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It Does Not Dissolve. It Disperses.

Black and white photograph of a person in a dark jacket seen from directly behind, standing at a tall window in hard morning light with one hand raised to the side of the face, the room around them in shadow. Illustrative image, not a patient. Commentary by Frank Agullo, MD, FACS.

Ask an injector how long under-eye filler lasts and you will hear “about a year.” That is true of the result. It is not true of the product.

“Fillers over time have started to come out of favor, as we are now noticing that the filler really never dissolves. The results can last about a year, but the filler does not dissolve, it just disperses.”

It disperses into the one place on the face that cannot afford it.

“I have seen cases where it blocks the lymphatic drainage, and patients start having bags under the eyes, which are worse in the mornings, or they have discoloration or lumpiness. Sometimes they can also get inflamed. So I have dissolved a lot of under-eye fillers in order to improve all these complications, and that is why I am more inclined to use fat rather than hyaluronic acid fillers.”

Worse in the mornings. If that sentence describes you and you had filler under the eyes a few years ago, that is the first thing I will look for.

So what do I put there?

“The tear trough is a very common area that we inject. My preference is the patient’s own fat, as it gives us a lasting result. It is done in the operating room, and I use cannulas to inject right above the inferior orbital rim. It softens the tear trough and gives us long-lasting results.”

Fat is what was there before it left. I wrote about how grafting works and how much of it stays in Fat Transfer 101. For a patient who wants the exam room and not the operating room, there is a donor fat graft.

“We can also use Lipoderma, which is a donor fat graft. This comes already prepared in a vial, so it can be injected in the office in one of the exam rooms, and it gives a lot of the same benefits as using your own graft. These benefits are that the results are soft, very long-lasting, and very natural.”

Either way, no needle.

“I prefer to use a cannula in this area, as it decreases the chance of bruising from piercing a vessel, or even intravascular injection.”

Same argument I made about hands. Thin skin, vessels near the surface, a blunt tip that slides past them. And if you want to know what a sharp tip in the wrong place looks like, the 60-minute window covers it.

Now the part nobody selling filler says out loud. Some under-eyes should not be injected with anything.

“Patients with festoons, thin skin, and true fat herniation are not the greatest candidates for fillers under the eyes. Fat is one of the procedures we perform when treating the periorbital area, and just adding volume to the tear trough can hide the under-eye bags for a while. But as they keep progressing, it comes to a point where adding volume is not going to help, and we actually need to remove those herniated fat pads.”

A real bag is fat pushing forward. You can hide it next to more volume for a while. Then it wins, and the answer is a lower lid operation, not a fourth syringe.

Festoons are their own problem.

“Festoons are frustrating because they are very difficult to remove completely. They are a combination of edema or swelling in the area, skin retraction from the facial ligaments, and loose skin. We can usually improve them, and in some cases remove them, using Morpheus8 microneedling with radiofrequency, and it often takes more than one treatment to repair this area. Sometimes it just has to be done surgically with a midface lift.”

Put filler in a festoon and you have made a heavier festoon.

So the order is: diagnose, dissolve what should not be there, and then, if the problem really is a hollow, fat. The full write-up with the three options side by side is on the Southwest Plastic Surgery blog.

It does not dissolve. It disperses. Plan accordingly.

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

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

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The Body Gets the Credit. The Face Pays for It.

Black and white photograph of a woman in profile at a tall dark window at dusk, one hand resting at her jaw, face turned to the glass. Illustrative image, not a patient. Commentary by Frank Agullo, MD, FACS.

Lose sixty pounds and everyone tells you how great you look. Then you catch your face in a car window.

The body gets the credit. The face pays for it.

I know the bill by heart, because I dictate it at the exam.

“Facial aging with loss of volume from massive weight loss. She has ptosis, temporal wasting. She has festoons with excess lower eyelid fat bags, excess upper eyelid skin resting on her eyelashes. She has deep nasolabial folds and marionette lines. She has excess skin in the neck. And submandibular gland show.”

Every item on that list is the same event seen from a different angle. The fat left. What it was holding up came down, and what it was covering showed through.

People call it Ozempic face. Bariatric patients had it long before the pen. It is deflation, and the fix follows from the diagnosis.

“Fat is the best filler for a deflated face. A deflated face has lost fat. And what we do when we do fat grafting is replace the fat in those spaces. So it’s like with like.”

That is the whole argument, and I would stop there if patients did not keep arriving with something else already in their temples.

“Many people are using other fillers like Sculptra. But we have to keep in mind that these fillers create scar tissue and fibrosis, which may make the facelift procedure more difficult. It creates collagen through an inflammatory reaction.”

Read that once more if you are on your third round of a biostimulator. The volume it gives you is scar, and scar is what I have to lift through later.

“And last, we have hyaluronic acid fillers, which are temporary, tend to dissipate into the tissues, and can look unnatural. I think they have value in areas that need small corrections and superficial corrections, but not to replace the fat that’s lost due to massive weight loss.”

