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The Men in My Waiting Room Are Not Here for Their Wives Anymore

Black and white photograph of a man seen from behind at a tall window, fastening the cuff of a dark shirt, in hard directional light. Illustrative image, not a patient. Commentary by Frank Agullo, MD, FACS.

The men in my waiting room used to be there for their wives. They held the purse and read the magazines.

Now they have their own appointment. And they have a list.

“In my practice, the most common procedure I perform in men is gynecomastia surgery. That is number one. Number two is liposuction, which usually involves the abdomen and the lower back, but sometimes it is extended to the neck, upper back, lateral chest and even the breast itself. Number three is eyelid surgery. Number four is rhinoplasty, which is very common in younger men.”

Then the one that is new.

“Last but not least, facelifts and neck lifts have become more and more common in men, especially with the GLP-1s. The face loses fat fast, and it is one of the most noticeable changes as a patient is losing their weight. They also look older from the loss of volume.”

Chest, waist, eyes, nose, face. I have written the gynecomastia story already, including the price, so this is about the other four, and about what changes in my hands when the patient is a man.

Nobody asks that question, and it is the interesting one.

“Although the techniques and the surgeries are pretty much the same in men and women, there are some specific changes. Most men want to appear more masculine, so the procedures are modified to achieve this desire.”

Start with the brow. “When we do facelifts, we do not like to raise the brow as much. In men, it should pretty much line up with the superior orbital rim.” A few millimeters too high and a man does not look rested. He looks startled, for good.

Then the hair, or the lack of it. “We also have to modify where the incisions lie so that they can be easily hidden, depending on whether the patient has lost hair in the scalp, including at the sideburn and temple.” A woman’s facelift scar disappears into a hairline. A man’s has to be planned around the hairline he will have at sixty.

The nose. “Male rhinoplasty is usually a more masculine, closed rhinoplasty aiming for a straight dorsum, the Roman style. We want to avoid the curved dorsum and the more projected, refined tip.” Nobody wants a pretty nose on a man. They want a straight one.

The waist. “In liposuction, it is more likely that we will perform etching to show off the abdominal muscles and the six-pack during liposuction. Sometimes we add fat grafting to the pectoralis major muscle to increase the size of the muscle itself, or even the biceps. For this we can use the patient’s own fat or alloClae.”

And the part men never think to ask about. “When we do buttock fat grafting in men, we usually skip fat grafting to the hips, because we want to avoid a feminine curvature and instead project the gluteus maximus muscle.”

People assume I spend the male consult talking men out of things. I do not.

“I don’t think I’ve actually encountered many situations where I have to talk somebody out of a procedure. Oftentimes they don’t come in wanting a specific procedure, they come in with a problem and a consultation on how we can fix it.”

The under-eye bag is the classic. He asks for a blepharoplasty. “Many think it is just a blepharoplasty, but I use the blepharoplasty approach to remove the fat bags, I use fat injections into the tear trough, and I use Morpheus8 microneedling with radiofrequency to tighten the skin. Sometimes I even use AccuTite to tighten the skin, avoiding an incision that can give you a visible scar, or even an ectropion.”

He came in with a procedure. He leaves with a plan.

And the wave behind all of it is the pen. “I think the GLP-1s are actually increasing the amount of demand we see in the office for consultations. The first thing patients notice is the deflation on the face.” Then the body catches up. “The patient feels better and is healthier, but the body, with the loose skin, is not showing that externally. So many men are coming in for gynecomastia and tummy tucks.”

“Men are getting healthier, slimmer, and ready for their bodies to match the way they feel.”

The prices for every one of these are published, and the full ranked list with what I do differently is on the male plastic surgery hub. The one procedure I left out of this post has its own.

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.

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The Next Wave in Weight Loss

Woman in a long robe standing on a bathroom scale in window light, black and white

There is a molecule Americans search for hundreds of thousands of times a month that has not reached a pharmacy shelf. Not because it is banned. Because it has not finished the process.

What it actually is:

“Retatrutide is a triple hormone receptor agonist that targets three pathways: GLP-1, GIP and glucagon receptors.”

