Dr. WorldWide | Frank Agullo, MD

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Most facial consultations begin with the same small gesture. Someone lifts the skin at their cheeks in the mirror, watches the jawline snap into place, and says, “I just want this back.”

Underneath that gesture is almost always the same set of problems. Jowls. A heavy neck. A lower face that sags when they smile. And, increasingly, a face tired of being chased with filler.

Here is how I talk about the fix, candidly.

A Facelift You Cannot See the Scars From

For the right candidate, I use a facelift with no visible scars. The incisions hide in the hairline, which is why it is called a ponytail facelift, and a good portion of the lift is done endoscopically.

It brings the brow up just slightly and lifts the cheek, so that when you smile the lower face softens instead of dropping. You can still wear your hair up.

“Is This Just Pulling the Skin Tight?”

No, and that is the entire point. It is a deep plane facelift, which means I reposition the deeper tissues rather than pulling on skin. That is what makes it look natural and last. You do not end up looking pulled or windswept, because the tension lives in the deep layer, not in your skin.

What the Neck Actually Needs

For the neck, I place a small incision under the chin and behind the ear. Through that I can remove a little of the gland and the deeper fat and build a tight, youthful jawline.

Taking out the deeper fat matters for the long run. Even if your weight changes later, the result will not blur as much, because the fat that tends to come back is more superficial.

And no, most people do not need a chin implant. If you already have a strong chin, the neck lift alone makes it look more pronounced and sharper, because right now it is getting lost.

My Strong Opinion on Old Filler

This is where I will not hedge. Chasing facial aging with more and more filler eventually stops helping and starts distorting, especially stacked over high cheekbones. Old filler often does not fully dissolve. It migrates.

So during the facelift, I can place medication to dissolve some of that old filler, which leaves us working with your own tissues instead of building on top of someone else’s product. I would rather reposition your own anatomy than keep adding to it.

The Add-Ons That Travel With a Facelift

On the forehead, the rule of thirds says it should measure about the same as the length of your nose. If your hairline sits high, I can make an incision at the hairline and move the scalp forward to close that distance, with a tiny scar in front, and refine it later with a hair transplant. It can be done at the same sitting as the facelift.

For the eyes, I almost always add a little fat to the folds and sometimes the upper eyelid hollows. The fat is permanent and very natural. It is alive, so it shifts a touch with weight, but it erases the tired shadow so you look awake, and it often keeps you away from a separate upper eyelid surgery.

What Recovery Is Really Like

The good news about facial surgery is that it does not really hurt. The pain level is close to zero. What you deal with is swelling and bruising.

Plan on a couple of weeks before you are comfortable being seen, and about six weeks to be ready for a special event. Most people return to work after two weeks, sometimes with a little makeup. We also offer an LED therapy called ElixirMD starting seven days after surgery that roughly doubles the speed of recovery, and Morpheus8 microneedling can refine skin quality later.

Who I Think Is a Candidate

I am candid in the room about who this is for. The ponytail deep plane facelift is for the patient who has real structural change, jowls, a softening jawline, a lower face that drops with a smile, not for someone whose only complaint is fine surface lines that a good skincare plan and a laser would handle. It is ideal for a patient who wants to keep wearing their hair up and who refuses the visible incisions in front of the ears. Healthy patients who do not smoke heal the cleanest, and I will tell a smoker to stop well before I will operate.

The other thing I look for is the neck. So often the neck is the tell, and a beautiful cheek lift over an untreated neck looks unfinished. When I assess a face, I plan the cheek, the jawline, and the neck as one unit, because that is how they age and that is how they should be corrected.

Why I Chose This Approach

I completed my plastic surgery fellowship at the Mayo Clinic and I teach facial surgery as a Clinical Associate Professor of Plastic Surgery at Texas Tech University Health Sciences Center Paul L. Foster School of Medicine. I trained for the deep plane and ponytail technique at the Ponytail Academy in Pittsburgh and Santa Monica. I chose this approach because it lasts and because it looks like you, not like surgery.

See the Patient-Facing Versions

For the patient-facing walkthrough, see the companion post on agulloplasticsurgery.com. For the treatment menu, see the version on swplasticsurgery.com.

Ready to Talk?

If you are pulling your cheeks up in the mirror, that is your sign to come in.

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

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

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Before we talk about the different uses of Botox, which is a very exciting topic, it’s important to understand how botulinum toxin works. In essence, it inhibits the release of acetylcholine, which is the chemical signal that nerves send to the tissue on the other side. In the traditional use of botulinum toxin for the prevention of wrinkles, the nerves are sending acetylcholine to the muscles to contract the muscle, and the botulinum toxin is preventing that release so that the muscle doesn’t contract and create a wrinkle. In the same fashion, it can work on other targets, like sweat glands.

