Transconjunctival or Transcutaneous Approach for Fat-preserving Lower Lid Blepharoplasty?

Background: Lower lid blepharoplasty (LLB) has evolved significantly since its early description. The traditional subciliary incision is no longer the standard, and primary use of fat pad excision has been challenged by orbital fat preservation and repositioning. The current review aimed at determining whether effective pedicled orbital fat repositioning is better performed with a subciliary transcutaneous or a transconjunctival incision. Methods: A comprehensive population, intervention, comparison, and outcome review of cohort clinical studies published from 2000 up to May 2025 in the English-language literature, adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, was conducted using the PubMed, Embase, and Web of Science databases. Results: Twenty-four studies met the inclusion criteria and were retrieved for analysis. LLB with fat excision or flap transposition can be safely performed with both approaches. However, the desired outcome seems to be equally achievable with both pedicle fat flap transposition and fat grafting. Conclusions: LLB may be safely performed with both transcutaneous and transconjunctival access incisions. Orbital fat transposition is also possible with both approaches, although it is probably easier with the transcutaneous approach. However, fat transposition may not be the ideal technique for blending the lid-cheek junction or correcting tear trough deformity. Fat grafting may be more appropriate and easier to perform. Unfortunately, the LLB literature lacks rigorous reporting of outcomes and complications, greatly limiting the identification of the most appropriate approach. This deficiency needs to be seriously considered and corrected in future studies.