“At this time, there is no FDA-approved branded retatrutide product available.”

Where it sits in the family:

“The GLP-1 originally came out as a medication for diabetics. There are receptors in the stomach that make us feel full, and that same signaling helps lower blood sugar, which is how it helps diabetics control their sugar. It also communicates with the brain so your appetite goes down, you feel fuller and more satisfied, and it slows the intestine so your portions naturally get smaller. You eat the same way but smaller portions, and certain foods, like very greasy or very sugary foods, stop appealing to you.”

“Semaglutide was the first one and has just one component, GLP-1. Tirzepatide has two components, GLP-1 and GIP. It helps more with inflammation, helps with more weight loss, and has fewer side effects like nausea, heartburn, and vomiting.”

One receptor. Then two. Retatrutide makes three.

On how I dose the approved ones:

“We start with the smallest dose, which is 2.5 milligrams, for four weeks, and I see how you feel. If you are doing well I increase the dose depending on how you feel. If you are losing a good amount of weight, I keep you at that dose until you stop losing, then we go up again.”

“I give you the four injections for the whole month, and you inject yourself once a week. The injections are like an insulin shot, a tiny drop, usually in the abdomen, alternating sides each week.”

In trial, retatrutide started at 2 mg weekly and stepped up every four weeks.

Why the body fights you in the first place:

“As estrogen starts to drop, the other hormones start to change, the thyroid, insulin, and cortisol, and women tend to start gaining around the middle.”

“Insulin makes you very hungry and tired and causes you to store more fat. The metabolism slows down and cortisol rises, and that is part of why we gain weight.”

“Even if you exercise a lot and eat well, sometimes we need some kind of help.”

On whether the new molecule is the better choice:

“Retatrutide, being a triple agonist targeting GLP-1, GIP, and glucagon receptors, may offer greater weight loss potential than semaglutide and tirzepatide. Semaglutide is a GLP-1 receptor agonist, whereas tirzepatide is a dual GLP-1 and GIP receptor agonist.

“Patient selection should be individualized rather than based on one peptide. Patients with obesity or overweight accompanied by metabolic complications such as prediabetes, insulin resistance, metabolic dysfunction-associated fatty liver, or cardiometabolic risk factors may all be appropriate candidates for any of the GLP forms.”

May. That word is doing real work and I am not going to pretend otherwise. There is no completed head to head trial against tirzepatide.

Why anyone cares this much

Lilly published Phase 3 TRIUMPH-1 in May. At 80 weeks, participants on 12 mg had lost an average of 28.3 percent of their body weight, about 70 pounds. Forty five percent lost at least 30 percent. Two thirds finished with a BMI under 30. A smaller group who ran to 104 weeks averaged 30.3 percent, roughly 85 pounds.

I have spent my career operating on people after weight loss like that. Until recently the only reliable route to those numbers was a surgeon.

The results carried a cost. At the top dose, 42 percent nausea, one in eight reporting abnormal skin sensation, about one in nine quitting over side effects. The lowest dose studied delivered 19 percent weight loss with fewer dropouts than placebo, which tells you the ceiling is not the target for everyone.

Where it stands

Lilly hinted it might file with the FDA before the end of 2026. In July it moved that to the first quarter of 2027, citing manufacturing and quality control data still being assembled. Then the review clock starts.

On sourcing, which is the part that keeps me up:

“An important safety consideration with GLP-1 based therapies and other peptide treatments is the importance of ongoing evaluation, treatment, and follow-up by a qualified licensed medical professional. Patients should undergo appropriate screening before treatment.

“Appropriate clinical oversight and sourcing medication through legitimate, appropriately licensed pharmacies can also help reduce the risk of obtaining counterfeit, contaminated, improperly compounded or otherwise unsafe products from unverified sources.

“Patients should be educated to obtain their medications only through authorized and reputable channels and to avoid products purchased from unverified websites, social media, or any other unauthorized sellers.”

