Dr. WorldWide | Frank Agullo, MD

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Last week HuffPost ran a piece by a mother of three who paid out of pocket to repair the abdominal wall that pregnancy had separated. The editor reached out to me for the surgeon’s perspective. I will repeat here what I told them.

Insurance companies will prescribe painkillers for decades to manage the back problems caused by an unrepaired diastasis recti. They will not pay to repair the separation itself. They will call the repair cosmetic, because the separation is not an emergency. That word, “cosmetic,” is doing an enormous amount of work in that sentence, and most of it is wrong.

Diastasis recti is not a flat-stomach problem. It is a structural problem with a cosmetic side effect.

What Diastasis Recti Actually Is

You have two long bands of abdominal muscle running down the front of your torso, one on each side of your midline. They are connected in the middle by a thin sheet of connective tissue called the linea alba. Pregnancy stretches that sheet. So does certain types of weight gain. In some women, the sheet stretches and recovers. In others, it stretches and stays stretched, and the two muscle bands stay further apart than they were before.

That is diastasis recti. The muscles themselves are fine. The wall between them is not.

When the wall between them is loose, the core can no longer brace the way a closed abdominal wall braces. Standing posture changes. The lower back has to do more work. Pelvic floor symptoms get worse. Some patients develop a visible dome that appears when they try to sit up out of bed. Some develop a true ventral hernia at the umbilicus and need a repair regardless of how the rest of the abdomen looks.

None of that is cosmetic.

How to Tell Diastasis Recti from the Other Things It Gets Confused With

This is the comparison most postpartum women are not given. They walk into a primary care visit, they describe a soft belly that did not bounce back, and they leave with “try some core work.” That is sometimes the answer. Sometimes it very much is not.

The table is honest about what physical therapy can do and what it cannot. For some patients, a good pelvic floor and core program closes the gap enough that they live a normal active life. For others, the connective tissue is permanently stretched, and no amount of training will rejoin it. PT cannot reattach a ligament. PT cannot close a hernia. PT cannot bring two muscle bellies that have been pulled apart by three pregnancies back to the midline.

When PT is the answer, I send patients to PT. When PT is not the answer, I tell them that too.

Who Is a Candidate for Surgical Repair

I look for three things in consultation. First, a real, measurable diastasis on physical exam, ideally confirmed on ultrasound or CT if the case is complicated. Second, symptoms that match the anatomy: back pain that started or worsened after pregnancy, core weakness, pelvic floor strain, the visible dome, or an umbilical hernia. Third, a patient who is finished having children and is at a weight she can hold steady through recovery.

If all three are present, surgical repair (most often as part of a tummy tuck, sometimes as a standalone abdominal wall reconstruction) is the operation that actually solves the problem. The rectus muscles are plicated back to the midline with permanent or long-acting suture. Loose skin and stretched lower-abdominal tissue are addressed at the same time. A hernia, if there is one, is repaired in the same operation.

That is a real surgery. It is not a vanity procedure. The fact that the patient also looks like herself again when she heals does not retroactively make the medical problem cosmetic.

Why the Insurance Argument Bothers Me

Here is what insurance pays for happily. Years of physical therapy that did not work. Anti-inflammatory medications. Muscle relaxants. Eventually opioids for the back pain. Specialist visits for the pelvic floor. Hernia repairs when the umbilical hernia finally herniates, because at that point the structural argument is impossible to deny.

Here is what insurance will not pay for. The one operation that addresses the root cause before the years of medication and the eventual hernia repair.

That is not medical sense. That is accounting.

I told HuffPost what I will tell you. The word “cosmetic” is being used as an exclusion code, not a clinical description. Diastasis recti repair has a strong functional rationale. The peer-reviewed literature has been catching up for years. A handful of insurers are starting to cover it under narrow circumstances. Most still will not.

Why You Want This Done Right

A diastasis repair done poorly recurs. The suture line pops, the dome comes back, the symptoms come back, and the patient now has a scar and a redo on her list. A diastasis repair done well lasts decades.

