frank agullo md Archives

June 26, 2026

Traditional Chinese Medicine and Hair Loss: What the Evidence Actually Supports, and What to Be Careful With

Black and white editorial still of dried botanical herbs beside a mortar in soft side light. Traditional Chinese medicine and hair loss, by Dr. Frank Agullo, MD, FACS.

He shou wu. People take it for their hair, and most of them have no idea it is one of the most reported causes of herbal liver injury in the world.

I get a lot of questions about Chinese medicine for hair. I never dismiss it out of hand, because some of it actually has studies behind it. But the he shou wu story is why I always say the same thing first. All natural does not mean automatically safe. So here is my plain version, the parts that work and the parts to watch.

Before grading any remedy, I want to be precise about what we are even treating. Normal shedding is fifty to a hundred hairs a day. True hair loss is more than that. The hair that grows back comes in thinner, with worse texture and worse density. We call that miniaturization. Here is the part that matters most. A shrunken follicle can still be revived with growth factors, medications, or therapies. A lost follicle cannot be brought back. So any herb that claims to help has to be judged against that line.

So What Is Traditional Chinese Medicine, Really?

It is a compounding of various treatments and diagnostic principles developed in China. Like a lot of Eastern medicine, it treats the body as one connected system and cares a lot about balance across that whole network. Herbs, acupuncture, diet, massage. On hair specifically, the thinking ties hair health to blood circulation and the kidneys. Hair is something you can see, so when it declines, they read that as the person’s vitality declining.

The Herb to Be Careful With

Polygonum multiflorum is a plant used in Chinese medicine to support the health and growth of hair. It can even counteract hair whitening. It acts on three mechanisms at the same time: DHT damage inhibition, cellular protection, and circulatory improvement of the scalp.

Here is the candid part. Most of the studies have been in vitro, which means in the lab, and in animals, and there hasn’t really been a strict comparison against Western medical treatments. There have been some cases of liver damage using this herb. Worldwide, it is one of the most reported causes of herbal liver injury. The risk is higher when using the raw root rather than the processed version. The reaction is really unpredictable. And since this is a dietary supplement, it’s not regulated by the FDA in the same way that traditional medication is.

That is exactly the kind of thing patients need to hear before they order a supplement off the internet because it is natural.

The Ones the Evidence Treats More Kindly

Ginseng is among the most well-known and most extensively researched traditional Chinese medicine herbs. It promotes scalp blood circulation, and the existing research shows promise and encouraging results.

Angelica sinensis was traditionally known as a blood tonic. It is an herb they believe moves blood, or prevents stagnation. Some of the published studies include laboratory research showing anti-inflammatory properties and improved circulatory blood flow.

Scalp acupuncture is the one that interests me most as a surgeon. If we think about it, it almost behaves like microneedling, which we’ve shown scientifically to improve hair growth. It improves the microcirculation of blood flow to the hair follicles.

Scalp massage is perhaps the simplest recommendation, and it has been scientifically proven to work. It improves circulation, which seems to be a recurring theme here, and studies have shown it can increase hair thickness and the number of hairs.

The Recurring Theme

Notice the pattern across the items that hold up. Ginseng, acupuncture, massage, and even the microneedling we do in clinic all improve the same thing, which is scalp circulation. It seems to be a recurring theme, and it is probably why the modern regenerative tools and the older traditions sometimes land in the same place.

The Two Things to Take Away

Well, I think the most important thing to know is that a remedy being all natural does not mean that it is automatically safe. There are dangers, like we spoke about previously with Polygonum multiflorum. And second, the most important thing is to visit a physician for consultation as soon as hair loss begins. This is the time when therapies can be initiated and actually help, and it’s also helpful to rule out any reversible causes.

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, member of the International Society of Hair Restoration Surgery, and Castle Connolly Top Doctor for thirteen consecutive years. I am happy to talk about the traditions seriously, and just as happy to tell you which herb has a liver-injury problem.

Ready to Talk?

If you want a read on what is worth trying and what is worth avoiding for your hair, that is a consultation.

