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Three Men, 70 to 80 Pounds Down, One Afternoon: The Consultations, Nearly Verbatim

Black and white editorial photograph for male skin removal after weight loss commentary by Dr. Frank Agullo, MD, FACS.

Three men in one afternoon. One lost 70 pounds with diet and exercise and no medication. One lost 74 on a GLP-1 and has kept it off for four months since stopping. One lost 80 over two years and trains five or six days a week. Different roads, same exam: the fat is gone, the skin is still there. I am publishing the exchanges nearly as they happened, identifiers removed.

The first man: tummy and neck

Me: “Have you lost weight? How much have you lost?”

Him: Seventy.

Me: “Oh, great. Congratulations. Let me have you stand. So there’s a lot of excess skin there. To completely get rid of this loose skin, it would be a tummy tuck. The incision is low, so you can hide it with shorts or boxers or swimsuit. I do have to go past where this fold ends to get rid of it completely. I would actually pretty much be able to get rid of everything from here down, and then use this skin, and we just pull it down. I also take some of the fat off of the mons and lift it up, so that also helps make everything nice and smooth all the way down.”

Me: “I suspect that because you were a lot heavier, there is maybe some separation in the muscles, so I actually repair that, so it makes everything tighter as well. And we combine that with liposuction, especially here on the waistline and here on the lower back, the upper back, and the sides. If we only did liposuction, I think we would get rid of the filling, but then everything would sag more.”

Him: And do you use a mesh?

Me: “We don’t really need to. I use it when there’s a hernia or like severe diastasis. If we can avoid putting something that we don’t need in the body, it’s better. Just with the sutures, we get great results.”

Me: “There’s still some visceral fat that, of course, is always pushing out a little bit. So that limits how much I can tighten everything, but I think you’re ready for the surgery, because there’s not that huge amount of fat anymore on the outside. It’s just mostly a lot of loose skin. I have a good handful, so it’s abundant. It’s enough that with liposuction, it’s not going to flatten out. We really need to cut it out.”

His neck

Me: “You have a combination of the fatty tissue that’s on the outside, which is not that much, but there is a fatty tissue that’s a little bit deeper inside, below the muscle itself. And of course, there’s a little bit of the gland here that actually fills that in as well. So to do this, I make an incision that goes right here, and then we do have to make one here on the back of the ear. I may have to go a little bit in front of the ear, because when I do that, it bunches up a little here, so I may have to just tuck a little bit here so that it doesn’t look funny. Once it heals, you really wouldn’t see it.”

Him: Do you recommend doing it at the same time, or doing it later?

Me: “The combination is something we could do together. The big advantage is just having that one recovery versus having to take time twice. The face part really doesn’t add anything to the recovery, because there’s really no pain in this surgery. It’s mostly just waiting for everything to heal and the swelling to go down. The tummy takes a couple of weeks to get back to normal, easy going activity, so by that time, your neck would be pretty much looking really good.”

Him: I work in a very public place, and everybody’s looking at me.

Me: “In two weeks, you would probably be pretty much healed. If you have something really important, I’d say six weeks is when it’s looking its best. But the same thing as in the tummy, if we just did lipo here, you’re not gonna see it because of the loose skin. The face and neck is the first thing. We’re seeing a lot more since Ozempic started. I’m almost doing three or four every week now.”

Him: As far as if you happen to find a hernia?

Me: “If I find it, I’ll fix it. I’m a board certified general surgeon too, so I have a lot of experience with hernias. If I find it beforehand, I’ll charge you a little bit. If I find it while I’m doing it, I just take care of it. There’s nothing additional.”

Him: The hard part is finding someone to help. I’d have to find somebody.

Me: “We do offer an overnight stay for people that don’t have anybody to transport them. We also have a transportation service. Eighty percent of my patients are from out of town, so we know how to deal with all these special situations. My nurse does do a visit at your house the day after, for the first shower and going over all the instructions. You can extend that, and we also have a service where somebody can actually be with you twenty-four hours a day for as long as you want.”

Him: Do you see a lot of male patients?

Me: “Yeah. And especially now with the weight loss, it’s becoming more and more common. You did it by yourself? That’s the hard way. If you did it the hard way, it means that you can really keep it off.”

The second man: tummy and arms

Me: “So you lost 80 pounds? That’s great. Over two years? And are you pretty stable now? Good. So for the abdomen, I do see that you have the loose skin here that kind of flaps over, and of course the fullness here. You don’t have a lot of fat on the outside, so a lot of the bulging here in the abdomen is some of the fat that’s on the inside pushing out, the visceral fat. Plus, when you were heavier, of course, you stretched out the muscles, so it kind of blows up a little bit easier.”

