More patients than ever are arriving at Southwest Plastic Surgery having lost a large amount of weight, after bariatric surgery or a year on a GLP-1, and asking about their face rather than their body. Dr. Frank Agullo sees the same pattern in nearly all of them.
What Dr. Agullo Sees on Exam
From one of his exam dictations, in his words:
Dr. Agullo: “On physical exam, patient has facial aging with loss of volume from massive weight loss. She has ptosis, temporal wasting. She has festoons with excess lower eyelid fat bags, excess upper eyelid skin resting on her eyelashes. She has deep nasolabial folds and marionette lines. She has excess skin in the neck. And submandibular gland show.”
In plain terms: the temples hollow, the cheeks flatten and drop, the lower lids bag, the upper lids fold down, the lines around the mouth deepen, the neck loosens, and the glands under the jaw become visible. Patients often call it Ozempic face. The cause is the deflation, whatever produced the weight loss.
Why Fat Comes First
Fat versus filler for the deflated face: what is your default, and when would you still pick filler?
Dr. Agullo: “Fat is the best filler for a deflated face. A deflated face has lost fat. And what we do when we do fat grafting is replace the fat in those spaces. So it’s like with like.
“My second choice would be a fat graft, a donor fat graft, like Lipoderma, or in the near future, DermaClae. Many people are using other fillers like Sculptra. But we have to keep in mind that these fillers create scar tissue and fibrosis, which may make the facelift procedure more difficult. It creates collagen through an inflammatory reaction.
“And last, we have hyaluronic acid fillers, which are temporary, tend to dissipate into the tissues, and can look unnatural. I think they have value in areas that need small corrections and superficial corrections, but not to replace the fat that’s lost due to massive weight loss.”
| Option | What it is | Where Dr. Agullo uses it |
|---|---|---|
| Fat grafting | The patient’s own fat, harvested by liposuction | First choice for a deflated face |
| Lipoderma | Donor fat graft, no harvest needed | Second choice, or when there is very little fat to take |
| Biostimulators (Sculptra) | Stimulate collagen through inflammation | Not preferred; the fibrosis complicates a later facelift |
| Hyaluronic acid fillers | Temporary gel | Small, superficial corrections only |
For a young man who lost 50 pounds after a gastric sleeve and wanted something more lasting than the Sculptra he had tried, Dr. Agullo planned fat grafting to the temples and cheek.
Dr. Agullo: “We overfill the areas, because he will lose about thirty to forty percent of the transferred fat. The remaining fat is permanent, though it will fluctuate with any future weight changes. Even at a low BMI of twenty one to twenty two, there is enough fat to harvest. The inner thighs are the best donor site, followed by the lower back or abdomen.”
When the Skin Has Dropped
Volume alone does not lift skin that has fallen. When the neck has loosened and the cheeks have slid, the answer is a facelift, and Dr. Agullo tailors it to the post weight loss face. From a consultation with a patient who lost 30 pounds on a GLP-1:
Dr. Agullo: “It would bring this back as well and fill in the cheekbone, bring it back up. And then it’s gonna also bring your neck back tight. So it does give you, it removes about fifteen years.”
On the jawline: “A little bit of this is the gland that you have here that I remove part of it so that in the end, you get a really nice tight jawline.”
On the upper eyelids, which the patient assumed needed a separate procedure: “Your upper eyelids get better when I do this. So I don’t think you need anything on your upper eyelids.”
He finishes every facelift with Morpheus8 radiofrequency microneedling while the patient is still on the table, to tighten the skin itself.
Timing: Stable Weight Before the Lift
GLP-1 timing for the face: do you want the patient off the drug and weight-stable before a facelift or fat grafting, and for how long?
Dr. Agullo: “Preferably I want the patient to have lost the weight that they had planned and be weight stable after any facelift procedure. The reason being that oftentimes patients after a facelift tend to lose further weight. And of course, if we lose the volume, then we will have some aging. As the face deflates, the skin tends to sag. So we would lose a lot of the benefit of having done the facelift if the patient continues to lose weight.
“In terms of fat grafting, it can be done while the patient is still losing weight, as long as the patient knows that it will require repeat treatments. But fat is one of the best fillers we can use, as it is natural, it is soft. It is the same tissue that belongs in those spaces, and can help slow down the aging process as the patient is losing weight.”
So fat grafting can begin while the weight is still coming off, with the understanding that a touch-up may be needed. The facelift waits until the weight has settled, the same rule the practice applies to body contouring after weight loss.
Planning Your Consultation
Bring your weight history: starting weight, current weight, and where you plan to stop. That single piece of information decides whether fat grafting, a facelift, or both is the right plan, and in what order.
Dr. Agullo is certified by the American Board of Plastic Surgery and the American Board of Surgery, completed his plastic surgery fellowship at the Mayo Clinic, and serves as Clinical Associate Professor of Plastic Surgery at Texas Tech University Health Sciences Center.
Schedule a Consultation
To discuss facial fat grafting, Lipoderma, or a facelift after weight loss at Southwest Plastic Surgery, call (915) 590-7900 or text 1-866-814-0038. #StayBeautiful
