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Who Paid for the Study: The Collagen Question Nobody Asks

Black and white closeup of an adult woman studying her own face and resting her fingertips along her jawline. Illustrative image, not a patient photograph. Commentary on the collagen supplement evidence by Frank Agullo, MD, FACS.

The collagen meta-analysis got quoted everywhere this year. Almost always for its top line, almost never for the finding underneath it.

What the Paper Found

“Oral collagen has real science behind it, in a meta-analysis of 23 randomized controlled trials with almost 1,500 participants. The supplement significantly improved skin hydration, elasticity, and wrinkles. The most common dose was 4 grams per day, with a median of about 3.5 grams per day.”

What the Paper Found Underneath That

“The most interesting thing about this meta-analysis is that it showed only the pharmaceutical-sponsored studies had significant improvement, while the independent studies did not see any change.”

The effect survives in the trials the industry paid for and disappears in the ones it did not. The authors’ own conclusion is that there is currently no clinical evidence supporting collagen supplements for preventing or treating skin aging. Both sentences live in the same document, and only one of them made it into the coverage.

That pattern is the reason to read aesthetic evidence by funding source before reading it by result.

Two Grams in a Bag of Chips

“Two grams of collagen in a bag of chips sits at the bottom of any range that has been studied. And keep in mind that the studies used a daily dose for three months, every single day. A bag of chips is not really recommended as a daily dose, so somebody eating these a few times a week is only getting a fraction of the dose studied to provide results. I think the same goes for the collagen coffee creamers and waters.”

Why It Is in Everything

“I think the reason the collagen ended up in these products is because it has marketing power for beautification, but also it’s flavorless, and it dissolves easily into foods and fluids. It’s an easy additive.”

Flavorless and soluble is a manufacturing property, not a clinical one.

Where I Land

“In conclusion, collagen is one of the few supplements in aesthetics that actually has some science behind it, and improves hydration, elasticity, and wrinkles. Patients should take 3 to 4 grams per day for at least three months, which puts them in the range that has actually been studied.”

Cheap and safe, and worth the studied dose if you want to take it. It is not a substitute for radiofrequency microneedling or medical-grade skincare, where the evidence is not split by who wrote the check.

The clinical version of this, with the dosing detail, is in the clinical version on agulloplasticsurgery.com. My earlier read on collagen formats covers powders, serums and gummies.

Frank Agullo, MD, FACS. Call (915) 590-7900 or text 1-866-814-0038, or book online.

#StayBeautiful

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A Peptide Is a Size, Not a Promise

Black and white still life of small glass peptide vials on a dark surface. Editorial on peptides by Dr. Frank Agullo, MD, FACS.

A peptide is a size designation, nothing else. Insulin is a peptide, and the contents of the vial someone ordered at two in the morning from an online store is also a peptide. Treating those two things as one story is how the public ended up this confused.

U.S. News asked me about peptides earlier this month. That is where I started, and it is where anyone honest has to start.

Take the Word Apart First

A peptide is defined as a chain of amino acids normally composed of anywhere from two to about fifty in number. It is a size range, not a drug class nor a benefit.

Insulin is a peptide, just like the peptide in an antiaging serum, just like the compounded vial someone ordered from an overseas website. They have all been thrown into the same box together, making people think they are identical, hence the rampant, widespread confusion on the issue.

Most marketing makes these products out to be better than they are, and the vagueness of the word is exactly what makes that possible.

The Serum on Your Counter

In short, the science is good, not great.

Copper peptides and signal peptides used in some consumer skincare have lab studies that show they can stimulate collagen synthesis, and a small selection have proven in trials to smooth fine wrinkles modestly over several months of regular use.

Then physics gets a vote. Delivery limits how much of this can penetrate the outer layer of the skin, which consists of dead skin cells built up as a shield designed to keep outside contaminants like large molecules, especially water-loving ones, from entering the body.

So here is the rule I give patients. A peptide is a reasonable addition to a product where a sunscreen and a retinoid are doing the real work. It is not a replacement for either one.

When a client tells me their plan for anti-aging is a peptide serum, that is when I feel a little uneasy. It is a quiet harm that we miss discussing within the safety debate.

Nobody gets hurt by the serum. They get hurt by the decade they spent on it instead.

The Vial in the Refrigerator

My real issues began with the injectable and compounded peptides.

It is about impossible to go a month without seeing at least one patient who is self-injecting peptides obtained without a prescription from who knows where, for an injury, for joint pain, or for what they are calling recovery. BPC-157 comes up all the time, and growth hormone secretagogues are about the most frequent second thing asked about, usually phrased as anti-aging.

Very few of them know how little human research is available on these compounds, know that most dosage regimens have been picked up from bodybuilding forums, or know that the vial is coming from an overseas research-chemical company, with no guarantee as to contents, purity or whether it is a sterile preparation.

