Dr. WorldWide | Frank Agullo, MD

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What are the earliest signs of infection after surgery? This question was posed to me for the Malpractice Monitor series at MDLinx. My response became the sentence that anchors their article. The boring, early warning signs, the ones easily rationalized and dismissed by medical providers, are the most critical ones to catch.

Here I expand slightly on that quote. The sentence is easily understood and difficult to practice, and its simplicity belies its gravity.

I do not know the facts of the malpractice case or the individuals involved. What I do know is a pattern, one that plays out in hospitals around the country, even at leading institutions.

Every Sign You Can Name Is a Late One

Ask a room full of seasoned clinicians to name the recognizable signs of sepsis and the list is exhaustive. Low blood pressure. Narrowing pulse pressure. Cold, clammy skin. Elevated lactate. An abnormal white cell count. High creatinine.

These are all legitimate. They are also all indicative of a patient who is already ill.

By that point, the window for the easiest intervention has slammed shut. A simple recheck, a phone call, one perfectly timed consultation will not turn the clock back. You are playing catch-up against a destabilizing physiology that moves faster than a hurried clinician.

The early warning signs are subtler. A pulse that sat at 78 yesterday reads 96 in the morning and 108 by evening. A temperature that rises slightly above the patient’s average but is not officially a fever. Urine output that declines inexplicably. Breathing that picks up a little. A patient who is slightly disoriented, a little sluggish, just not himself. After abdominal surgery, pain that increases without resolving, plus new bloating, nausea, or no passage of gas.

Individually, none of these would raise much of an alarm. Taken together and moving consistently in the same direction, they are the whole warning.

Sepsis Lives in the Trends

That is what I gave MDLinx, and it is what I would emblazon on the ward board of every surgical unit in the country.

The most egregious failure is dismissing a vital sign as a single isolated value rather than reading it as one point on a moving line. Heart rate of 104? Just a number. Heart rate of 82 turning to 91, then 98, then 104 across four sets of vitals? That is a story, and it tells a clear direction.

Our focus narrows to the current number because the current number is the only thing the chart makes easy. The chart is great at providing a value and terrible at providing trajectory. The nurse sees the elevated heart rate. A resident looks. A covering physician looks. One at a time, each person reasonably concludes that 104 is acceptable.

Each of them, individually, is not technically wrong. All of them together are demonstrably wrong.

Fragmented Care Kills the Curve

The problem is not intent or a lack of caring. It is a broken process.

Care is fragmented. At the next shift rotation, the nurse who saw the patient looking sickly at midnight is replaced by the nurse present for rounds at eight in the morning. The surgeon who operated is not always the one rounding afterward. The handoff, which is the critical moment to transfer a patient’s trajectory, often degenerates into a list of tasks.

Handoffs are where the trend dies. “Vitals stable overnight” can be factually accurate and clinically ruinous. Stable from what level? Stable compared with when?

There is no complicated or flashy fix for this. Call the direction out loud. Say instead: “Her heart rate has climbed thirty points since yesterday evening and her urine output is down.” That handoff communicates the trend. The extra five seconds are the price of knowing a patient instead of a chart.

Why I Take This Personally

I completed my general surgery residency at Texas Tech University Health Sciences Center and my plastic surgery fellowship at the Mayo Clinic, and I am board certified in both general surgery and plastic surgery. I trained and worked on wards where perforation, peritonitis, and postoperative sepsis are not abstractions.

The drama of sepsis arrives abruptly in some patients and subtly in others.

It is the subtle ones I still think about.

People assume aesthetic surgeons exist in a pleasant vacuum, far removed from all this. Not true. Infection after an elective operation is rare, and rarity, if anything, makes people less vigilant rather than more. When you expect a clean result every time, your mind subconsciously learns to rationalize the one odd finding. She is tachycardic because she is nervous. He feels warm because the room is too hot. Her pain is up because she missed a dose.

Each of those explanations is usually right. That is exactly what makes them dangerous.

What I Do In My Own Practice

I follow my patients closely and early, and I do not hand them to autopilot. A form gives me a value. A patient standing in front of me gives me a trajectory, and the trajectory is what I need.