Me: “When you lay down, does it go pretty flat? Let’s take a look, because laying down gives us an idea of how flat we can get it. Yeah, so that looks a lot better. And sit up for me. You see the diastasis here, that’s the muscle separation. So when we put that together, your stomach will look like this when you’re standing.”

Me: “So the arms, you’ve lost the elasticity here. There is a little bit of fat, but nothing major. It’s mostly just loose skin. So we would have to do an incision that goes right here, and with that I can cut all that out and really make it tight so it’s uniform all the way and nothing’s dangling. It hides on the inner part of the arm.”

Me: “So this surgery takes right about five hours. It’s general anesthesia. The tummy takes about two weeks to get back to normal, easy going activity, driving, things like that. And then six weeks where you wouldn’t have any more limitations. The arms really don’t add much to the recovery. The tummy is the main thing. You would have a drain in the tummy area, and that one’s gonna stay between seven and fourteen days. Everybody’s a little different, but what we wanna do is for all that fluid to come out so it doesn’t pool behind your skin, because that can create irregularities or other problems.”

Him: So that two weeks, that’s like no work for two weeks, right?

Me: “You may be able to start doing some at home a little bit earlier, maybe like on day seven or nine. I think the first week’s a little tough, because more than anything, you’re going to feel fatigued, because your body’s working overtime trying to heal everything. It does take about two weeks to feel comfortable driving.”

Him: What about the drain? It’s two weeks with the drain in.

Me: “So the drain is a little tube, and it has a little bulb, and it’s just suctioning fluid into the bulb. Every day, at the beginning it’s gonna be more than once a day, you just empty it into a cup to read the measurement, write it down, flush it down the toilet, and then close the drain and you keep going. You can shower and everything. We’ll give you a lanyard where you can clip the drain to so it doesn’t get stuck on anything.”

The third man: tummy and chest

Him: I was at two ninety-eight. I’m at two twenty-four.

Me: “Did you do any of the GLPs?”

Him: Yes. I stopped it like four months ago already.

Me: “And you’ve been able to maintain? Good. Excellent. So you have a lot of skin here hanging. The incision’s gonna be below that fold, right here, and it’s gonna go to where the fold ends. With that, I can remove pretty much all the skin from here down. Then I use this skin, and that’s the one I’m gonna pull all the way down. And then we can also do liposuction on the mons, remove the fat pads and pick it up. That also helps to show the penis a little bit more, but also so that everything’s nice and flat all the way down.”

Him: And it was like this area too, like here.

Me: “Would you wanna do some on your chest too, or just the sides? So here, what I would do is just liposuction with the skin tightening to get it tight. When I do liposuction here, sometimes we still have this gland here. So through that little same incision, I put in an arthroscopic shaver. I actually take that gland off so that everything is nice and flat, and then we see your muscle instead of any fullness.”

Me: “We can do all that together. It takes about five hours. It’s general anesthesia. We’ll keep you overnight. You go home the next day. If we do the chest area, we also give you like a vest. You will have a drain in the chest and the tummy, and those usually come out in seven to fourteen days. Then with any liposuction, I really recommend doing the lymphatic drainage massages. It just helps get the swelling down faster, and also gets you up and going a lot faster as well.”

One question all three asked, in some form

Me: “If you continue to lose weight, you may see a little loose skin again. You might need like a touch-up. More often than not, no, because I’m really gonna pull on the skin. I’d like you to be pretty close to where you wanna be for the surgery. If you do that, then your results are pretty much permanent.”

My exam notes that afternoon, in order: exuberant pannus with diastasis and submandibular gland show; excess skin with a substantial amount of visceral fat, much flatter lying down, six to seven centimeters of rectus diastasis, no palpable hernias; pannus, rectus diastasis, excess tissue of the chest with fullness and ptosis.

A man who has lost 70 or 80 pounds has already done the hard part. What is left is a skin problem, and skin problems are surgical. Cut out what will not shrink, repair the muscle, lipo the edges, and get him back to the gym in six weeks.

I am a double board-certified plastic surgeon, a Mayo Clinic fellowship alum, and I teach plastic surgery as a Clinical Associate Professor at Texas Tech University Health Sciences Center.

Call the office at (915) 590-7900, text us at 1-866-814-0038, or book a consultation at drworldwide.com.

