Transconjunctival Lower Eyelid Fat Removal (Invisible Eye Bag Surgery) and Transcutaneous Lower Eyelid Surgery (External Approach) are the two primary methods for correcting eye bags. The transconjunctival approach leaves no visible external scar and is ideal for younger patients with good skin elasticity. In contrast, the transcutaneous approach allows removal of excess skin and fat simultaneously, making it more suitable for patients with significant skin laxity.
Eye bags refer to the protrusion of orbital fat beneath the lower eyelid. As this fat gradually bulges forward, it is often accompanied by laxity of the surrounding muscle and skin layers. With age, this combination leads to a more prominent under-eye fullness. Visible eye bags tend to convey a tired, weary, or aged appearance, affecting facial aesthetics and often making a person look fatigued or older than their actual age.
In the 19th century, neurologists discovered that a genuine smile is controlled by two key muscle groups: the zygomaticus major, which elevates the corners of the mouth, and the orbicularis oculi, which gently lifts the cheek area near the nose and creates a subtle fullness beneath the eyes.
Compared with the zygomaticus major—which can be voluntarily activated—the orbicularis oculi includes fibers that contract involuntarily and only engage during moments of genuine happiness. This natural contraction produces a slight puffiness under the eyes, communicating authentic joy and warmth.
This lower portion of the orbicularis oculi is what we commonly call aegyo-sal. Individuals with prominent aegyo-sal are often described as having "smiling eyes," as it conveys a youthful, cheerful, and approachable expression.
The tear trough is the concave area located between the inner lower eyelid and the upper cheek. Its formation is closely related to two key anatomical structures: the orbicularis retaining ligament and the zygomatic cutaneous ligament. As these ligaments lose elasticity and descend with age, the area becomes hollowed. At the same time, protrusion of orbital fat above the orbicularis retaining ligament can accentuate the depression, making the tear trough appear deeper and more prominent.
Transconjunctival eye bag surgery is performed through an incision on the inner side of the lower eyelid, beneath the conjunctiva. Because no external skin incision is made, it is also known as a scarless or no-visible-incision lower eye bag procedure.
Much like how women of different ages may have similar abdominal size during pregnancy but achieve different levels of abdominal flatness afterward due to variations in skin and muscle elasticity, patients with good eyelid skin elasticity are well suited for the transconjunctival approach. When the skin retains strong elastic recoil, this method typically achieves a smooth and flat postoperative contour.
Transcutaneous eye bag surgery involves making an incision on the skin just below the lower lash line. Because the incision sits directly beneath the eyelashes, it becomes nearly invisible—especially in patients with dense lashes or those who have lower eyeliner tattoos. Compared with the transconjunctival approach, the transcutaneous method offers several advantages: it allows reconstruction of a weak or flattened tear trough–like bulge (the "aegyo-sal"), removal of excess skin, midface lifting to address nasolabial folds and midface descent, and can create a noticeably rejuvenated and more youthful appearance.
If lower eyelid looseness is not corrected and a transconjunctival approach is used instead, it may lead to postoperative ectropion.
One week before surgery:
・Discontinue anticoagulants (such as aspirin) after confirming with your prescribing physician.
・Stop all supplements (e.g., fish oil, ginkgo, ginseng, vitamin E).
・Avoid smoking and alcohol from one week before to one month after surgery.
On the day of surgery:
・Arrive with no makeup and remove any eyelash extensions.
・Do not wear jewelry or metal accessories; remove piercings in advance.
・If you wear contact lenses, you may arrive with them on, but they must be removed before surgery. Bring a case, glasses, or sunglasses.
You may choose local anesthesia or IV sedation/general anesthesia.
・Local anesthesia does not require fasting; you may eat normally.
・Sedation/general anesthesia requires fasting for 8 hours—do not eat or drink (including water or gum).
・Please avoid driving or riding a motorcycle after surgery.
・Cold and warm compresses: Apply cold compresses for the first 72 hours to reduce swelling and bruising, and keep the head elevated. After 72 hours, warm compresses may be used to promote circulation and healing.
・Wound care: Keep the incision dry and change dressings as directed. Skin sutures (if present) are typically removed around postoperative day 6–10, depending on healing.
・How to clean the incision: Clean the area twice daily with sterile saline using cotton swabs, pat dry, and apply the prescribed ointment. Place gauze between the skin and the compress to prevent infection.
・Medications & eye hygiene: Use prescribed eye drops/ointment as instructed to prevent infection and aid healing.
・Visual habits & lifestyle: Avoid prolonged phone or computer use and prolonged downward gaze to ensure adequate rest for the eyelids.
・Diet & medications:
- Pain medication may be taken as needed.
- Avoid irritants such as alcohol, caffeine, tobacco, spicy foods, and supplements (e.g., vitamin E, herbal medicine).
- A light diet, good hydration, and adequate protein and vitamin C intake help support wound healing.
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