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The Bump That Would Not Leave: Wedge Excision and the Art of the Smaller Lip

Black and white editorial still life for a lip lesion wedge excision commentary by Dr. Frank Agullo, MD, FACS.

People assume the operations I love most are the big ones. Facelifts, makeovers, the marathon cases.

Sometimes it is a bump on a lip.

By the time that patient reaches me, she has been at war with a spot the size of a pencil eraser for a year. Creams. Freezing. Injections at two different offices. The thing keeps winning. And the fix, when everything else has failed, takes me forty minutes.

The Part Where I Stop Treating and Start Removing

Here is the shift I make that the previous offices did not. They were trying to shrink the lesion. I stop negotiating with it.

When something on the lip is painful, persistent, and has shrugged off every medical treatment, surgical removal becomes the most reliable option. Not another round of cryotherapy. Out, completely, with a clear margin all the way around, so there is nothing left to regrow.

Why a Wedge and Not a Shave

If the lesion takes up a real portion of the lip, I take it out in a V shape, through the lip, and bring the edges back together.

Shave only the surface and the base stays. Cut out only the spot and you get a notch, a dip in the lip line that everyone sees and nobody can name. The wedge keeps the lip continuous. It reads as a normal lip. Just a little shorter than it used to be.

That is the honest trade, and I make it out loud before anyone books: smaller lip, normal lip. Most patients had a longer lip to begin with, which gives me slack to close without tightness. There is some tension at first. It fades, the lip stretches, and every one of these patients tells me the same thing afterward. It feels better than the bump ever did.

The Scar and the Clock

A fine line where the wedge closes, with a short taper toward the chin so the lip does not pucker. Beard? It disappears. No beard? It softens month by month, the way lip scars reliably do.

Thirty to forty-five minutes. Local anesthesia. Home the same day. Two weeks until the lip stops announcing that something happened.

The Step I Will Not Skip

Everything I remove goes to pathology. Everything. Even when a prior biopsy came back reassuring.

Some of these growths are viral, which means recurrence is possible, and I want to know exactly what we were dealing with. Then we watch the spot together. If anything stirs, we catch it while it is still trivial.

Small Procedure, Full Attention

I am a double board-certified plastic surgeon with a Mayo Clinic fellowship, and none of that is necessary to cut a bump off a lip. It is necessary for what comes after the cutting: a closure that rebuilds the most expressive line on the face so it still looks like it belongs to you.

Rested is the standard for facelifts. For lips, the standard is invisible. Nobody should ever guess.

For the patient-facing walkthrough, see the companion post on agulloplasticsurgery.com. The practice team covers the recovery side on swplasticsurgery.com.

Ready to Talk?

If you have a growth on your lip that will not respond to treatment, let me take a look and tell you honestly whether surgery is the right move. 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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The Profile Fix Nobody Talks About: Why a Chin Implant Beats the Nose Job You Were Planning

Black and white editorial profile portrait illustrating chin implant facial balance. Surgical commentary by Dr. Frank Agullo, MD, FACS.

She booked the consultation about her nose. Convinced, the way patients usually are, that the nose was the villain. So we pulled up her side profile, I laid my thumb over the nose, and she went quiet.

The nose was fine. It was the chin, sitting too far back, throwing off everything in front of it.

That moment happens far more than you would guess. Here is what I reach for when it does, and why I will argue the chin is the most underrated fix on the whole menu.

How to Tell If Your Chin Is the Real Problem

I read the profile from the side. What I want is a clean line dropping from the nose to the lips to the chin. Let the chin fall behind that line and the whole face tips out of balance. The nose looks bigger than it is. The neck looks heavier than it is. Neither one is the real problem.

Most of the time the patient is almost there, needing only a touch of projection. A quarter inch, maybe half an inch, and the profile clicks into place. Small change, outsized payoff.

Will It Make My Face Look Wider?

Only if you want it to.

I always ask the question up front. Narrow, or a little wider? The implant shape goes either way. The one I use is anatomical, meaning it is carved to follow your own bone instead of sitting on top of it like a block. Got a slight indentation on either side of the chin? The anatomical shape fills it. And if it does not fill it all the way, a touch of filler or a little fat down the road smooths the transition.

