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Most Surgeons Will Not See Another Surgeon’s Patient. I Do.

Black and white photograph of a woman in a long dark coat seated alone in an airport lounge at night, seen from behind, a small suitcase beside her. Illustrative image, not a patient. Commentary by Frank Agullo, MD, FACS.

“Most surgeons do not accept patients from other surgeons, which makes it difficult for these patients to obtain optimal treatment. We are here for patients, and we are available if we can help.”

I understand the no. Liability, no operative report, somebody else’s judgment in the wound. I still think the no is wrong, because the patient is standing in El Paso and the surgeon is in Miami.

“These are patients that have had their procedures done elsewhere. Most commonly they have traveled outside of El Paso. They are locals; they come from and live in the El Paso area or the Southwest. They’ve had their surgeries done throughout the United States, but most commonly in the Florida, Miami area, or in Mexico. After their surgery, they still need aftercare. Whether it is routine or not, they find themselves in a bind because they cannot easily travel back to see their surgeons.”

The Line I Will Not Cross

“In the early stages, we really cannot revise any of the surgery itself.”

Drains, sutures, seromas, scars, massage, LED, fluids. Yes. Reopening someone else’s work in week two. No.

The Phone Call

“Communication with the other surgeon is ideal, but it is not always possible, or desired by the patients themselves. Oftentimes the patient has been in communication with the other surgeon’s office, and they have recommended certain treatments, whether it’s a drain placement or a splint removal after rhinoplasty, suture removals, or even a drain removal.”

The ER Is Not Me

“In terms of when to go to the ER, this is very clear, and the patient should already have these instructions from their original surgeon. This includes any changes in vital signs, such as low blood pressure, tachycardia, which is a high pulse rate, fever, lightheadedness, or fainting; redness, purulent discharge, changes in the color of the drain output, specifically if it becomes white, yellowish, or creamy; a fluid collection that keeps growing, shortness of breath or chest pain, swelling in the legs or tenderness in the calves, a breast that suddenly gets larger and painful, or uncontrolled bleeding.”

The Revision Question

“Some patients do come in unhappy with their results and are looking for a revision surgery. This is not possible in the early stages, and patients are usually told to wait until healing has been achieved, which can vary depending on the procedure from three months to a year. For their own particular reasons, many surgeons do not perform revision surgeries on other doctors’ patients. At Southwest Plastic Surgery, I believe that we are here to help patients, and we do perform revision surgeries on other surgeons’ patients, as long as we believe that the results can be improved and that the patient’s expectations are appropriate.”

The full list of what my office does, what it needs from you, and how it is billed is on agulloplasticsurgery.com. The med spa side of recovery is on the Southwest Plastic Surgery post. And if you have not operated yet, read flying in for surgery first.

Why Choose Dr. Agullo

Double board-certified, by the American Board of Plastic Surgery and the American Board of Surgery. Mayo Clinic plastic surgery fellowship. Clinical Associate Professor of Plastic Surgery at Texas Tech University Health Sciences Center. Castle Connolly Top Doctor for 13 consecutive years.

Ready to Talk?

Your surgeon is a flight away. I am not. (915) 590-7900, text 1-866-814-0038, or book at agulloplasticsurgery.com/appointments. #StayBeautiful

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

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AI Invented the References: A Surgeon on What It Can and Cannot Do for Your Doctor Visit

Black and white editorial photograph of a patient holding a phone in a waiting room, for commentary on AI and the doctor visit by Dr. Frank Agullo, MD, FACS.

A reader asked whether they could use AI to get more out of a doctor visit. I am going to give the answer I actually gave, because the polite version is less useful.

“Your reader is actually right, and that’s making a lot of doctors uncomfortable. With AI, you have unlimited time and patience, and there are no interruptions. The limitation, and the benefit, is that AI can fill in the gaps during the doctor visit, but it cannot fill in what the doctor can actually do or prescribe or treat.”

Unlimited time and patience. No doctor has that, and pretending otherwise helps nobody.

What it is genuinely good at

“I feel AI is a great tool for preparation for a doctor’s visit, and it’s even a good tool to summarize and review the information afterward. It’s generally good at explaining and simplifying medical information and complicated words. It’s really good at gathering information and putting it in a timeline, which can be very helpful when you’re describing your problems to the doctor. It’s also great at putting together questions you may want to ask during the visit.”

The questions are the part I would not skip.

“This is where most patients stumble. Once the visit is over and the doctor says, ‘Do you have any questions before stepping out?’, a lot of patients blank out, and having something written down definitely helps. Doctors actually like it when patients have questions ready. Sometimes patients feel like they have to make up a question when they don’t have one.”

