Debate continues over the relative merits of transconjunctival and the more customary subciliary transcutaneous approaches for lower lid blepharosplasty. Ten consecutive patients presented for blepharoplasty, and in all patients the transcutaneous subciliary musculocutaneous flap approach was used on the left lower eyelid and the transconjunctival preseptal approach was used on the right. Patients served as their own controls. Follow-up was evaluated clinically by patient questionnaire and by standardized photographs preoperatively and at 5 days, 1 month, 3 months, and 6 months postoperatively. Photographs were graded independently by four blinded examiners. No statistical difference was identified in measured fornix depth between preoperative patients and postoperatively on each side. Average fat removed from each side was the same, and no patient had an identified 'missed fat compartment.' Three patients had mild bilateral scleral show postoperatively, and a fourth developed it on the left (transcutaneous) side. However, overall grading on both sides was universally very good with no significant difference on the two sides-0.68 on the right and 0.60 on the left (maximum worst grade could be 5.0 and best grade 0). The potential for external scarring was never a perceived problem in the transcutaneous technique.
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