Dr. WorldWide | Frank Agullo, MD

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Australia’s GP-trade journal, Medical Republic, opened a piece on me last month with the line above, and I will admit to laughing out loud when the alert hit my phone. The piece, titled “Jingle bells, your butt smells,” reprinted the four-bullet post-operative hygiene protocol I wrote for Brazilian Butt Lift patients, credited me as a founding vice-president of the World Association of Gluteal Surgeons, and pushed the conversation out of the back rooms of the practice and into the GP literature halfway around the world.

The reason it traveled is that the topic genuinely is one of the least discussed parts of BBL recovery. The reason I wrote the protocol down in the first place is that nearly every BBL patient in my practice eventually asks me a quieter version of the same question. So here is the longer surgeon-to-surgeon version of the protocol, with the clinical reasoning behind each step.

What the Inside of a Fresh BBL Looks Like at Week Two

A BBL is two operations done together. A liposuction harvest from the donor sites, which can include the abdomen, the flanks, the back, the lower back, the inner thighs, and any other compartment from which the fat has been planned. And a structured gluteal injection, in which the harvested and processed fat is distributed in the subcutaneous compartment of the gluteal region using anatomic, low-pressure cannula technique that respects the safe planes.

By week two, the patient is in the compression garment most of the day. She is sleeping prone or side-lying. She is restricted from sitting in the conventional way. Sweating is increased because the garment is occlusive. Lymphatic fluid is weeping slowly through the small liposuction port incisions. The perineum and the intergluteal cleft are spending most of the day inside a humid, occluded, bacterially friendly environment.

That environment, without disciplined hygiene, produces three predictable problems. A surface odor. A surface skin breakdown. And, in the worst case, a low-grade bacterial colonization of an incision that should have closed cleanly. The patient experiences all three as a single, embarrassing question she does not want to ask out loud, and the answer to that question is a protocol she can run at home.

The Four-Part Protocol, With the Why

Chlorhexidine (Hibiclens) as a Body Wash, Days One Through Twenty-One

Hibiclens is a chlorhexidine gluconate antibacterial wash widely used in pre-operative skin preparation. It has a meaningful residual antibacterial effect on the skin after rinsing, which means the protective effect carries past the shower into the hours when the patient is back in the compression garment. For BBL patients, the perineum and intergluteal cleft are the highest-risk zones in the first two weeks, and a daily Hibiclens wash to that area measurably reduces the bacterial load on the skin without requiring a prescription.

Above the neck, normal soap. Off the eyes, the ears, and any frankly broken or rashy skin. In the small subset with a chlorhexidine sensitivity, substitute a different antibacterial wash, but in my practice the substitution is rare and the protocol holds.

Bidet for the Perineum and the Intergluteal Cleft

Toilet paper after a BBL is abrasive, leaves residue, and tends to drag through tissue that has been freshly operated on. A bidet (full installed unit, sprayer attachment, or a peri-bottle, in that order of luxury) rinses without abrading. The compression garment then goes back on over genuinely clean tissue. Dry gently with a soft towel after the rinse. The same hardware that fifty percent of new mothers swear by after a vaginal delivery serves the same function after a BBL.

Two Compression Garments in Rotation, Washed Daily

This is the change with the largest single effect on odor and on incision-site comfort. Own two garments. Wear one. Wash one. Rotate every twenty-four hours. Cold to warm wash with a gentle detergent. No fabric softener. Flat air dry. Dryer heat tends to break down the medical-grade fabric over time. Patients who try to run a single garment for the entire six weeks discover that the inside of the garment is doing a lot of the work the protocol is supposed to be preventing.

Post-Operative Manual Lymphatic Drainage by an Experienced Therapist

Two to three sessions a week for the first two weeks, weekly through week six, tapering through week twelve. The technique mobilizes lymphatic fluid out of the donor sites and the gluteal compartment along the body’s natural drainage pathways. The recognized benefits, less swelling, faster bruise resolution, less fibrosis, better contour at six weeks, are the headline reasons. The hygiene-related benefit, which is less discussed but real, is that a well-drained donor site is a less hospitable environment for low-grade skin colonization than a poorly drained one.