#StayBeautiful

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Fifty to Eighty Percent, Not Zero

Black and white studio photograph of an adult woman standing in swimwear, photographed from behind, illustrating buttock contour. Illustrative image, not a patient photograph or a surgical result. Commentary by Frank Agullo, MD, FACS.

Two things patients believe about fat transfer, both wrong.

The first is that none of it lasts.

“One of the biggest misconceptions is that all the fat disappears. Patients think that none of it lasts, when in actuality, we do get a fifty to eighty percent retention rate. This could be less than what the patient wanted, but it’s still an addition and not a complete loss.”

The second is that they will see it right away.

“The other misconception is that the results are instant, but the patient has to keep in mind that swelling often hides the results. It does take about four to six weeks to start seeing the actual retention, volume, and new contours.”

Now the rest of it.

“Fat transfer is exactly what it sounds like. We take fat from one place and move it to another place. So a lot of times, patients get a double benefit. They get to reduce the amount of fat from a place they want to reduce, and they get to augment the amount of fat in a place they want to augment.”

The list of places it can go is longer than most people expect.

“In my practice, we routinely do fat transfer to the face, which can go in the temporal hollows, the periorbital area or around the eye, the nasolabial lines, the lips, the jawline, the chin, and the cheekbone area.

“We can also use it to augment the breasts or to hide rippling. We can use it for fixing a bad liposuction where there’s a lot of contour irregularities. We can use it to enhance the buttock, the hips, and the thighs. We can also inject it into the muscles to create muscle definition in the biceps, triceps, trapezius, the calf muscles, and even the thighs. You can also enhance the six-pack by injecting into the rectus muscles.”

On what drives the retention number:

“A lot is determined by the patient’s own healing response and circulation, and also if they adhere to instructions, keeping them away from exercise and on a healthy diet. I often use AuraClens, which contains Poloxamer 188, to wash out the fat graft and also strengthen the cell membrane for higher retention rates.”

If you think you are too lean to donate:

“Although you may think that lean patients don’t have any fat that they can donate for themselves, there are usually areas where some amount of fat can be obtained. And these areas are usually the flanks and the medial thighs.”

And against the alternatives:

“Fillers are going to be more palpable, and fat is going to feel a lot more natural, but it is unpredictable in terms of how much retention we can get. The great thing about fat is that it’s free, and we can use as much as we need to correct the deformity, or augment, or sculpt, versus fillers, which have a cost per unit.”

One condition on all of it:

“Remember that fat grafts will change with the patient’s weight, so it is ideal to maintain your weight over time.”

The graft is living tissue. It gains and loses along with the rest of you, which is the part nobody mentions when they are selling it.

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

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Not Medically Necessary, Until It Is: The Case for Just Removing That Cyst

Black and white editorial still life of a surgical marking pen, fine forceps, and a specimen jar on a bare surface. Minor excision editorial by Dr. Frank Agullo, MD, FACS.

Cindy Crawford built one of the great modeling careers of the century without ever touching the mole on her upper lip. Some moles can be beautiful. She is the perfect example.

Most of the lumps and bumps that walk into my office are not that mole.

They are the cyst on the back that keeps catching on a bra strap. The soft lump on the forearm that has been growing for a decade. The skin tag collection along the collar line. Most patients are self-aware of these. They have been watching the thing for years, and somewhere along the way a doctor told them it was not medically necessary to remove it.

I want to talk about that phrase, because I have seen where it ends up.

The Three Things I Remove Most

Excision of moles is one of the most common minor procedures we do. These are usually on the face, but they can be anywhere in the body. It’s a pretty simple procedure, done under local anesthesia, and patients walk out with a line where the mole used to be.

Inclusion cysts are just as common. These are usually sebaceous cysts, where a hair follicle has been clogged, and the follicle continues to create the oil for the skin. This turns into sebum, which continues to grow. The biggest risk is that it could get infected. And here is the part most people are never told: if you don’t remove the root of the cyst, it usually comes back. Draining one is not removing one.

And then lipomas. These are just fat cells that have gone haywire and continue to grow and create a contour deformity on the skin. They are usually benign, and they are usually more of a shape problem than a health problem, which is exactly why a surgeon who spends his life on contour should be the one taking them out.

