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He Broke It With a Baseball: A Septorhinoplasty Consult, Nearly Verbatim

Black and white editorial photograph for septorhinoplasty commentary by Dr. Frank Agullo, MD, FACS.

He had never had surgery. He exercised four times a week. He was not on any medication. The only thing wrong with him was a nose that had been crooked since a baseball hit it when he was a kid.

I am publishing this consult nearly as it happened, identifiers removed, because the questions men ask about their nose almost never get answered out loud.

Him: I broke it when I was young. It was a baseball. But ever since that, I’ve had complications and I know I have trauma inside. You can tell it’s kind of deviated. So I wanted to get that corrected. But if I’m going to do that, I might as well get the exterior as well.

Me: “Do you have problems breathing?”

Him: Yes. I get congestion right away. But I’ve lived like this for a long time, so it’s kind of normal for me. I do notice that I get congested a lot if I start doing exercise.

Me: “And what would you want to change about the way it looks?”

Him: Pretty much, I want to straighten it out. And I noticed that the tip is a little bit down. And I know the bridge here is kind of low. I don’t like that look, it’s too low for me.

He had already been to someone else

Him: I had an appointment with somebody else. The way they wanted to make my nose was too small for my face.

He had gone home, downloaded an app, and made his own version.

Him: I actually liked it more.

He was right. I said it out loud: “It doesn’t balance.”

What I found on exam

Me: “Your nasal base is a little bit wide. So we do bring these bones in, and that helps me straighten everything out. So they probably healed a little bit off. I’m going to look inside just to check your septum too.”

Me: “Your nose looks really irritated. I feel like you have a lot of allergies. And then your septum is going this way. So there’s a lot less space on this right side, and the left side is very open.”

Me: “So we’ll straighten that out. The breathing should improve, but it’s not going to change the congestion when it gets congested or there are allergies. Really, we can’t do much about that, but we can make it structurally more open.”

The tip, and why it barely moves

Him: Doctor, I don’t want my nostrils to be too…

Me: “No, we’re just going up a little bit, so really we shouldn’t change the nostrils at all.”

Me: “It’s just the tip a little bit, because on men we still like a right angle here. We don’t want to make it bigger than that, that’s more feminine.”

Him: So by lifting it, it won’t make it more round or anything?

Me: “No, it’s just going to rotate it up a tiny bit. We’re talking about like two millimeters.”

Him: And the tip of the nose, is it going to be kind of rounded?

Me: “Do you want to change that?”

Him: No.

So we left it.

Where the cartilage comes from

Me: “For this, I have to put in cartilage to fill that in, so it’s permanent and you don’t have to be adding anything else later. So first I’ll use the cartilage that’s in your septum. If it’s not enough, then we do have donor cartilage that we can use. It’s irradiated, doesn’t have any cells, but it saves me and you from having to get any from your ear or your rib, which can be more painful. So this makes it a lot easier, because the rib hurts a lot. And the ear can be uncomfortable too, and sometimes it can make it look funny too.”

The turbinates question

Him: Inside we have the ones that filter the air, the turbinates. Are those going to be reduced?

Me: “So they don’t look big, but on this right side, usually when your septum is deviated, the open side gets bigger, but in your case it’s not that big. So if anything, when I’m in there, if I see that they’re a little bit big, what I do is I fracture them and that makes them shrink a little bit. But I don’t think you need to get mucosa removed or anything like that.”

The scar

Him: The incision right here, am I going to have a visible scar?

Me: “You’re going to have a scar, but it’s going to be very hard to see. Usually it heals in a way that nobody sees it, and you’ll have to look at it in a mirror like this to see it.”

Recovery, in his words and mine

Me: “So it’s an open rhinoplasty. We’ll get everything centered, and the surgery takes about two, two and a half hours. It’s general anesthesia, you go home the same day. I do have to put splints on the outside and on the inside, so it might be a little stuffy for about seven days, then we’ll remove everything. At that point, your breathing should be better.”

Me: “You’ll see the changes in the nose, but it’s still going to be a little swollen. So it’s probably going to take a couple of weeks to start looking better and better. And then about six weeks, we’re pretty close to what it’s going to look like, but the nose itself takes about a whole year for it to keep getting better and better.”