Why an Implant Instead of Filler

Filler has its place. For previewing a look, for a temporary lift, it does the job. But a real, lasting change to the profile calls for the implant, and I will say so plainly.

Mine is solid silicone. Permanent. Nothing to change out down the line, and it cannot rupture or leak the way people fret about. Need to refine the sides later? Fat is the more permanent touch-up there, though I do not rush to it. We let the swelling settle first, so we are working with what is actually there rather than guessing through the puffiness.

Question Filler Chin Implant
How long it lasts Months Permanent
Best use Preview, small refinement Lasting profile change
Predictability Varies with product Reliable, fixed shape
The procedure A few minutes, a needle About thirty minutes, tiny hidden incision

How Big a Deal Is the Surgery?

Small. The incision tucks right underneath the chin where nobody will spot it, and the whole thing runs about thirty minutes. Local anesthesia works fine if you feel you can sit through it. Prefer it to go quicker? We add a little IV sedation.

Recovery, honestly, reads a lot like a dental visit. Swollen for a while. Your smile might feel slightly off at first from some minor nerve irritation, and then it settles right back to normal. No long downtime on this one.

The Best Place to Use It: In Combination

This is where a chin implant earns its keep. Someone already addressing the neck or the jawline? Adding a small chin implant is easy, and it amplifies the whole result. You can read how I think about the jaw and neck together on the facelift side, and how the smaller in-office refinements fit in at the Med Spa.

A small chin implant beats a much bigger jaw surgery on recovery and still lands a balanced result. I would rather do the smaller thing well than overcorrect and chase it.

The Credential Behind the Restraint

I am double board-certified by the American Board of Plastic Surgery and the American Board of Surgery, a Mayo Clinic plastic surgery fellowship alum, and a Castle Connolly Top Doctor for thirteen consecutive years. The chin is a place where a millimeter or two changes everything, so the goal is balance, not a brand-new face. Done right, no one knows you had anything done. They just think your profile looks good.

Ready to Talk?

If your profile has always nagged at you and you cannot quite name why, your chin may be the answer.

For the patient-facing version of this read, see the companion post on agulloplasticsurgery.com. For the El Paso treatment menu, 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.

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Tired Eyes, Honestly: Eyelid Surgery, Eye Bags, and the Under-Eye Filler I Keep Dissolving

Black and white close study of a woman's eyes in soft light, rested and open. Eyelid surgery commentary by Dr. Frank Agullo, MD, FACS.

The eyes are where people notice age first. They are also where the smallest, best-hidden procedures in my whole practice live.

Patients point at the same things. Heavy upper lids. Puffy lower bags. Hollows that read as exhaustion no matter how much they sleep. And, very often, old under-eye filler that simply never went away.

Here is how I talk about the eyes, candidly.

“Heavy, Uneven Upper Lids. Is That a Muscle Problem?”

Usually not. A true lazy eye is a muscle issue, but in most cases both lids line up the same distance from the pupil, which tells me the problem is the fold and the weight of extra skin, not the muscle.

The fix for the upper lid is surprisingly minor. I remove the fold of skin, and the scar sits inside the new crease. When you open your eyes, you do not see it.

“Will Surgery Change the Shape of My Eye?”

No, and this is the worry I hear most. I am only removing the fold. In most cases I do not extend out to the side, I finish right at the crease, and that is what avoids the pulled, changed look. Your crease is already drawn by your own anatomy, so I follow it. The goal is more symmetric, not different. Faces are always a little different side to side, so I make it better, not identical.

What Eye Bags Actually Are

Lower eyelid surgery removes the fat bag. If you keep your face still and roll your eyes up, you will watch the bags pop out more. Those are what come out.

I do it through an incision on the inside of the lid, so there is no scar on the outside and no external stitches. I add a little fat to blend the transition, and I often pair it with Morpheus to tighten the skin.