For the patient-facing guide to the hair cycle and the five most common causes, see the companion post on agulloplasticsurgery.com. For the scalp-health and hair-restoration program at the practice, 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.

June 26, 2026

Traditional Chinese Medicine and Hair Loss: What the Evidence Actually Supports, and What to Be Careful With

He shou wu. People take it for their hair, and most of them have no idea it is one of the most reported causes of herbal liver injury in the world.

So What Is Traditional Chinese Medicine, Really?

The Herb to Be Careful With

That is exactly the kind of thing patients need to hear before they order a supplement off the internet because it is natural.

The Ones the Evidence Treats More Kindly

The Recurring Theme

The Two Things to Take Away

The Credential Behind the Opinion

Ready to Talk?

If you want a read on what is worth trying and what is worth avoiding for your hair, that is a consultation.

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.

June 25, 2026

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

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.

June 24, 2026

The Many Uses of Botox: A Surgeon’s Tour From the Well-Established to the Experimental

Black and white editorial close-up of a fine syringe held in gloved hands in soft side light. The many uses of botulinum toxin, by Dr. Frank Agullo, MD, FACS.

Before we talk about the different uses of Botox, which is a very exciting topic, it’s important to understand how botulinum toxin works. In essence, it inhibits the release of acetylcholine, which is the chemical signal that nerves send to the tissue on the other side. In the traditional use of botulinum toxin for the prevention of wrinkles, the nerves are sending acetylcholine to the muscles to contract the muscle, and the botulinum toxin is preventing that release so that the muscle doesn’t contract and create a wrinkle. In the same fashion, it can work on other targets, like sweat glands.

Once you understand that one mechanism, the whole long list of uses makes sense. So here is the tour, from the well-established to the experimental.

Excessive Sweating

Botulinum toxin can be used for excessive sweating, in medical terms, hyperhidrosis. This is what a fitness audience tends to care the most about. The FDA has actually approved botulinum toxin for excessive underarm sweating. In this case, the toxin is injected into the skin every half an inch to cover the area of the sweat glands that produce the sweat. A single underarm treatment usually lasts anywhere between four to six months, and it does have to be repeated.

Off-label, we can use it in the same fashion for sweaty palms, the soles of the feet, a sweaty scalp, and even the forehead. It doesn’t change how much you’re going to sweat in other places that aren’t treated, but it is very effective. I’ve had patients whose excessive sweating is disabling, and for them these treatments are life-changing.

Chronic Migraine and Headaches

The FDA has approved the treatment of chronic migraines and headaches with botulinum toxin for more than fifteen years now. There is a very specific protocol, and it consists of about thirty injection points in the forehead, scalp, and neck. This is considered a preventative treatment, which means it prevents the onset of new headaches. It would not cure an active headache at the time of injection.

I’ve had a lot of patients who just routinely get botulinum toxin for cosmetic reasons, to prevent wrinkles in the forehead, crow’s feet, and glabella, and they tell me that they’ve had fewer headaches since they started using the botulinum toxin.

Jaw Clenching, Tics, and Symmetry

Botulinum toxin is also used for jaw clenching and teeth grinding. It’s injected into the masseter muscle, which decreases the strength of the bite. As a side effect, it can be used to slim a heavy jawline by decreasing the size of the masseter muscle, creating that shadow effect that a lot of women aspire to.

It can also be used for spasms or continuous nervous tics around the eyes, to soften them. We use it often in patients with facial nerve palsy to create more symmetry between the non-paralyzed and paralyzed sides. It can be used in neck muscle spasms and even in overactive bladders.

The Less Traditional Uses

Less traditional uses of Botox include TrapTox, which is injected into the trapezius muscle, and sometimes it’s called the Barbie. It reduces the mass of the trapezius muscle, which creates a more slender neck, and a longer, more slender neck. Some people use it for comfort in this area, as they feel they carry significant stress in their shoulders, and this can help alleviate that.

