Incision Hamra technique vs. transconjunctival Hamra—which to choose? Comparing skin sagging and lower-eyelid concerns

Both the incision Hamra technique (cutting from the skin side) and the transconjunctival Hamra technique (performed from inside the eyelid) reposition fat under the eye to even out bulges and hollows. A review of 24 studies found no major difference in outcomes[1]. The key factor in choosing is whether excess skin needs to be removed[2]. The skin-side approach requires attention to lower-eyelid malposition[3].

Skin-side vs. transconjunctival approach—is there a difference in results?

No major difference is believed to exist. A synthesis of 24 studies comparing the skin-side and transconjunctival methods found that both safely remove or reposition fat, with no significant difference in outcome[1].

However, no published study has yet directly compared both techniques on the same person's left and right eyes[2]. It is more practical to consider which method suits your individual anatomy rather than which is superior overall.

How does skin sagging factor into the choice?

The general principle is: transconjunctival if sagging is minimal, skin-side if sagging is significant[2]. The transconjunctival approach leaves no external scar and reduces the risk of lower-lid ectropion[4].

However, the transconjunctival approach cannot fully correct excess skin, skin laxity, or bulging of the lower-lid muscle[3]. In such cases, a pinch-excision of skin or similar refinement may be added[3].

In patients with substantial skin excess, the skin-side approach is considered essential[2]. In older patients with marked sagging, a combination of skin-side incision and skin excision is necessary[4].

What complications should I watch for with the incision technique?

The primary concern is lower-eyelid malposition. The skin-side approach carries a 15–20% reported risk of malposition—including visible sclera show or ectropion[3].

In one comparative study, visible sclera show occurred in 3% with the transconjunctival method and 28% with the skin-side method[2]. Since this is one study's result, it may not directly apply to current surgical techniques.

Preventive measures exist. Reinforcing the lateral canthus support during surgery or refining the skin-side incision to prevent ectropion have been reported[5]. Avoiding over-resection of skin is also fundamental to preventing ectropion[6].

How does fat removal alone (defatting) differ?

Fat removal alone can leave hollowing. A reduction in bulging does not correct tear-trough deformity and may actually worsen hollowing, as reported[4].

. For this reason, repositioning fat while preserving volume is now widespread practice. A survey of surgeons found approximately 80% perform fat repositioning[2].

However, in patients with very abundant fat, repositioning alone may result in over-fullness of the cheek[7]. Surgical refinement by removing some fat to optimize volume has been reported[7].

How does this compare to hyaluronic acid injection?

Injection is convenient but serves a different role. While injection poses less bodily burden, challenges remain including Tyndall effect, nodule formation, and vascular occlusion[8].

Surgery produces more dramatic change but carries risks such as scarring and longer recovery[9]. Hyaluronic acid is also used after surgery to address residual hollowing or asymmetry[10].

What should I confirm during consultation to find the right method for me?

No single 'best method' applies to everyone[2]. During consultation, the surgeon assesses lower-eyelid position, skin excess, fat prominence, hollow depth, eyelid laxity, and cheek height to decide[2].

At consultation, ask which approach—incision or transconjunctival—is recommended and why, how much skin will be removed, and whether lateral support will be reinforced. Have your lower lid examined directly, and choose the method suited to your individual sagging and fat volume.