What separates the two is technique. The closure has to be tension-balanced and layered. The plication has to extend the full length of the diastasis, not just the visible portion. The surgeon has to understand the umbilical stalk well enough to address a small hernia if one is hiding there. The recovery instructions have to actually protect the repair while it heals.

I trained in general surgery before I trained in plastic surgery. I did my plastic surgery fellowship at Mayo Clinic. I teach abdominal wall and body contouring as a Clinical Associate Professor of Plastic Surgery at Texas Tech University Health Sciences Center. I have been Castle Connolly Top Doctor for thirteen consecutive years. I am explaining the procedure to you the way I explain it to the residents and fellows who scrub with me. Because that is the version that actually holds up.

Why Choose Dr. Agullo

Double board-certified (American Board of Plastic Surgery, American Board of Surgery). Fellow of the American College of Surgeons. Mayo Clinic plastic surgery fellowship. Clinical Associate Professor of Plastic Surgery, Texas Tech University Health Sciences Center. Affiliate Professor, UTEP. Castle Connolly Top Doctor, thirteen consecutive years. Founder of Southwest Plastic Surgery and Plastic Surgery Studios. Quoted in HuffPost, USA Today, Allure, Texas Today, and Featured.com on procedures across the face and body. Over 3.5 million followers across Instagram, TikTok, and Snapchat.

Ready to Talk?

If you have been told for years that what you are feeling in your abdomen is “just being a mom,” or that the back pain that started after your last delivery is something you need to live with, come see me. I will examine you, tell you whether what you have is a diastasis, and tell you honestly whether surgery is the right answer for your case. If physical therapy is still your best move, I will say that. If repair is the right answer, I will explain what that operation involves and what your recovery looks like.

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

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A patient came in last week and put her phone on my desk. Photo of her vanity drawer. Serum she couldn’t pronounce. Her mother’s old YSL lipstick. A small fridge pouch with a vial of compounded semaglutide. Which of the three, she asked me, was actually doing the work.

Keep all three. Probably not for the reasons she thought.

This kind of question hits my office a lot now. Several times a week. Eighteen months ago it was once a month. And the women asking aren’t the ones with a hundred pounds to lose. They eat clean. They do Pilates. They’re stuck on the last fifteen before a wedding, a fiftieth, or a surgery date already on my books. Ozempic. Mounjaro. Now, more and more, the third one. The one their trainer keeps name-dropping. Retatrutide.

So let me answer the way I’d answer across the desk, without the marketing copy.

Three vials, three generations

The brand names dominate the popular conversation. The compounds underneath are not the same drug.

Semaglutide is the one everyone started with. Single receptor. Mimics GLP-1, the gut hormone for satiety. Translation: walks into your brain and tells you you’re not hungry, and means it. Trial data puts loss around fifteen percent of body weight by twelve months. Life-changing for plenty of people. On some faces, it also produces the hollow look the wellness columns have been calling Ozempic face. I’ll get to that.

Tirzepatide added a second receptor. GLP-1 plus GIP, an insulinotropic peptide. What the GIP receptor does, on the data we have, is two things. It spares a bit more lean mass. And it pushes loss past where sema usually stalls. Twenty percent at twelve months is where good responders are landing in the trials. In my program, tirz is where I move someone after sema plateaus and the scale stops moving.

Retatrutide is the newest. Three receptors. GLP-1, GIP, and glucagon. Early-phase data is striking. Patients pushing toward twenty-five percent loss at a year, which is a number that didn’t exist in this category two years ago. We offer it as a compounded formulation. Not casually. The patients we put on it are screened with a level of caution that the popular coverage hasn’t, frankly, been encouraging.

These are not interchangeable shots. Choosing among them is a clinical call. Not a pricing decision.

The face the internet noticed

So about that hollow look.

Weight comes off the face first. Cheeks lose volume. Temples sink. The jawline appears, but the skin that draped over a fuller face is now draping over nothing. People call it Ozempic face. A surgeon calls it volume loss layered on top of skin laxity that the weight had been hiding.

Not a reason to skip a GLP-1. A reason not to take one in a vacuum.