Me: “But the good thing is that there’s no pain after surgery, so it’s a relatively easy recovery. We do have to wait about six weeks before going back to exercise. And going back to normal activity, you’ll feel fine after about three days. It’s just a matter of whether you want people seeing you with the splint or not.”

Me: “If you get any bruising, sometimes you get bruising, I would say only twenty percent of our patients get any bruising underneath the eyes, it can take two weeks to go away, and you can always put a little makeup on if you want to hide it.”

The last thing I told him

Me: “In the beginning, it may look a little extra. Because some of that gets reabsorbed, so we have to plan on it, on how it’s going to come down a little bit.”

He asked me to follow his own simulation during the surgery. I told him I would save it and reference it in the OR. That is not a concession. A patient who can show me what he wants has already done half of my planning for me.

My exam note from that afternoon: sunken and relaxed dorsum, deviation to the left with a subtle deviation to the right, previous trauma, slight downward tip rotation. Plan: rotate the tip up about two millimeters, shave the hump, add a graft for the radix, straighten the nose.

The takeaway

An old broken nose is a structural problem before it is a cosmetic one. The septum and the outside are the same operation. The tip on a man moves two millimeters, not ten. And the version of your nose that looks right is almost never the smallest one on offer.

I am a double board-certified plastic surgeon, certified by both the American Board of Plastic Surgery and the American Board of Surgery, a Mayo Clinic fellowship alum, and I teach plastic surgery as a Clinical Associate Professor at Texas Tech University Health Sciences Center.

Ready to Talk?

If you have been breathing through one side of your nose since middle school, you do not have to keep doing it. Call the office at (915) 590-7900, text us at 1-866-814-0038, or book a consultation at drworldwide.com.

#StayBeautiful

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

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I Have a Hair Transplant: What FUE Actually Looks Like From the Other Side of the Chair

Black and white editorial photograph for FUE hair transplant commentary by Dr. Frank Agullo, MD, FACS.

Hair consultations are different from the rest of my practice. Nobody walks in with a wish photo of a celebrity. They bring a photo of themselves, from a few years ago, and they want that hairline back without anyone knowing.

A patient came in recently, 37, never had any treatment before. He brought a picture of his own face. I am publishing the exchange nearly as it happened, identifiers removed, because these are the same questions I get every time.

My exam note from that day: bilateral temporal recession points with loss of hairline definition. Plan would be to graft these two areas with as many follicles as possible. 2,500 to 3,000 follicles and may need a repeat procedure.

Me: “Okay, so I do see that you have the temporal recession areas on both sides, and the front is also thinning out a little bit. And I got your wish picture, which creates a very tight straight hairline. So there is a lot of area we have to fill in to create that. But it is definitely doable. It looks like you have good donor hair.

“So there’s two ways of doing it. Are you familiar with the strip and the FUE?”

Him: No, I kind of read it a little bit. Any recommendation of which one would be better?

Me: “Sure. I see that on the back you like to wear it short.”

Him: Yeah, usually from the sides it can’t be that long. Usually I had it like kind of a high fade.

Strip Versus FUE

Me: “Right. So when people wear the hair short on the back, that’s where we get the hair from. So those are the follicles that we use to fill in the front. So one way to take them from the back is doing the FUE, which is the one by one, the neograft. We take them one by one, it heals in, and you don’t see any scars. The other one is doing a strip where I actually cut like a sliver of hair follicles or scalp, but it does leave a scar. So if you wear your hair short, you would see that long scar.

“So in your case, probably the best is gonna be the FUE, which is the one by one, so you don’t have any scars, and we transfer those from the back and we put them in the front one by one, so it looks very natural. I have a hair transplant, so it really looks very natural, and of course, you can do everything normal afterwards, so you can do sports, swimming, you can dye your hair, everything’s back to normal.”

Him: For the haircut you gotta be like a little bit meticulous with that area?

Me: “No, after everything’s healed, everything’s back to normal. There’s zero special care.”

Follicle Count and the Day Itself

Me: “The main thing here is filling in that area. It’s a pretty big area. With the FUE, we can do maximum twenty-five hundred, sometimes twenty-eight hundred follicles. The procedure takes about six to eight hours. We give you a little bit of sedation through an IV so you’ll be comfortable, you’ll sleep through most of it. And then you need about a week for everything to heal and set in.

