The tummy is the part everybody plans for. It is the part they have been pinching in the mirror for years, the part the tummy tuck was invented for. So when a patient a hundred pounds lighter sits down across from me, they are ready for that conversation.
They are not ready for the rest of it. I said as much on a podcast last week, to a host 126 pounds down, and I have written up the timing half already. This is the other half.
“It’s a 360 thing. It’s the whole body, not just the tummy like most people expect.”
Start with the physics, because it explains everything after it.
“The skin envelope has been stretched out. It’s lost those connections with elastin, and you can’t make any new elastin. Once you deflate, just like a balloon, the outside wrinkles. We’re going to get some contracture, it’s just not as much as we would want.”
A balloon does not wrinkle in one spot. So, zone by zone.
The breasts, and I mean both sexes.
“The breast loses its fat content, and this is for both men and women, which is also surprising. You suddenly have saggy breasts, and that can affect a lot of patients mentally.”
The men are the ones blindsided. Fixable. Not the reward they pictured.
The buttock is the one I want you to understand, because it deflates twice.
“The same thing happens in the buttock area, and there we have a combination. A lot of these patients losing weight fast are not taking in enough protein, so they’re also losing muscle. About a quarter of the weight loss is going to be muscle mass. So the body loses muscle mass plus the fatty content, and then we have the sagging in the buttock.”
A quarter of it is muscle. The buttock is mostly muscle. So the weight-loss months matter here.
“It depends on the amount of weight you lose, how fast you do it, and how you take care of yourself during that time. Are you taking protein? Are you doing weightlifting and building muscle? The skin is going to react the way it does. We can’t do a lot about it. We can help it in some ways, but you shouldn’t feel bad if you have excess skin.”
Then the zones nobody mentions until I ask.
“Some patients have it in the inner thighs, the arms, the back.”
Inner thighs rub. Arms show in a short sleeve. The trunk I covered in the body lift post.
Will it come back if you wait? Some.
“Younger patients are going to retract better. Everybody retracts some, probably not as much as we would want, and it’s also sooner than people think. It really happens in the early stages, and I think at a maximum of a year it’s all done.”
A year is the ceiling.
Where do I start?
“If you’re losing 40 pounds, I think you’re going to need a surgical procedure. It depends: some people care about the face, some about the buttocks, so it’s very personal what gives the patient the self-confidence.”
The face changes first. You rank the rest, not me.
“What I’ve been seeing is about a six to nine month weight loss and then about a three month stabilization until we’re ready for surgery.”
“And the main thing is not to bounce back. When you stop taking it, if we have a bounce back, that can pretty much destroy everything we did, and the fat is not going to come back in the right places necessarily.”
One last thing, usually said as an apology.
“Patients lose the weight, the envelope stays, and some patients feel ashamed of it, like they did something wrong. That’s not the fact. It’s just the way things work. Skin stops producing elastin after puberty, so it just doesn’t contract like it does during puberty.”
You did the hard part. The skin is the part I do.
The full clinical version, with the zone-by-zone table and the procedure pages, is on agulloplasticsurgery.com.
A patient came in last week and put her phone on my desk. Photo of her vanity drawer. Serum she couldn’t pronounce. Her mother’s old YSL lipstick. A small fridge pouch with a vial of compounded semaglutide. Which of the three, she asked me, was actually doing the work.
Keep all three. Probably not for the reasons she thought.
This kind of question hits my office a lot now. Several times a week. Eighteen months ago it was once a month. And the women asking aren’t the ones with a hundred pounds to lose. They eat clean. They do Pilates. They’re stuck on the last fifteen before a wedding, a fiftieth, or a surgery date already on my books. Ozempic. Mounjaro. Now, more and more, the third one. The one their trainer keeps name-dropping. Retatrutide.
So let me answer the way I’d answer across the desk, without the marketing copy.
Three vials, three generations
The brand names dominate the popular conversation. The compounds underneath are not the same drug.
Semaglutide is the one everyone started with. Single receptor. Mimics GLP-1, the gut hormone for satiety. Translation: walks into your brain and tells you you’re not hungry, and means it. Trial data puts loss around fifteen percent of body weight by twelve months. Life-changing for plenty of people. On some faces, it also produces the hollow look the wellness columns have been calling Ozempic face. I’ll get to that.
Tirzepatide added a second receptor. GLP-1 plus GIP, an insulinotropic peptide. What the GIP receptor does, on the data we have, is two things. It spares a bit more lean mass. And it pushes loss past where sema usually stalls. Twenty percent at twelve months is where good responders are landing in the trials. In my program, tirz is where I move someone after sema plateaus and the scale stops moving.
Retatrutide is the newest. Three receptors. GLP-1, GIP, and glucagon. Early-phase data is striking. Patients pushing toward twenty-five percent loss at a year, which is a number that didn’t exist in this category two years ago. We offer it as a compounded formulation. Not casually. The patients we put on it are screened with a level of caution that the popular coverage hasn’t, frankly, been encouraging.
