Interview with Frank Agullo MD, Board Cerified Plastic Surgeon, Southwest Plastic Surgery

This interview is with Frank Agullo MD, Board Cerified Plastic Surgeon, Southwest Plastic Surgery.

For readers meeting you on Featured, how do you introduce your role as a board-certified plastic surgeon and the core focus of your aesthetic and reconstructive practice today?

I am Frank Agullo, M.D.. Im double board-certified in plastic surgery and the founder and medical director of Southwest Plastic Surgery in El Paso, Texas. I am certified by both the American Board of Plastic Surgery and the American Board of Surgery; I was elected a Fellow of the American College of Surgeons and completed my plastic surgery residency and fellowship at the Mayo Clinic in Rochester, Minnesota. I am also an Associate Clinical Professor of Plastic Surgery at Texas Tech University Health Sciences Center, Paul L. Foster School of Medicine. I have been involved in the training of plastic surgery residents and medical students since 2009.

Many of my patients and colleagues know me online as Dr. WorldWide because I see patients from around the United States and internationally. I have become recognized for advocating transparency in aesthetic surgery through social media education, with over 3 million followers.

Today, my focus is entirely on aesthetic plastic surgery of the face, breast, and body, with a preservation-first philosophy. In my facelifts, I use modern techniques such as full-face and total endoscopic deep-plane lifts to tighten and reposition tissue rather than to pull it tight. When performing breast surgery, the goals are long-term health of breast tissue, natural movement, and natural aging of the result. In body contouring, I focus on the overall harmony of the stomach, back, and gluteal areas, reflecting more than 15 years of experience, including my role as President of the World Association of Gluteal Surgeons.

In addition, I provide thoughtful, non-surgical care at our MedSpas, including injectables (Botox, fillers), skin-quality treatments using energy-based devices (laser, ultrasound, radiofrequency), and medically assisted recovery programs.

My philosophy is built around three pillars:

1. Personalized care, since no two patients have the same anatomy or the same goals.
2. Natural, balanced results that allow people to look like themselves—an improved version.
3. The utmost commitment to safety and long-term patient outcomes.

This commitment is demonstrated by my role on the editorial board of the Aesthetic Plastic Surgery journal (the premier journal of the International Society of Aesthetic Plastic Surgery), along with hundreds of peer-reviewed publications by other physicians and hundreds of our own publications.

My job is not to change who you are. It is to make sure the mirror finally agrees with you.

Looking back, what pivotal experiences in your general surgery, microsurgery, and aesthetic training most shaped how you approach cosmetic advancements and facial rejuvenation now?

I originally trained in general surgery and trauma at Texas Tech University Health Sciences Center, then completed a plastic surgery fellowship at Mayo Clinic. Many younger plastic surgeons enter an integrated plastic surgery residency straight from medical school, but my path is uncommon today and has been absolutely formative in how I approach my practice.

After years spent stabilizing patients with severe trauma, running critical care units, and managing acute physiologic stress responses, long, complicated, multi-hour combination cosmetic surgery has always felt familiar and comforting rather than intimidating. My trauma and critical care experience makes a body contouring case less daunting. It’s not only why I’m comfortable performing extended excisions after massive weight loss and combining face and body procedures, but also why I’ll confidently repair a hernia on the table during a tummy tuck (if I find one) and proceed instead of stopping to refer it to a general surgeon.

I was introduced to and mentored in plastic surgery and aesthetics during my third year of medical school and even spent a year working with and assisting a plastic surgeon after graduation, before starting residency training. So when I began my formal plastic surgery training in July, I had already experienced variation in techniques and in how different surgeons approached the same problem—more than many of my peers would encounter during their years of plastic surgery training. All of this informs why I practice, and why facial rejuvenation using advanced techniques such as the deep plane facelift or the total endoscopic deep plane facelift can deliver lasting, natural, and incredible results.

Trauma surgery taught me how to keep a patient safe. Aesthetic surgery taught me how to make a result last. You need both.

Building on that foundation, which recent aesthetic technologies—such as energy-based devices, regenerative tools, or ultrasound/3D planning—have truly changed your day-to-day decision-making, and what criteria must a new technology meet before you adopt it?

A few recent technologies have genuinely changed how I plan and perform cases:

• Ultrasound guidance for gluteal fat grafting. As president of the World Association of Gluteal Surgeons, I’ve seen the safety record of this operation dramatically improve since visual confirmation of cannula placement became standard. Gluteal fat grafting has transitioned from a “by feel” procedure to one in which we can see where we are. One of the studies I published shows a markedly reduced risk of fat embolism during gluteal augmentation when performed under ultrasound guidance.