The hard limit

“I would never trust it with anything that requires a physical exam. AI has now been trained to recognize photos and evaluate lesions, but it cannot touch and feel the way we do when we perform a physical exam, to evaluate hernias or rectus diastasis, masses or lumps in the body or breast, skin laxity, and quality of skin.”

Skin quality is the one I would point at. Two people can photograph identically and have completely different tissue under the hand, and that difference is what decides the operation. It is the whole reason a tummy tuck plan cannot be made from a picture, and the same hand exam is what routes someone toward a MedSpa treatment instead.

“It’s also not good at predicting results, especially in cosmetic or plastic surgery, where a patient may upload a photo and ask for the postoperative result, which may or may not be a good expectation or even a possible one. This is where the surgeon’s experience and assessment of each patient’s anatomy and tissues comes in.”

The part that should worry you

“It’s really difficult to recognize hallucinations or wrong information, because AI always feels like an authority, all-knowing. I’ve had experiences where I’m researching a topic and AI comes up with completely false references to support what it’s saying. So this is really the difficult part, and the one where the doctor can come in and rectify and explain what is actually happening, or what’s actually in the literature. So many times when I’m researching a topic, after I receive an answer I’ll ask for references, and then I’ll go look for the source to see if it exists, and read about it to make sure it’s factual. Sometimes, if the information seems strange, I’ll ask again in another question, and a lot of times it will recognize that it made a mistake and rectify it.”

That is my actual habit, and I would recommend it to anyone. Ask for the references. Then go find them. It is the same standard I hold myself to when I write about a procedure here.

“And one of the most dangerous answers AI can give is false reassurance, that you shouldn’t be worried, that it’s really nothing, when in fact it may be, and only a doctor can make that determination.”

Of everything here, that is the sentence I would want people to keep.

Supplement, not replacement

“I don’t think AI would realistically replace office visits. The main factor is the physical exam, which is absent. A lot of times there’s no check of the vitals either, unless a patient has a way to measure these and upload them at the same time. I think it’s a supplement to medical care.”

“Patients worry that if they research too much and come into the office with information, it seems like they know more than the doctor, and that it may undermine the doctor-patient relationship. But as doctors, we’re up to date on the most recent technologies, and we’re aware that patients are using AI, so most of us are very open to it. I’ve always said that an educated patient is a better patient. I’m a proponent of educating patients, and the use of AI is a way to educate yourself more efficiently than going to the library and reading a bunch of books and articles.”

Privacy, plainly

“In terms of privacy, you have to assume that none of your information is private. The AI programs I use in the office are all HIPAA compliant, and we have a business agreement with each of them that protects the patient’s information. This is not the case with most chatbots and AI tools available to the public. You should really keep your name, date of birth, Social Security number, address, and anything identifiable out of it, because you have to assume the companies are using these to train their AIs and may also be sharing it, and it could end up in their own hands.”

When to close the laptop

“What I would skip discussing with a chatbot is anything that seems like an emergency. An unstable patient, chest pain, difficulty breathing, severe headache, facial droop, a new breast lump, a mole that’s changing, fever, spreading redness. If you believe you might have to go to urgent care or the emergency room, or you’re really worried about something, those are all signs that you need to go to the hospital or a doctor as soon as possible.”

Two prompts

Before a visit: “I am having the following symptoms, and I have a doctor’s visit. Can you give me five questions I should ask my doctor about?”

After a visit: “My doctor diagnosed me with [blank], recommended the following tests, and started me on the following medications. Can you explain this to me, and what questions should I ask at the next visit?”

The takeaway

Prepare with it. Review with it. Keep your identifiers out of it. Demand references and then verify they exist. Never accept reassurance from it. And anything that has to be touched, felt, or measured stays in the exam room, which is where every body contouring decision is actually made.

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?

Come in with your list. If you want a straight answer about what actually applies to you, let’s talk. Call the office at (915) 590-7900, text us at 1-866-814-0038, or book a consultation.

#StayBeautiful

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

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Where the Fat Goes: The Science of BBL Survival, From My OR

Moody greyscale photograph of a woman resting face down on a recovery lounge in a surgical compression garment. BBL fat survival science explained by Frank Agullo, MD, FACS, Dr. WorldWide.

Every BBL I consult ends the same way: “So, how much of that fat stays long-term?”

Patients arrive from the internet convinced the fat basically just melts away. Colleagues outside the field ask because they suspect the results will not last. Both parties have a mistaken perception of what the surgery does, so here is the answer I would give across the conference table: the biology.