We use it around the mouth to correct gummy smiles. We inject it into the muscles that elevate the upper lip excessively, and it reduces the gum show, or gingival show, when smiling. Another area where it’s injected into muscles to decrease their mass is the calf muscles, which is very common in the Asian population. It can also be used to treat the pebbly chin, or orange peel appearance of the chin. Relaxing the mentalis muscle smooths this area of skin.

The Skin Itself

There are applications where we do microdroplets of botulinum toxin over the skin. These are very superficial injections, and overall they decrease oil production and smooth out the skin over time. It’s something we’ve noticed just in treating patients aesthetically for the prevention of frown lines and wrinkles, that the area where the Botox is injected, the skin quality improves over time and looks younger. It is also used for rosacea flushing, where microdroplets are injected into the skin to decrease facial flushing and redness, which is considered off-label. It pairs naturally with skin-quality work like microneedling.

The Experimental Frontier

Depression is actually being studied at the moment, but some studies already suggest that relaxing the glabellar frown muscles influences emotional feedback mechanisms and pathways in a way that improves depression. It’s not FDA-approved for depression, but it remains an active area of research.

There is a nonstandard indication where botulinum toxin can be injected into the clitoris, which relaxes the capillaries and promotes engorgement during sexual stimulation, which can increase sensitivity. In the same manner, it can be injected around the vagina to prevent vaginismus, sexual pain, and pelvic floor spasms. And some physicians actually use it in places you would never imagine, like the vocal cords, the salivary glands to decrease saliva production, the pelvic floor for problems in women, and the hands for circulation disorders.

One of the side effects of injecting into areas for decreased sweat production is that there’s also a decrease in body odor production, since the smell is produced by the same glands that produce the excessive sweat.

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. The reason I keep a long mental map of these uses is that the same molecule, in the right hands and the right plane, solves a surprising range of problems.

Ready to Talk?

If a use on this list speaks to something you have lived with, the conversation is worth having.

For the patient-facing clinical guide, see the companion post on agulloplasticsurgery.com. For the MedSpa toxin menu at the practice, 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.

June 23, 2026

When the Implant Rides High and Hard: A Surgeon’s Take on Revision and Capsular Contracture

Black and white study of a woman's torso in soft light, hand resting near the collarbone. Breast implant revision commentary by Dr. Frank Agullo, MD, FACS.

A large part of my week is not first-time augmentation. It is revision.

Women come in years after surgery done somewhere else, and they describe the same handful of things. One breast riding high. A firmness that crept in. A sense that the implant has wandered off where it should be. Or simply, it has been ten years and they want a change.

These are not vanity complaints. They are mechanical problems with mechanical fixes, and they deserve a straight answer rather than a shrug.

What That High, Hard Lump Usually Is

When the description is one side that sits high and feels firm, almost like a lump, it is usually a capsular contracture.

Here is what is happening. Whenever we place an implant, the body forms a capsule of scar tissue around it. That is normal and even helpful, because it keeps the implant in place. But sometimes that capsule, driven by inflammation or an old low-grade infection, tightens and hardens around the implant. It squeezes the implant up and in, and the breast goes firm.

If it hurts, the contracture is more severe. No pain is actually a good sign. And it surprises people that this can show up long after the original surgery, sometimes many years later, but it does.

How I Actually Fix It

The repair is more than swapping the implant. I go in, remove the hardened capsule, take out the old implant, and place a new one.

When I do that and switch the patient to a Motiva implant, the risk of contracture recurring drops below one percent. The nano-surface on these implants provokes a much lower inflammatory response, which is the whole reason the recurrence rate falls so far.

To lower it further, I will often place a mesh, an internal bra layer of support, over the area. With that combination, recurrence approaches zero. And if you want to change size while we are in there, we usually can, through the same incision.

Revision Decisions at a Glance

What You Notice	What It Often Means	The Usual Move
One side high and firm	Capsular contracture	Remove capsule, exchange implant, often add mesh
Implants past ten years	Older-generation wear	Exchange to Motiva, reassess size and position
New, fast asymmetry over weeks	Worth imaging	Ultrasound or MRI, then a plan
Several prior surgeries	Disturbed tissue planes	Careful planning, honest expectations

“Should I Just Swap Old Implants?”