• Three-dimensional imaging and simulation. For breast and rhinoplasty operations, being able to show the probable range of outcomes on an anatomically realistic 3D image or model results in a more educated decision on the part of the patient, greater informed consent, and better alignment with what the surgeon can achieve.

• Advanced energy-assisted technologies. Tools such as radiofrequency-assisted liposuction and helium plasma tightening have expanded options for contouring the face or body with a minimally invasive approach. Used judiciously, these tools represent valuable assets.

• Structured fat grafting and the use of adjuncts such as platelet-rich plasma, exosomes, and platelet-derived growth factors (PDGF) have found firm footing in the surgical practice of both facial plastic and body contouring surgeons. The research continues, and the techniques continue to be refined.

• The nano-polished blade, Planatome, showed a significant reduction in hypertrophic scarring in our study of facelift patients.

Before adopting a new technology, I ask myself:

• Is there substantial, peer-reviewed clinical evidence for its validity (not marketing data)?

• Does it improve patient safety?

• Does it achieve something I cannot do with existing techniques?

• Will the result still look aesthetically appropriate on the patient in five years?

In aesthetic surgery, “new” isn’t the same as “better”. Evidence is better.

On the facial side, what clinical signs tell you it’s time to recommend structural surgery—like facelift, blepharoplasty, or a brow lift—instead of adding more fillers or neuromodulators?

This is one of the questions I most enjoy discussing with my patients, and it is not something that is typically explained well elsewhere. Fillers are wonderful tools, but they can only do so much to correct volume deficits and dynamic wrinkles. They are not capable of restoring the face when its structure has collapsed. When I detect this, I point it out.

“Once tissue has been displaced or accumulated, there isn’t a syringe that can return it. That’s the point at which fillers stop and repositioning is initiated.”

In the lower face and neck, there are three main signs I look for to determine whether a patient has surpassed the limits of dermal fillers and neuromodulators:

• Jowls — caused by the downward sliding of the midface and mandibular tissues; no amount of filler will truly restore them to their previous positions.
• Platysmal banding of the neck — caused by lax, separated neck muscles; this requires surgical correction.
• Deeply entrenched marionette lines that don’t change even at rest — in this situation, the problem is not dynamics but gravity and skin position. A deep-plane facelift would resolve the underlying cause. Filler injected into or below the jowls typically adds weight to the jowls and the face, making the face appear broader, which is the opposite of the desired result.

Signs for the lower lids are similar: bulging fatty pads in the lower lids are anatomical issues that need correction, not hollows to be filled with a syringe. A blepharoplasty with minor repositioning of the fat pads is required to correct this.

Excess skin on the upper lid that lies on the lashes does not need filler; the problem is obstructed vision and a loss of youthful eyelids, which is easily resolved with a tidy upper blepharoplasty. If the brow itself has dropped, injecting more filler into the forehead or temples only adds weight to an already heavy, low brow. That requires the opposite: a brow lift to pull the tissues upward.

In simple terms: if the face is losing volume, it can benefit from fillers. If the face is losing position or has excess skin hanging off it, then surgery is the true answer. If one tries to pump fillers into a structural issue, one usually ends up looking heavier, wider, and older.

“Fillers soften the face, but surgery rebuilds it. The distinction between the two is my job.”

For the growing cohort of patients after GLP‑1–related weight loss, how do you time and sequence facial volume restoration, skin tightening, and body contouring to balance safety with natural, durable results?

GLP-1–related weight loss has changed aesthetic surgery in real time and is probably the number-one consultation I’m doing right now. This is not the traditional bariatric patient; they usually lose weight faster and more disproportionately and come in with deflated facial features, along with some degree of residual body laxity and remaining fullness that can’t be treated with a single intervention.

I want patients to be at a stable weight on a maintenance dose before performing any significant surgery. We cannot operate on a moving target; the results won’t last. So, I typically want to see three to six months of stable weight, good protein intake, and lab work before I proceed with major surgery.

The sequencing is dictated by what bothers the patient the most and is medically sound. In almost all cases, I start with the face. GLP-1–related facial volume loss is often the first thing patients really hate about it and the first thing they come in for because it’s difficult to get used to. I can do some very targeted fat grafting to replace the volume in those areas using the patient’s own tissue. For patients who are really in early descent, they need a deep-plane facelift in combination with it. We’re doing that at the same time, so we are repositioning those tissues rather than chasing fat replacement of that lost volume with filler.

Body contouring happens after a stable weight has been reached. Many GLP-1 patients require extended abdominoplasty, body lift, brachioplasty, or thigh lift. Those procedures can often be combined safely. Radiofrequency and helium plasma energy devices are useful adjunct technologies for those patients, but they are not a substitute when the skin is truly lax and requires excisional correction.