Unverified websites, social media, unauthorized sellers. That is where a great many of those searches end up, and there is no approved product waiting at the other end of any of them. I wrote recently about what the word peptide actually means and why I now ask every surgical patient what they have been injecting. Same problem, newer name.

What I tell people instead

The approved medications work. What I say to patients on them has not changed:

“Your appetite will go down. Many patients stop eating and only eat at mealtime, but I do not want you to do that, because if your blood sugar drops you will feel tired. I want you to eat small amounts during the day, snacking on something like a fruit, so your blood sugar stays more stable. I also want you to eat more protein so you do not lose as much muscle and we burn more fat.”

“Walk twenty to thirty minutes a day. Once you feel a little better, add light weights while you walk. That helps the muscle grow and burns more fat.”

A better obesity medication does appear to be coming. On the optimistic reading it is about a year from a pharmacy. Nothing about that timeline improves by buying a vial from someone who will not tell you where it came from.

For the full trial breakdown, dosing as it was studied, and what to do in the meantime, read the complete guide on the Southwest Plastic Surgery site. The version I wrote for my surgical patients is at agulloplasticsurgery.com, and body contouring after major weight loss is the surgical side of this story.

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.

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A Peptide Is a Size, Not a Promise

Black and white still life of small glass peptide vials on a dark surface. Editorial on peptides by Dr. Frank Agullo, MD, FACS.

A peptide is a size designation, nothing else. Insulin is a peptide, and the contents of the vial someone ordered at two in the morning from an online store is also a peptide. Treating those two things as one story is how the public ended up this confused.

U.S. News asked me about peptides earlier this month. That is where I started, and it is where anyone honest has to start.

Take the Word Apart First

A peptide is defined as a chain of amino acids normally composed of anywhere from two to about fifty in number. It is a size range, not a drug class nor a benefit.

Insulin is a peptide, just like the peptide in an antiaging serum, just like the compounded vial someone ordered from an overseas website. They have all been thrown into the same box together, making people think they are identical, hence the rampant, widespread confusion on the issue.

Most marketing makes these products out to be better than they are, and the vagueness of the word is exactly what makes that possible.

The Serum on Your Counter

In short, the science is good, not great.

Copper peptides and signal peptides used in some consumer skincare have lab studies that show they can stimulate collagen synthesis, and a small selection have proven in trials to smooth fine wrinkles modestly over several months of regular use.

Then physics gets a vote. Delivery limits how much of this can penetrate the outer layer of the skin, which consists of dead skin cells built up as a shield designed to keep outside contaminants like large molecules, especially water-loving ones, from entering the body.

So here is the rule I give patients. A peptide is a reasonable addition to a product where a sunscreen and a retinoid are doing the real work. It is not a replacement for either one.

When a client tells me their plan for anti-aging is a peptide serum, that is when I feel a little uneasy. It is a quiet harm that we miss discussing within the safety debate.

Nobody gets hurt by the serum. They get hurt by the decade they spent on it instead.

The Vial in the Refrigerator

My real issues began with the injectable and compounded peptides.

It is about impossible to go a month without seeing at least one patient who is self-injecting peptides obtained without a prescription from who knows where, for an injury, for joint pain, or for what they are calling recovery. BPC-157 comes up all the time, and growth hormone secretagogues are about the most frequent second thing asked about, usually phrased as anti-aging.

Very few of them know how little human research is available on these compounds, know that most dosage regimens have been picked up from bodybuilding forums, or know that the vial is coming from an overseas research-chemical company, with no guarantee as to contents, purity or whether it is a sterile preparation.

I have seen and operated on patients with abscesses as well as infected lesions at injection sites that stem from these supplies.

That is not a warning I am passing along. That is an operation I performed.

What I Now Ask Before I Operate

Before operating, I routinely ask my patients if they have been injecting peptides, much like asking about their supplements, mainly because I have no idea what is in the vial my patient received and neither do they.

The Part Everyone Is About to Get Wrong

If some peptides could now go through licensed compounding pharmacies with an actual prescription, that would be safer than the massive, unregulated market people are already buying from on the internet. I am in favor of that.