How They Compare

Mole Inclusion Cyst Lipoma Skin Tag
What it is Pigmented skin lesion Clogged follicle filling with sebum Overgrowth of fat cells Small hanging skin growth
Main concern Appearance, rule out malignancy Infection, recurrence if root left behind Growing contour deformity Irritation, catching on clothing
Anesthesia Local Local Local, sedation if large Local
Comes back? Rarely when fully excised Yes, unless excised to the root Rarely when fully removed New ones can form elsewhere
Pathology Yes When indicated When indicated When indicated

Not Medically Necessary, Until It Is

A lot of doctors may say, oh, this is not an emergency, you don’t really need to get this taken off, it’s not really medically necessary.

Well, if the cyst ends up getting infected, it becomes an emergency.

You usually have to go to the emergency department and get it drained. The way you drain it is you make a cut over it and remove all the purulent discharge, and get on antibiotics. Sometimes you have to be admitted, because the infection may have spread, and you may even become septic.

So something very simple that can be treated early can prevent a major complication. I always recommend excising the inclusion cyst all the way down to the root, so that we don’t have a recurrence, and we avoid any major complications or emergencies. A planned twenty-minute procedure under local, or an unplanned night in the emergency department. That is the actual choice.

No Insurance, and Why That Is the Point

This part of my practice is cash based. No insurance, on purpose.

The biggest advantage is that there’s no need to preauthorize with the insurance, which can take time and effort. Once we have a consultation, and often this can be done via email, virtually, or in person, you get a quote which includes the entire treatment, with the scar management products as well as pathology if it’s necessary.

Instead of dealing with insurance, where you have to use a surgeon that’s within the plan, you’re free to have surgery with me.

The rough price range for an excision is usually around one thousand dollars, but it could be from five hundred dollars and up, depending on the size and number of lesions, tumors, or skin tags we’re removing. One conversation, one quote, one visit. No codes.

The Malignancy Question

If there’s any suspicion that a lesion may be malignant, or we simply want to rule that out for peace of mind, we send it to the pathologist. We send all lesions when there is anything to rule out. The pathologist can be paid through insurance, or it can be included in the package, and we usually get results within three to five days.

Peace of mind turns out to be one of the most underrated things I sell.

The Scar Is the Whole Argument

Anybody with a scalpel can take a lump off. The reason patients seek out a plastic surgeon is what the spot looks like a year later.

As plastic surgeons, we usually do a layered closure of the incisions, which means we approximate the deep layer, the intermediate layer, and the skin level, so that there’s really no tension on the incision itself, and we get the best possible scarring. And this is usually done not only with the care taken during the surgery and the stitching, but also with the follow-up treatments after the surgery, which include taping, silicone sheeting, scar creams like Skinuva, and at certain points for certain patients, we can do steroid injections, laser resurfacing, or microneedling through the med spa at Southwest Plastic Surgery.

The scar itself continues to get better and better, reaching its final result in about a year. Early on, it may be a little bit red and a little raised, and this continues to get better with the scar protocol. Recovery is the easy part. Most patients return to work the next day with light duties, we wait a couple of weeks before any exercise, and if there are sutures, they come out in seven to ten days.

Most lesions, including cysts, lipomas, skin tags, and moles, can be excised under local anesthesia. The only exception is when these are larger than usual, and the patient may not be comfortable, or they may be anxious about the procedure. That’s when we recommend doing IV sedation. It is rare to have to do general anesthesia for these procedures, but it is possible. And sometimes we do it on small children, because they’re not able to stay still.

I trained in plastic surgery at the Mayo Clinic. I teach it as a Clinical Associate Professor at Texas Tech. I have spent my career obsessing over incisions far bigger than these, and a two-centimeter excision gets the same closure philosophy as a facelift. That is the whole pitch.

Ready to Talk?

If there is a mole, cyst, lipoma, or skin tag you have been watching for years, stop watching it. Call my office at (915) 590-7900, text my consult line at 1-866-814-0038, or book online. Recovery is easy: most patients are back at work the next day. #StayBeautiful

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

Related reading: the clinical walk-through of in-office excisions on agulloplasticsurgery.com, and the practice-side view with scar aftercare options at swplasticsurgery.com.

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One Seam Is Not a Corset: The Triple Plication Tummy Tuck

Black and white editorial close-up of corset seams and laces on ivory fabric in soft light. Triple plication tummy tuck editorial by Dr. Frank Agullo, MD, FACS.

Go pick up any waist trainer in any store and look at it for a second. Count the seams. There are always several, and there is a reason: you cannot cinch a cylinder from one line.

Now here is the strange part. Most tummy tucks, performed by most surgeons, are built on exactly one seam.

I do three. I have been doing three for more than seventeen years, and I remain one of the few surgeons who will. This is the triple plication, the internal corset, and it deserves a proper explanation.