If you are at the ten-year mark with older-generation implants, an exchange is reasonable, and it is a good moment to reassess size and position at the same time. I often move patients from an older implant to a Motiva, which lasts much longer and carries far less contracture risk.

“I Have Had Several Surgeries Already. Is It Too Late?”

No. I see patients whose first operation was decades ago with several since. More history does not mean nothing can be done. It means I plan carefully and stay honest with you about what is realistic. Revision is harder than a first augmentation because the tissue planes are already disturbed, which is exactly why it should be planned, not rushed.

Why the Implant Surface Is the Whole Story

When patients ask why a Motiva exchange drops the recurrence rate so far, I bring it back to one thing: the surface. The Motiva implants I use have a nano-surface called SmoothSilk, which produces the lowest inflammatory response of any implant I know of. Capsular contracture is fundamentally an inflammatory problem. The capsule hardens because the body keeps reacting to the implant. When the implant barely provokes a reaction, the capsule that forms stays soft and thin.

That is the mechanism behind a sub-one-percent recurrence rate, and it is why I rarely reach for an older-generation implant during a revision. There is no reason to put back the kind of implant that contributed to the problem.

A Revision Is Often an Upgrade

Patients arrive bracing for damage control, and they are surprised when I tell them a revision is frequently a chance to end up better than the original. The new implants are soft, the gummy bear type, and they move with the body and settle into a natural teardrop when you stand. So while we are correcting the contracture, we can also correct a size you never loved, a position that sat too high, or an asymmetry that was there from day one. The same incision usually does all of it.

On Imaging, and Doing More at Once

If you are feeling a change, an ultrasound or MRI helps me confirm whether the implants are intact and whether what you feel is a contracture, scar, or something that needs more attention. I review your imaging before I commit to a plan.

A firm, high, or newly asymmetric implant, especially a change over a few weeks, is worth coming in for. And if you also want to refine your waistline, we can add liposuction and use J-Plasma to tighten the skin in the same setting, so it is one recovery instead of two.

Why I Take Revision Seriously

I am a double board-certified plastic surgeon with a Mayo Clinic plastic surgery fellowship, and I have been a Castle Connolly Top Doctor for thirteen consecutive years. Revision rewards a surgeon who slows down. I want to examine you and review your imaging before I promise anything, because the tissue tells me more than a photo ever will.

See the Patient-Facing Versions

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

Ready to Talk?

If something feels high, hard, or out of place, do not sit on it. Come 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.

June 22, 2026

The Field Is Diverging From Thread Lifts: A Surgeon’s Read on Nonsurgical Lifting in 2026

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.

June 22, 2026

The Field Is Diverging From Thread Lifts: A Surgeon’s Read on Nonsurgical Lifting in 2026

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

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

The Tightening Tools

Why I Have Almost Left Thread Lifts Behind

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

The Test That Sends a Patient to Surgery

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.

June 21, 2026

The Augmentation That Never Touches the Muscle: Why I Switched to Preserve

A woman sat in my consult room last week, pulled up a photo of herself at twenty-five, and said the line I hear several times a week. She wanted the fullness she used to have, and she wanted to know why she should drive past three closer surgeons to see me.

Here is the honest answer. For most augmentations I do now, I never touch the muscle. Not minimally. Not partially. Not at all.

That is a bigger deal than it sounds, and it is the reason recovery looks nothing like what your mother or your older sister went through.

What the Preserve Actually Is

The Preserve augmentation is prepectoral. The implant sits in front of the pectoralis muscle and behind your breast gland, above the muscle but below the gland. I do not cut the muscle, release it, or go under it.

That distinction is everything. A traditional submuscular augmentation goes behind the pectoralis and partially releases it off the chest wall. That release is the source of the long, sore, six-to-eight-week recovery patients remember. Preserve never goes there, so that whole chapter disappears.