The big risk is that people read the news and think a scientist gave their blessing simply because it became more available.

Expanding legal options answers the question, who is allowed to make these? It does not address the question of how effective these peptides actually are. One of those questions deals with legal access and the other asks about scientifically verified results, yet they will both get treated the same.

Allowing a pharmacy to compound it means a pharmacy can make it. Allowing them to make it does not mean it will work.

Where I Land

Peptides are not peptides, and one answer is not the answer.

Topical peptides applied to the skin are mostly not toxic and, in most circumstances, they have been exaggerated. Peptides that are compounded or injected are promising enough to merit genuine study, and they are already used a great deal, far ahead of the studies and with almost no supervision.

Both of those sentences are true at once. Any coverage that picks one and runs with it is going to mislead somebody.

Why I Get Asked

I am board certified in plastic surgery. I practice in El Paso, Texas, and I am a Clinical Associate Professor of Plastic Surgery at Texas Tech University Health Sciences Center Paul L. Foster School of Medicine. I also sit on the editorial boards of Aesthetic Plastic Surgery and Plastic and Reconstructive Surgery Global Open.

I am not against peptides. I am against a word doing the work that evidence is supposed to do.

Ready to Talk?

If you are injecting something and cannot say what is in it, bring the bottle. Call (915) 590-7900, text 1-866-814-0038, or book online. #StayBeautiful

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

Companion reads: the plain guide to what is in the bottle at swplasticsurgery.com, and the surgical safety piece on agulloplasticsurgery.com.

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The Ozempic Earlobe: What Weight Loss and Heavy Earrings Do to Your Ears

Black and white editorial close-up of a single pearl drop earring resting beside fine suture material on a linen surface. Earlobe repair editorial by Dr. Frank Agullo, MD, FACS.

A bride-to-be sat in my office earlier this year with a problem no one warns you about. She had lost about fifty pounds with Ozempic in a four-month period, and noticed that her earrings didn’t sit the same way anymore. Her earlobe had become empty and wrinkly.

She was young. In her thirties. The weight loss was a win. Her ears did not get the memo.

Nobody thinks about earlobes until theirs stop cooperating, and then they think about them constantly. Wedding photos have a way of accelerating that timeline.

The Earlobe Has a Rough Job

The most common cause of earlobe tears, or elongated piercings that haven’t torn quite yet, is the chronic use of heavy earrings. It’s a gradual stretching that happens over time.

And as we age, we also lose some of the fat and collagen in the earlobes, which decreases the tissue strength, and the stretching or tearing can speed up. Then there is trauma: the earring getting stuck on something and pulling, or a baby pulling on the earring. Every mother of a grabby infant knows exactly the moment I am describing.

The GLP-1 era added a new chapter. Aging earlobes have actually increased in demand, not just because of aging, but also because of the GLP-1s like Ozempic and tirzepatide. Patients lose the good fat in the earlobes, and these become deflated or elongated. Everyone talks about Ozempic face. The earlobes deflate right along with the cheeks.

The Repair Is Simpler Than You Think

The repair itself is rather simple. The first step is to do it in a sterile fashion, so we sterilize the area to decrease the risk of any infection. Then we use local anesthesia, which is infiltrated into the earlobe. This is the part that can sting a little bit, but it’s very quick. After that, the whole area is anesthetized, and you don’t feel anything.

Depending on how big the tear or stretch is, we cut out that area, and then we suture it in a layered fashion, approximating the deep tissue coming all the way up to the superficial skin layer. The procedure usually takes fifteen to thirty minutes. And to keep the ear natural, we rearrange the tissues so there’s no puckering or indentations. That last sentence is where the plastic surgery training earns its keep. Anyone can close a tear. The art is a lobe that looks like nothing ever happened, the same philosophy I bring to my in-office excisions.

A partial tear versus a complete split changes less than people expect. The approach is about the same. The only thing that’s affected is the length of the incision, and whether it goes all the way to the edge or can be repaired within the tear itself.

And a fact that surprises patients: not all tears happen on the earlobe. They can happen anywhere there is a piercing, including the belly button, genitalia, nose, and the helical rim of the ear. We repair those too.

