BLOG

Preservation, Not Minimalism: I Wrote a Manifesto for Connectively

I keep hearing the same thing in consults. “Doctor, plastic surgery is going smaller now, right? Less volume. Subtler results.”

Half true. Mostly misleading.

Connectively just published my bylined piece on this, and I wanted to push back on the frame in my own voice here too. Volume has not gone anywhere. Patients in my OR this month still wanted fuller breasts. Fuller hips. I still placed implants. I still grafted hundreds of cc of fat per side.

What changed in the last decade is what we refuse to damage when we add that volume.

The Old Bargain

For thirty years, adding volume came with a quiet compromise we did not really put into words for patients.

Breast augmentation, the way I was first taught to do it in training, meant a wide pocket dissection. That meant cutting through the suspensory ligaments of the breast. Those are the fibers that hold the breast up against gravity. We took them down to make room for the implant and we did not think twice about it. The implant looked great at six months. At year five, the breast started to bottom out, and by year ten the patient was back asking what happened.

Gluteal fat grafting in its early era was a free pass. Pre-2015, the field grafted into and through planes that we now know are dangerous. Plenty of surgeons added beautiful volume. A subset of patients did not survive it. The complication that killed people was fat embolism, and the cause was depth, not volume.

Facelifts of that era depended on tension. We pulled skin tight over tissue that had already failed structurally. At one year the patient looked rested. At ten years the patient looked pulled. The lateral sweep. The wind-tunnel mouth. That look did not come from “too much” facelift. It came from a facelift that was working only at the surface.

We did not really articulate any of that to patients at the time. Two reasons. The long-term follow-up data on these trade-offs was incomplete, and in some cases still is. And we did not have reliable alternatives. So we delivered volume, and the side effects came due fifteen years later in someone else’s consult room.

I had the luxury, during my Mayo Clinic plastic surgery fellowship, of seeing both eras in the same hospital. The old habits and the new evidence in the same hallway. That bothered me then. It still drives how I plan a case now. So does the Ponytail Academy training I did later, intermediate course in Pittsburgh, advanced course in Santa Monica, which gave me a deep plane facelift approach that holds at year ten the way an earlier-era SMAS tightening simply does not. Thirteen consecutive Castle Connolly Top Doctor years (2014 through 2026) is a long enough patient sample to feel honest about that claim.

What Preservation Actually Looks Like in My OR

The word “preservation” gets used loosely. So let me show you what it actually means at a case-planning level, by procedure.

Breast Augmentation

I am using ergonomic, lighter implants now (Motiva is the line I use most, see my Motiva Preserve post for what the recovery actually looks like). They project differently, with less weight per cc on the native tissue. That alone lets me use a slightly smaller implant for the same on-camera result.

My pocket dissection is narrower. The suspensory ligaments of the breast, particularly the inframammary ligament along the fold, are preserved instead of divided. The dual-plane release is precise rather than broad. The implant sits where I put it and stays there, because the soft tissue scaffold underneath it is still intact.

My patient leaves the OR with a result that looks finished on day one. The deeper test is what the breast looks like at year five and year ten. That is what preservation buys.

Gluteal Fat Grafting

If you are a regular reader, you know I do not graft above three or four hundred cc per side without a reason. The reason for me is not volume restraint. It is plane discipline.

Every BBL I do is ultrasound-guided. The probe sits on the buttock while I am cannulating. I can see the fascia. I can see the cannula. I can see the plane I am working in, in real time. That is not optional anymore. That is the standard.

Three hundred, four hundred, five hundred cc per side is achievable safely now in carefully selected patients with the right anatomy. Volumes that fifteen years ago carried a risk profile I would not accept. The volume number is not the safety story. The plane is the safety story.

This is the era I trained into. I sit on safety task forces for the Aesthetic Society and the conversation is no longer whether to use ultrasound. It is which probe and how to teach it.

Facial Volume

Here is where most patients have the wrong mental model entirely.

The patient sits down and tells me, “I do not want to look puffy. I do not want filler face.” Good. Neither do I. So I am going to put more volume in your face than you think, just not where you are picturing it.

