purpose: external dacryocystorhinostomy is routinely performed through a cutaneous vertical incision placed on the lateral aspect of the nose. the lower eyelid crease approach has been seldom reported. the purpose of this study is to report the cosmetic and functional results of the lid crease approach for external dacryocystorhinostomy in a series of patients. methods: prospective, interventional case series. twenty-five consecutive patients (17 women) ranging in age from 3 to 85 years (mean ± sd= 44.84 ± 23.67) were included in the study. all patients but one underwent unilateral external dacryocystorhinostomy with a 10 to 15 mm horizontal incision placed on a subciliary relaxed eyelid tension line. the inner canthus was photographed with a nikon d70s digital camera with a macrolens and resolution of 3008 x 2000 pixels at 1, 3 and 6 months after surgery. the resulting scar was judged from the photographs by 3 observers (ophthalmologist, plastic and head and neck surgeons) according to a four level scale (1= unapparent, 2= minimally visible, 3= moderately visible, 4= very visible). results: the surgery was easily performed in all patients with a 90.48% success. three of the elderly patients (ages 61, 79 and 85 yr) developed mild lacrimal punctum ectropion, which resolved with conservative treatment. one patient had a hypometric blink which spontaneously recovered within one month. the mean score for scar visibility was 2.19 (1st mo), 1.65 (3th mo) and 1.44 (6th mo). conclusions: the eyelid crease approach is an excellent option for external dacryocystorhinostomy. it leaves an unapparent scar since the first month after surgery, even in younger patients. the functional results are excellent and comparable to other techniques. care should be taken in elderly patients with lower eyelid laxity in order to prevent lacrimal punctum ectropion.