Dr. WorldWide | Frank Agullo, MD

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A large part of my week is not first-time augmentation. It is revision.

Women come in years after surgery done somewhere else, and they describe the same handful of things. One breast riding high. A firmness that crept in. A sense that the implant has wandered off where it should be. Or simply, it has been ten years and they want a change.

These are not vanity complaints. They are mechanical problems with mechanical fixes, and they deserve a straight answer rather than a shrug.

What That High, Hard Lump Usually Is

When the description is one side that sits high and feels firm, almost like a lump, it is usually a capsular contracture.

Here is what is happening. Whenever we place an implant, the body forms a capsule of scar tissue around it. That is normal and even helpful, because it keeps the implant in place. But sometimes that capsule, driven by inflammation or an old low-grade infection, tightens and hardens around the implant. It squeezes the implant up and in, and the breast goes firm.

If it hurts, the contracture is more severe. No pain is actually a good sign. And it surprises people that this can show up long after the original surgery, sometimes many years later, but it does.

How I Actually Fix It

The repair is more than swapping the implant. I go in, remove the hardened capsule, take out the old implant, and place a new one.

When I do that and switch the patient to a Motiva implant, the risk of contracture recurring drops below one percent. The nano-surface on these implants provokes a much lower inflammatory response, which is the whole reason the recurrence rate falls so far.

To lower it further, I will often place a mesh, an internal bra layer of support, over the area. With that combination, recurrence approaches zero. And if you want to change size while we are in there, we usually can, through the same incision.

Revision Decisions at a Glance

“Should I Just Swap Old Implants?”

If you are at the ten-year mark with older-generation implants, an exchange is reasonable, and it is a good moment to reassess size and position at the same time. I often move patients from an older implant to a Motiva, which lasts much longer and carries far less contracture risk.

“I Have Had Several Surgeries Already. Is It Too Late?”

No. I see patients whose first operation was decades ago with several since. More history does not mean nothing can be done. It means I plan carefully and stay honest with you about what is realistic. Revision is harder than a first augmentation because the tissue planes are already disturbed, which is exactly why it should be planned, not rushed.

Why the Implant Surface Is the Whole Story

When patients ask why a Motiva exchange drops the recurrence rate so far, I bring it back to one thing: the surface. The Motiva implants I use have a nano-surface called SmoothSilk, which produces the lowest inflammatory response of any implant I know of. Capsular contracture is fundamentally an inflammatory problem. The capsule hardens because the body keeps reacting to the implant. When the implant barely provokes a reaction, the capsule that forms stays soft and thin.

That is the mechanism behind a sub-one-percent recurrence rate, and it is why I rarely reach for an older-generation implant during a revision. There is no reason to put back the kind of implant that contributed to the problem.

A Revision Is Often an Upgrade

Patients arrive bracing for damage control, and they are surprised when I tell them a revision is frequently a chance to end up better than the original. The new implants are soft, the gummy bear type, and they move with the body and settle into a natural teardrop when you stand. So while we are correcting the contracture, we can also correct a size you never loved, a position that sat too high, or an asymmetry that was there from day one. The same incision usually does all of it.

On Imaging, and Doing More at Once

If you are feeling a change, an ultrasound or MRI helps me confirm whether the implants are intact and whether what you feel is a contracture, scar, or something that needs more attention. I review your imaging before I commit to a plan.

A firm, high, or newly asymmetric implant, especially a change over a few weeks, is worth coming in for. And if you also want to refine your waistline, we can add liposuction and use J-Plasma to tighten the skin in the same setting, so it is one recovery instead of two.

Why I Take Revision Seriously

I am a double board-certified plastic surgeon with a Mayo Clinic plastic surgery fellowship, and I have been a Castle Connolly Top Doctor for thirteen consecutive years. Revision rewards a surgeon who slows down. I want to examine you and review your imaging before I promise anything, because the tissue tells me more than a photo ever will.

See the Patient-Facing Versions

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

Ready to Talk?

If something feels high, hard, or out of place, do not sit on it. Come let me take a look.

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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There is a growing demand for lifting and contouring of the face without surgery. This actually also extends to the breast, body, even the buttocks. I think the growing demand has accelerated due to GLP-1 treatments, where patients undergo rapid weight loss and the appearance of aging shows up much more accelerated. There is also a tendency for maintenance early on, in order to avoid bigger procedures later.

I want to lay out where I think these technologies actually earn their place, and where the field is quietly moving on.

