Transconjunctival blepharoplasty: no external scar, for fatty bags without excess skin

What transconjunctival blepharoplasty corrects

This type of blepharoplasty concentrates exclusively on removing or redistributing the fat pads of the lower eyelid. Those structures are reached through the conjunctiva, the internal membrane of the eyelid, so no external incision in the skin is needed.

The changes it treats most effectively are:

• Protrusion of the lower fat pads.
• A localised build-up of volume under the eyes.
• Slight asymmetry in how the pads project.
• A permanently tired look from the bulge below the eye.

The surgery does not remove lines or tighten the skin of the eyelid. That is why it is only indicated where the patient’s skin keeps its quality and firmness. In cases where there is also laxity or folds of skin, it can be combined with other complementary techniques, such as laser or tightening with radiofrequency.

The profile of the ideal patient

Selecting the patient is an essential step in obtaining predictable aesthetic results and avoiding complications. Transconjunctival blepharoplasty is particularly suitable for:

• Younger people, between 30 and 50, with inherited bags.
• Patients with no excess skin in the lower eyelid.
• Patients with good tone in the orbicularis muscle and no marked laxity.
• People looking for a discreet correction with no change to the expression of the eyes.
• Patients concerned to avoid visible scars.

It is essential that the patient understands that this technique does not replace other operations in cases where there are lines, laxity or loose skin. In those situations a conventional lower blepharoplasty with removal of skin, or combined procedures, are the better choice.

Clinical assessment beforehand

Before indicating this technique, the surgeon carries out a detailed assessment of the anatomy of the lower eyelid. That consultation includes:

• Analysis of the quality and thickness of the skin.
• Assessment of the volume and distribution of the fat pads.
• Assessment of the muscle tone and lateral support of the eyelid.
• An eye examination to rule out dry eye, laxity or diseases of the ocular surface.
• General medical history and any previous surgery around the eye.

At the Instituto de Cirugía Plástica del Mediterráneo, each case is studied individually. The technique is planned precisely so as to act only on the fat compartment causing the bulge, without disturbing the other structures of the eyelid.

The surgical technique

Transconjunctival blepharoplasty is carried out in theatre under sterile conditions. The surgery usually lasts between 45 and 60 minutes and can be done under local anaesthetic with sedation, or under a light general anaesthetic, according to the patient’s profile and how comfortable they feel.

The main steps of the procedure are:

• Applying anaesthetic drops and local anaesthetic to the lower eyelid.
• Making an incision in the conjunctiva of the eyelid, on its inner surface.
• Identifying and exposing the fat pads.
• Partial removal or redistribution of the fat, according to the case.
• Spontaneous closure of the conjunctival tissue, with no visible stitches.

During the procedure the skin is not cut and the lash line is not disturbed. Nor is muscle removed or the shape of the eye altered. That is why it is considered a minimally invasive technique, which respects the anatomical integrity of the eyelid and keeps the natural expression of the face.

Specific advantages of the transconjunctival technique

This surgical option offers a number of benefits when carried out on the right patient:

• No external scar at all.
• Quicker recovery than with conventional techniques.
• Lower risk of retraction or of change to the shape of the eye.
• Precise correction of the fat pads without altering the natural volume.
• A reproducible technique, with a high degree of satisfaction.

What is more, since the skin is left intact, this technique can be combined with other non-surgical treatments such as fractional laser or hyaluronic acid to improve the overall appearance of the area below the eye.

Aftercare and recovery

Recovery after a transconjunctival blepharoplasty is generally well tolerated and does not usually call for complex aftercare. The basic advice includes:

• Applying cold locally during the first 48 hours to reduce swelling.
• Sleeping with the head slightly raised during the first week.
• Avoiding rubbing the eyes or wearing contact lenses for the first few days.
• Not applying cosmetics around the eye until permitted.
• Following the antibiotic or anti-inflammatory treatment prescribed by the surgeon.

With this technique no external stitches are placed, so the patient does not need an appointment to have them removed. The initial swelling and any bruising usually disappear within 7 to 10 days. In most cases patients can resume their everyday activities within a week.

The results begin to be apparent from the second week, and the final appearance can be seen at around the fourth to sixth week, once the tissues have settled completely.

The results to expect

The aim of this operation is to give the face a fresher, more rested look by removing the unnecessary volume created by the protruding pads. The most common results include:

• The bags under the eyes disappearing or being significantly reduced.
• An improved transition between the lower eyelid and the cheek.
• A natural expression restored, with no signs of tiredness.
• The shape of the eye and the function of the eyelid entirely preserved.

The results last a very long time, since the fat removed does not usually grow back. Ageing nevertheless continues, so other signs of laxity or changes in the skin may appear in future and call for further treatment.

What is particular about entering from inside the eyelid

The obvious advantage of this route is that it leaves no scar on the skin. The less obvious one, and the reason it has come to be preferred, is that it does not disturb the orbicularis muscle or the septum in front of it, which is where malpositions of the lower eyelid come from. Recent reviews of the lower approach record that trend: the transconjunctival route is preferred whenever anything more than a simple removal of skin is needed.

That said, entering through the conjunctiva has its own issues, and they deserve naming. A trial of 78 patients randomly assigned compared two ways of making this same incision — CO₂ laser against monopolar electrosurgery — and measured what happens to that lining:

• Chemosis (swelling of the conjunctiva, that jelly-like puffiness of the white of the eye in the first few days, which settles on its own as the inflammation goes down) was significantly more frequent with electrosurgery.
• Three patients in the electrosurgery group (7.89%) developed a conjunctival granuloma; in the laser group, none.
• Patients felt more heat during the operation with electrosurgery.

And a warning against enthusiasm, because the same trial sets it down in writing: there was no difference in theatre time, in pain during surgery, in bruising, in conjunctivitis or in aesthetic satisfaction. The instrument used to open the conjunctiva changes how comfortable the first few weeks are, and the odd healing problem in that lining; it does not change the result you see in the mirror.

Risks and possible complications

Like any operation, transconjunctival blepharoplasty is not free of risks, although these are uncommon when the procedure is carried out by a specialist in facial surgery. The possible complications include:

• Bruising or prolonged swelling.
• Slight asymmetry between the two eyelids.
• Eye irritation or a temporary sensation of something in the eye.
• The bag partly remaining if it is not completely removed.
• A temporary change in tear production or dry eye.

At the Instituto de Cirugía Plástica del Mediterráneo, scheduled postoperative checks are carried out to monitor how the patient progresses and to act immediately on anything untoward.

---

Transconjunctival blepharoplasty is an effective, precise and minimally invasive technique, ideal for correcting the fat pads of the lower eyelid in patients with no excess skin. Its main advantage is that it gives natural and lasting results with no visible scars, respecting the anatomy and the function of the eye.

If you are considering this surgical option, we recommend booking a specialist consultation at the Instituto de Cirugía Plástica del Mediterráneo. Our medical team will give you an individual diagnosis and explain with complete clarity whether this technique is right for you. Precision, experience and respect for your natural expression are our priority in every operation.