Surgeons who are good at one technique rarely deviate to other ways... I don't appreciate the loose skin that others say you have and I do use laser to tighten the lower lid skin when doing a transconjunctival approach. The fat bag has to be transposed to the trough that you have and that will smooth your skin/lower lid. And if you have to much skin, then a pinch blepharoplasty can be done to remove it without impacting your lower lid tension.
In our practice, we have been performing trans-conjunctival approach fat removal for over 25 years. It is the preferred method of removal of the fatty deposits creating the puffy look in the lower lids. IF, and only if there is excess skin on the lower lids and patients want to tighten the lower lid skin, then a very small incision is made underneath the eyelash line and a pinch of skin is performed. In our practice, we close this incision with tissue glue, so there is no sutures. This incision usually heals very imperceptibly. For many trans-conjunctival lower blepharoplasty before and after results, please see the link and the video below
A transconjunctival approach allows fat removal, repositioning or even repair. The inevitable skin laxity as this has been a long term issue for you, could be addressed with laser to shrink the tissues. this will treat the overall skin quality but has the disadvantage of a period of discoloration and ultimately lightening of the skin relative to the cheek.
I totally agree with the consultants that you saw during your consultations. Transconjunctival fat removal does nothing to remove the excess skin, and without skin muscle tightening, the only way to get the fat bags not to show is to remove more fat than you actually want to.
When fat is removed and nothing is done to replace the degenerated septum orbitale which has been holding the fat back all these years, what will happen is either the fat will start coming forward and in a few months to years, it will look like the surgery was not done sufficiently or, if more fat than necessary was removed, then you get the hollowed out look which is very unattractive.
A transcutaneous excision with removal of skin and minimal fat will allow the tightening of the skin and muscle, and then a muscle sling from the lower lid to the upper lateral orbital rim will allow the fat to be pushed backwards replacing the septum orbitale with a tightened obicularis muscle.
For years, I did transconjunctival fat removal with no external scar. The results were never of the same quality as transcutaneous lower lid bleph surgery.
This is a very sophisticated surgery first described by Malcolm Paul M.D. of Newport Beach, California. It has been my experience that even poor surgeons rarely, if ever, get scars on lower eyelids because the dermis is so thin on eyelids, and the thinner the dermis, the finer the scar.
There is no reason that I see why you could not undergo lower blepharoplasty with no scar and a little fat repositioning. We routinely do this surgery on people in their 50's and 60's. Finding the right surgeon is a process. Be well and good luck!
Transconjunctival lower blepharoplasty (with some fat removal and some fat repositioning) is the ideal way to address under eye bags. It eliminates risk of lower eyelid malposition (ectropion), give natural results with natural eye shape, and heals a lot quicker than transcutaneous lower blepharoplasty. If there is excess skin present, then a safe way to address that would be skin pinch excision. See an oculoplastic specialist.
Based on your desires, I would proceed with a fat preservation lower lid bleph through the transconjunctival approach. The fat will redrape over the rim and soften the tear trough, elimating the bags.
Several factors go into the decision of which type of blepharoplasty to perform.
1) should the fat be removed or repositioned
2) will the skin need some type of tightening procedure, such as surgical excision or laser, or can it be left alone to shrink on its own
3) will you need a lid tightening procedure, i.e. do you have a positive or negative vector?
As you continue your research, ask these questions of the surgeons you visit. It will help you understand your situation better. Based on your photo, I would probably suggest the transcutaneous approach, with repositioning of the fat, a gentle "lift" of the mid face, and a conservative removal of skin. I wish you the best!
Based on the photos, you have large fat pads. These are best addressed via a transconjunctival surgical approach. It sounds like the surgeons you saw are not comfortable with that approach although it has been popular for many years and is very successful.
If you prefer no scar, I see no reason why a transconjuctival approach could not be done. If you are not satisfied with the answers you've received thus far, its reasonable to pursue other opinions from consultants.