The Protocol at a Glance

Why the World Association of Gluteal Surgeons Exists

I serve as a founding vice-president of the World Association of Gluteal Surgeons. The organization was founded because the BBL became, very rapidly, one of the most commonly performed aesthetic body procedures in the world, and the field needed an organized peer body that could push safety standards, training standards, and post-operative care standards across borders. The hygiene protocol is one of a series of standards that exist because the early operation, while transformative, was also producing avoidable post-operative problems that better technique and better aftercare could prevent.

Ultrasound-guided injection has been the largest single safety advance in BBL technique in the past five years. The hygiene protocol is one of the largest single comfort-and-infection advances in BBL aftercare. Neither is exotic. Both are now table stakes.

What This Protocol Does Not Replace

It does not replace the antibiotic course if one has been prescribed. It does not replace the surgical follow-up cadence. It does not replace the position restrictions and the activity restrictions of the early weeks. And it does not replace a phone call to the operating surgeon if any of the warning signs appear: a fever above 100.4 F, focal redness, swelling, increasing pain, or a frank wound discharge. The protocol is the layer on top of the surgical plan that quietly prevents the problems nobody wants to discuss out loud. The surgical plan, the follow-up, and the patient’s communication with the operating surgeon are still primary.

How I Built the Protocol

I built the protocol the same way every honest piece of clinical guidance gets built. By doing a high volume of the operation, by listening to the patients who came to follow-up visits, and by writing down the steps that, repeated reliably, eliminated the problems they kept describing. By the time the Medical Republic piece picked it up, the protocol had been in my recovery handout for years and the GP author had simply found that handout via the BBL recovery post on my practice site.

It is short. It is repeatable. It costs almost nothing in dollars. And it does as much work as any peri-operative antibiotic in keeping a BBL recovery on the curve the patient expected when she scheduled the operation.

Ready to Talk?

If a BBL is on your mind and you want to know what a serious recovery plan looks like before you book the operation, the first step is a consultation. The protocol is part of the plan from the beginning, not a handout at discharge.

For the clinical patient-facing version, see What Nobody Tells You About BBL Recovery on agulloplasticsurgery.com. For the practice-program version with the in-house recovery support, see The BBL Recovery Program at Southwest Plastic Surgery.

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.

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A UK paper called me on a Friday afternoon last week for a quote on a public figure whose face had been the subject of a thousand “what did she have done” comments online. The reporter wanted a technical read. She had already spoken to a colleague of mine, Dr. Douglas, who had focused on the lower half of the face. She wanted to know whether I agreed.

I did. Not because I had any inside knowledge of the patient. Because the lower third of that face was the part of the face that had changed, and the change was readable from the photographs.

Every plastic surgeon has had this exact conversation a thousand times in private, across a desk, with a real patient sitting on the other side of the desk asking about a feature that is not actually the feature that needs the work. The features the patient points to are almost always the upper or middle third. The eyes. The brows. The cheekbones. The features the surgeon wants to talk about are almost always in the lower third. The jawline. The cheek pad. The perioral region. The chin.

So let me write the long version of why. Not for the celebrity story. For the patient.

The Three Thirds, and What Lives in the Lower One

The face divides into three horizontal thirds. Upper, hairline to brow. Middle, brow to base of nose. Lower, base of nose to chin. Each third ages on its own clock. Each third answers to different operations. Each third tells the surgeon something different.

The lower third holds the jawline border, the jowl, the prejowl sulcus, the labio-mandibular fold, the marionette region, the corner of the mouth, the perioral skin, the chin, the submental fat pad, the platysma, and the cervicomental angle. The cheek pad, anatomically a midface structure, drops down into the lower third as the supporting ligaments lengthen and is therefore best read together with what is happening below it.

The lower third is the integrator. Almost every change in the upper and middle thirds eventually shows up in the lower third. Volume loss in the midface drops into the marionette region. Skin laxity above the jaw drops into the jowl. Loss of mandibular definition takes the line that the eye reads as “young” and erases it. A small chin makes the whole lower face look heavier than it is.

The features a patient points to in the mirror are the noise. The lower third is the signal.

The Five-Minute Read Across the Desk

When I sit across from a new patient, the read happens in the first five minutes, before the patient has finished telling me what she came in for. The order goes roughly as follows.

The mandibular border, angle to chin. Clean line, or interrupted by a jowl that has migrated forward and down over the bone.

