When You Have Outgrown Filler: How Southwest Plastic Surgery Decides Between Volume and a Lift
“Anything you do like that with your finger, it means you needed a scar. To pull up the skin. Because that’s what you’re doing. You’re pulling up the skin.”
That is Dr. Frank Agullo, the founder of Southwest Plastic Surgery, and he tends to say it early in a consultation rather than late in one. There is a mirror on the wall of every consultation room here, and the staff has learned to watch what patients do in front of it rather than listen to what they say about it, because a patient who reaches up, catches the skin at her cheek with two fingers and lifts has already answered the question she is about to ask.
He puts it a second way for patients who want a rule they can take home with them:
“Anything you wanna lift, or to take out skin, it’s a scar.”
It is a blunt thing to hear on a first visit, and it is also the most useful three seconds in the whole appointment, because it can save somebody several years of paying for the wrong thing.
The Med Spa Is Not the Enemy of the Operating Room
This is worth saying up front, because posts like this one usually turn into an attack on injectables and that is not the position here.
Filler, neuromodulators, microneedling, and laser resurfacing all do real work, and the Med Spa at Southwest Plastic Surgery is busy for good reasons. Injectables even have a job after surgery:
“It’s not gonna look wrinkled right after surgery, but your muscles will start working again. So we do need to put a little bit of Botox here just to soften that so you don’t make that many wrinkles.”
Running those treatments inside a surgical practice changes how they get done, too. Dr. Agullo has been dissolving under-eye filler for a patient whose first attempt at it somewhere else did not accomplish much:
“I wonder if they used enough of the enzyme that breaks it up, and which brand they used. We use the top brand and give pretty high doses so you see it a lot faster. Sometimes places put very little because it’s costly, but you have to do a good amount to start seeing results. Sometimes they don’t know the anatomy as well, so they’re hesitant to go a little deeper where it’s needed.”
What the practice will not do is sell somebody a fourth round of something that did not solve her problem the first three times, and having a surgeon and a Med Spa under one roof means there is always somebody in the building qualified to say out loud that she has outgrown it.
Two Problems, One Complaint
Almost everyone walks in saying a version of the same sentence, which is “I look tired.”
Underneath that sentence are two different mechanical problems that need opposite treatments. The first one is volume loss. Fat compartments deflate over the years, the temples hollow out, the area under the eyes sinks, the cheek flattens, and the hip develops a visible depression between the hip bone and the upper thigh. Nothing in any of those areas has fallen anywhere, there is simply less of it than there used to be. The second problem is laxity, which is a stretched skin envelope sitting over deeper structures that have descended, and in that case the volume is mostly still present. It has just moved south.
Filling fixes the first one and cannot touch the second, and Dr. Agullo describes the physics without softening any of it:
“It’s gonna fill this in, so you would have more, you wouldn’t have the dips. It will fill in and give you a shape, but it’s not gonna tighten the skin. You understand? So it’s not gonna pull anything up. It’s just, we’re blowing it up a little… it does get to be just like with implants, when we put in implants, the skin looks a little tight.”
When a patient asked what it would take to get the shape she was making with her own hands on her buttock, the answer moved to a different room in the building:
“If we just want volume, then it will fill it in. But it’s not gonna do this. If you wanna do that, we need to do a buttock lift. So you would have an incision that goes like this… in the groin area, and it goes towards the back, and it lifts this up.”
A cushion that has lost its stuffing needs stuffing. A fitted sheet that has stretched off the corners of the mattress does not need stuffing, it needs to be taken in. Two problems, two entirely different fixes, and the mirror test tells you which one you have.
Fill Versus Lift, at a Glance
| Filling | Lifting | |
| Treats | Volume loss, hollows, hip dips, flat midface | Ptosis, loose skin, descended deep tissue |
| Delivered at | Med Spa or minor procedure room, often under local | Operating room, usually under general anesthesia |
| What it will not do | Tighten skin or reverse descent | Restore lost volume on its own |
| Downtime | Hours to a few days | Weeks, planned in advance |
| Leaves behind | Puncture sites | A planned scar, placed where it hides |
| The mirror tell | Fingers press into a hollow | Fingers pull skin upward |
Where the Practice Sends Patients to Filling, Happily
Hip dips are the example Dr. Agullo reaches for most often, because they are the cleanest case of a problem that filling actually solves.
“In your case, you have pretty prominent hip dips. So if we fill them in with the allograft, this is gonna look nicer. Right now you have the waist, you have this prominence, you have a dip, and then you have this prominence. So if we fill this in, then you’re gonna have a waist. And hips.”