The Number, and Why It Is a Range

Fifty percent to eighty percent. So the difference is a 30% span? Yeah, that is kind of the magic. But that difference is not random; there is really little random variance from one patient to another.

A fat graft is living tissue that comes from the recipient. I took fat tissue that had its blood source detached, squeezed it through a syringe-like tool called a cannula and then put it in a place where it can only rely on diffusion to get to nutrients for the first 2 weeks until it is able to build a blood supply. The tissue that successfully reattaches will last for the next few decades. In contrast, the tissue that did not attach will simply be absorbed into your body, resulting in volume loss.

It is much more than just moving tissue. Every decision the surgeon makes is focused on making sure those cells can live on for two weeks.

The Wash Most Patients Never Hear About

Surgeons often want to see my fat-washing protocol more than any other piece of my entire fat-grafting procedure. And before all that nice soft fat goes back to the patient, I am washing that fat thoroughly with AuraClens, a solution that contains Poloxamer 188.

What is the best way? First is housekeeping. When you get lipoaspirate harvested from patients, it is not clean: it includes tumescent solution, free oil due to burst adipocytes, as well as dead adipocytes. This process removes the sludge to deliver a concentrated product of viable cells. Each cc injected contains the maximal amount of living fat possible. Now you double pay when you inject nonviable debris. That mass will disappear as the cellular detritus dissolves, and this trash creates a massive amount of inflammation among the living adipocytes attempting to survive.

The second benefit is the one worthy of a journal club. Poloxamer 188 is a membrane-active surfactant; it does more than simply scrub/clean the membrane. What makes it so unique is how it actually works to repair and stabilize the adipocyte membrane, essentially patching up damaged holes in cell walls and making them resist apoptosis, the programmed self-destruction that stressed adipocytes would carry out, whereas the ones scheduled for elimination instead just keep kicking along.

The Patient’s Half of the Equation

I can scrub and prep the fat perfectly and still lose the graft to a barstool. Pressure destroys grafts in the first two weeks, which is why my sitting protocol is non-negotiable. For two weeks: nothing hard under the buttock, a BBL cushion shifting the weight onto the thighs for any sitting, and stomach sleeping, or a wedge-supported beach chair position for anyone who cannot manage the stomach.

The other patient-side lever is the massage table. Lymphatic drainage two, preferably three times a week for the entire first month, and honestly as often as the schedule allows: it works scar tissue and fluid out of the donor sites. My patients run theirs through the post-surgical massage program at Southwest Plastic Surgery. It is an unsexy part of the operation and the one that makes the most substantial difference in the final contour.

The payback comes fast. Final volume is essentially there at week four, when every restriction lifts, and the settled result is declared at three to six months. Out-of-town patients, most of my practice, fly home on day five.

What I Tell Colleagues About the Long Game

If the fat makes it through its first month, it is no longer vulnerable. It is permanently on the payroll and it behaves like fat behaves. Weight loss will cause it to shrink; weight gain will cause it to expand. The ruined results I occasionally witness are almost never a result of the surgery itself. They are yo-yo cycles, losing and regaining weight, which stretch out the skin, sag the mound I painstakingly created, and leave contour issues that no revision entirely fixes.

For all my fellow plastic surgeons: We choose our patients not only for their anatomy but also for their understanding of what it will take to maintain results. Before an op, tell those considering significant weight fluctuations that the size of their gluteal graft will inevitably follow their weight journey. The full patient-facing timeline, week by week, lives on my practice page for the Brazilian butt lift.

Where I Sit in This Field

The procedure itself started to really coalesce as an entity in the last 10 years, partially through my contribution, as I am a founding vice-president of the World Association of Gluteal Surgeons. Back then, all you heard about was the normal BBL; now you have the ultrasound-guided BBL and the supercharged BBL, which pairs fat grafting with intramuscular implants. That means you have a variety of approaches just as rhinoplasty now has different styles to choose from and all of them stem from the science behind the survival.

The Mayo Clinic taught me to treat every graft like the transplant it truly is. The liposuction that harvests it, the wash that protects it, and the two weeks that anchor it are one operation, not three separate events. Surgeons who treat them separately end up stuck at the fifty percent end of the range, wondering why.

Ready to Talk?

Whether you are a patient counting weeks or a colleague comparing protocols, my door is open.

