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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.