What the One Seam Does

In a traditional tummy tuck, most surgeons will perform a plication of the rectus fascia. Women undergo changes during pregnancy or with weight changes: when the abdomen is fuller, the fascia is stretched, and unlike the muscles, the fascia does not contract back. Exercise strengthens the muscle, but the fascia stays loose, and there’s still an abdominal bulge, or a separation in the rectus called rectus diastasis. I wrote a whole piece on this, the sit up lie, because no amount of core work tightens fascia.

So in a standard tummy tuck, surgeons repair the midline of the rectus fascia to correct the diastasis. This flattens the abdomen and brings in the waistline somewhat. One seam. The front dimension only.

What the Three Seams Do

I like to perform a triple plication. It includes the plication of the rectus muscles down the midline, from the sternum all the way down to the pubis. But then I also plicate the oblique muscles laterally to the lateral rectus fascia, on both sides, which brings in the obliques just like a waist trainer and creates an internal corset.

This significantly reduces the waistline at the same time as it flattens the anterior abdomen. Instead of keeping things in one dimension, just fixing the front, we’re also bringing in the sides. A more wholesome body contouring, front and flanks in the same operation.

Essentially, most surgeons are making a waist trainer with one seam. I use three.

I Did Not Invent This, and That Is the Point

The triple plication is something I have published on, but I can’t take credit for inventing it. The Brazilian plastic surgeons described it many years ago. Somehow, a lot of plastic surgeons never implemented it into their procedures.

My published article covered using a triple plication during a mini tummy tuck, which is possible through a small incision, something patients are always surprised to hear. Seventeen years of doing it has made it a reflex: almost every female patient in my practice gets the triple plication, because a flatter abdomen with a smaller waist is exactly what they came for.

Who does not get it: most male patients, because we don’t want to create a waistline on a man. Who does: male-to-female patients who desire a more feminine figure.

The Waistline Stack

The triple plication rarely works alone. All my tummy tucks include liposuction, especially of the anterior abdomen, waistline, and lower back, and many patients add the upper back and lateral chest. I often combine that with Renuvion J-Plasma for skin tightening.

And for patients chasing the maximum, the internal corset combines with rib repositioning, the procedure marketed as RibX or RibXcar, to bring the waistline in even further. Corset inside, ribs repositioned, fat contoured. That is the whole stack, and I covered the rib half of it in its own article.

What It Costs You in Recovery: Almost Nothing

Here is the honest math on adding two more plication lines. The procedure may increase operating time by fifteen or twenty minutes. It doesn’t change how long drains stay in. It doesn’t change the recovery: two weeks to normal activity, six weeks to running, jumping, and heavy lifting.

Patients do feel a tighter abdomen after surgery. I use Exparel injected into what we call a TAP block, which numbs the area for three days, and I’m happy to say that fifty percent of my patients experience no pain whatsoever. Everybody is different, but it makes the recovery so much easier.

Fifteen extra minutes on the table for a permanently cinched waist. I have never had a patient hear that trade and decline.

Why It Matters

The best thing about this technique is that it creates a much more defined waistline and a flatter abdomen, and that’s what patients want after losing weight or having babies. The one-seam version flattens. The three-seam version sculpts.

I trained at the Mayo Clinic, I teach at Texas Tech, and I have published on this technique. If your surgeon has not heard of the triple plication, the Brazilians and I would both like a word.

Ready to Talk?

If you want the internal corset version of a tummy tuck rather than the single seam, let’s plan it. Call (915) 590-7900, text 1-866-814-0038, or book online. #StayBeautiful

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

Companion reads: the clinical explainer on agulloplasticsurgery.com, and the practice overview at swplasticsurgery.com.

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The Barbie Waist Has a Skeleton: Rib Repositioning, Explained by Someone Who Does It

Black and white editorial photo of a woman with a defined hourglass waist studying her reflection in an arched full-length mirror. Rib repositioning editorial by Dr. Frank Agullo, MD, FACS.

Scroll aesthetic TikTok for ten minutes and you will meet the same operation wearing six different outfits. RibX. RibXcar. Ribella. WASP. RIBOSS. H-Curve rib remodeling. The nicknames are even better: the Barbie waist, or Invisarib.

These are all the same procedure with different names, due to marketing or surgeon preference. We tend to call it rib repositioning. It can also be referred to as rib remodeling or minimally invasive rib contouring.

Whatever you call it, the interesting part is not the branding. It is the anatomy, because the anatomy explains why some waists will not shrink no matter how disciplined the diet is.