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

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

  • Week-by-week patient guide on agulloplasticsurgery.com: “BBL Recovery Week by Week: What Actually Happens After a Brazilian Butt Lift” (link once live)
  • Aftercare version on swplasticsurgery.com: “The Aftercare That Makes a BBL: Massages, Garments, and the Two-Week Rules” (link once live)
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I Had Kybella Myself: A Surgeon’s Honest Read on the Fat-Dissolving Shot

Moody greyscale photograph of a woman in profile examining her jawline and under-chin in a handheld mirror. Kybella fat-dissolving injection review by Frank Agullo, MD, FACS, Dr. WorldWide.

It surprises people every time: the plastic surgeon telling you to think twice about Kybella has had Kybella under his own chin.

I remember the first time turkey neck started creeping into the mirror, a few years back. So I took my own advice: one session, my own central pocket, my own experiment. This means I am not reviewing a brochure. I have been the injector, the surgeon who performs the more definitive operation, and the guy sitting in the chair.

The Three-Chair Review

It looks elegant. Your body already produces a form of deoxycholic acid. It is how your gut processes fat in your food. If you make a more concentrated version, inject it into the submental fat pad, and it kills the cells. The cells will burst and then be cleared out. Fat-cell-killing fact. Destruction is permanent, those cells do not come back.

Lying back, less glamorous. You get a bunch of injections that really burn. That is where the “unseen part” of this whole trend begins. You get swollen up to where you have a more janky turkey neck than the one you paid to fix up and it will be a while before the effect starts showing. Two to four weeks is how long you can expect, or even longer. Now remember, that was after just one treatment and people generally get three sessions.

Looking at it from the doctor’s standpoint, it is a basic sum: Twenty percent of the central fat compartment is eliminated with Kybella. CoolSculpting likewise eliminates about twenty percent, except it freezes the fat instead of dissolving it, and I like it even less. In terms of effectiveness, even on a strong candidate, twenty percent of the single center compartment reads as a subtle change at best. On the wrong candidate, it reads as nothing.

Who the Shot Actually Fits

My peers and I may squabble a lot on many of the above issues, but Kybella candidature has little debate among people performing these procedures daily.

You want superficial subcutaneous fat, directly underneath the skin, not below the platysma muscle. The needle is too short to reach that far and the ads do not mention it, which is one of the reasons why it makes some people look worse. It needs to be mostly in the mid neck region. Lateral neck fat and jowls are off the map. The skin quality must be of good elasticity to take the deflation of fat within; if you just remove the fat below loose skin, you will have a worse neck.

A younger individual with elastic skin has one specific, isolated fat pocket right in the middle. That patient does exist, and for that person the Kybella program at our med spa is a legitimate option.

What I Do for Every Other Neck

In most necks walking into the office, the fat has migrated beyond being a simple neck issue and has already wrapped around the jawline, spilled onto the sides, or the skin has been relaxed for a long time. So for that patient, for many years, my solution has been neck liposuction combined with FaceTite.

It is not even close. Liposuction takes out up to 80% of the excess fat and treats the entire aesthetic unit (lower face, jawline, center neck, sides of neck). FaceTite runs RF underneath the skin through the same 3 little entries, one behind each ear and one below the chin, and tightens the envelope up as the volume drops. A real neck lift is the choice when the problem is larger than a single energy device will help, point-blank!

Plus, it all costs about as much as three sessions of Kybella. It is not like people were choosing cheap versus expensive. They are deciding between 20% off of one pocket versus 80% of the entire neck for the same price.

The Part I Trained For

The Mayo Clinic taught us that the diagnosis IS the surgery. The neck is our classic teachable moment. Is the fullness fat or gland? Is it above the platysma muscle or below? Is the neck fullness a narrow strip down the front or has it completely encircled it? Is the overlying skin a bystander or the focus of pathology?

They all swap out the correct tool, not that these questions could possibly be found on a spa menu, nor that 90 seconds’ worth of exam would not find the best tool. Ninety seconds is the most important part of every consultation on necks, even mine. This is precisely the reason I keep both the needle and cannula within arm’s reach of the procedure, rather than deeming one “king”.

My Bottom Line

Kybella is real. The science is sound, the fat it kills stays dead, and my own neck carries the proof years later.

However, in a one-pocket room, the shot has a ceiling of 20 percent, and most necks need more than that. When someone only talks about a particular needle treatment that is the only thing a clinic is willing to offer, they are not telling you what a treatment is supposed to be; they are telling you about an ingredient they offer.

Ready to Talk?

Bring me your neck and ninety seconds. I will tell you which chair you actually belong in.

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

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

  • Med spa version on swplasticsurgery.com: “Kybella in El Paso: What the Fat-Dissolving Shot Can and Cannot Do” (link once live)
  • Surgical version on agulloplasticsurgery.com: “Why I Still Reach for Liposuction and FaceTite Over Kybella” (link once live)