Hollows Are a Volume Problem, Not a Bag Problem

If the issue is hollowness rather than bags, I add volume with your own fat. The face has essentially no pain, and fat grafting under the eyes is very safe. I do it routinely, on facelifts and on younger faces that simply have less tissue.

It looks a little full at first, because you absorb about thirty to forty percent of grafted fat, so I slightly overfill. As it settles, it looks completely natural, because it is your own tissue.

My Strong Opinion on Under-Eye Filler

I am cautious about filler in that area, and I have seen what it does. Filler under the eyes can hold water and stay puffy for years, and it tends to migrate rather than fully dissolve.

Fat is the safer, more natural way to address true hollowing. If you already have problem filler there, dissolving it is often the first step before we do anything else.

Eyes, At a Glance

What You See What It Usually Is What I Do
Heavy upper lid Fold and extra skin Remove the fold, scar hidden in the crease
Puffy lower bag Fat bag Remove from the inside, no external scar
Hollow, tired shadow Volume loss Fat grafting, slightly overfilled
Puffy for years Old migrated filler Dissolve first, then reassess

“Will I Have Stitches Across My Lid? Will It Scar?”

Not visible ones. On the upper lid I place the sutures under the skin, so they do not leave the track marks you see in some photos. You might have two or three small ones that fall out on their own. On the lower lid, done from the inside, there are no external stitches at all.

As for keloids, on the eyelids and face they are almost unheard of. Keloids happen on the ears, shoulders, sternum, and joints. On the eyelids, I have never seen one.

What Recovery Is Really Like

The procedure takes under two hours. You are back to normal in three or four days, with some swelling and bruising. If you bruise, it can take up to two weeks, but usually after a week you can cover it with a little makeup. Exercise at four weeks.

To soften any old scars elsewhere, microneedling with PDGF, a growth factor stronger than PRP, works well over a few sessions at the Med Spa. ElixirMD LED therapy can speed the early healing.

Who I Think Should Have It, and Who Should Not

I am as quick to talk a patient out of eyelid surgery as into it. The right candidate can point to one specific thing, heavy upper lids, a lower bag, a tired shadow, rather than asking me to remake the eye. This is refinement, and patients who want transformation are usually asking the wrong procedure for the wrong reason.

The harder conversation is the patient whose tired look is really coming from the cheek dropping or the brow descending. In that face, an eyelid surgery alone chases the symptom. Sometimes the honest answer is a little fat, a brow that needs addressing, or a facelift, and I would rather say that than hand someone a procedure that will not fix what bothers them. Healthy non-smokers heal cleanest, and I am direct about that too.

Why I Work This Way

I am a double board-certified plastic surgeon with a plastic surgery fellowship at the Mayo Clinic, and I teach as a Clinical Associate Professor of Plastic Surgery at Texas Tech University Health Sciences Center Paul L. Foster School of Medicine. Eyelid work rewards restraint. The goal is for you to look rested, not operated on, and that comes from removing exactly what needs to go and hiding every incision.

See the Patient-Facing Versions

For the patient-facing walkthrough, see the companion post on agulloplasticsurgery.com. For the treatment menu, see the version on swplasticsurgery.com.

Ready to Talk?

If people keep asking why you look tired, your eyes may be the answer. Come in and let me take a look.

Call the office at (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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The Facelift With No Visible Scar: Deep Plane, the Neck, and Why I Dissolve Old Filler

Black and white profile portrait of a woman with hair pulled back into a ponytail, jawline catching the light. Ponytail deep plane facelift commentary by Dr. Frank Agullo, MD, FACS.

Most facial consultations begin with the same small gesture. Someone lifts the skin at their cheeks in the mirror, watches the jawline snap into place, and says, “I just want this back.”

Underneath that gesture is almost always the same set of problems. Jowls. A heavy neck. A lower face that sags when they smile. And, increasingly, a face tired of being chased with filler.

Here is how I talk about the fix, candidly.

A Facelift You Cannot See the Scars From

For the right candidate, I use a facelift with no visible scars. The incisions hide in the hairline, which is why it is called a ponytail facelift, and a good portion of the lift is done endoscopically.