Compound
Receptors
Typical loss at 12 months
Where it fits in our program
Semaglutide
GLP-1
~15%
Default for most patients
Tirzepatide
GLP-1 / GIP
~20%
Plateaued patients, or larger loss goals
Retatrutide
GLP-1 / GIP / glucagon
~25%
Specific candidates, closely supervised
These are not interchangeable shots. Choosing among them is a clinical call. Not a pricing decision.
The face the internet noticed
So about that hollow look.
Weight comes off the face first. Cheeks lose volume. Temples sink. The jawline appears, but the skin that draped over a fuller face is now draping over nothing. People call it Ozempic face. A surgeon calls it volume loss layered on top of skin laxity that the weight had been hiding.
Not a reason to skip a GLP-1. A reason not to take one in a vacuum.
The fix, when needed, is the kind of thing I do every week. Filler done by someone who actually does faces. A deep plane facelift if the laxity is real. A skin program in any case. What I do not want is the patient who spent six months losing weight and only realizes at month seven that no one on her care team was thinking about her face. Body and face are one conversation. They have to be.
Where this gets interesting
This is the side of the GLP-1 story I find more fascinating than anyone else seems to. The wellness press isn’t writing about it. The trainers aren’t. The patients usually haven’t put the pieces together yet.
A patient drops thirty to forty pounds in three months on one of these drugs (a number we see week in and week out now) and walks into my body contouring consult a meaningfully different person than she’d have been at her starting weight. The fat is gone. The skin envelope she’s wearing was sized for the fat. That gap is where my side of the work begins.
I lay hands on an abdominal wall that, three months earlier, would’ve been hidden under a layer of subcutaneous fat thick enough to bury the rectus muscles. I feel the diastasis through skin. A real triple plication is suddenly on the table. So is a waist reduction I used to reserve for thinner patients. The BBL I’d have offered her at her starting weight isn’t the BBL I’d offer today. Proportions changed. Canvas changed. What I can build on it changed.
The GLP-1 didn’t produce that result. It let me do the operation I’d have done anyway, except now the operation hits twice as hard.
That’s the quiet thing nobody’s writing about. The aesthetic ceiling on body contouring went up the day this drug class went mainstream. Every plastic surgeon I know who’s been operating on bodies for fifteen-plus years is having some version of this realization, mostly in private, mostly over coffee at the annual meetings.
How our program runs
Patients ask less than they should about how a weight loss program is supervised. So here is ours.
I am the medical director. My nurse practitioner runs day-to-day. I stay in the loop on dosing, intake, and any patient who needs a second medical opinion before we change anything. Labs at intake, no exceptions. Nobody on my team hands a vial to a patient who has only filled out a form.
That sounds heavier than the GLP-1 you can have shipped after a five-minute online questionnaire from an Instagram brand. The point is that it is. Pancreatitis is the side effect that should make patients nervous about how they get their drug. A flare on a shot you ordered yourself becomes a 2 a.m. trip to an ER where a stranger has to figure out what you took and at what dose. The same flare on the same drug, prescribed in our program, is a phone call to my office, where your chart is already open.
One more thing about the glow
A patient asked me last month, half-joking, whether the program would make her glamorous. I told her it would not.
What it will do is hand her back a body she can dress, photograph, and walk into a room in without the internal commentary that comes with the wrong size of denim. That is what patients are pointing at when they say glow. The rest of glamour, the part the wellness press is trying to bottle, is built out of unsexy fundamentals nobody puts on a billboard. Sleep. Skin care. The correct surgery if and only if. A stress level somewhere south of catastrophic.
I have been doing plastic surgery long enough to watch four or five “miracle” technologies arrive and underdeliver. The GLP-1 class, on the evidence so far, is the rare one doing more than it advertised. That deserves real respect, and respect means running it like medicine, not a cosmetic line.
Why this lives inside a plastic surgery practice
A weight loss program in 2026 isn’t an isolated medical service. It’s a step inside a longer arc. Face, body, skin, recovery, sometimes surgery. Pretending otherwise is how patients end up disappointed by the result they paid for.
I’ll say it. The Mayo Clinic fellowship taught me, above everything else, to treat volume, skin envelope, and structural support as one system. Not three. One. The thirteen straight years on the Castle Connolly list, the Texas Tech academic appointment I’ve held since 2011, the peer-reviewed work, all of it points the same direction: stay close to what actually moves a patient’s outcome, and let the rest go. None of that overlapped with weight loss medicine until the medicine started visibly reshaping who walks into a body contouring consult. Once that happened, sending the program to a med spa across the parking lot was never going to be my answer.
So I run it. With my NP. With my chart open in front of me on the days a patient needs an actual physician on the line.
Ready to talk?
A GLP-1 is a medication. The first move should be a conversation, not a prescription. Bring your goals. Bring any recent labs. Bring a photo of the version of yourself you are trying to come back to. If surgery is also on your mind, we plan the arc together. If the only goal is to drop fifteen pounds and feel like yourself again in clothes, that is a real goal too, and we run that program with the same care.
Call (915) 590-7900, text 1-866-814-0038, or book online at agulloplasticsurgery.com. Follow along on social at @RealDrWorldWide on Instagram, TikTok, and Snapchat, @Agullo on X, or @AgulloPlasticSurgery on Facebook. #StayBeautiful