“After a week, you’re back to normal. You can do normal activity, exercise, running, jumping, swimming, everything back to normal. For this procedure, we do have to shave the hair down all the way to be able to get the hairs one by one. We could spare the top, we could do just the sides if you want to keep the top, or we do the whole thing, whichever is better for you.”

Why Your Hair Type Matters

Me: “So the idea is obviously to fill in as much as we can and get the tightest hairline possible. It is possible you may need another treatment later to make it even fuller, more dense. I think with the first treatment we can get pretty close to what you want, but we may need to add density later. Your hair is good because it’s coarse and it’s a little bit curly, so that covers a lot more than fine hair. So I think we’re gonna get a really nice result for you.”

Timing Around Travel

Him: Does it matter whether I do it before or after?

Me: “No, it really doesn’t matter, it just depends on your timing. You gotta keep in mind your haircut, but the hair grows really quick so you really just need a week where you’re here, and that’s all you need, whether it’s before or after, whichever works better for you, and my coordinator can help you find the right dates.”

The Timeline Nobody Wants to Hear

Me: “Yeah, we can do it after, no problem, as well. There’s no rush. Remember the hair does take four to six months to start growing. So at six months we’re only like fifty percent of the results. At a full year, year and a half is when we have a hundred percent of all the hairs are growing. The graft take is very high, usually ninety-nine percent. We do use PRP, which means we draw a little bit of your blood and get the platelets, and we inject that into the area so that the hairs grow faster with the growth factors, and we get that really high take.”

Him: I was actually completely bald, so for me, it made a huge difference to have hair again.

Me: “Exactly. Psychologically, it really gives you more self-esteem and you feel better. So it is a procedure I highly recommend. There’s really no pain afterwards, it’s easy recovery. You may get a little swollen around your eyes for two or three days but it is, I think, one of the ones where everybody’s happy.”

The takeaway

FUE if you wear your hair short, because there is no line to hide. Twenty-five hundred to twenty-eight hundred follicles in one session, six to eight hours under IV sedation, one week local. Then wait. Four to six months before anything grows, fifty percent at six months, the full result at a year to a year and a half. That last part is the whole job of the consult.

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.

Ready to Talk?

If your hairline has been bothering you and you want a straight answer about what FUE can and cannot do, let’s talk. Call the office at (915) 590-7900, text us at 1-866-814-0038, or book a consultation at drworldwide.com.

#StayBeautiful

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

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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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The Triangle Under the Cheekbone: Buccal Fat, Done on the Right Face

Black and white editorial still life for buccal fat removal commentary by Dr. Frank Agullo, MD, FACS.

Buccal fat removal is having its internet moment, which means I now spend part of every week talking someone out of it.

That is not because the procedure is bad. In the right person, removing a portion of the buccal fat pad brings out the cheekbones and gives the face a triangular, sculpted shape, a small procedure with a genuinely big effect. It is because the procedure only works on the face that actually has the fullness. Done on the wrong face, it does nothing good, and the wrong faces are lining up for it online.

So the first job, before any discussion of incisions or recovery, is deciding whether you are the right face. Here is how I decide, in the words I use in my own exam room.

The Candidate Question Comes First

The mistake is doing it on somebody who does not really have the fullness. If you have a genuinely round face with fullness in the lower cheeks, you are a good candidate. If you are thin there already, taking that fat out will only hollow you as you age.

So I look first, and I am honest about whether it will help you. Some of the best outcomes of this procedure in my practice are the patients I sent home without it.

The Aging Myth, Retired

The fear I hear most: will removing cheek fat make me age faster? It is a reasonable worry, and it is misunderstood.

The buccal fat pad is not the fat your face relies on for support. Watch where we place filler as people age: up on the cheekbone, never down in the buccal area, even in very old patients. The buccal pad gives you lower-cheek fullness and nothing else. Removing the right amount takes away roundness. It does not take away the scaffolding that keeps a face looking young. In fact, slimming the lower face makes the good fullness up on the cheekbone read even better.

Inside the Mouth, Under Thirty Minutes

Everything happens inside the mouth, so there is no visible scar. The pad itself starts in the cheek and extends up toward the temple, and I remove only the portion that sits in the cheek, through two small incisions about a centimeter each on the upper inside of the mouth. Sutures go in, and the incisions heal within about five days.

The procedure runs under thirty minutes, under local anesthesia or light sedation. You go home the same day.