I make the pocket by balloon dissection. No cutting, no electrocautery. The tissues are pushed outward, and the pocket is defined by your breast’s own ligaments. Those ligaments hold the implant in position, which is why I do not need mesh to support it.

That also means the nerves and arteries stay where they belong. You keep a higher likelihood of preserving sensation and breast function, because I am not dividing the structures that supply them.

Preserve Versus Traditional, Side by Side

Question	Traditional Submuscular	Preserve Prepectoral
Where the implant sits	Behind the muscle	In front of the muscle, behind the gland
Is the muscle cut	Yes, partially released	No, never touched
How the pocket is made	Cutting and cautery	Balloon dissection
What holds the implant	Muscle and capsule	Your own ligaments
Typical recovery	Six to eight weeks	Back to work in one to three days

How I Pick Your Size

Cup size is a starting point, not a measurement. I work from your dimensions and a Chrysalix 3D simulation, not from a letter on a bra tag.

Almost everyone has some asymmetry, and that is normal. Breasts are sisters, not twins. So I will often choose slightly different volumes on each side to get you closer to even.

There is a quieter advantage to placing above the muscle. I can put the implant precisely where your breast needs the most volume instead of filling the whole breast uniformly. A smaller implant can give a larger apparent size and a little lift. Lighter breast, same result you wanted.

The Implants I Use, and the Ten-Year Myth

I use Motiva Ergonomix. The old rule about swapping implants every ten years does not apply to these. The rupture rate is under half a percent, and they carry a lifetime guarantee.

The surface matters too. These use a nano-surface called SmoothSilk, which produces the lowest inflammatory response of any implant on the market and an extremely low capsular contracture risk. They are soft, the gummy bear type, and they take on a natural teardrop shape when you stand. Ergonomix implants move with the body, so you do not get that fixed, stuck-on look.

What Recovery Honestly Looks Like

This is the part that surprises people, so I will be specific.

I do it under light conscious sedation. You breathe on your own, and you will not remember much. I place Exparel, a long-acting local, between the ribs so the breast stays numb for about the first three days. The incision is two and a half to three centimeters in the fold under the breast, hidden where you will not see it.

The implant placement takes about thirty minutes. Patients are usually awake, pain-free, and able to raise their arms overhead before they leave, often within an hour. Many go back to work the next day, and the gym is reasonable at about two weeks if augmentation is the only thing we did. Add a lift or liposuction and the timeline shifts, and I will tell you that up front.

Why I Was One of the First to Do This

Being an early adopter of Preserve was a deliberate choice. Motiva trained me directly as one of roughly twenty highly selected surgeons in the United States, and I traveled to Costa Rica twice for that training. There are still fewer than forty surgeons in the country doing this.

I am a double board-certified plastic surgeon, certified by the American Board of Plastic Surgery and the American Board of Surgery. I completed my 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. I committed to preserving your own anatomy because it recovers faster and ages better than cutting through muscle ever did.

The Animation Problem You Avoid

Here is a detail patients rarely hear about until it bothers them. With a traditional submuscular implant, every time you contract your chest, the muscle squeezes the implant and the breast moves or distorts. Surgeons call it animation deformity, and it is a direct consequence of putting the implant under a muscle that is built to move.

Preserve sidesteps it entirely, because the implant never goes under the muscle. You can do a push-up, a plank, or a heavy press without watching your breast jump. For an athlete, a CrossFit patient, or anyone who lifts, that is not a small thing, and it is one of the quieter reasons I prefer this plane.

One Honest Caveat

Preserve is not for absolutely everyone. Very thin patients with almost no breast tissue sometimes need a different plan, and I will say so in the room rather than force the technique. If a standard augmentation or a fat-based approach fits you better, that is the conversation we have.

Read the Patient-Facing Versions

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

Ready to Talk?

The honest answer to what size and which implant is right for you needs an exam and a 3D simulation. Come see me.

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.

June 20, 2026

The Quiet Boom in Male Enhancement: What the Demand Is Really Telling Us

Black and white editorial portrait of a man in his forties in soft side light, composed expression. Male enhancement commentary by Dr. Frank Agullo, MD, FACS.