My patients can call the office directly and they can text. Send me ten messages that turn out to be nothing so that I do not miss the one that was something. That is not customer service. It is clinical care. The patient is the only person present for every single data point, which makes their trend line the most complete one in the building.

So do not ask “is the pain bad.” Ask “is the pain worse than yesterday.” Do not ask “do you have a fever.” Ask “is your temperature climbing.” I care very little about the number on any given day. I care where it is going.

What a Patient or Family Member Should Escalate On

If someone you love is recovering from surgery, at home or in a hospital bed, be loud about these:

• Pain that is steadily worsening, or spreading instead of staying focal
• A heart rate that keeps climbing, even when any single reading looks acceptable
• A fever, or a temperature whose trend line is heading the wrong way
• Confusion, abnormal drowsiness, or simply not acting like themselves
• Passing far less urine than they should
• Breathing faster or more labored than expected
• After abdominal surgery, bloating, nausea, vomiting, or an inability to pass gas

You are not trying to be right. Your burden is to be loud.

Use the word trend. Ask what the numbers were last night. Put the direction in front of the team, not just the value. A spouse who says “she has gotten worse every day for three days” has handed over the one piece of information nobody in the institution managed to preserve.

That is not impolite. In the right moment, it is the only actionable thing anyone says all day.

The Point

No one misses sepsis because nobody knows what sepsis looks like. It gets missed because each of the early signs looks uneventful on first pass, each one can be explained away, and the points land on the shoulders of four different people who will only ever know their own piece.

Read the curve. #StayBeautiful.

For the patient-facing version of this post, see the companion on agulloplasticsurgery.com. For the way we follow up with postoperative patients in the practice, see the version on swplasticsurgery.com.

Ready to Talk?

Planning surgery and want the follow-up routine explained to you in detail? Ask. Any surgeon worth choosing will give you an exact answer.

Call (915) 590-7900, text 1-866-814-0038, or book online at agulloplasticsurgery.com.

@RealDrWorldWide on Instagram, TikTok, and Snapchat, @Agullo on X, or @AgulloPlasticSurgery on Facebook.

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If you ask a plastic surgeon which part of liposuction is the hard part, and he answers you honestly, he will not tell you it is the fat.

I started using Renuvion J-Plasma in 2019. I was one of the very early adopters, and I saw a missing need after liposuction, which was skin tightening. We were able to perform liposuction effectively, but after deflating the subcutaneous tissue layer, many patients were left with loose skin, which required surgical excision. When we began using Renuvion, we noticed that the tissues would contract, and oftentimes the surgical excision of excess skin was not necessary anymore.

Read that last part again, because it is the whole reason I am writing this. Not that the skin looked somewhat better. The excision was not necessary anymore. A second operation, and a permanent scar, came off the table.

What It Is Doing Under There

This is the explanation I give in clinic, and I have never seen a reason to keep a simpler version for patients and a smarter one for colleagues.

Renuvion J-Plasma activates helium plasma and radiofrequency in the subcutaneous layers, making the connective tissue underneath shrink and contract, resulting in skin tightening and a smoother result. The helium plasma is important because it keeps the temperatures cool, which avoids burning.

That last sentence is where the engineering lives. Radiofrequency by itself will contract tissue. Radiofrequency by itself, at the wrong settings, will also cook it, and our literature has documented what that looks like. The helium is what lets the energy arrive hot and get out fast. The handpiece goes in through the same access sites the liposuction cannula already made, so nothing new is cut and nothing new is closed.

How Much I Use It

We use Renuvion J-Plasma almost every day, performing more than ten to twenty Renuvion cases per week. I am among the ten highest users in the world, according to Apyx, the company that manufactures the device.

I put that near the top rather than the bottom for a reason. When a surgeon speaks well of a device, you are entitled to know how far into it he already is before you weigh anything else he tells you. I am very far into this one.

The Huber Paper

Apyx circulated a study through its clinical newsletter this spring. I read manufacturer mailings the way most of us do, with a raised eyebrow, because the company sending the envelope has an obvious interest in what I conclude. This one held up.

Huber, Bittencourt, Koteski and colleagues published it in Plastic and Reconstructive Surgery Global Open in March 2026. They reviewed 113 consecutive patients from one surgeon’s practice, treated between October 2021 and October 2023. Seventy-three had power-assisted liposuction alone, and forty had power-assisted liposuction followed by Renuvion J-Plasma. Past the twelve-month mark, they went back and asked the patients themselves, using BODY-Q, a validated instrument rather than a satisfaction form somebody drew up in a marketing meeting.