It brings the brow up just slightly and lifts the cheek, so that when you smile the lower face softens instead of dropping. You can still wear your hair up.

“Is This Just Pulling the Skin Tight?”

No, and that is the entire point. It is a deep plane facelift, which means I reposition the deeper tissues rather than pulling on skin. That is what makes it look natural and last. You do not end up looking pulled or windswept, because the tension lives in the deep layer, not in your skin.

What the Neck Actually Needs

For the neck, I place a small incision under the chin and behind the ear. Through that I can remove a little of the gland and the deeper fat and build a tight, youthful jawline.

Taking out the deeper fat matters for the long run. Even if your weight changes later, the result will not blur as much, because the fat that tends to come back is more superficial.

And no, most people do not need a chin implant. If you already have a strong chin, the neck lift alone makes it look more pronounced and sharper, because right now it is getting lost.

My Strong Opinion on Old Filler

This is where I will not hedge. Chasing facial aging with more and more filler eventually stops helping and starts distorting, especially stacked over high cheekbones. Old filler often does not fully dissolve. It migrates.

So during the facelift, I can place medication to dissolve some of that old filler, which leaves us working with your own tissues instead of building on top of someone else’s product. I would rather reposition your own anatomy than keep adding to it.

The Add-Ons That Travel With a Facelift

Concern What I Often Add
High forehead, hairline sits high Hairline-lowering incision to move the scalp forward, hair transplant later
Hollow folds, tired upper-eye shadow A little fat grafting, often sparing you an upper eyelid surgery
Old filler over the cheeks Medication to dissolve it during surgery
Slow bruising and swelling ElixirMD LED therapy starting day seven

On the forehead, the rule of thirds says it should measure about the same as the length of your nose. If your hairline sits high, I can make an incision at the hairline and move the scalp forward to close that distance, with a tiny scar in front, and refine it later with a hair transplant. It can be done at the same sitting as the facelift.

For the eyes, I almost always add a little fat to the folds and sometimes the upper eyelid hollows. The fat is permanent and very natural. It is alive, so it shifts a touch with weight, but it erases the tired shadow so you look awake, and it often keeps you away from a separate upper eyelid surgery.

What Recovery Is Really Like

The good news about facial surgery is that it does not really hurt. The pain level is close to zero. What you deal with is swelling and bruising.

Plan on a couple of weeks before you are comfortable being seen, and about six weeks to be ready for a special event. Most people return to work after two weeks, sometimes with a little makeup. We also offer an LED therapy called ElixirMD starting seven days after surgery that roughly doubles the speed of recovery, and Morpheus8 microneedling can refine skin quality later.

Who I Think Is a Candidate

I am candid in the room about who this is for. The ponytail deep plane facelift is for the patient who has real structural change, jowls, a softening jawline, a lower face that drops with a smile, not for someone whose only complaint is fine surface lines that a good skincare plan and a laser would handle. It is ideal for a patient who wants to keep wearing their hair up and who refuses the visible incisions in front of the ears. Healthy patients who do not smoke heal the cleanest, and I will tell a smoker to stop well before I will operate.

The other thing I look for is the neck. So often the neck is the tell, and a beautiful cheek lift over an untreated neck looks unfinished. When I assess a face, I plan the cheek, the jawline, and the neck as one unit, because that is how they age and that is how they should be corrected.

Why I Chose This Approach

I completed my plastic surgery fellowship at the Mayo Clinic and I teach facial surgery as a Clinical Associate Professor of Plastic Surgery at Texas Tech University Health Sciences Center Paul L. Foster School of Medicine. I trained for the deep plane and ponytail technique at the Ponytail Academy in Pittsburgh and Santa Monica. I chose this approach because it lasts and because it looks like you, not like surgery.

See the Patient-Facing Versions

For the patient-facing walkthrough, see the companion post on agulloplasticsurgery.com. For the treatment menu, see the version on swplasticsurgery.com.

Ready to Talk?

If you are pulling your cheeks up in the mirror, that is your sign to come in.

Call the office at (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.