A man who lost fifty pounds after a sleeve came to me having tried Sculptra and been unhappy with how long it lasted. He wanted permanent. Here is what I told him.

“We overfill the areas, because he will lose about thirty to forty percent of the transferred fat. The remaining fat is permanent, though it will fluctuate with any future weight changes. Even at a low BMI of twenty one to twenty two, there is enough fat to harvest. The inner thighs are the best donor site, followed by the lower back or abdomen.”

Then there is the question of the knife, and when.

“Preferably I want the patient to have lost the weight that they had planned and be weight stable after any facelift procedure. The reason being that oftentimes patients after a facelift tend to lose further weight. And of course, if we lose the volume, then we will have some aging. As the face deflates, the skin tends to sag. So we would lose a lot of the benefit of having done the facelift if the patient continues to lose weight.”

The fat can go in early.

“In terms of fat grafting, it can be done while the patient is still losing weight, as long as the patient knows that it will require repeat treatments. But fat is one of the best fillers we can use, as it is natural, it is soft. It is the same tissue that belongs in those spaces, and can help slow down the aging process as the patient is losing weight.”

Two procedures, two clocks. Fat while the scale is still moving. The lift when it stops. Same rule as the body: you do not tighten what is still shrinking.

And when the lift does happen, in a post weight loss face, it is more than a pull. From a consult with a woman who lost thirty pounds on a GLP-1:

“It would bring this back as well and fill in the cheekbone, bring it back up. And then it’s gonna also bring your neck back tight. So it does give you, it removes about fifteen years.”

She had come in asking for a brow lift.

“Your upper eyelids get better when I do this. So I don’t think you need anything on your upper eyelids. There, you see that hooding. That is the skin. But when I do this, it fixes it.”

Fewer operations than she expected. Better order than she expected. That is usually how these consults end.

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

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

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Half of It Might Not Survive, and It Is Still the Better Option

Black and white torn-paper collage of two cut-out portraits with engraved magnolia beside a large numeral reading 39 percent.

Facial fat grafting grew 39 percent last year, the largest jump of anything in my specialty’s annual report. It made no top five list, because those rank by volume.

What is wrong with filler

“I think we have seen that facial fillers have been quite overdone, and patients are really getting away from looking overfilled and want to look more natural. We have seen that these hyaluronic acid fillers may not dissolve completely, and they do tend to migrate. It seems like they create some kind of inflammatory response in some patients, creating nodules or inflammation.”

“And of course, the feel of a filler is not quite like natural fat, which is squishy and soft, something whose borders you wouldn’t be able to identify the way you can with a filler.”

“When patients use fillers, they see that they have to have this redone anywhere from every six months to one year. And what we’re also seeing is that not all of that filler goes away, but it’s migrating and flattening out, so it’s not giving us the volume exactly where we want it.”

The part where I argue against myself

“The main factor that disappoints people with fat injections is that the amount of retention is really unpredictable. Even though we know the patient is going to keep fifty to eighty percent of the volume, that percentage is quite unpredictable, so we are always overfilling. Patients that lose fifty percent of the volume we inject are sometimes disappointed, and we have to go back and inject more fat.”

Fifty to eighty is a wide range to hand somebody.

“The good thing is that whatever does stay is going to be quite permanent, and of course maintaining your weight is going to help with that. We know that with aging, fat will decrease in the face regardless, so it is a procedure that we probably have to repeat in the future.”

The pricing nobody mentions

“We have been using the patient’s own fat, because we have the benefit of using however much volume we really need, as the number of fat CCs does not increase the cost of the procedure, and the patient’s own fat is free.”

Filler is sold by the syringe, every year, forever.

If you want it without the harvest

“For some patients that don’t want as much downtime, we’ve been using Lipoderma, which is a donor fat graft that gives us very similar results to the patient’s own fat grafting.”

alloClae does the same job. On the biostimulator route:

“We have been using Sculptra, but this does create inflammation like scarring and fibrosis.”

It was never only Ozempic

“I think fat grafting has been rising for many years. It’s an essential component of almost all facial procedures. I incorporate fat grafting into lower eyelid surgery, I incorporate it into all my facelifts, and I incorporate it in any facial procedure where the patient has lost a considerable amount of weight.”

“So the GLP-1 wave has certainly increased the demand, but just normal aging is comprised of loss of fat and volume in the face, as well as skin laxity and quality. So just with normal aging there was already a high demand for fat transferred to the face, and now with GLP-1s that demand has increased even further.”

The report says it too: the rise extended beyond GLP-1 patients and was underway before them.

Consultations at Southwest Plastic Surgery in El Paso.

Call (915) 590-7900 or text 1-866-814-0038.

#StayBeautiful

Source: ASPS 2025 Procedural Statistics Report. Commentary from Dr. Agullo’s 2026-09-07 dictation.