The Recovery Curve, Honestly

The next day you will be a little swollen, a lot like having your wisdom teeth out. The worst day is the third day. Then it gets better and better, and by day six or seven most people around you will notice nothing. Ice and sleeping propped up speed the settling. Soft food at first, no chips or spicy food, and no working out for a week so you do not invite swelling. You are essentially back to normal at two weeks.

Planning around an event? Book it six weeks or more ahead, and you will be photographing your final result rather than fighting swelling in the pictures.

The Pairings That Build the Triangle

For many round faces, buccal fat removal is half of the answer. It targets the fullness in the front of the cheek. Masseter Botox, placed in the chewing muscle at the angle of the jaw, shrinks the back half, and the two together create a stronger triangle: buccal in front, the shadow of a slimmer jaw behind. Remember that masseter Botox works on a different clock, taking about six weeks to show because we are waiting for muscle to shrink, and it can be done at the same sitting.

For a more powerful change, I often add liposuction of the lower face and neck through a tiny incision behind the ear. Whenever I lipo the face, I take a pass on the neck too, which sharpens the jawline. That adds perhaps some neck bruising that fades within two weeks, and a light facial garment for the first five days.

About Those Cable Lines You Have Seen Online

The strange cord-like lines people fear are fibrosis, and they come from two errors: taking out too much fat, and skipping the aftercare. That is why I leave a little fat behind rather than chasing the maximum, and why I insist on lymphatic massages afterward, done here in the office. The massages pull the fluid out and let everything heal smooth. Skip them and you invite exactly the problem you were afraid of.

And two reassurances I give constantly: your dimple stays, since it is not touched, and people actually pay me to create dimples. And the fullness up on your cheekbone is never touched either. That is good fullness. We keep it.

Why Restraint Is the Skill

I am double board-certified by the American Board of Plastic Surgery and the American Board of Surgery, a Fellow of the American College of Surgeons, and a Mayo Clinic plastic surgery fellowship alum. I treat the face as one connected unit: buccal pad, masseter, jawline, neck.

The art of this procedure is not the removal. It is knowing how much to take and what to leave, so the result reads as a naturally sculpted version of you rather than a hollowed one. Restraint is the difference between the before-and-afters people want and the cautionary threads they read.

For the patient-facing version, see the companion post on agulloplasticsurgery.com. The med spa pairings live with the team at swplasticsurgery.com.

Ready to Talk?

If your lower face has always looked rounder than you would like, come in and let me look. I will tell you honestly whether buccal fat removal will sculpt you or hollow you. Call (915) 590-7900, text 1-866-814-0038, or book online at agulloplasticsurgery.com. #StayBeautiful

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

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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.

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The Ozempic Earlobe: What Weight Loss and Heavy Earrings Do to Your Ears

Black and white editorial close-up of a single pearl drop earring resting beside fine suture material on a linen surface. Earlobe repair editorial by Dr. Frank Agullo, MD, FACS.

A bride-to-be sat in my office earlier this year with a problem no one warns you about. She had lost about fifty pounds with Ozempic in a four-month period, and noticed that her earrings didn’t sit the same way anymore. Her earlobe had become empty and wrinkly.

She was young. In her thirties. The weight loss was a win. Her ears did not get the memo.

Nobody thinks about earlobes until theirs stop cooperating, and then they think about them constantly. Wedding photos have a way of accelerating that timeline.

The Earlobe Has a Rough Job

The most common cause of earlobe tears, or elongated piercings that haven’t torn quite yet, is the chronic use of heavy earrings. It’s a gradual stretching that happens over time.

And as we age, we also lose some of the fat and collagen in the earlobes, which decreases the tissue strength, and the stretching or tearing can speed up. Then there is trauma: the earring getting stuck on something and pulling, or a baby pulling on the earring. Every mother of a grabby infant knows exactly the moment I am describing.

The GLP-1 era added a new chapter. Aging earlobes have actually increased in demand, not just because of aging, but also because of the GLP-1s like Ozempic and tirzepatide. Patients lose the good fat in the earlobes, and these become deflated or elongated. Everyone talks about Ozempic face. The earlobes deflate right along with the cheeks.