Compared to five years ago, we weren’t doing any of these procedures. Since then, the procedures have increased in demand exponentially, to where we’re probably doing twenty to thirty procedures per month, since around 2024. We’ve actually seen a lot of patients traveling for these procedures from other states and around the country.

I want to talk about it the way I would with a colleague, because the demand is telling us something. So here is the candid version.

Who Is the Typical Patient

The typical patient is actually anything you can imagine. There are really no stereotypes in terms of who’s seeking these procedures. There’s a wide range of ages and a wide range of races. You would think that a lot of men would consider themselves small, and that’s why they’re obtaining these procedures, but actually, a lot of men are already well-endowed, and they’re just looking for enhancements. I can see that the age between thirty and fifty is the most common, but again, we see all types of patients.

What They Are Asking For

They’re asking for several different kinds of procedures. The most common is size enhancement, which is usually done with fillers. The most common fillers, which give the most volume in the penis, are Voluma and VoluX. These fillers are going to increase girth and can increase length up to half an inch, but that’s not the main objective or how it physically works.

Men who want to enhance sensation or who have erectile dysfunction are getting the P-Shot, which is essentially PRP, platelet-rich plasma derived from your own blood, which is injected into the cavernous bodies of the penis and the crown to increase sensation, libido, and erection strength.

Recently, we’ve seen an increased demand for Bocox, which is botulinum toxin injected into the cavernous bodies of the penis. This creates vasodilation, which creates a larger erection. It usually increases length by half an inch to one inch, creates a stronger erection, and is used in normal patients as well as for erectile dysfunction.

Some men are looking for a descended testicle look, where the testicles hang more pronounced, and smoother scrotal skin, and to avoid the scrotal shrinkage that we sometimes see with changes in temperature. These men are good candidates for Scrotox, which is Botox injections into the dartos muscle and the scrotal skin.

The Part I Make Sure Everyone Hears

It is very important to know that Scrotox can cause sterility, because really, those muscles we have are for temperature control of the testicles and the spermatic cord. A patient who would not be a candidate for Scrotox is one who would still want to have a family, as the procedure can make a male sterile.

It’s also important to understand that all of these treatments are off-label. Even though the products are FDA-approved, we are using them in an off-label nature, with the patient’s consent and understanding of the risks and complications.

What Is Really Driving It

I think, essentially, it’s increased self-esteem in sexual encounters and increased performance. Some of the procedures are more about appearance, such as the Scrotox for smoother skin and more descended testicles. Some men actually come for injections to increase the testicle or scrotal size, so that’s more about appearance. I think length and girth are a combination of appearance and sexual confidence. And I think erectile strength is more about sexual confidence and performance.

The Misconceptions Men Walk In With

One of the biggest misconceptions men have when considering these procedures is that the procedure will considerably lengthen the penis. As I’ve discussed before, these procedures really don’t create a lot of length. If anything, it’s half an inch maximum, or one inch. But they do seem to create a lengthening effect at rest, when the penis is not erect, and they mostly create an increase in girth.

The other misconception is that these results are permanent, where, for example, fillers can last one to two years, and Botox usually lasts three to six months.

And then I think the biggest misconception of them all is that bigger is always better, and that’s not necessarily the case. Sometimes the quality of the erection is more important than the size.

Where the Risk Lives

There are many risks and complications. It’s extremely important that you go to a board-certified physician to obtain these enhancement procedures, that the facility is using FDA-approved botulinum toxin and fillers, and that these procedures are performed in sterile environments. This is certainly not a procedure where you would want to bargain or look for the least expensive provider, if that means cutting back on safety and quality products.

The main risks, especially with the penile fillers, would be some areas of contour deformities, which can always be touched up later. Sometimes there could be nodules that are palpable, which can also be dissolved if necessary. It’s very important that the product be injected in the right plane. If it’s injected too superficially, then the nodules and irregularities will be more apparent. They can even create edema in non-circumcised men, which can interfere with intercourse and even regular voiding. The most dangerous complication would be an infection in this area, which is avoidable with the right sterile technique and postoperative care.