I have seen and operated on patients with abscesses as well as infected lesions at injection sites that stem from these supplies.

That is not a warning I am passing along. That is an operation I performed.

What I Now Ask Before I Operate

Before operating, I routinely ask my patients if they have been injecting peptides, much like asking about their supplements, mainly because I have no idea what is in the vial my patient received and neither do they.

The Part Everyone Is About to Get Wrong

If some peptides could now go through licensed compounding pharmacies with an actual prescription, that would be safer than the massive, unregulated market people are already buying from on the internet. I am in favor of that.

The big risk is that people read the news and think a scientist gave their blessing simply because it became more available.

Expanding legal options answers the question, who is allowed to make these? It does not address the question of how effective these peptides actually are. One of those questions deals with legal access and the other asks about scientifically verified results, yet they will both get treated the same.

Allowing a pharmacy to compound it means a pharmacy can make it. Allowing them to make it does not mean it will work.

Where I Land

Peptides are not peptides, and one answer is not the answer.

Topical peptides applied to the skin are mostly not toxic and, in most circumstances, they have been exaggerated. Peptides that are compounded or injected are promising enough to merit genuine study, and they are already used a great deal, far ahead of the studies and with almost no supervision.

Both of those sentences are true at once. Any coverage that picks one and runs with it is going to mislead somebody.

Why I Get Asked

I am board certified in plastic surgery. I practice in El Paso, Texas, and I am a Clinical Associate Professor of Plastic Surgery at Texas Tech University Health Sciences Center Paul L. Foster School of Medicine. I also sit on the editorial boards of Aesthetic Plastic Surgery and Plastic and Reconstructive Surgery Global Open.

I am not against peptides. I am against a word doing the work that evidence is supposed to do.

Ready to Talk?

If you are injecting something and cannot say what is in it, bring the bottle. 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 plain guide to what is in the bottle at swplasticsurgery.com, and the surgical safety piece on agulloplasticsurgery.com.

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The Glow Is Real: What Skin Boosters Can and Cannot Do

Black and white close-up of a gloved injector's hands treating a patient's cheek with a fine needle. Skin booster editorial by Dr. Frank Agullo, MD, FACS.

Patients ask me about Jalupro several times a week because they see it on social media.

Injectables and skin quality treatments are a large portion of my practice. Yes, I do skin boosters, biostimulators, and fillers. I also train people to inject.

So understand that I am not arguing against the category. I sell the category. Forbes asked me about Jalupro in July, and this is the longer version of what I sent them.

What the Category Genuinely Does

Chasing volume versus treating skin quality is a real change in aesthetics, and I see it every day. Whether Jalupro itself is a new era is a different question. It is HA plus amino acids, and studies that look at Jalupro alone are typically small and often industry funded.

When I inject skin boosters, I notice the skin improves in hydration and texture as well as increases light reflection. This is a real result.

Light reflection. Not lift, not volume, not tightening.

Where the Promises Outrun the Evidence

But it is a subtle one, and much of the marketing promises things that have never been evidenced by any clinical studies.

You may also want to know it is not approved by the FDA as an injectable here in the USA, which is why most of its following is in the UK and Europe.

Skin boosters like Jalupro treat skin quality instead of shape, and that is genuinely new for an injectable. The results are real but modest, better hydration and texture for a few months at a time. When someone on social media promises a lifted face from a skin booster, that is marketing, not medicine.

What to Expect, and What Not To

The one misconception I fix most often is how a skin booster operates versus a filler, or whether one can skip a surgical procedure altogether.

Skin boosters will not lift anything up. They cannot return volume where none exists anymore. They cannot tighten sagging skin at all meaningfully. Results vary between different people. They last temporarily, and they do not necessarily guarantee an effect after one treatment.

If your jawline has dropped and your midface has fallen, that is a facelift, or it is acceptance.

What a Course Actually Costs You

It is doubtful that someone with significant laxity, major deep folds, or a great deal of volume loss will notice anything enough to shell out the kind of money this procedure requires. A course usually means 2 to 4 sessions plus maintenance, so the total spend adds up quickly for a subtle result.

The length of time before you need maintenance is similar across the injectable options, with most lasting roughly 3 to 6 months.

What I Rank Highest

At this moment in time, Profhilo, polynucleotides, and microneedling occupy the same skin quality column and add nothing in terms of volume. Profhilo is the more commonly known of the HA boosters, and has worked similarly to Jalupro in my personal experience. In the US, the FDA approved option in this family is SkinVive by Juvederm, and that is what we offer at our med spa.

I am, however, encouraged by the early data that has emerged on polynucleotides. These show particular promise for the area surrounding the eyes.

