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I Called Fillers a Tax. The World Just Stopped Paying It

Black and white close portrait of four women of different backgrounds and ages, bare natural skin, lit by a single hard light. Illustrative image, not patients. Frank Agullo, MD, FACS.

The International Society of Aesthetic Plastic Surgery counted 4,737,957 hyaluronic acid filler treatments worldwide in 2025. That is 25.2 percent fewer than the year before, and fewer than in 2021. Poly-L-lactic acid fell 33.7 percent. Calcium hydroxyapatite fell 25.7. Fat grafting to the face held at 944,410.

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.

What I Have Been Doing All Year

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. 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.

Why Fat

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.

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. This gives a very natural, soft result, which is of course long lasting. 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.

The Catch, Because There Is One

Now, 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.

The good thing is that whatever does stay is going to be quite permanent.

The table, the Botox line and the hand numbers are in the full post on the Agullo Plastic Surgery site.

Why Me

Double board-certified, Mayo Clinic trained, Clinical Associate Professor of Plastic Surgery at Texas Tech, Castle Connolly Top Doctor 2014 through 2026. Fat in almost every facial operation I do, and a lot of other people’s filler dissolved this year.

Ready to Talk?

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

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

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The Only Non-Surgical Number That Went Up in 2025

Black and white photograph of four women of different backgrounds seated close together in a dark studio, faces lit by a single hard light, bare skin and strong bone structure. Illustrative image, not patients. Frank Agullo, MD, FACS.

The International Society of Aesthetic Plastic Surgery just published its survey of procedures performed in 2025. Ten non-surgical treatments are tracked. Nine fell. Hyaluronic acid fillers fell 25.2 percent. Non-surgical fat reduction fell 42.2 percent. Even botulinum toxin slipped 7 percent.

Non-surgical skin tightening rose 23.3 percent, to 1,528,552 treatments. Since 2021 it is up 52.3 percent.

I Called the Filler Part

I think the truth is that fillers have decreased considerably compared to other procedures, botulinum toxin still being number one. In my practice, I’ve seen more than a twenty to thirty percent decrease in the use of fillers, and a shift toward biostimulators and donor fat grafts instead.

Really, what I think is that there has been a huge tendency to overfill faces with fillers, and maybe that’s why it’s difficult to count. But truly, what I feel is that there has been such a decrease in the use of fillers that manufacturers and even med spas have become worried, as this is really the only thing they provide, since they do not have a way to provide surgical procedures, which are becoming far more common than hyaluronic acid fillers.

Where the Demand Went

The latest and most promising innovation in plastic surgery has been radiofrequency. Before radiofrequency, the only skin tightening we would see was from some fibrosis created after liposuction or VASER treatments, but it wasn’t truly skin tightening.

I run four radiofrequency devices. BodyTite treats the external skin and the internal fat as a bipolar radiofrequency device. Renuvion J-Plasma treats the subcutaneous tissue, the tissue below the skin, with radiofrequency and helium plasma. And Morpheus8 is limited to treating the superior layers of the skin, dermis, and subcutaneous tissue. QuantumRF treats the deep subcutaneous tissue and skin, creating contracture using higher delivery powers in a safe fashion.

If I had to pick just one, I would pick QuantumRF over all the other devices, mainly because it delivers more power, and does so much faster, in a safe and controlled fashion.

The Catch

Massive weight loss patients may not be candidates. If we see a lot of stretch marks on the skin, or large folds with loss of collagen and dermal tears, the likelihood that the skin will contract is lower, and this would require excisional plastic surgery procedures.

The same report has body lifts and arm lifts rising. Energy tightens skin that still has collagen in it. Skin that has lost it gets removed. The full read, with the device-by-layer table and pricing, is on the Southwest Plastic Surgery site.

Why Me

Double board-certified, Mayo Clinic trained, Clinical Associate Professor of Plastic Surgery at Texas Tech, Castle Connolly Top Doctor 2014 through 2026. Four tightening devices in one practice, and I have tried the newest one on my own face.

Ready to Talk?

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

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The Page Nobody Reads in the Plastic Surgery Statistics

Black and white editorial collage, cut-out portraits with torn paper edges and engraved botanicals.

There is a ritual to this. My specialty publishes its annual numbers, two hundred outlets publish the top five list, and everyone moves on by Thursday.

Liposuction won. It has won five years running. It actually declined 1 percent and still won by a mile.

Now turn to page 26, where the country gets split into regions. On five procedures, my eight-state region went the opposite way from the national number. The one I want to talk about is the nose.

Rhinoplasty fell 5 percent nationally. Here it rose 16.

“This does match what I see. I’ve seen an increase in surgical rhinoplasty procedures in both men and women. In many places, people are turning to injectable fillers for a liquid rhinoplasty, or non-surgical nose job. But many patients have noticed that when this is done, the nose actually becomes bigger, because filler is volume.”

“We’re adding volume to hide the dorsal hump and maybe push the tip up. But with time, the filler flattens out and migrates to the sides, making the nose look wider and the tip more bulbous.”

You are solving a shape complaint with volume, and volume does not stay where you put it.

“For a real reduction, surgical rhinoplasty reshapes the structure of the nose and reduces its size, removing the dorsal hump, refining the tip, and even narrowing the nose, and it can also remove old filler. A surgical rhinoplasty is a permanent procedure.”

Why the top five is a boring list

Four of the five barely moved. The only real mover is eyelid surgery, up 19 percent.

“These are the usual procedures that made the top five, and they really didn’t move much during 2025. I could see that during 2025 there was a bit of a slowdown in plastic surgery procedures, and I think that was due to changes in the economy. But we’re seeing an increase in 2026.”

“Eyelid surgery did blow up a lot, and it’s also a procedure we’ve performed increasingly over the last two years. It seems to be the first part of the face that patients notice as they age, especially the upper eyelid skin, which can hang and even rest on the eyelashes, giving the patient the impression of being tired and even making makeup hard to put on.”

An economic read, not an aesthetic one. That is not in the report either.

What I am actually seeing

“In my practice, I’ve really seen a huge increase in face procedures, specifically the deep plane face lift and deep plane neck lift, as well as the total endoscopic deep plane face lift, otherwise known as the ponytail lift. These face lifts are often combined with facial fat grafting, upper and lower eyelid surgery, microneedling with radiofrequency or laser resurfacing, sometimes an upper lip lift, fat transfer to the lips, and earlobe reduction.”

“The reason we’re seeing this increase exponentially is that patients are noticing signs of facial aging earlier, or they’ve been on GLP-1s and have had accelerated aging from fat loss in the face and skin sagging.”

“The most interesting thing about a face lift procedure is that it can make you look ten to fifteen years younger. Of course, that depends on the age at which you get the procedure. If you get it at forty, you’re probably going to look like you’re in your early thirties, or even late twenties. But time keeps moving forward, so if we repeat the procedure ten years later, we take you back to that earlier stage of yourself. Now you’re in your fifties, looking like you’re in your thirties.”

The honest caveats

Region 4 is eight states, so I cannot tell you what El Paso did. Nobody publishes that.

These count only board-certified plastic surgeons. For the procedures growing fastest, the uncounted volume is the part worth worrying about.

I have written the full regional breakdown, including the one figure in the report I refuse to quote until ASPS explains it.

Ready to talk?

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

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

#StayBeautiful

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