The revision row is the one that stopped me. Thirty-seven and a half percent down to twelve. Any surgeon who has had to bring a patient back for a skin excision that neither of them wanted knows that the distance between those two numbers is not measured in questionnaire points.

The complication row matters too, more quietly. Adding energy under the skin did not add risk here, 2.5 percent against 2.7 percent, and no complication was attributed to the device.

The caveat, which the newsletter was not built to emphasize, so I will. Retrospective, not randomized, one surgeon. The authors say so themselves. It is a strong signal that happens to match what I watch happen in my operating room every week, and a strong signal is not proof. I would rather hand you that limitation myself than have you find it in the discussion section and wonder why I skipped it.

Where I Use It, and Where I Stop

I prefer to use Renuvion J-Plasma in the abdomen, the flanks, the upper back, the lateral chest, and around the knees. We also use it on the arms and thighs. I prefer not to use it in overly thin skin. If I encounter overly thin skin, I transition to BodyTite.

There is a sweet spot in using J-Plasma, where more passes and more energy are not going to give you any further results. So being accurate in the number of passes and the energy for each area is extremely important to get the most benefit with the least risk.

That is the sentence I would put on the wall of every practice that just bought one of these. The dose does not scale in a straight line. Past a point you are collecting risk and buying nothing with it, and the device will happily let you keep going, because it has no way of telling you that what you have already done is enough. That judgment belongs to the surgeon.

The Unpopular Part

The most important thing is really knowing the limitations, and knowing that J-Plasma will not tighten extremely loose skin after pregnancy or massive weight loss. It is very powerful in contracting the skin, and it often keeps patients away from needing a brachioplasty or excision of back rolls.

Both halves of that are true at once, and the industry has a habit of quoting whichever half suits it that quarter. It really is strong enough to spare somebody an arm lift or an excision of the back rolls, and those are not small scars to spare a person. It is also nowhere near strong enough to replace a tummy tuck in a patient who needs one. Stretch marks it does nothing for at all, because a stretch mark is a tear in the dermis, and contracting the tissue under a tear does not repair the tear.

So here is the candidate, exactly as I describe him or her in the room.

In the right patient, one who does not have a lot of skin laxity or stretch marks and no rectus diastasis, the Renuvion J-Plasma can help keep patients away from an abdominoplasty and let them have just liposuction.

Three conditions, and all three are required. If the rectus muscles have separated, the abdomen is pushing forward because the wall came apart, and energy delivered into the fat layer above that wall does nothing about it.

Recovery Does Not Change

I lead with this now, because patients assume the opposite.

It is important to know that Renuvion J-Plasma is not going to increase recovery times. The recovery itself and the protocol are the same with or without Renuvion J-Plasma when you have liposuction. We still use the garments, and we still use lymphatic massages.

You are not buying downtime here. You are buying a better envelope at the end of the downtime you had already agreed to. The skin also keeps contracting for months after you go home, which is why judging an abdomen at six weeks is a mistake, and why I spend part of nearly every week talking somebody down off that ledge.

Why I Am the One Saying This

I am double board-certified by the American Board of Plastic Surgery and the American Board of Surgery, I completed my plastic surgery fellowship at Mayo Clinic, and I have taught as a Clinical Associate Professor of Plastic Surgery at Texas Tech University Health Sciences Center Paul L. Foster School of Medicine since 2011. Castle Connolly has named me a Top Doctor for thirteen consecutive years.

None of that is why I trust this device. Seven years of using it almost daily is why. The credentials are why I am comfortable telling you where it fails.

#StayBeautiful

Ready To Talk?

If someone has told you that you will need a tummy tuck no matter what, it is worth a second opinion before you accept a scar you cannot undo. Call the office at (915) 590-7900, text 1-866-814-0038, or book a consultation at agulloplasticsurgery.com/appointments. You can also read more about liposuction at Southwest Plastic Surgery.

Follow along at @RealDrWorldWide on Instagram, TikTok, and Snapchat, @Agullo on X, or @AgulloPlasticSurgery on Facebook.