Microneedling has the longest track record and the most independent evidence, especially when combined with radiofrequency. Microneedling combined with growth factors, PRP or PDGF, shows the most promise with a true change at the microscopic level.

The least fashionable option has the best evidence.

When I Say Wait

I do not treat patients who are pregnant or breastfeeding with Jalupro or any skin booster. Unfortunately, there is no safety data available for use in this patient demographic. In patients suffering from active skin infections or those who poorly control autoimmune diseases, I suggest caution with Jalupro or similar skin boosters.

Why You Can Trust the Answer

I am board certified in plastic surgery. I practice in El Paso, Texas, and I am also a Clinical Associate Professor of Plastic Surgery in the Texas Tech University Health Sciences Center Paul L. Foster School of Medicine. I trained at the Mayo Clinic and I have been a Castle Connolly Top Doctor for thirteen consecutive years.

I would rather lose a booster sale than have a patient work out six months from now that hydration was never going to lift her face.

Ready to Talk?

Bring the screenshot to your consultation. If what you saw will not work on your skin, I will say so. 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: what The Medspa actually offers at swplasticsurgery.com, and where skin quality sits next to surgery on agulloplasticsurgery.com.

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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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Nothing Gets Cut: Preservé and the Preservation Era Comes for Breast Augmentation

Black and white editorial still life of delicate ivory lace lingerie folded on linen in soft light. Preservé breast augmentation editorial by Dr. Frank Agullo, MD, FACS.

Preservation is the most important word in plastic surgery right now. Preservation rhinoplasty keeps the nasal structures intact. The deep plane facelift respects the anatomy instead of fighting it; I have written the facelift version of this argument before. The whole idea is to preserve as many of the structures that are naturally there without dividing them or cutting them.

Breast augmentation just got its preservation moment, and I was in the room when it arrived in this country.

It is called the Motiva Preservé technique, and the name is literal. We’re not cutting any nerves, arteries, or breast tissue. Nothing gets cut. Let me walk you through what that actually means, because it changes almost every number patients care about.

A Pocket Without a Blade

A traditional augmentation and a Preservé share the basics: an implant, and a pocket to hold it. I use Exparel on all my patients either way, injected between the ribs to numb the breast for up to three days.

From there the two operations separate. The Preservé incision sits in the inframammary fold, but it is much smaller, about two and a half centimeters, an inch. The patient can be under light sedation. And there is no cutting involved in creating the pocket, and no electrocautery either. Instead, we create the pocket with a dilator and a balloon, precisely made above the muscle, behind the breast tissue.

Then the implant, a Motiva Ergonomix, the gummy bear type, goes in through a Keller funnel. The whole procedure takes thirty minutes or less.

The Ligaments Do the Work

Here is the part I find most elegant. Because nothing is divided, the natural breast ligaments survive intact, and they now act like a mesh that keeps the implant in the pocket.

Two things follow from that. By using these ligaments, we get a lot more of a lift from the breast with just the implants. And we obtain greater volumes in the end result using smaller implants. The breast is lighter, but we get more out of the implant in terms of size compared to a traditional augmentation. Smaller implant, bigger result, better support. That arithmetic does not exist in the standard operation.

No Muscle Release, and What That Buys You

The implant goes above the muscle, behind the breast gland, so the muscle does not need to be released as in a dual plane augmentation.

Long term, when patients exercise, flex their pectoralis muscles, or do upper body weights, the implant does not animate. There is no motion. It looks a lot more like a natural breast in that respect, and this technique prevents animation deformity altogether. Muscle function is not jeopardized, strength is not affected, and it is very athlete-friendly.

The short-term version is just as striking: patients notice immediately after surgery that they can raise their hands above their head without any discomfort or pain. Back to work the next day. Gym within two weeks. A traditional augmentation runs about a week to return to work and four weeks to exercise.

The Honest Limits

This is not the operation for everyone, and I would rather tell you that here than in a consultation you paid to attend.

The implant ceiling is 325cc. If a patient desires more than a two cup size increase, we need a traditional augmentation over the muscle, or dual plane. And significant breast ptosis is not solved by this procedure alone; those patients need a breast lift at the same time. The patients who seek out Preservé are chasing the natural result and the ultrafast recovery, and those it delivers.

The implant choice is also not negotiable. The Motiva Ergonomix is really the only implant that can work through such a small incision and tunnel; other implants would easily rupture. Its surface has been studied thoroughly and creates the least inflammatory reaction with the body compared to other implants, and the Motiva line carries a capsular contracture rate under 0.5 percent and a rupture rate under 0.5 percent, well ahead of its competitors.

Where I Fit In This Story

I was one of the very early adopters of this technology. I was in the select thirty-surgeon group that launched the procedure in the United States, chosen by Motiva, and trained in Costa Rica with the surgeons who developed and invented this technique.