Aging is not a wrinkle problem. Aging is a volume-loss problem. Deep facial fat compartments empty out over decades. Bone resorbs. The midface loses structural support. The skin you can see is the last thing to fail, and tightening it without restoring what collapsed underneath is the wind-tunnel facelift I described above.

A preservationist face today gets more volume, placed deeper, in the compartments that actually emptied. Buccal extension. Deep medial cheek. Pyriform aperture. Done correctly, the patient does not look “added to.” They look like themselves, ten years younger, because the architecture is back. I cover the technique side of this in my Deep Plane and Ponytail Lift post on this same site.

The Face Volume Surprise

I want to sit with this one for a paragraph because it is the most counterintuitive part of the whole conversation.

Filler trends pushed in the opposite direction. We watched a decade of overfilled, surface-level work go viral. Patients walked into my office showing me Instagram screenshots of what they did not want. Reasonable.

The correction was not less volume. It was deeper volume.

Volume placed superficially, in the wrong compartment, without regard for architecture, gives the puffed, frozen, unnatural read everyone fears. Same patient, same milliliter count, placed in the deep medial cheek and along the bony pyriform: that patient looks rested, not filled. The volume restored structure. It did not distort it.

This is also why I keep telling patients that fillers, used the wrong way, are a tax. You pay every nine to eighteen months, and you slowly add surface volume in places that should not carry it. A correctly planned surgical fat graft, deep, compartment by compartment, lasts years and does the architectural job instead of the cosmetic one.

What To Ask At Your Consult

If you take one practical thing from this piece, take this. The question to bring to a consultation is no longer “How much volume can I get?”

The better one is “What do I want preserved?”

For a breast augmentation: ask the surgeon how wide the pocket dissection is, and how they handle the inframammary ligament.

For a gluteal fat graft: ask whether ultrasound guidance is used intraoperatively, and which plane they graft into.

For a facelift or facial volume restoration: ask which compartments they target, and at what depth.

A surgeon who answers in those terms is operating in the modern framework. A surgeon who answers only with the volume number, with no thought to what is preserved underneath, is using a thirty-year-old playbook on a 2026 patient.

I wrote the full version of all of this for Connectively, with examples and the broader case the field needs to make to patients. You can read it here.

Volume was never the issue. It never was. What we have learned, sometimes the painful way, is that volume and preservation are not in opposition. The craft is knowing precisely where to put what you add, and what you refuse to damage to get there.

That is the shift worth paying attention to.

Ready to Talk?

If you want to have this conversation in person, my office line is (915) 590-7900 and our text consult line is 1-866-814-0038. Book online at agulloplasticsurgery.com. Follow along at @RealDrWorldWide on Instagram, TikTok, and Snapchat, @Agullo on X, and @AgulloPlasticSurgery on Facebook.

#StayBeautiful

BLOG

Three Days in Boston: A Surgeon’s Read on The Aesthetic Meeting 2026

The Aesthetic Society’s annual meeting wrapped Sunday in Boston after kicking off on Wednesday. The press releases will tout innovation and “the next big thing.” For me, what actually mattered came out of three days of panels, technique sessions, and lobby-bar conversations with surgeons who do this work every week.

I came home with three things: the rise of the deep plane facelift, the evolution of the rules around endoscopic access, and AI. I am saving AI for last because there is the most to unpack there.

The Deep Plane Was the Room

The entire track devoted to deep plane facelifts was the focal point of the face program this year. Full rooms. I would guess that half the attendees already perform deep plane dissections and were present for subtle refinements rather than basic technique. The other half are clearly contemplating the move. Just five years ago, you would find a deep plane discussion running opposite a SMAS plication panel that would pack the bigger convention center room. Now the SMAS panels are the side rooms, empty except for the hardy few who still rely solely on that dissection.

I had several key takeaways from the deep plane content.