Your Waist Has a Floor, and It Is Made of Bone

The waist is defined, or restricted, by the distance between the superior crest of the pelvis and the last rib. In some patients, this last rib almost touches the pelvis, which means that there really can be no further reduction in the waistline. You can lose fat. You can build obliques. The bones do not care.

To create a smaller waist, what we do is cut the outer portion of the last two floating ribs so that we can reposition them in a narrower configuration. That’s the way we create a smaller waistline. We move the floor.

What Changed: From Rib Removal to a Needle

This used to be done by removing the ribs in their entirety, which required a large incision, had an increased risk of injury to the lung or nerves, and sometimes led to chronic pain. That version earned its bad reputation.

The way this procedure is done now is through a small needle incision, using a device called a Piezotome, which is an ultrasonic needle device that helps us cut the outer portion of the rib with ultrasound guidance, and then the ribs are fractured into their new position. Today it is a scarless procedure with substantially fewer risks and complications.

I think this was a controversial procedure when we were removing entire ribs and accepting large scars and increased risks. With this new scarless technique, the risks are minimal. There is no scar. And if we only treat the two floating ribs, it’s an easy recovery. It’s not controversial at all.

The Real Numbers

Two floating ribs Adding the two false ribs
Waist reduction About 3 to 4 inches 6 to 7 inches
Complication rate Under 1 percent Around 1 to 2 percent
Extra requirement None CT scan before surgery
How it works Outer portion cut, ribs repositioned Ribs cut at the cartilage in front and in back, converted into floating ribs, then repositioned

Not every patient is a good candidate for the false rib extension, which is why it starts with imaging rather than a wish list.

Who Actually Books This

The ideal candidate is somebody who wants to reduce their waistline and get a more feminine figure. This is very common in women who have an athletic body build and do not have much waist. It is also very common in male-to-female transgender patients. And it’s very common in women who are already curvy but want to reduce their waist further.

Other times, I see patients who have already had liposuction and tummy tucks and just want even more waist definition, and this would be the last option for them to achieve it.

The Ultimate Waist, Assembled

Rib repositioning rarely works alone in my practice. Liposuction is a very strong tool for the waist contour, and I often combine the two: if you’re able to pinch excess fat in the waistline area, liposuction there buys more definition.

The way I perform a tummy tuck also gives a lot of waist definition, because I plicate the rectus muscles and the oblique muscles. It’s like an internal corset, a triple plication, which brings in the waistline further. (That triple plication deserves its own article, and it will get one.)

And corset training is not a gimmick here, it is the recovery. We actually use the waist trainer for three months to help heal the ribs in their new position. Many patients notice their waist trainer can be placed tighter and tighter as they heal, and they often have to downsize to a smaller waist trainer toward the end of the three months. Watching your own recovery require smaller equipment is a satisfying way to convalesce.

So the ultimate waist definition procedure would be a combination of liposuction, rib repositioning, a triple plication internal corset through a standard or mini tummy tuck, and then the waist trainer for recovery. For some patients this folds into a larger body contouring or mommy makeover plan.

Pain, Risk, and the Three-Month Rule

The risk of injury to the lung, if we’re only targeting the floating ribs, is minimal, probably less than one percent. I inject Exparel in the area prior to the procedure, a local anesthetic that lasts for three days and numbs the area for a much smoother recovery. Most patients describe the pain as mild to moderate, and they feel the waist trainer helps them through it.

The non-negotiable: abstain from strenuous exercise and activity for three months while the ribs heal in their new position.

Why Me, for This

This technology did not come into development until about two or three years ago, so be careful who you let near your ribs. I am a board-certified general surgeon and plastic surgeon, and I have experience with rib fractures and rib removal procedures from both careers. I use the ultrasound to identify the ribs and visualize while I’m cutting the outer table before repositioning, and this decreases the risk of injury to other structures. The Mayo Clinic fellowship taught me many things, and one of them was respect for what sits behind a rib.

Ready to Talk?

If your waist has stopped responding to everything you throw at it, the limiting factor may be bone, and that is now a solvable problem. Call (915) 590-7900, text 1-866-814-0038, or book online. #StayBeautiful

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

Companion reads: the clinical candidate guide on agulloplasticsurgery.com, and the practice overview at swplasticsurgery.com.

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After the Shelf: What a BBL Reversal Actually Involves

Black and white photo of Dr. Frank Agullo in black scrubs making pre-operative markings on a BBL reversal patient's hip in an exam room. BBL reversal editorial by Dr. Frank Agullo, MD, FACS.