Refilling the Deflated Lobe

For the empty, wrinkly earlobe, we can do various things that involve filling the earlobe back.

Option What it is How long it lasts
Hyaluronic acid filler (Juvederm, Restylane) Injectable gel, done in minutes Temporary, repeat about every year
Lipoderma Donor fat injected into the lobe Longer lasting, what I used for the bride
Your own fat Harvested and injected Long lasting, requires a small harvest
Trim and tuck Surgical reduction of redundant skin Permanent reshaping for elongated lobes

For the bride, we used Lipoderma, one syringe on each earlobe. That filled in the void of the earlobes, plumped the skin, and actually reduced the size of her piercings, so that the earrings were now sitting like they used to. The whole procedure took about thirty minutes or less. She went back to work the next day, and back to the gym in five days. She was very happy overall, and I suspect the wedding photographer never knew.

Maintenance for filler options lives at the med spa at Southwest Plastic Surgery, alongside the laser treatments we use when skin quality needs help too.

Re-Piercing: Yes, You Can

The question every patient asks before I finish the first sentence: when can I wear earrings again?

To re-pierce, we usually wait three to six weeks depending on the area. For ears, it’s usually three weeks, and we can re-pierce right here in the office. We sterilize the earring or stud that you’re going to use, which will need to remain in place for about a month before it can be taken out. Then wear what you want. Maybe rotate the chandelier earrings to special occasions this time.

What It Costs

The cost range usually starts around a thousand dollars, and the final cost depends on the type of anesthesia, the location, and the size of the defect. Like the rest of my minor procedure practice, this is cash based with a single upfront quote, no insurance and no preauthorization. A photo by email is usually enough to quote it.

I trained at the Mayo Clinic and have spent two decades repairing tissue far more complicated than an earlobe. This is one of the smallest operations I do, and one of the most quietly satisfying. Patients hide torn ears behind their hair for years. Fifteen to thirty minutes later, they stop.

Ready to Talk?

If your earlobes are torn, stretched, or deflated, send a photo and we can usually quote the fix without a visit. Call (915) 590-7900, text 1-866-814-0038, or book online. #StayBeautiful

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

Companion reads: the clinical step-by-step on agulloplasticsurgery.com, and the practice overview with med spa options at swplasticsurgery.com.

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A Surgeon’s Read on the Katie Miller Before and After: The Lower Face Did the Talking

Black and white editorial comparison of two portraits side by side. Before-and-after read by Dr. Frank Agullo, MD, FACS.

A national outlet asked me for a technical read on Katie Miller’s transformation, and I agreed with my colleague that the lower half of the face was where the change was. Here is the longer, candid version. It is an educational read from photographs, not a diagnosis. I have not treated her, and a photo is not a consultation.

The Before

In her earlier pictures, we can see that Katie has pretty full cheeks and fullness in the lower face, making her face very rounded, giving her a tired appearance. There’s also a lack of definition of the jawline.

The After

I think a combination of things has occurred since then. She does look younger and more refreshed. Her face is more triangulated, and her jawline is more defined.

What Could Explain It

I think she’s had a combination of botulinum toxin around the forehead, the glabella, and crow’s feet. I think she’s had some weight loss, probably aided by GLP-1, but the lower face change is rather significant.

I think this would only be achievable either with liposuction, with the aid of something like FaceTite for skin tightening and Morpheus8, both of which are radiofrequency treatments, and removal of the buccal fat pad. If she truly has had weight loss, she may be keeping the upper cheek fullness with fillers or biostimulators like Sculptra. Or if she actually had the liposuction and buccal fat removal, she may have had some fat injections to the cheek and zygomatic area. I think it would be a little bit too far-fetched to think that she’s had a lower face lift, although it’s not out of the question.

Why “She Had X” Is the Wrong Read

This is what I want colleagues and readers to take from it. From a photograph, the honest read is a hedged read. The lower-face change here could be a real procedure, a real GLP-1 weight loss, or a combination, and telling those apart from press photos is hard. The technical read is fair game. The flat “she had a buccal fat removal” headline is not, because the same look can be produced more than one way.