The neck content was tighter than I have seen it in years. Speaker after speaker explained the same idea from different perspectives. Durability in the neckline truly comes from the deep neck. The sub-platysmal compartment, the digastric muscles, the submandibular gland, the deep fat. A platysmaplasty alone, done superficial to that compartment, gets you a decent result at three months and a disappointing one at three years. The data on properly executed direct sub-platysmal work, including selective digastric reduction and partial submandibular gland resection in the right anatomy, is solid enough that the focus of the discussion is no longer “should we do it,” but “on whom, and to what extent.”

The midface release content was stronger than last year. The zygomatic ligament releases that I routinely include in my deep plane were thoroughly confirmed by anatomical talks and by ten-year-plus follow-up photos. The newer development this year was a more aggressive discussion around the masseteric ligaments and the platysma-auricular ligament, with several speakers now strongly recommending full versus partial release. It gave me pause. I am hesitant to adopt much more aggressive ligament releases without firsthand dissection experience on cadavers. Boston was a stark reminder to schedule cadaver lab time before I move my own technique to include deeper and wider releases.

The submandibular gland question turned out to be less about whether to reduce the gland and more about where to put the scar. A vocal subset of surgeons is committing to a longer low cervical incision, almost at the neck crease, to give themselves direct line of sight to the gland. I have a hard time with that. The submental incision under the chin hides beautifully in the natural shadow, and that is the access I prefer for partial gland reduction. For hemostasis I use the LigaSure, which most of the room supported. I also keep a cell saver running as a backup. If we have any meaningful blood loss the patient gets her own red cells back instead of someone else’s. It is an inexpensive safety net for an elective operation and there is no good reason not to have one in the corner of the room.

The opinionated take after the weekend. Deep plane has won. The remaining question is not whether to operate beneath the SMAS. It is how deep, how wide and on which patient.

Endoscopic Access Evolved, Rules Solidifying

The endoscopic facelift track ran parallel to the open deep plane sessions, which was the right organization. The fundamental dissection philosophy and tissue manipulation are the same. The problem lies in the access route and the visualization.

I trained for the endoscopic deep plane, the operation often referred to as the Ponytail Lift, at the Ponytail Academy. The intermediate course was in Pittsburgh and the advanced course was in Santa Monica. I came to Boston wanting a clearer picture of which patients are actually good candidates for this approach versus which ones absolutely need the open operation. This year’s meeting delivered.

The endoscopic deep plane facelift is the right operation for the patient who is beginning to experience descent in the midface and brow, still has robust skin elasticity, and has a firm refusal of any pre-auricular scarring. Hairline incisions simply vanish into the temporal and post-tragal tufts. The surgical dissection plane is exactly the same as my workhorse open deep plane. The outcome is a full deep plane lift without any external signs that surgery happened.

Conversely, the endoscopic deep plane is the worst operation for the patient with significant skin laxity, jowl-dominant aging in the lower third of the face, or a long ear-lobe-to-mandible distance that is clearly going to demand open redraping to get a good twelve-month result. A few speakers were refreshing in their blunt honesty. The conversion-to-open rate when you over-select for the endoscopic lift is a real number, and the twelve-month photos show it on their own, whether you present them or not.

The fixation chatter was useful. Endotines and bone-anchored fixation are not the hardline debate they used to be. Most rooms I sat in are converging on suture fixation to the deep temporal fascia for the temporal and lateral fixation in primary cases. For that part of the operation, my hands look like everyone else’s. The midface is where I split off. In my hands, the endoscopic Ponytail Lift with an Endotine Ribbon at the midface delivers a stronger and more durable lift than any suture-only construct I have tried, and Boston did not show me a long-follow-up photo set that gave me a reason to put the Endotine Ribbon away.

There is one more piece of my technique I want to mention here, because patients ask about it on consult. When the face calls for an open deep plane in 2026, I am running a hybrid. The brows, forehead and midface go through Ponytail Lift access, with the Endotine Ribbon midface fixation. The lower face and the deep neck get the open deep plane. The combination, on the right patient, gives me the lift quality of an open deep plane in the lower face with the scar discipline of the Ponytail Lift across the top of the face. Boston did not invent that operation for me. Boston confirmed that the surgeons whose twelve-month photos I trust are quietly doing the same thing.

