the lower eyelid, allowing excess sagging skin to be removed. In contrast, the transconjunctival approach offers the advantage of avoiding a visible external scar, as the incision is made inside the lower eyelid. However, this approach primarily addresses bulging under-eye fat through fat repositioning and does not allow for the removal of excess skin.
Therefore, the transconjunctival approach is generally recommended for patients with prominent under-eye bags but without significant skin laxity.
An in-person consultation is necessary to thoroughly assess the condition of your lower eyelids and determine the most appropriate surgical approach for the patient's individual needs.
What are the risks of lower eyelid surgery?
Lower blepharoplasty can cause anesthesia reactions, bleeding, hematoma, infection, delayed wound repair, wound separation, persistent pain and visible scars. Other risks include swelling, bruising, irritation, dry eye, tearing, corneal injury, incomplete eye closure, lid retraction, ectropion, entropion, double vision and asymmetry. Rarely, orbital bleeding or vascular injury can cause temporary or permanent vision loss. It does not guarantee correction of dark circles, hollows, skin texture or pigment change. The full notices are printed below.
How do I prepare for the assessment?
For an online evaluation, send front and side photographs taken straight on and at right angles to the face, without makeup or colored lenses, along with your surgical and medical history with the name of each procedure and the year and month it was done, any medical conditions, and the medications and supplements you are currently taking.
It is recommended to avoid wearing any contact lenses or makeup for a more accurate assessment of the current facial condition.
However, please note that a more precise surgical recommendation can be made during the in-person consultation.
Frequently asked questions
Q1) What is the difference between transcutaneous and transconjunctival lower eyelid surgery?
A1) The transcutaneous approach addresses skin laxity, nasojugal grooves and bulging eye bags through an incision along the lower lash line; the transconjunctival approach is performed through the inner surface of the eyelid to reposition the under-eye fat.
Q2) Is one approach safer?
A2) Neither can be said to be safer or longer-lasting. The appropriate approach is chosen based on the patient's lower eyelid condition after an in-person examination.
Q3) Does a transconjunctival approach guarantee no visible scar?
A3) No. The internal incision must heal, and no approach can guarantee an invisible scar.
Q4) Does lower eyelid surgery correct dark circles?
A4) It does not guarantee improvement in dark circles, under-eye hollowness, skin texture or pigmentation. For concerns related to skin quality and pigmentation, a consultation with a dermatologist is recommended to explore appropriate treatment options.
Q5) What is assessed before eyelid surgery?
A5) The eyelid skin laxity, fat, muscle and surrounding tissue, together with previous procedures.
About the Author
Dr. Min-Hee Ryu is the Medical Director and Founder of RNWOOD Plastic Surgery in Seoul and a plastic surgery specialist certified in Korea (2008). He has been Faculty of the Mendelson Advanced Facial Anatomy Course (MAFAC) since 2016, an Editorial Board Member of the Aesthetic Plastic Surgery Journal since 2019, and an Educational Council Member of the International Society of Aesthetic Plastic Surgery (ISAPS) since 2024.
Lower Blepharoplasty — Lower blepharoplasty can cause anesthesia reactions, bleeding, hematoma, infection, seroma, delayed wound repair, wound separation, persistent pain, and visible scars. Other risks include swelling, bruising, irritation, dry eye, tearing, chemosis, corneal injury, incomplete eye closure, lid retraction, ectropion, entropion, double vision, and asymmetry. Orbital bleeding or vascular injury can cause temporary or permanent vision loss and, rarely, blindness. It does not guarantee correction of dark circles, hollows, skin texture, or pigment change, and revision surgery can become necessary. No result or symmetry can be guaranteed. Transcutaneous / Transconjunctival — Transcutaneous lower blepharoplasty leaves an external scar beneath the lashes. The transconjunctival approach avoids an external skin incision, but the internal incision must heal, and no approach can guarantee an invisible scar. Both can cause bleeding, hematoma, infection, swelling, bruising, dry eye, changes in eyelid position, asymmetry, and rare complications affecting vision. The approach is chosen after examination, and neither can be said to be safer or longer-lasting.