A patient called me from the East Coast for a virtual consultation. Years ago I had done her BBL myself, a supercharged one, implants plus fat. Since then she had babies, started her family, and moved somewhere more conservative. She wanted her body back, or at least a quieter version of it. More discreet. More athletic.

She is not an outlier. She is a wave.

I wrote earlier this year about how beauty standards keep moving, and the buttock is where that pendulum is swinging hardest right now. So let me explain what a BBL reversal actually is, because it is more interesting, and more surgical, than the headlines suggest.

Why They Come Back

The most important reason is time. A BBL is a procedure where liposuction is done in the trunk, including the upper back, lower back, lateral chest, abdomen, and sometimes the thighs and arms, and that fat is transferred to the buttock. Once liposuction is done in those areas, they do not increase in volume as much when the patient gains weight. The buttock becomes the one area that increases the most.

So a patient gains weight years later, and the proportions run away from her. The buttock is no longer proportionate, or has developed cellulite or even droopiness. Some patients develop a double butt crease deformity, which patients themselves call elephant butt or frog butt. Their words, not mine, and they are not wrong about the shape.

Another portion of patients have not gained anything. They just want a more natural, less aggressive body contour. And a certain percentage were never happy in the first place: exaggerated hips, too much projection, a lower back scooped too aggressively, a buttock that doesn’t transition well into the thighs.

The Reversal Toolkit

Reversal surgery can involve a combination of a lot of procedures, and the plan is assembled per patient.

Tool What it does
Liposuction Reduces buttock volume and recontours
Renuvion J-Plasma Radiofrequency with helium plasma for skin contraction
Morpheus8, stacked on top Microneedling with radiofrequency, more contraction
Buttock lift, lateral thigh lift Removes loose skin and lifts when volume loss is significant
Miami thong lift Corrects the double butt crease deformity
Implant removal For the supercharged BBLs of the 2010s

The honest caveat: when we perform liposuction, the skin often becomes looser, and the buttock can droop more. Renuvion and Morpheus8 help create skin contraction, but the amount of contraction is hard to predict, as each patient reacts differently to these technologies. If we’re removing a significant amount of fat, then oftentimes a buttock lift, and even a lateral thigh lift, is necessary. Skin quality work continues afterward with microneedling when needed.

I prefer to do the surgery all at once, which gives the best results. The exception is the patient trying to avoid scars, who declines the lifts in hopes that the energy devices create enough contracture. Those patients know that at three or six months, if they develop buttock ptosis or loose skin, the lift conversation returns.

Can You Get Your Old Body Back?

We can get patients to their pre-BBL body, although most patients don’t really want to go that far back. They’re looking for a result in between: tighter contours, tighter skin, sometimes a more athletic look. That target gets set at consultation, along with an honest answer about whether it is achievable given which procedures they are willing to undergo.

How the East Coast Case Went

Her plan: buttock implant removal, liposuction of the lateral thighs, saddlebags, and buttock, a buttock lift with a lateral thigh lift, and a Miami thong lift to correct the double crease and create a sweeping curve where the lower buttock meets the thigh.

Four and a half hours under general anesthesia. Hotel the same day. My nurse saw her the next morning with IV fluids, helped with her first shower, got her into her garments. Lymphatic massages every other day. Drains out on day seven, and she flew home. No complications, and at four months she is mostly healed and very pleased with the new contour. Most of my reversal patients fly in exactly like this; the majority had their original surgery out of town or in another country, usually more than five years ago. This kind of travel case is routine in my body contouring practice.

Recovery in general runs about a week to get back to normal activity and driving, and about four weeks to return to the gym, running, and jumping. The risks specific to reversal are asymmetries, development of cellulite, and buttock ptosis if a lift is not performed at the same time.

No, the BBL Era Is Not Over

The BBL era is far from over. Patients’ desires have shifted, but it really depends on their culture and each person’s definition of beauty. I still perform minimal BBLs, or skinny BBLs. I also still perform some exaggerated ones.

The tendency is toward a reduced size: maybe only the hip dips and a little projection, more of an upside-down heart shape than a shelf, some reduction in hip width. And still, plenty of patients want a very small waist with larger hips.

My tool for keeping everyone honest: photographs. The buttock is a hard anatomical place to describe with words, so I have patients bring pictures of what they want to the consultation, and again on the day of surgery, so that we’re both on the same page.