AI’s Clinical Relevance? Underwhelming.

So, AI.

I went into those sessions wanting to be impressed. A real-world intraoperative ligament mapping tool. A planning system that shaves time off my deep plane markup without introducing risk. A preoperative simulator that produces an outcome image the patient can actually rely on instead of being fooled by. Anything someone is using on a real patient next Tuesday.

Nobody gave that talk. The clinical AI content at this meeting was, in my honest read, half a letdown. A few academic posters on imaging analysis. One talk on AI-assisted aesthetic ranking that was interesting but unusable in clinic. No one stood up and said “I run this tool in my operating room on a real face, here is the workflow, here is the data on outcomes.” That gap is enormous, and it is the gap our specialty needs to close before the marketing copy stops being embarrassing.

The other half of the AI track, though. That was actually useful, and I had a stake in it. I presented in the practice-management track this year on AI for reputation management in plastic surgery. The practice management content was stronger than I expected. So was the patient communication content. So was the lead handling content. A lot of the practical AI work in aesthetic medicine is happening on the patient experience side and the panels reflected that.

AI front-desk coverage and after-hours support are now a real thing. The good tools handle scheduling, qualify inbound leads against the practice’s actual aesthetic criteria, send tailored pre-op and post-op communication, and escalate the unusual cases to a human at the right moment. A handful of practice owners walked through deployment timelines and conversion numbers. The numbers were credible.

EMR-integrated documentation tools (ambient scribes, structured note generators, post-op summary drafting) are not a demo anymore. Surgeons in private practice are running them on real cases. The hours back per surgeon per week are not trivial.

For my practice in El Paso, this is already in place. The chatbot is live on my homepage, picking up the after-hours inbound that used to sit in a queue until Monday morning. An ambient AI scribe runs in the consultation room so my eyes stay on the patient and not on a keyboard, and the chart is largely drafted by the time she stands up to leave. Neither tool is there to automate away the humans in my office. Both are there because the patient who fires off a text at midnight from Toronto, or who sends a recovery question from Seattle on a Sunday morning, deserves a prompt and accurate first response. The humans on my team are then free to focus on the conversations where a human interaction is the appropriate and beneficial tool.

I will absolutely not overstate the role AI plays in the surgical planning phase. The patient who shows up for a consultation in 2026 expecting a computer algorithm to design her facelift has been oversold something the field has yet to fully develop. I will not be the doctor playing along with that notion.

Why Choose Dr. Agullo

Double board-certified by the American Board of Plastic Surgery and the American Board of Surgery. Fellow of the American College of Surgeons. Plastic surgery fellowship at Mayo Clinic. Clinical Associate Professor of Plastic Surgery at Texas Tech University Health Sciences Center, Paul L. Foster School of Medicine. Affiliate Professor at the University of Texas at El Paso. Castle Connolly Top Doctor for thirteen consecutive years. Texas Super Doctors Hall of Fame, 2025. Aesthetic Everything Top Plastic Surgeon, 2026. Ponytail Academy intermediate (Pittsburgh) and advanced (Santa Monica) training.

Ready to Talk?

If you are seriously considering a facelift, a Ponytail Lift, or a deep neck lift this year, the consultation is where the real work starts. Bring pictures of yourself from a decade or so ago. Bring the current photos that are causing you the most concern. Most importantly, bring the questions that you would only trust asking a surgeon you feel comfortable with. I will assess your anatomy and tell you which surgical approach, if any, it is asking for. If filler is the right answer for now, I will tell you so, plainly. And if it is the right time for a more definitive procedure, I will tell you that just as plainly.

Call (915) 590-7900, text 1-866-814-0038, or book online at agulloplasticsurgery.com. Follow along on social at @RealDrWorldWide on Instagram, TikTok and Snapchat, @Agullo on X, or @AgulloPlasticSurgery on Facebook. #StayBeautiful