The cheek pad position. Sitting high on the zygoma, or slid forward and down into the upper lower third.

The perioral region. Lip volume, vermilion border, philtrum, upper lip length, dental show in repose, dental show in animation, corner of the mouth, marionette.

The chin and the cervicomental angle. Projection in profile. Submental fullness or laxity. Platysma. The line between face and neck.

That read is what shapes the next forty minutes of the consultation. If the patient came in to discuss her cheekbones and the read says the lower face has dropped, we are going to spend the next forty minutes on the lower face, because that is the conversation that produces a plan that matches her actual face.

The Five Forces That Change the Lower Third

There are five primary drivers of change in the lower third, and most patients have more than one of them in play.

Bone resorption. The mandible and the maxilla both lose bone with age. The lower jaw narrows. The chin recedes a few millimeters. The soft tissue above the bone has more space to drift.

Ligament lengthening. The retaining ligaments that hold the cheek pad to the zygoma and the jowl out of the mandibular border lengthen over decades. The soft tissue slides down the rails.

Volume loss. Deep fat compartments shrink unevenly. The midface flattens. The nasolabial fold deepens. The corner of the mouth turns down because the structures behind it have lost volume, not because the patient is unhappy.

Skin laxity. Collagen and elastin both decline. The dermis thins. The skin loses its grip on the underlying structures and starts to read the shape of whatever has moved.

Weight change and prior treatment. Significant weight loss, especially the rapid loss now common with the GLP-1 medications, can age a lower third by a decade in eighteen months. Years of poorly placed filler can create a lower face that reads heavier than it would have aged on its own. I see both of these often enough now that they deserve their own line in the read.

The Operation That Addresses the Lower Third Best in 2026

For most patients with a dropped cheek pad, an early jowl, and a marionette region that has lost its definition, the right operation in 2026 is a deep plane facelift. The deep plane lifts the cheek pad back to the zygoma, repositions the jowl behind the mandibular border, and restores the line that the eye reads as “young.” It does not stretch the skin to do the work. It moves the deeper structures back to where they used to live and lets the skin redrape.

I trained the deep plane facelift the long way around. Mayo Clinic plastic surgery fellowship, then the Ponytail Academy intermediate course in Pittsburgh and the advanced course in Santa Monica, then years of doing the operation. The “facelift won” debate is over. The debate now is how deep, how wide, on whom, and through which access. The answers depend on the lower third.

Why Editorial Reads of Public Figures Are Almost Always Wrong

When a paper or a website asks a surgeon to read a public figure’s face, the answer is usually written in the form of “she had X.” Filler, threads, deep plane, deep neck lift, buccal fat removal, chin implant. The shortcut sells better than the longer answer.

The longer answer is that the change you are reading on a public figure’s face is almost never one thing. It is almost always a combination of things, layered over years, sometimes with a real operation in there, sometimes without, sometimes with a weight change or a hormonal change or a hair change that contributes more than any procedure on the list. Telling the difference from a press photograph is hard. Telling the difference from across a desk in a consultation room, with the patient’s photographs from a decade earlier and the chance to put hands on the face, is easy.

That is why I take the call from a reporter when one comes, and that is why I am careful with my answer. The technical read is fair game. The diagnosis of “she had X” is not.

What I Will Not Do

I will not chase the cheekbone with filler in a face whose lower third has dropped. That makes the lower face look heavier, not the upper face younger.

I will not place a filler pillow under a marionette fold that needs the jowl repositioned.

I will not augment a chin that needs the soft tissue above it moved, not added underneath.

I will not perform a facelift on a patient whose ligaments are still intact and whose lower face is still well-defined, because that patient does not need one yet.

The honest consultation starts with the honest read. The honest read starts with the lower third.

Ready to Talk?

If a facial procedure is on your mind and you are not sure where the conversation should start, the conversation should start with the lower third. We will read it across the desk, set it next to the rest of your face, and build a plan that matches the face in front of me, not the feature you walked in to ask about.

For the clinical patient-facing version of this conversation, see The Lower Third Tells the Story: How a Surgeon Reads a Jawline on agulloplasticsurgery.com. For the practice-program version that lays out the surgical and non-surgical continuum at Southwest Plastic Surgery, see The Lower Face Program at Southwest Plastic Surgery.

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.