Why the Lower Face Did the Talking

The lower third integrates almost everything that happens above it. Volume that drops, skin that loosens, and weight that comes off all collect along the jawline and the lower cheek. So when a face moves from rounded and tired to triangulated and defined, the lower third is where I look first, because that is where the story almost always is. That is exactly why my colleague and I both landed on the lower half of the face.

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, Editorial Board Member at Aesthetic Plastic Surgery, and Castle Connolly Top Doctor for thirteen consecutive years.

Ready to Talk?

If your own before-and-after is what is on your mind, the read on your face is the place to start.

For the patient-facing version of this read, see the companion post on agulloplasticsurgery.com. For the lower-face treatment menu, 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.

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Reading the Ambassador Face: A Candid Surgeon’s Breakdown of Layered Aesthetic Work

Black and white editorial comparison of two portraits side by side. Aesthetic analysis commentary by Dr. Frank Agullo, MD, FACS.

Reading a face from photos is one of the more interesting things I do, and influencers make it easier. So much of their work gets documented, especially when they are a brand ambassador for a med spa and probably get a lot of their care in exchange for the publicity. Let me read one of these faces candidly, the way I would talk it through with a colleague. This is an educational read, not a diagnosis. I have not treated her, and a photo is not a consultation.

What We Can Be Fairly Sure About

We know for a fact that she’s had neurotoxin to the upper face, which includes the forehead, crow’s feet, and glabella, in hopes of making her eyes more open. She’s had Sculptra to the temples to fill in her temporal recession, hollowness, or temporal wasting. She’s also had Renuva to the temples, also for volume. This is a fat graft. It’s a donor fat graft that is processed, and it encourages ingrowth of fat in that area.

She also had hyaluronic acid filler in the lips, which it seems she did not like and then had dissolved, even though I still see some hints of more volume than she previously had. There is some filler still there that wasn’t completely removed. She had a Botox lip flip. She’s also had PDGF for the under eyes, which is platelet-derived growth factor, which encourages collagen ingrowth. She’s had various lasers and radiofrequency, including Tixel, a thermal resurfacing device, Moxi, a resurfacing laser, and Agnes RF, which is very similar to Morpheus8.

The Weight Loss Is Doing a Lot of the Work

Judging by her earlier photos and her photos now, she’s definitely lost too much weight. I’m not sure if she’s been using a GLP-1, but this has caused her to lose a lot of the good fat in the face, which is the reason she had to fix the temporal wasting. You can notice in the current pictures that she has a lot less lower cheek fat and a lot more angulated jawline. This could all be from weight loss.

Now she has a lot more anterior malar volume, so she may have had some Sculptra and Renuva in the upper cheek area. I’m sure she maintains the skin also with broadband light, like BBL. And I think she’s probably had neurotoxin also to the masseters and lower face, which you can see from her slimmer jawline. She probably has good skin quality maintenance with medical-grade topicals, so tretinoin, vitamin C, but this has never been disclosed.

Why the “She Had X” Take Is Usually Wrong

When you read a face like this, the honest answer is never one thing. It stacks many small treatments over years, plus a real weight change, plus maybe one well-chosen surgical step. The internet wants “she had a facelift” or “she had buccal fat removal.” The truth is messier, and from a photograph you can only ever offer a careful, hedged read.

The One Thing That Hints at Surgery

Now, what calls my attention the most, and I’m not sure she’s had any surgical work, and she is rather young, under forty, is that her brow position is significantly different from her earlier days. It’s pulled up and laterally, which actually opens her eyes. Although a certain degree of this can be achieved with botulinum toxin, the degree she’s showing looks more pronounced. She may have had an endoscopic brow lift, the ponytail type, which can help with brow shaping, and it’s very effective and looks very natural.

Other than that, I don’t see any other signs of actual surgical work. You can see that her nose is unchanged. Although she may have had a rhinoplasty in her early life, you can see that it is off the midline and could actually use improvements. It does look unchanged from her previous photos to now.

