Dr. Wong Thoughts

What Approach to Use for treating your Eye Bags?

posted October 5th, 2017 by waesthetics in Eyelids

Patients commonly present with the complaints of Eye Bags and Looking ‘Tired’. Treating the eye bags, when appropriately performed, targeting not only the eye bags but ageing of the surrounding areas, will give the patients a refreshed appearance – looking rejuvenated with no tell tale signs of surgery.

The main decision that needs to be made is the surgical approach to the eye bags. This would be either performing the surgery via the incision on the external skin just under the eyelashes – called the transcutaneous approach (Figure 1)

Figure1: The Outside Incision Method

Figure1: The Outside Incision Method

or via the inner side of the lower eyelid – called the transconjunctival approach (Figure 2). Because the latter does not involve any incisions of the external skin, it is also called the ‘scarless’ eye bag removal method.

Figure 2: The inside approach, also call the 'scarless' approach

Figure 2: The inside approach, also call the ‘scarless’ approach

Many surgeons prefer one method or the other, depending on their experiences, expertise and training. However, the best method for a particular patient depends on the wishes of the patient, desired changes and the condition of the patient (specifically the severity of the ageing changes in the mid cheek).

Accordingly patient selection is of critical importance.

The ‘Scarless’ / Transconjunctival approach


The transconjunctival approach is advantageous for its quick recovery and no visible incision on the lower eyelid skin – accordingly called the scarless eye bag removal technique.

The technique is generally very good for patients with prominent eye bags, minimal sagging of the cheeks and minimal wrinkles of the lower eyelids. An example of a good candidate is shown in Figure 3.

Figure 3: A good Candidate for the Scarless Method

Figure 3: A good Candidate for the Scarless Method

While this is a well-established technique used by many surgeons, the ‘conventional’ transconjunctical method of doing the surgery involves only fat removal to reduce the bulge of the lower eye lids, eliminating the eye bags. While its simplicity is very attractive, it is also limited in that the tear trough deformity and the volume deficiency in area below the tear trough would not be corrected with this technique.

In 2017, I published a technique that I developed in the international peer-review journal Plastic and Reconstructive SurgeryIn addition to the meticulous removal of the excess fat from the eye bags, the technique that I use releases the ligament that is responsible for the tear trough deformity (the Tear Trough Ligament) and precisely graft the fat that was removed from the eye bags onto the depression on cheeks to correct the sunken part of the inner cheek below the eyebags. This technique delivers a superior results than that that can be achieved with conventional technique.

The Transcutaneous Approach- The ‘outside’ approach.

The transcutaneous technique or ‘Outside technique’ is a different approach in that the incision is made just below the eye-lashes with a slight extension onto the cheek skin (Figure 1). This is well a well-established method of treating eye bags and has been used by many plastic surgeons for many years. When done properly, the incision is virtually invisible after healing is complete.

Figure 4: A good candidate for the Outside method, with Cheek Lift done at the same time

Figure 4: A good candidate for the Outside method, with Cheek Lift done at the same time

The ‘Outside technique’ has several advantages. It allows the cheek to be lifted at the same time while treating the eye bags and allows for removal of excess creepy skin of the lower eyelid.

Accordingly, this technique is good for patients with more severe aging changes, large eyebags, sagging of the cheeks with prominent nasolabial folds and skin wrinkling of the lower eye lids. An example of a good candidate for this method is shown in Figure 4.

While the recovery is slightly longer, with slightly more bruising and swelling, with modern surgical techniques, the down time may be minimized. This method is able to deliver a more profound rejuvenation in patients with more severe ageing changes with sagging of the mid cheek soft tissues- because of the CHEEK LIFT component added to the traditional eye bag procedure.

In 2015, I published my technique of performing lower eyelid blepharoplasty with mid cheek lift international peer-review journal Plastic and Reconstructive Surgery. This method, minimized swelling and bruising while delivering a powerful lifting of the cheeks, to not only eliminate the eye bags but also rejuvenate the mid cheek.

Transconjuntival or Transcutaneous Approach to treating Eye Bags?

In summary, the optimal approach should be selected for each patient according to the patient’s specific needs, condition and anatomy. The patient’s preferences, social and work requirements are further considerations in the selection of the ideal procedure for each patient.

These aspects would be discussed in detail during the consultation process with Dr. Wong.