Lower bleph - which is a better option - having fat removed from inside lid or removed from under eyelash line?

A blepharoplasty is done to remove or re-position the tissue around the eyes to improve the way they look. This can involve removing excess eyelid skin, removing or re-positioning the underlying orbital fat, and possibly tightening or re-positioning the lid margin. 
There are two approaches to a blepharoplasty:
Through the lid. Sometimes called a skin or skin-muscle flap. The skin and possibly the underlying muscle are elevated from the lid margin down. A cut or three small cuts are made through the lid to gain access to the protruding fat and then the excess skin, and possibly muscle, is cut away. This approach damages all three layers of the eyelid, has a longer recovery, and has a higher risk of lid pulldown (ectropion) as the lid scars. Behind the lid. Called trans-conjunctival. Access to the herniated fat is through a thin layer of tissue called the conjunctiva which is located between the eyelid and the eyeball. Excess skin, if present, can be addressed through a skin pinch below the eyelashes or, in mild cases, laser. This approach does not damage the support layers of the eyelid - decreasing the risk of lid pull-down - and results in a shorter recovery for most patients.I prefer a trans-conjunctival approach with a skin pinch because of its lower risk and faster recovery. For more information on blepahroplasty see the link below.
A detailed examination and discussion will help delineate the best surgical option. Consultation with a plastic surgeon would be the next best step.

The internal bleph approach is safer and gives a great result. The only reason to use an external incision is if there is a lot of extra skin to remove or if the lower eyelid needs to be tightened. Be sure to see an eyelid specialist for consultation.

Thank you for your question.
You are correct in that there are two different incision approaches when it comes to a lower blepharoplasty: transconjuctival and subciliary.  The choice of approach is highly dependent upon the patient's pre-op lower lid anatomy, most critically whether or not the patient has excess skin of the lower lid that will require excision.  
A transconjuctival incision is one that is made on the inside of the lower eyelid.  The primary advantage of this approach is that there are no external incisions, and therefore there is no risk of visible scarring, making this approach the patient favorite!  This approach is best suited for patients with primarily 'puffiness' of the lower lid, the result of an overdevelopment or pseudoherniation of fat.  Because this approach does not allow for removal of skin, this is not ideal for patients who have more than minimal skin laxity.
In contrast, a subciliary incision is an external incision that rests just below the lower lid lash line.  Due to its position, it tends to be very well hidden but there is always the possibility of a visible scar.  This approach allows the surgeon to address both the 'puffiness' and lax skin of the lower lids.
It would be important and recommended that you seek a consultation with a board certified plastic surgeon who is well-experienced in lower blepharoplasty procedures.  A consultation would be necessary to determine your candidacy for a lower blepharoplasty and to elucidate which approach would be of most benefit for you.  In my practice, I do prefer utilizing the transconjuctival approach, however, in some patients a subciliary incision will be required to address any more than mild skin laxity.
I hope you find this helpful and I wish you all the best!

This is complicated topic based on a number of factors.  I have personally performed several thousand eyelid procedures (I have three today!)  Transconjunctival eyelid procedures are best for patients (sometimes younger) with limited skin laxity and mostly puffiness (pseudoherniation of fat). Advantage of this procedure is no external incision.  Disadvantage is that nothing is done to address the skin (although laser can be performed in the right candidate).Transdermal (subcilliary) eyelid procedures are excellent for addressing skin laxity and puffiness.  Even eyelid position can be adjusted if need be.  The results can be extremely dramatic and all aspects of lower eyelid aging can be addressed.  Disadvantages of this procedure include the incision.  That said, it is extraordinarily subtle and is nearly invisible after healing.Best of luck!

Hello and thank you for your question. The best advice you can receive is from an in-person consultation. If fat needs to be removed or transposed, I prefer to do this through a transconjunctival incision (inside the eyelid), as this does not violate the orbital septum.  I think this is a safer approach in my hands and less risk for ectropion.  If skin also needs to be removed, this can be performed through a subciliary incision.
Make sure you specifically look at before and after pictures of
real patients who have had this surgery performed by your surgeon and evaluate
their results.  The most important aspect is to find a surgeon you are
comfortable with. I recommend that you seek consultation with a qualified
board-certified plastic surgeon who can evaluate you in person.
Best wishes and good luck.
Richard G. Reish, M.D.
Harvard-trained plastic surgeon