The fix, when needed, is the kind of thing I do every week. Filler done by someone who actually does faces. A deep plane facelift if the laxity is real. A skin program in any case. What I do not want is the patient who spent six months losing weight and only realizes at month seven that no one on her care team was thinking about her face. Body and face are one conversation. They have to be.

Where this gets interesting

This is the side of the GLP-1 story I find more fascinating than anyone else seems to. The wellness press isn’t writing about it. The trainers aren’t. The patients usually haven’t put the pieces together yet.

A patient drops thirty to forty pounds in three months on one of these drugs (a number we see week in and week out now) and walks into my body contouring consult a meaningfully different person than she’d have been at her starting weight. The fat is gone. The skin envelope she’s wearing was sized for the fat. That gap is where my side of the work begins.

I lay hands on an abdominal wall that, three months earlier, would’ve been hidden under a layer of subcutaneous fat thick enough to bury the rectus muscles. I feel the diastasis through skin. A real triple plication is suddenly on the table. So is a waist reduction I used to reserve for thinner patients. The BBL I’d have offered her at her starting weight isn’t the BBL I’d offer today. Proportions changed. Canvas changed. What I can build on it changed.

The GLP-1 didn’t produce that result. It let me do the operation I’d have done anyway, except now the operation hits twice as hard.

That’s the quiet thing nobody’s writing about. The aesthetic ceiling on body contouring went up the day this drug class went mainstream. Every plastic surgeon I know who’s been operating on bodies for fifteen-plus years is having some version of this realization, mostly in private, mostly over coffee at the annual meetings.

How our program runs

Patients ask less than they should about how a weight loss program is supervised. So here is ours.

I am the medical director. My nurse practitioner runs day-to-day. I stay in the loop on dosing, intake, and any patient who needs a second medical opinion before we change anything. Labs at intake, no exceptions. Nobody on my team hands a vial to a patient who has only filled out a form.

That sounds heavier than the GLP-1 you can have shipped after a five-minute online questionnaire from an Instagram brand. The point is that it is. Pancreatitis is the side effect that should make patients nervous about how they get their drug. A flare on a shot you ordered yourself becomes a 2 a.m. trip to an ER where a stranger has to figure out what you took and at what dose. The same flare on the same drug, prescribed in our program, is a phone call to my office, where your chart is already open.

One more thing about the glow

A patient asked me last month, half-joking, whether the program would make her glamorous. I told her it would not.

What it will do is hand her back a body she can dress, photograph, and walk into a room in without the internal commentary that comes with the wrong size of denim. That is what patients are pointing at when they say glow. The rest of glamour, the part the wellness press is trying to bottle, is built out of unsexy fundamentals nobody puts on a billboard. Sleep. Skin care. The correct surgery if and only if. A stress level somewhere south of catastrophic.

I have been doing plastic surgery long enough to watch four or five “miracle” technologies arrive and underdeliver. The GLP-1 class, on the evidence so far, is the rare one doing more than it advertised. That deserves real respect, and respect means running it like medicine, not a cosmetic line.

Why this lives inside a plastic surgery practice

A weight loss program in 2026 isn’t an isolated medical service. It’s a step inside a longer arc. Face, body, skin, recovery, sometimes surgery. Pretending otherwise is how patients end up disappointed by the result they paid for.

I’ll say it. The Mayo Clinic fellowship taught me, above everything else, to treat volume, skin envelope, and structural support as one system. Not three. One. The thirteen straight years on the Castle Connolly list, the Texas Tech academic appointment I’ve held since 2011, the peer-reviewed work, all of it points the same direction: stay close to what actually moves a patient’s outcome, and let the rest go. None of that overlapped with weight loss medicine until the medicine started visibly reshaping who walks into a body contouring consult. Once that happened, sending the program to a med spa across the parking lot was never going to be my answer.

So I run it. With my NP. With my chart open in front of me on the days a patient needs an actual physician on the line.

Ready to talk?

A GLP-1 is a medication. The first move should be a conversation, not a prescription. Bring your goals. Bring any recent labs. Bring a photo of the version of yourself you are trying to come back to. If surgery is also on your mind, we plan the arc together. If the only goal is to drop fifteen pounds and feel like yourself again in clothes, that is a real goal too, and we run that program with the same care.

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