Start With What Aging Actually Is

As we know, aging is a combination of two things: skin laxity and volume loss. In weight loss patients, the skin has already been stretched out. The volume loss shows up as aging. Added to that, the skin that had previously been stretched out is now sagging, so the aging shows up much, much faster than in regular patients.

That is why the GLP-1 patient is changing how this conversation goes. The clock runs faster on them, and the early-maintenance mindset has become the norm rather than the exception.

The Volume Tools, Old and New

We’ve been using fillers underneath the eyes and the temples for quite a long time. The newer volume replacement materials include Sculptra, which is a biostimulator. After it is injected, the body tries to absorb the material and thus produces collagen.

The more exciting category is biostimulating and regenerative. PRP, protein-rich plasma, and PDGF, the platelet-derived growth factor. PDGF has not been cleared for injection, although some practitioners are using it off-label, but it is a great adjunct to any procedure that performs microneedling or resurfacing. It regenerates the tissues quicker, and with the growth factor we get a younger appearance and more protection of collagen.

Lipoderma is one of the newest available fillers. It is a donor-derived fat graft, which has a framework that allows the ingrowth of your own fat cells. This is a more permanent solution, more natural and more like the actual fat that we have in our face, rather than scar tissue or collagen. Tiger Aesthetics is going to come out next year with a similar product called Derma Clay, for the face and hands. They currently have one called Aloe Clay, which we use in the breast and buttock as a natural donor fat graft filler. That filler is more coarse, so it does not work well on the face.

The Tightening Tools

For skin tightening, the best therapies at the moment are radiofrequency. The use of Morpheus8, which is microneedling with radiofrequency, is one of the most sought-after treatments in our practice. We also use FaceTite in the face, which is a more invasive radiofrequency treatment that treats under the skin and above it, and is usually combined with even liposuction of the neck.

We haven’t seen a lot of new technologies in laser, but the fractionated lasers are still the most used. One has to be careful with skin types, as darker skin types tend to create hyperpigmentation or scarring.

Why I Have Almost Left Thread Lifts Behind

I think thread lifts had a peak in the last two years, but patients have found that they’re really not long-lasting. The threads can behave differently on one side of the face than the other and do create asymmetries. Sometimes these threads are not completely absorbed by the body and can be palpated, or give other problems. We’ve really almost diverged away from thread lifts, and we’ve started to do more minimally invasive surgical procedures instead.

That is the quiet shift in the field worth naming out loud. The threads promised a surgical result without surgery, and they did not deliver it consistently enough to keep.

Set the Expectations Honestly

All these treatments are good in the early stages of aging, or weight-loss-related aging, and they usually give subtle improvements. They can correct specific areas like temporal wasting, hollowness underneath the eyes, or nasolabial lines. The longevity depends on the therapy. Regular fillers can last up to a year. Sculptra tends to last longer, as the collagen generated stays around. The new regenerative treatments, like Lipoderma, or in the future Derma Clay, will be longer-lasting, if not permanent. But aging continues once we set the clock back, even in surgical procedures.

The expectations have to be toned down in nonsurgical procedures and well communicated to the patient. This is true especially with skin tightening using radiofrequency. A lot of the tightening is going to depend on the patient’s own response and cannot be foreseen. Every patient reacts differently and gets different tightening results.

The Test That Sends a Patient to Surgery

Here is my rule of thumb. If the patient is consulting with me and they reach up to their face and pull with their fingers upwards, bringing their brows and cheeks and jowls up, or even tightening their neck back, that’s a sign the patient needs a surgical procedure and not a noninvasive one.

The deep plane lift and the endoscopic deep plane lift are great procedures, which create very natural and long-lasting results. We’re seeing patients completely avoid the noninvasive procedures and go straight to the surgical procedures early on. I trained the deep plane facelift the long way, through the Ponytail Academy intermediate course in Pittsburgh and the advanced course in Santa Monica, after a Mayo Clinic fellowship. The patients who skip straight to it are usually the ones who already did the mirror test on themselves.

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. I do both the injectables and the surgery, which is exactly why I can tell you when the injectable is the wrong answer.

Ready to Talk?

If you want the honest read on which side of the line your face is on, that is a consultation, not a sales pitch.

For the patient-facing clinical guide and the mirror test in detail, see the companion post on agulloplasticsurgery.com. For the MedSpa-to-surgery continuum, 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.