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, Editorial Board Member at Aesthetic Plastic Surgery, and Castle Connolly Top Doctor for thirteen consecutive years. The technical read is fair game. The flat “she had X” diagnosis is not.

Ready to Talk?

If there is a look you are chasing, the real question is which of these layers applies to your face, and in what order.

For the patient-facing treatment-by-treatment guide, see the companion post on agulloplasticsurgery.com. For the treatment menu behind this kind of work, 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.

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Patients Used to Come in Ready to Book. Now They Come in to Plan.

Black and white editorial still of a printed surgical quote and a calendar on a desk in soft side light. Aesthetic planning commentary by Dr. Frank Agullo, MD, FACS.

Before, patients used to come in ready to book and asking for the next available date, using credit for the payments or financing. That has definitely changed over the last five years. Now I see patients in their early twenties and thirties who come in for a consultation without any intention of booking, but rather to learn about the procedure, the recovery times, and the cost of the surgery, so that they can start saving up for it.

It is one of the more interesting behavior shifts I have watched across the desk, and I think it is worth writing down.

What the New Patient Looks Like

I see it in patients in their forties and fifties who are thinking about a facelift or facial rejuvenation procedure in three to five years. I also see the patients who just want to avoid credit debt, so they bypass financing or paying with their credit cards. Although they may have an earlier timeline for their procedure, maybe within a year, they prefer to save once they learn the cost and pay it off before surgery. Or some of them actually start making payments directly here at the clinic, without any interest, before they have their procedure.

It is surprising that a lot of patients are coming in this way.

Why the Planning Makes Sense

The planning actually makes sense, because aesthetic treatments fall into two buckets. The first bucket is the treatments that are performed routinely, like botulinum toxin every four months, fillers every year or every two years, facials every one or two months, and skin tightening procedures once or twice a year. These are expenses that patients have already learned and can foresee. The other bucket is the surgical procedures, which obviously have a larger sticker price, and they do require financial planning, whether it’s done beforehand or by budgeting for payments afterwards.

The Part I Find Most Encouraging

What I do see is that the patients who are planning ahead are actually making better decisions and choices, rather than looking for the latest bargain or deal. They’re looking for the most qualified surgeons for their procedures. They’re looking for board-certified plastic surgeons. They’re doing their research. And although many times these providers are on the more expensive side, they’re planning for that expense and that quality.

Patients who haven’t planned for these financial expenses tend, a lot of times, to look for the least expensive option, which sometimes is a non-board-certified provider, or they choose to travel abroad. And these are the patients who usually run into trouble or complications. That is the part that matters. The planning behavior is not just financially smart. It correlates with better, safer choices.

The GLP-1 Driver

This trend has become more evident with the GLP-1s, like Ozempic, or semaglutide-like treatments. These patients see a quick weight loss, which a lot of times transforms into accelerated aging and changes in their body contour. And as they’re seeing this, they’re starting to plan ahead toward when they will achieve their weight loss goal.

While they’re getting some treatments to slow the changes and restore some of the lost volume, they are planning toward more long-lasting and effective solutions like facelifts, breast lifts or augmentations, tummy tucks, buttock lifts, or even Brazilian butt lifts. And these patients really stem from twenty-year-olds to patients in their sixties and seventies. There is not one age-specific sector in the GLP-1 population.

Why This Is Good for the Field

A patient who plans is a patient who shops on quality instead of price. That is good for them and good for the field. The bargain hunt is where the complications come from, and a planning culture pushes patients toward board certification, real research, and a sequence that makes sense, rather than the cheapest available date. The routine maintenance treatments hold the line while the patient saves for the surgical step that actually solves the concern.

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 would rather a patient plan for two years and choose well than book tomorrow and choose badly.

Ready to Talk?

If you are planning rather than booking, that is exactly the right instinct. Come learn the procedure, the recovery, and the real cost.

For the patient-facing version with the two buckets in detail, see the companion post on agulloplasticsurgery.com. For the practice’s planning and financing resources, 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.