The Bigger Picture

I think this is part of a broader male aesthetics trend. We are seeing men more frequently in our clinics for cosmetic procedures, hair restoration, hormone replacement, weight loss therapies, peptides, and wellness IV drips. I think men are getting more comfortable with these treatments. I think a lot of it has to do with finding the right provider that they’re comfortable with and that they can trust.

So many men are curious but embarrassed to ask about these treatments. A lot of them do research online. We even have a chatbot that can talk to them, and at least they seem to think it’s a little bit more private. But what I would say is that these are actually very common procedures that most men know about and have even researched for themselves, that we just don’t talk about. Clinics that perform this on a regular basis understand the needs of men and usually cater to them in a very respectful and private way, where they’ll feel understood and not judged.

The Credential Behind the Opinion

I am double board-certified by the American Board of Plastic Surgery and the American Board of Surgery, an American College of Surgeons Fellow, Mayo Clinic plastic surgery fellowship trained, and a Clinical Associate Professor of Plastic Surgery at Texas Tech University Health Sciences Center Paul L. Foster School of Medicine. Castle Connolly Top Doctor for thirteen consecutive years. I write about this candidly because the field is growing faster than the honest conversation around it.

Ready to Talk?

If you are a man weighing any of this, or a colleague trying to build this part of a practice the right way, the principles are the same: honesty up front, sterile technique, FDA-approved products, and realistic expectations.

For the patient-facing clinical guide, see the companion post on agulloplasticsurgery.com. For the MedSpa and men’s wellness side, 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.

June 19, 2026

A Sharper Edge: A Surgeon’s Read on Blade Geometry, Inflammation, and the 114-Patient Study That Changed How I Pick My Scalpel

Every plastic surgeon has had the same conversation a thousand times across a desk. The patient is in for a consultation about a planned operation. The operation is well-understood, the indication is clear, the plan is in place, and then the patient asks, quietly, almost as an afterthought, the question that turns out to matter most. What is the scar going to look like.

The honest answer, for years, has been a list of variables that the surgeon controls only partially, layered on top of a list of variables, like genetics and skin type, that the surgeon does not control at all. That answer has been mostly true. It has also been incomplete, because one of the variables sitting right at the surgeon’s hand has been almost entirely absent from the conversation.

The variable is the blade itself. A 114-patient clinical study I served as a principal investigator on, picked up by MPO Magazine in early 2025 under the headline “Significant Reduction in Hypertrophic Scarring Seen With Planatome’s Surgical Blades,” put a hard number on what I had been suspecting in my own practice for years. A cleaner cut produces a quieter scar.

This is the longer surgeon-to-surgeon version of that finding, and what it means for the consultation that starts with “what is my scar going to look like.”

The Study, in One Paragraph

I co-led the 114-patient clinical study evaluating the Planatome surgical blade alongside Michael Sanchez, PhD. The Planatome blade is manufactured with a polishing process that produces a smoother, sharper cutting edge than a standard surgical blade. The study followed patients through standardized incisions and assessed scar quality at multiple time points. The headline finding was a measurable reduction in hypertrophic scarring in the Planatome arm. The trade industry coverage called the reduction significant. I will let other investigators replicate the finding on other populations and in other operations before I make stronger claims, but the result is internally consistent and clinically meaningful.

Why a Cleaner Cut Produces a Quieter Scar

The wound healing cascade begins the moment the blade enters the skin. The depth of the cellular insult at the incision edge is one of the largest single inputs into the inflammatory response that follows. A standard surgical blade, even a brand-new one straight out of the package, has microscopic irregularities along the cutting edge that are functionally invisible to the surgeon at the time. Under a high-magnification image, those irregularities tear the tissue along the incision rather than cleanly transecting it. The cells along the wound edge respond not to the surgeon’s intent but to the cellular environment they are actually in.

