Background: acquired obstruction of the lacrimal excretory outflow system whether functional, structural or both will produce the symptoms of epiphora, mucopurulent discharge, pain, dacryocystitis and even cellulitis, promoting the patient to seek the ophthalmologist for evaluation and treatment. Objective: comparative study between conventional external DCR with postoperative scar modulating treatment, external DCR via subciliary incision and DCR via transconjunctival approach evaluating their functional outcome and final cosmetic scar. Patients and Methods: study cases were non-randomized 30 eyes in patients who inclusion and exclusion criteria are applied for them and dacryocystorhinostomy operation was done. Transconjunctival approach was done for 10 eyes, subciliary approach was done for 10 eyes while conventional approach with scar modulating treatment was done for last 10 eyes. Results: Aesthetic outcome of our study showed improvement in postoperative conventional approach scar with using scar modulatory treatment postoperatively and the results were 30% invisible, 50% minimally visible and 20% moderately visible after three months follow up. Also, subciliary approach study showed a significant improvement in scar outcome which was 60% invisible and 40% minimally visible. Conclusion: in spite of all the new innovations and competition, external DCR remains the gold standard and the most successful surgery in the management of complete NLDO.