The Repair Is Simpler Than You Think

The repair itself is rather simple. The first step is to do it in a sterile fashion, so we sterilize the area to decrease the risk of any infection. Then we use local anesthesia, which is infiltrated into the earlobe. This is the part that can sting a little bit, but it’s very quick. After that, the whole area is anesthetized, and you don’t feel anything.

Depending on how big the tear or stretch is, we cut out that area, and then we suture it in a layered fashion, approximating the deep tissue coming all the way up to the superficial skin layer. The procedure usually takes fifteen to thirty minutes. And to keep the ear natural, we rearrange the tissues so there’s no puckering or indentations. That last sentence is where the plastic surgery training earns its keep. Anyone can close a tear. The art is a lobe that looks like nothing ever happened, the same philosophy I bring to my in-office excisions.

A partial tear versus a complete split changes less than people expect. The approach is about the same. The only thing that’s affected is the length of the incision, and whether it goes all the way to the edge or can be repaired within the tear itself.

And a fact that surprises patients: not all tears happen on the earlobe. They can happen anywhere there is a piercing, including the belly button, genitalia, nose, and the helical rim of the ear. We repair those too.

Refilling the Deflated Lobe

For the empty, wrinkly earlobe, we can do various things that involve filling the earlobe back.

Option What it is How long it lasts
Hyaluronic acid filler (Juvederm, Restylane) Injectable gel, done in minutes Temporary, repeat about every year
Lipoderma Donor fat injected into the lobe Longer lasting, what I used for the bride
Your own fat Harvested and injected Long lasting, requires a small harvest
Trim and tuck Surgical reduction of redundant skin Permanent reshaping for elongated lobes

For the bride, we used Lipoderma, one syringe on each earlobe. That filled in the void of the earlobes, plumped the skin, and actually reduced the size of her piercings, so that the earrings were now sitting like they used to. The whole procedure took about thirty minutes or less. She went back to work the next day, and back to the gym in five days. She was very happy overall, and I suspect the wedding photographer never knew.

Maintenance for filler options lives at the med spa at Southwest Plastic Surgery, alongside the laser treatments we use when skin quality needs help too.

Re-Piercing: Yes, You Can

The question every patient asks before I finish the first sentence: when can I wear earrings again?

To re-pierce, we usually wait three to six weeks depending on the area. For ears, it’s usually three weeks, and we can re-pierce right here in the office. We sterilize the earring or stud that you’re going to use, which will need to remain in place for about a month before it can be taken out. Then wear what you want. Maybe rotate the chandelier earrings to special occasions this time.

What It Costs

The cost range usually starts around a thousand dollars, and the final cost depends on the type of anesthesia, the location, and the size of the defect. Like the rest of my minor procedure practice, this is cash based with a single upfront quote, no insurance and no preauthorization. A photo by email is usually enough to quote it.

I trained at the Mayo Clinic and have spent two decades repairing tissue far more complicated than an earlobe. This is one of the smallest operations I do, and one of the most quietly satisfying. Patients hide torn ears behind their hair for years. Fifteen to thirty minutes later, they stop.

Ready to Talk?

If your earlobes are torn, stretched, or deflated, send a photo and we can usually quote the fix without a visit. 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 step-by-step on agulloplasticsurgery.com, and the practice overview with med spa options at swplasticsurgery.com.

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The Field Is Diverging From Thread Lifts: A Surgeon’s Read on Nonsurgical Lifting in 2026

Black and white editorial portrait of a woman in profile in soft side light, jaw and cheek defined. Nonsurgical lifting commentary by Dr. Frank Agullo, MD, FACS.

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

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

Start With What Aging Actually Is

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

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

The Volume Tools, Old and New

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

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

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

The Tightening Tools

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

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

Why I Have Almost Left Thread Lifts Behind

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

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

Set the Expectations Honestly

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

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

The Test That Sends a Patient to Surgery

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

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

The Credential Behind the Opinion

Double board-certified by the American Board of Plastic Surgery and the American Board of Surgery, American College of Surgeons Fellow, Mayo Clinic plastic surgery fellowship, Clinical Associate Professor of Plastic Surgery at Texas Tech University Health Sciences Center Paul L. Foster School of Medicine, and Castle Connolly Top Doctor for thirteen consecutive years. I do both the injectables and the surgery, which is exactly why I can tell you when the injectable is the wrong answer.

Ready to Talk?

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

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

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

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