I’m upfront with patients: if they regain weight, their results will change. The result is conditional, not a free pass.

“GLP-1 patients need a surgeon who thinks in sequence, not in single procedures. That is how you protect both safety and the result.”

When combining procedures such as a “mommy makeover,” what specific guardrails—patient selection, operative time limits, intraoperative resources, and recovery protocols—do you use to keep risk low and outcomes high?

One of the most miscommunicated concepts in cosmetic surgery is the combination procedure. If performed improperly, they are dangerous, but they are much safer and more effective for a patient than having separate procedures and recoveries done independently, assuming proper precautions are taken. I routinely complete full-body makeovers, including facial procedures.

Patient selection is everything:

• Healthy BMI
• No chronic disease or poorly controlled medical conditions
• Reasonable desires
• Social support at home to provide help

If the patient isn’t eligible, no protocol can make it safe.

Intraoperative limits: Maximum 6 to 8 hours in total surgery; anything more will increase complication risks, no matter the technique used. I work with a skilled, long-established surgical team that has strong communication among themselves, something that often isn’t discussed when these combined operations are presented.

Intraoperative resources and prophylaxis measures include:

• Cell saver and blood available when warranted
• DVT prophylaxis methods, including Sequential Compression Devices (SCDs)
• Patient mobility and early walking
• Chemoprophylaxis, if recommended for the specific patient

Recovery. This is the area where most practices are underdeveloped. I have focused my efforts on establishing depth in this area. Patients who have combined procedures stay overnight in our controlled setting. My team is available for direct calls 24/7. Furthermore, an in-home nurse makes visits during the immediate postoperative period.

Additional supportive measures include:

• IV therapy and hydration support
• Lymphatic drainage and massage
• Various peptides tailored to the patient’s healing
• ElixirMD for medically guided recovery optimization

The goal is simple: the first two weeks of recovery post-op are when complications are most likely to occur and when results are truly set in stone. That means staffing accordingly during this critical window. I tell everyone considered for these procedures that safe combined procedures aren’t determined by how much a surgeon can squeeze in a day, but by the infrastructure the surgeon provides for the patient.

“The question isn’t how you can do combined operations, but how the team and recovery system you are a part of can sustain the patient safely through those operations.”

How do you integrate fat grafting with biostimulatory fillers (e.g., Sculptra, Radiesse) and resurfacing modalities (lasers, chemical peels) to rejuvenate the face, and what one pearl most improves longevity and naturalness?

There’s no “magic bullet” for facial rejuvenation. The face has many aspects: structure, volume, skin quality, and texture. Different aspects require different treatments.

The gold standard for restoring facial volume is autologous fat grafting. For me, this procedure surpasses any biostimulatory filler used today. You’re using your own tissues, which naturally integrate into the structure. If the fat survives, it can last a lifetime.

There are several biostimulatory products, such as Sculptra, that work well for certain patients. These are good for those who don’t want surgery and prefer a lighter touch, or who don’t qualify for it. These fillers stimulate collagen production. However, the response to fillers can be variable. One patient may have a great collagen response at the same depth and in the same facial areas as another patient receiving the same product at the same location from the same provider.

A relatively new development, Lipoderma, makes fat transfer feasible in the office. While it won’t replace surgical autologous fat transfer, it offers the same advantages to patients. It bridges the gap between “injectable” options and true fat transfer to the face.

Surface treatments such as resurfacing lasers, medium-depth chemical peels, and Morpheus8 (a resurfacing radio-frequency microneedling procedure) are wonderful procedures. These will tighten skin and smooth pigment and pores. They don’t lift tissue or replace volume, so they shouldn’t be sold as such. When combined with structural correction, such as lifting or fat transfer, these procedures complete the rejuvenating effect.

In general, the order in which you should tackle rejuvenation is as follows: First, correct position and volume with a deep-plane facelift, fat grafting, or both. Six to twelve weeks later, after those procedures have settled and healed, address the skin quality with lasers, peels, or resurfacing devices.

The most important tip to achieve long-lasting, natural-looking results is moderation. Inject fat where the face has lost volume—not where a trendy aesthetic dictates. When cheeks are overfilled, or you attempt to make the jawline more chiseled by adding fat, these treatments often do not age well and don’t photograph well.

“Facial rejuvenation is architecture first, skin second. Treat them in that order and the result looks natural for years.”

Beyond the OR, which preoperative and postoperative practices—nutrition optimization, lymphatic therapy, activity progression, and scar management—most move the needle on results that patients and even clinicians often overlook?

We focus on technique, but everything that happens around surgery influences the result. More than 15 years of high-volume aesthetic practice has led me to concede that care outside the operating room moves the needle just as much as care inside.

