"I did not have these lines before"
About a week after under-eye fat repositioning, as the swelling starts to go down, some patients notice lines under the eye that they are sure were not there before: a crease under the aegyo-sal, fine wrinkles on the lid, a border that shows up when they smile. It is one of the most common questions ST's surgeon receives, from his own patients and from viewers of his channel. The timing is what makes it alarming. In the first days the swelling hides everything, so the lines seem to appear from nowhere at exactly the moment the patient expected to start looking better. There are four distinct explanations. Three of them are part of healing or were present all along, and the fourth is a genuine problem of surgical planning. Telling them apart is mostly a matter of where the line is and when it shows.
The line under the aegyo-sal
The aegyo-sal — the small roll just under the lashes that appears with a smile — is made of muscle, the lid's supporting plate, and skin. It contains no orbital fat. Before surgery, though, bulging fat sits directly beneath it and the two merge into one continuous fullness, so the lower boundary of the aegyo-sal is invisible. When the fat is moved down into the groove, that boundary appears. It is not a new wrinkle. It is the lower edge of a structure that was always there, and an aegyo-sal cannot exist without it. What varies is how sharp the edge looks. For the first month or two it is sharper than it will eventually be, because of wound contraction: an incisional approach places a scar line just under the lashes, and a transconjunctival approach leaves a healing wound at the same level on the inside of the lid. Either way the tissue at that level tightens temporarily, and the crease deepens with it. As the scar matures and softens, the line relaxes. Patients who feel that the aegyo-sal now looks too small or uneven can consider muscle, fat, or filler augmentation later, judged at about three months when the shape has settled.
Wrinkles that were always there
A bulging fat pad behaves like a balloon pressing against the skin from behind, and stretched skin does not show its fine lines. Remove the pressure — by moving the fat down where it belongs — and the skin settles onto a flatter surface, where creases that have existed for years become visible for the first time. Patients are understandably sceptical of this explanation, because from their side the sequence is simple: no wrinkles, then surgery, then wrinkles. But the mechanism is the same one that makes a deflated balloon look wrinkled when the inflated one looked smooth. These lines are a skin matter and not a fat matter, and they respond to skin treatments. ST's surgeon notes that lines around the eyes often respond to skin treatments, though results vary. Lines that appear with movement are softened by botulinum toxin, lines etched in at rest can be improved with a fine filler or with laser resurfacing, and these can be carried out once the surgical healing is complete. Surgery on the fat and treatment of the skin are two separate layers of the same plan, not evidence that the first one failed.
The border that shows when you smile
The muscle that closes the eye is a single sheet encircling the whole eye. Fat repositioning works beneath roughly the lower third of it. For some weeks afterward that operated portion is swollen, a little stiff, and partly numb, while the rest of the muscle is entirely normal — and the two portions do not move together. When the patient smiles, the normal part contracts as usual and the recovering part lags, and a line forms at the junction between them. At rest it may be invisible. This is a border between tissue that has been operated on and tissue that has not; it is not a wrinkle in the usual sense, and it fades as the operated muscle regains its normal movement. ST's surgeon hears about it from a minority of patients, and his guidance is that it typically resolves by about three months.
| What you see | Cause | Usual course | What helps |
|---|---|---|---|
| A crease directly under the aegyo-sal | The aegyo-sal's own lower edge, revealed once fat no longer blurs it; sharpened by early wound contraction | Softens over 1 to 3 months | Time; optional aegyo-sal augmentation after 3 months |
| Fine lines on the lower lid at rest | Existing creases, previously stretched flat by the fat | Persist unless treated | Botulinum toxin, fine filler, or laser after healing |
| A border that appears only when smiling | Operated and unoperated parts of the eye muscle moving out of step | Fades by about 3 months | Time |
| Several crepey wrinkles across loose skin | Skin excess that was not addressed at surgery | Does not resolve on its own | Skin excision through an incisional or partial-incision approach |
The cause that is a planning problem: skin that needed trimming
The fourth explanation is different in kind. Some patients' lower lids look more wrinkled after surgery than before — not a single line but several, with a crepey texture — and who are well past the three-month mark. In these cases the skin was usually already loose before the operation: older patients, or younger ones whose skin had been stretched by years of rubbing from allergies. They had a transconjunctival repositioning, which by definition removes no skin. The fat was moved correctly, the volume under the skin went down, and the same amount of skin was left draped over a smaller surface. It folds. No amount of waiting resolves this, because there is nothing left to heal; there is simply more skin than the lid needs. The remedy is to remove the excess through an incisional or partial-incision approach. This is why the choice between a scarless approach and an incisional one should be made on the condition of the skin and not on the patient's preference alone. A patient with lax skin who prefers to avoid an incision should be told clearly before surgery that more visible wrinkling is a likely consequence.
The trade-off: smoothness versus recovery
How much skin to remove is a judgment with a cost on both sides. Remove more and the lid is smoother, but recovery is longer and the lid is under more downward tension. Remove less and recovery is quicker, but fine lines remain. ST's surgeon knows this from his own face. When he had incisional fat repositioning, he asked his colleague to take less skin than would normally have been removed, because he needed to be back in front of patients quickly. He returned to work sooner, and some fine wrinkles remained. He describes it as the trade he chose, and he uses it in consultation to explain that a smooth lid and a fast recovery pull in opposite directions. The right amount of skin removal is not a fixed number. It is decided for the individual patient, with the patient understanding what is being traded. All surgery carries risks, including bleeding, infection, asymmetry, scarring and lid malposition; results and recovery vary between individuals.