I served as founding vice president of the World Association of Gluteal Surgeons. I have watched this pendulum from the front row, in both directions. The surgeons who did the shelf era well are the ones patients now trust to quiet it down.

Ready to Talk?

If your BBL no longer fits your life, there is a surgical path back, and it can usually be planned from a virtual consultation. Call (915) 590-7900, text 1-866-814-0038, or book online. #StayBeautiful

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

Companion reads: the clinical reversal guide on agulloplasticsurgery.com, and the destination-patient overview at swplasticsurgery.com.

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Lie Down, Now Stand Up: Why Your Tummy Tuck Did Not Hold, and the Revision That Will

Black and white editorial photo of a tummy tuck revision patient standing in profile before a gold antique mirror, hands framing her waist. Tummy tuck revision editorial by Dr. Frank Agullo, MD, FACS.

“From your photos, it seems that you still have abdominal wall laxity, and when you lay down, this looks like it’s corrected. It also seems like you still have some excess subcutaneous fat between the skin and the muscle.”

That is me, on a virtual consultation last week, reading two photos a patient sent through my tummy tuck revision page. She had her tummy tuck a few years ago in another city. Standing, the abdomen still pushes forward. Lying down, flat.

She asked me if her first surgery failed. Not exactly. It stopped short.

The Part Nobody Repaired

Here is what I told her next, word for word:

“I see patients like you routinely, where the diastasis was repaired, that’s just the separation between the rectus muscles. But during pregnancy, or when patients gain weight and then lose it, the fascia is stretched throughout the abdomen, not just between the rectus muscles.”

The first surgeon fixed the midline. The stretch was everywhere. That is the whole story of most revision consultations, and it is why the bulge survives a technically successful operation.

She had also been working her core for two years on a trainer’s advice. “Performing core exercises will strengthen the muscle, but will not tighten the fascia.” I have written about that trap before, the sit up lie. Revision patients are its most frustrated victims, because they already did everything right once.

The Retightening

“That’s why I often recommend performing a triple plication, where I plicate from the sternum to the pubis, bringing together the fascia of the rectus, and I also plicate the obliques to the lateral edge of the rectus. This is called a triple plication, which in essence creates an internal corset, or waist trainer.”

Regular readers know my analogy for the triple plication. If you look at any waist trainer at any store, you’ll see that there are multiple seams in the waist trainer. Essentially, most surgeons are just making a waist trainer with one seam, versus using multiple seams, in this case three, to bring in the waistline.

In a revision, those two extra seams retighten the fascia the first operation never touched, laterally over the obliques, and they add something the patient did not have even on her best day after the first surgery: a waistline.

The triple plication is something I have published on. I can’t take the credit for inventing it, as it is something the Brazilian plastic surgeons described many years ago. But somehow, a lot of plastic surgeons did not implement it into their procedures. I’ve been performing it for more than seventeen years, which is exactly how long revision patients have been finding their way to my office after one-seam operations.

The Fat, the Skin, the Scar

Remember the second finding in her photos, the excess subcutaneous fat between the skin and the muscle. The wall repair alone does not fix that. All my tummy tucks include liposuction, especially of the anterior abdomen, waistline, and lower back, and I often combine it with Renuvion J-Plasma for skin tightening. A scar that healed wide or rides too high gets revised in the same operation.

So the revision is really three corrections in one: retighten the wall, remove the residual fat, and improve the scar.

Recovery, Second Time Around

Patients brace for a worse recovery than the first surgery. Then I tell them my numbers. I use Exparel injected into what we call a TAP block, which numbs the area for three days, and I’m happy to say that fifty percent of my patients experience no pain whatsoever. Most patients recover in two weeks to get back to normal activity, and six weeks for exercise, running, jumping, and heavy lifting.

Patients do feel a tighter abdomen after surgery. This time it stays tight standing up, which is the entire point.

The Two-Photo Test

Standing, then lying down. If the bulge disappears when you lie flat, the wall is the likely problem, and a wall problem has a surgical answer. If it does not disappear, the answer may be liposuction, or skin, or something else, and I will tell you which.

I trained at the Mayo Clinic and I teach plastic surgery at Texas Tech. Revisions are where that training earns its keep, because the first operation already spent the easy options.

Ready to Talk?

If your tummy tuck left you flatter lying down than standing up, send me the photos. Call (915) 590-7900, text 1-866-814-0038, or book online. #StayBeautiful

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

Companion reads: the clinical revision guide on agulloplasticsurgery.com, and the practice overview at swplasticsurgery.com.