Once you understand that one mechanism, the whole long list of uses makes sense. So here is the tour, from the well-established to the experimental.

Excessive Sweating

Botulinum toxin can be used for excessive sweating, in medical terms, hyperhidrosis. This is what a fitness audience tends to care the most about. The FDA has actually approved botulinum toxin for excessive underarm sweating. In this case, the toxin is injected into the skin every half an inch to cover the area of the sweat glands that produce the sweat. A single underarm treatment usually lasts anywhere between four to six months, and it does have to be repeated.

Off-label, we can use it in the same fashion for sweaty palms, the soles of the feet, a sweaty scalp, and even the forehead. It doesn’t change how much you’re going to sweat in other places that aren’t treated, but it is very effective. I’ve had patients whose excessive sweating is disabling, and for them these treatments are life-changing.

Chronic Migraine and Headaches

The FDA has approved the treatment of chronic migraines and headaches with botulinum toxin for more than fifteen years now. There is a very specific protocol, and it consists of about thirty injection points in the forehead, scalp, and neck. This is considered a preventative treatment, which means it prevents the onset of new headaches. It would not cure an active headache at the time of injection.

I’ve had a lot of patients who just routinely get botulinum toxin for cosmetic reasons, to prevent wrinkles in the forehead, crow’s feet, and glabella, and they tell me that they’ve had fewer headaches since they started using the botulinum toxin.

Jaw Clenching, Tics, and Symmetry

Botulinum toxin is also used for jaw clenching and teeth grinding. It’s injected into the masseter muscle, which decreases the strength of the bite. As a side effect, it can be used to slim a heavy jawline by decreasing the size of the masseter muscle, creating that shadow effect that a lot of women aspire to.

It can also be used for spasms or continuous nervous tics around the eyes, to soften them. We use it often in patients with facial nerve palsy to create more symmetry between the non-paralyzed and paralyzed sides. It can be used in neck muscle spasms and even in overactive bladders.

The Less Traditional Uses

Less traditional uses of Botox include TrapTox, which is injected into the trapezius muscle, and sometimes it’s called the Barbie. It reduces the mass of the trapezius muscle, which creates a more slender neck, and a longer, more slender neck. Some people use it for comfort in this area, as they feel they carry significant stress in their shoulders, and this can help alleviate that.

We use it around the mouth to correct gummy smiles. We inject it into the muscles that elevate the upper lip excessively, and it reduces the gum show, or gingival show, when smiling. Another area where it’s injected into muscles to decrease their mass is the calf muscles, which is very common in the Asian population. It can also be used to treat the pebbly chin, or orange peel appearance of the chin. Relaxing the mentalis muscle smooths this area of skin.

The Skin Itself

There are applications where we do microdroplets of botulinum toxin over the skin. These are very superficial injections, and overall they decrease oil production and smooth out the skin over time. It’s something we’ve noticed just in treating patients aesthetically for the prevention of frown lines and wrinkles, that the area where the Botox is injected, the skin quality improves over time and looks younger. It is also used for rosacea flushing, where microdroplets are injected into the skin to decrease facial flushing and redness, which is considered off-label. It pairs naturally with skin-quality work like microneedling.

The Experimental Frontier

Depression is actually being studied at the moment, but some studies already suggest that relaxing the glabellar frown muscles influences emotional feedback mechanisms and pathways in a way that improves depression. It’s not FDA-approved for depression, but it remains an active area of research.

There is a nonstandard indication where botulinum toxin can be injected into the clitoris, which relaxes the capillaries and promotes engorgement during sexual stimulation, which can increase sensitivity. In the same manner, it can be injected around the vagina to prevent vaginismus, sexual pain, and pelvic floor spasms. And some physicians actually use it in places you would never imagine, like the vocal cords, the salivary glands to decrease saliva production, the pelvic floor for problems in women, and the hands for circulation disorders.

One of the side effects of injecting into areas for decreased sweat production is that there’s also a decrease in body odor production, since the smell is produced by the same glands that produce the excessive sweat.

The Credential Behind the Opinion

Double board-certified by the American Board of Plastic Surgery and the American Board of Surgery, American College of Surgeons Fellow, Mayo Clinic plastic surgery fellowship, Clinical Associate Professor of Plastic Surgery at Texas Tech University Health Sciences Center Paul L. Foster School of Medicine, and Castle Connolly Top Doctor for thirteen consecutive years. The reason I keep a long mental map of these uses is that the same molecule, in the right hands and the right plane, solves a surprising range of problems.

Ready to Talk?

If a use on this list speaks to something you have lived with, the conversation is worth having.

For the patient-facing clinical guide, see the companion post on agulloplasticsurgery.com. For the MedSpa toxin menu at the practice, see the version on swplasticsurgery.com.

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

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