A polished, sharper edge produces a different cellular environment. The cells along the incision are cleanly transected rather than crushed. The local inflammatory cascade is quieter. The fibroblast recruitment, the collagen deposition, and the final remodeling that produces the mature scar all start from a different baseline. In the patient who would have formed a flat, fine scar under almost any technique, the difference is invisible because the result was always going to be good. In the patient who would have formed a raised, thickened, hypertrophic scar under any technique, the quieter starting point shifts the curve.

This is the kind of finding that, in retrospect, looks obvious. A sharper knife should produce a cleaner cut and a quieter cellular environment. The reason we needed a study to confirm it is that “obvious” is the most dangerous word in medicine, and the difference between intuition and data is the difference between marketing and a recommendation a surgeon can stand behind.

What the Study Did Not Claim

The study did not claim that blade quality is the only variable in scar formation. It did not claim that a sharper blade will turn a keloid-prone patient into a fine-line healer. It did not claim that the blade matters more than the closure technique, the incision design, the tension on the wound, or the genetics the patient brought with her.

It did claim that, holding the other variables steady, the edge of the blade itself moves the needle. That is a meaningful claim. It is not the only claim.

What I Tell Patients at the Consult

Scar quality is decided across six decisions and one variable I do not control.

The variable I do not control is the patient. Genetics, skin type, anatomic risk, and personal scar history all enter the room with her.

The six decisions are mine. The incision location. The incision orientation. The incision length. The blade. The closure plan, including the layers and the suture choice. The post-operative scar care plan, including silicone, compression, sun protection, and any post-op laser or microneedling on indication.

A sharper blade is the easiest of those six decisions to make. The hardest is honest expectation setting with the patient about what her skin will actually do, regardless of any decision I make.

Where This Lands in Practice

I use the Planatome blade in operations where scar quality is most consequential, including breast augmentation, tummy tuck, mommy makeover, facelift, and any operation on a patient at elevated risk for hypertrophic or keloid scarring.

I also use the study’s existence at the consultation. The patient who wants to know what can be done to give her the cleanest possible scar gets a real answer rather than a vague reassurance, and the answer includes a study I helped design rather than a generic platitude about being careful with the incision.

The trade industry coverage in MPO Magazine framed the result as significant. I would agree. I would also frame it as one of several variables a surgeon can and should optimize for scar quality, and the variable that is easiest to control. The reason it took a 114-patient study to put the finding on the record is that the field genuinely needed the data.

A Brief Word on What the Field Should Do Next

The Planatome study is one data point in a larger conversation about how blade geometry, blade manufacturing, and blade sharpness interact with the inflammatory cascade and the final scar. The questions worth answering next are predictable. Does the effect hold across all skin types and all anatomic locations. Does it hold for procedures that involve electrocautery for the deeper dissection but a cold blade for the initial skin incision. Does it interact with newer scar management modalities, like silicone alternatives, post-op fractional laser, and microneedling at the right interval.

Other investigators will answer those questions in time. The study I co-led is the floor for that work, not the ceiling.

How I Talk About the Whole Scar Equation

When a patient asks “what is my scar going to look like” at a consultation, the honest answer takes ten minutes. It is the most useful ten minutes of the consultation, because the scar is the part of the operation she will see in the mirror for the rest of her life. The plan we make about the scar is the plan we make about her relationship to the result of the operation.

The blade is one part of that ten minutes. The study makes it possible to discuss the blade as a variable backed by real data rather than as a vague reassurance about surgical care. The rest of the ten minutes is still about the patient, the operation, the closure, the post-op plan, and the contingency plan if the scar does not behave the way we hope.

Ready to Talk?

If a planned operation is on your mind and the scar is part of what you are weighing, the first conversation is a consultation. The ten minutes about the scar will be the most useful ten minutes of the visit.

For the clinical patient-facing version of this conversation, see A Sharper Edge: How Blade Geometry Reduces Hypertrophic Scarring on agulloplasticsurgery.com. For the practice-program version of the scar management continuum, see The Scar Management Program at Southwest Plastic Surgery.

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.