The bottom eyelid may be approached externally or through a transconjunctival approach.

The external approach begins with a subciliary incision.
Then a skin, skin-muscle, or stepped skin muscle flap may be used.
This approach is useful for removal of skin and muscle, but has an increased risk of ectropion.

The transconjuntival approach may be preseptal or postseptal, allowing removal of fat without any external scars and a much lower risk of ectropion.
Since many surgeons feel the goal of bottom eyelid surgery is to remove orbital fat, the transconjunctival approach has become increasingly popular.