I have now performed more than fifty Preservé procedures. I haven’t had to do any revisions, although it might be a little too soon to tell, and I say that out loud because honest data matters more than marketing. What I can say without hedging: my patients have been very happy, every one has returned to work the next day, and they have resumed exercise two weeks later.

The full technique details live on my Motiva Preserve technique page, and the implant background on the Motiva breast implants page.

Ready to Talk?

If a natural result and a next-day recovery sound like your version of an augmentation, come talk about Preservé. 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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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.

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You Cannot Unstretch an Ear: What Gauge Repair Actually Rebuilds

Black and white editorial still life of a black ear gauge plug retired beside fine surgical sutures on a linen surface. Ear gauge repair editorial by Dr. Frank Agullo, MD, FACS.

Half the gauge repair consultations in my office start with a job application on somebody’s phone.

Most of the people who show up for an ear gauge reversal or earlobe repair do so because they’re joining the workforce. Jobs like the military, police, and border patrol require the earlobes to not be gauged. This is usually due to the risk of the earlobes getting caught or torn. I practice in El Paso. Border Patrol hires a few miles from my office. You can guess how often I see this.

A lot of patients are also joining professional jobs and have decided to clean up their look, so they appear more appropriate for their job position. It is rare, but sometimes it is in preparation for weddings or other special events. Grandma has opinions.

Whatever the reason, they almost all arrive with the same wrong assumption. They think I am going to close the hole.

We Do Not Close Gauges. We Rebuild Earlobes.

Here is the part nobody explains at the piercing shop. We really don’t close your gauges. What we do is reconstruct the earlobe with the skin and fatty tissue that’s left after stretching out the gauge.

Essentially, any size gauge can be reconstructed, even if it has been torn. The bigger the gauge, the more the remaining tissue has been thinned and draped into a hanging loop, and the more sculpting it takes to turn that loop back into something that reads as an earlobe.

This is also why gauge repair is different from an earlobe tear repair, which is usually just trimming the edges and bringing the tissues together. With a gauge, we usually discard some of the tissue, and we actually have to reshape the skin into an earlobe. One is a seam. The other is a rebuild.

There is not one standard technique. The repair is planned for each individual case, depending on how much tissue is left, how much skin, and the quality of the skin and tissues. I have never drawn the same plan twice.

The Timeline, From Chair to Uniform

Milestone When
The procedure About 30 minutes, local anesthesia
External sutures out 7 to 10 days
Eligible to join military or law enforcement As early as 7 to 10 days after suture removal
Back to exercise About 2 weeks
Re-piercing possible 4 to 6 weeks
Hard to tell the ear was ever gauged About 3 months

That third row matters most to my recruits. For military and law enforcement applicants, it is usually a requirement that the ears are not gauged, for safety reasons. We treat these patients very often, and they can join the forces as early as seven to ten days after we remove the sutures. If you have a ship date, tell me at the consultation and we will work backward from it.

Yes, You Can Wear Earrings Again

You can re-pierce your ears after a gauge repair. We usually wait at least four to six weeks, and we can do it in the office. We just need an earring stud that we can keep in place for at least a month, and we sterilize it before placing it so the new piercing heals.

A normal stud, through a normal lobe, that you put there on purpose. Full circle.

What It Costs and How It Heals

The cost range usually starts at fifteen hundred dollars, and it depends on how much the ear has been gauged, how much tissue is left, and the complexity of the reconstruction. Like my earlobe tear repair and in-office excisions, this is cash based with one upfront quote, and a photo is usually enough to price it.

It heals very well. Usually, after three months, it would be difficult for anybody to tell that the patient had a gauged ear before. The scars are very difficult to identify or see. If skin texture needs a final polish, laser treatments can refine it, but most patients never need that.

The Part Where I Am Blunt

I don’t think a lot of surgeons in other specialties actually know how to repair gauged ears. It’s really something that plastic surgeons have been trained for, as we take care of a lot of ear deformities and trauma. Congenital ear differences, torn lobes, cancer reconstructions, keloids. The earlobe is small, but it sits next to your face in every conversation you will ever have.

So for a procedure like this, I would look for a board-certified plastic surgeon. I trained at the Mayo Clinic and I teach plastic surgery at Texas Tech. I can tell a closed hole from a rebuilt earlobe across a room. Everyone else can too.

Ready to Talk?

If a gauged ear is in the way of a job or a uniform, send me a photo and we will quote it, usually the same week. Call my office at (915) 590-7900, text the consult line at 1-866-814-0038, or book online. Sutures out in a week. Uniform shortly after. #StayBeautiful

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

Companion reads: the clinical walk-through on agulloplasticsurgery.com, and the practice overview at swplasticsurgery.com.