Preoperative nutrition requires patients entering surgery to have consumed adequate protein, maintained appropriate vitamin D levels, had stable iron levels, kept glucose under good control, and been well hydrated. In particular, patients receiving GLP-1 injections or who have had a prior gastric bypass have their labs checked and any deficiencies corrected before surgery. Patients whose operations are well optimized heal much faster, have better scars, and experience far fewer complications.

• Adequate protein intake
• Appropriate vitamin D levels
• Stable iron levels
• Good glucose control
• Proper hydration

Postoperative manual lymphatic massage makes a huge difference in recovery. It reduces swelling, shortens visible recovery, and improves contour after liposuction or body-contouring procedures. Patients begin it on day one and continue for several weeks of intensive lymphatic therapy. This is not an elective luxury; it is part of the outcome.

Activity also matters more than patients realize. Gentle walking within hours of surgery reduces the risk of deep vein thromboses (DVTs) and promotes circulation.

ElixirMD delivers medical-grade, FDA-approved LED therapy in the postoperative period, reducing inflammation, accelerating tissue healing, and improving scar quality as part of our recovery protocol.

Scarring is the final layer. Silicone sheeting, sun protection, and appropriately timed topical or laser treatments help the scar age normally during the first year. We27ve published on the use of the Planatome nano-polished blades in our facelift procedures and observed a significant reduction in hypertrophic scarring.

“The operation is one day. The result is built in the weeks around it.”

When a patient’s goals don’t align with clinical reality or you suspect body image disturbance, how do you communicate boundaries, preserve trust, and decide when to say no?

Learning to say no is a crucial skill for plastic surgeons. Surgeons universally agree that the patients you turn away often contribute more to your overall success than those you accept.

My process begins with attentive listening. It is important to grasp not just what a patient wishes to alter, but the underlying reasons for it, what they anticipate it will mean for their lives, and how they’ve considered the idea. If desired outcomes diverge from surgical realities, I address this candidly during the consultation. If expectations remain misaligned even after this discussion, I decline to proceed with surgery.

When I suspect an underlying body image disturbance or body dysmorphic disorder, I approach the situation with heightened sensitivity. Surgery can’t rectify a problem not rooted in physical appearance, and operating in such circumstances can be detrimental to the patient, irrespective of the technical execution.

Our practice uses two hashtags that encapsulate our philosophy: #StayBeautiful and #HappyIsBeautiful. These are more than just slogans; they serve as reminders that the aim of aesthetic surgery is to enhance a patient’s comfort with themselves, not to pursue an unattainable outcome. A contented patient is an attractive patient, and this begins with realistic expectations long before surgery is considered.

“The hardest word in aesthetic surgery is no. Used correctly, it is also the one that protects the most patients.”

Thanks for sharing your knowledge and expertise. Is there anything else you'd like to add?

Plastic surgery is in a renaissance era today. Technology, the imaging we use, the devices we operate with, and the biological products we apply are better than ever. Our patients know more about their options than they did a decade ago. On the other hand, the noise in the field has increased tremendously. With social media influencing trends and device companies pushing aggressive marketing, patients are placed under incredible pressure to maintain appearances with trending modifications, while surgeons are under extreme duress to upsell procedures. My job, along with many of the thousands of plastic surgeons I9m proud to associate with in the field of aesthetic surgery, is to fight against this noise by speaking the honest truth.

I continue to rely on several key guiding principles: prefer preservation over augmentation; repair over replacement; and honesty over the hype, exaggeration, and misinformation we9re inundated with from Instagram and other sources. I am committed to educating the upcoming generation of plastic surgeons. As a member of the plastic surgery faculty at Texas Tech University Health Sciences Center Paul L. Foster School of Medicine for over 15 years, I know the skills of the young men and women who train today will form the substance of plastic surgery 20 years down the line. This is a serious commitment to the field I9m privileged to practice in.

For prospective patients, a good plastic surgery journey 7 the result 7 is a lifelong, lasting relationship with the surgeon and the team that tell you the real, honest truth, who help you navigate your recovery, and who care for you through this journey from the first interaction to decades down the line. This is the distinction between getting a surgery and engaging in plastic shopping. To this end, I suggest early readers of this text do your homework. Please, do go to the American Board of Plastic Surgery website (absplasticsurgeons.org) to verify your surgeon is board-certified in plastic surgery, not in some subspecialty or a field you9ll not benefit from if things go well, and not because this person is a top performer on some popular social platform. Get informed, look at long-term photos 7 not single viral pre- and post-op results 7 ask questions, and trust the judgment of your surgeon if something doesn9t end perfectly. He is the surgeon to choose, both in cases when things don9t turn out ideally and when things work out beautifully.