A specific set of complaints after skin-excision surgery
Some people who had a traditional lower blepharoplasty — the operation that removes skin and fat through an incision under the lashes — describe a recognisable pattern afterwards. The bulge is gone, but the small roll under the lashes, often called aegyo-sal, has flattened. The groove between the lid and the cheek looks deeper than before, not shallower. Some notice a firm lump near the outer corner. Others find that the lid has been pulled down. This column explains why these changes can follow this type of operation, what a revision addresses, and what it realistically cannot promise. It is not a judgement on any individual operation; outcomes depend on anatomy, technique, and healing.
Why the aegyo-sal can flatten
Aegyo-sal is not fat. It is the skin and the thin band of orbicularis muscle that sit directly in front of the eyelid plate, just under the lashes. A traditional lower blepharoplasty tightens the lid by removing skin, sometimes with muscle, and pulling the remaining tissue taut. If the skin is drawn tight to achieve a smooth result, that tension can press on the area that forms the aegyo-sal and leave it flatter. A transconjunctival repositioning works from the inside of the lid and does not remove skin from under the lashes, so it is not designed to remove the aegyo-sal. It can, however, change how it looks: when the bulge of fat beneath it is smoothed out, the roll often looks more defined but smaller, because before surgery the aegyo-sal and the fat bag were partly read as one shape.
Why the groove can look deeper: higher peaks, same valley
Two mechanisms can make the tear trough look deeper after this kind of operation. The first is fat removal. When the bulging fat is taken out, the area above the groove loses volume, and the under-eye can look hollow. The second involves fat grafting placed directly into the groove. The tear trough is held to the bone by a ligament. If that ligament is not released, grafted fat tends not to settle in the groove itself and may take hold above and below it instead. The effect is sometimes described as higher peaks with the valley left where it was — the groove is now flanked by raised areas and looks deeper than before. This is why releasing the ligament is generally regarded as a key step in tear trough correction, rather than adding volume alone.
What a revision aims to do
A revision for this pattern generally follows the structure rather than simply adding volume. The tear trough ligament is released. Remaining fat pads are located — even after removal, remnants are often present — and repositioned and secured over the groove. Where the remaining fat is not enough, volume is supplemented with grafted fat placed within and beneath the repositioned fat, and concealer fat may be used near the surface. Raised areas left by earlier grafting may need to be reduced so that the contour becomes continuous again. When the tension that flattened the lid is relieved, part of the aegyo-sal contour can reappear, but how much returns depends on what was removed in the first operation and cannot be promised.
When the lid itself was pulled down
If more skin was removed than the lid could spare, the remaining skin can pull the lid margin down and outward, producing scleral show or ectropion. This is a different problem from contour and is corrected differently: by tightening the lid where it has lost tension, often with a pentagonal wedge technique, and, when the lid has also been pulled down, by adding internal support such as a graft of mucosa from the roof of the mouth. Where skin is genuinely missing, a skin graft may be needed. Grafted tissue can contract as it heals, so a single revision does not always reach the full goal.
A lump at the outer corner
Lower blepharoplasty is often combined with lateral canthal fixation, in which the outer corner of the lid is anchored to the bone to support it. If the muscle used for the fixation is very thin, or the skin bunches as it heals, a firm lump or an indented area can form near the outer corner, sometimes resembling scar tissue. Some of this settles with time. A lump that is still unchanged around five months after surgery is more likely to persist. When it does, correction may involve redoing the fixation through the same area and re-trimming and re-closing the skin; how much improves varies between individuals.
Scars, expectations, and what to bring to a consultation
A previous incision under the lashes can sometimes be removed during a revision, if it falls within the new incision line; a scar that lies outside it, for example closer to the lashes or further down, will usually remain. Bring photographs from before the original operation, because comparing with your own baseline is more useful than comparing with an ideal, and bring whatever details you have about what was done — skin removal, fat removal, grafting, fixation, and any later injections. If you are still within the first months after surgery, raise your concerns first with the surgeon who performed it. All surgery carries risks, including bleeding, infection, asymmetry, lid malposition, dryness, scarring, and the need for further treatment; revision carries higher risks than a first operation, and results vary between individuals.