Filling that dip produces a waist without lifting anything at all, and it works because the waist was never the problem in the first place.
For patients who do not want a traditional fat transfer, or who do not have donor fat to spare, the practice offers an allograft adipose matrix, which is a processed donor fat product that the body gradually populates with its own cells.
“Allograft works really well. It’s a donor fat. Whatever I inject stays… So sometimes we start with, like, 100 ccs and then start building up if we need to do more sessions. The good thing is that we can do it just with local anesthesia, so it doesn’t require going to the OR or anything like that.”
“I wouldn’t do it all at once because we want your body to replace that with its own fat, and then we can always repeat the sessions.”
There is also none of the sitting restriction that comes with fat transfer to the buttocks, which is usually the first thing a patient asks about: “With allograft there’s no, you know, when we do fat, we say no sitting and things like that. With the allograft, you can sit and everything, so it’s not an issue.”
The face is handled differently, with the patient’s own fat rather than the donor product. “I do need to put a little bit of fat here, and here, and a little bit even on your eyes that are a little bit hollow here and in your temples. And I can get that from your inner thighs. The allograft is too thick for the face.”
The Honest Ceiling on Energy Devices
Skin tightening technology is where the conversation gets slippery in a lot of practices, so here is the version patients get at Southwest Plastic Surgery.
Renuvion J-Plasma uses helium plasma with radiofrequency energy delivered under the skin through the same tiny access sites used for liposuction, and it makes the connective tissue underneath contract. Morpheus8 delivers radiofrequency through microneedles from above. Both are real tools, and Dr. Agullo has used Renuvion J-Plasma since 2019, runs it most operating days, and is counted by the manufacturer, Apyx Medical, among the ten highest-volume users of the device in the world. This is how he offers the pair of them for loose skin around the knees:
“The only thing you can do that’s noninvasive without any scars would be to do some Morpheus and J-Plasma just through a little incision. And that does tighten the skin around the knees, but a lot of it is gonna depend on how your body reacts to that radiofrequency and how tight it gets. For that we just make a tiny, tiny incision here, just to put in a probe to do the radiofrequency.”
His caveat carries weight for exactly that reason. Asked whether the devices could deliver what the patient was showing him with her hands, he said:
“It will, but in that area it’s a lot looser. So it may not give you as much. It’s gonna give you some result, but it’s not gonna be what you’re doing in the mirror.”
That is the ceiling, stated plainly. Energy devices work up to the line where the mirror test starts, and past that line they give you some result rather than the result your fingers just demonstrated, and no number of additional sessions changes it.
When the Answer Is an Incision, the Practice Says So
For a loose abdomen the answer is a tummy tuck, and here is how that conversation usually goes when a patient asks whether the skin can be tightened without a scar:
“Your abdomen is not bad, but you do have loose skin. The only way to get rid of the loose skin on the abdomen would be an incision like this, and that’s where we pull everything down and even tighten your muscle to make them flat. But it’s a tummy tuck.”
The length of that incision is tied directly to how much can actually be corrected, which is why it is not something to negotiate down:
“If you make it short, then we can only do a little bit like that. It’s not doing anything up here. If we make it long, then we can really pull everything down.”
Arms after significant weight loss need a brachioplasty, and most of the body contouring conversation at the practice turns out to be a conversation about scar placement, with patients shown exactly where the scars will sit before anything gets scheduled. The neck is worth spelling out too, because so little of a neck lift is actually about skin:
“The scars for the neck are behind the ear, right on the edge of the hair and the ear, so you really can’t see them, and one right underneath the chin, which you can’t see either, but it makes a difference. It’s actually the muscle, the platysma. We’re fixing the muscle, removing the deep structures here so this is nice and flat, then putting the muscles together and pulling them this way. We pull the skin a little, but the effect is more from the muscle. Then I put a special suture from the muscle to the bone right here, and that’s what gives us a really tight sling.”
On the face, the deep plane facelift with endoscopic brow and temple work is the operation Dr. Agullo believes in most, and he still tells patients the truth about the incision:
“The scar’s gonna be here, so they’re gonna be behind the hair, so you’re not gonna see those. But you are gonna have one scar here, and then it’s gonna go behind the ear, and hug in the hairline. So everything hides really, really well. I can’t do it without any scars in front of the ear. I’m afraid, because we do have to lift significantly, you’re gonna have these wrinkles here if I don’t take out your skin.”
The scar is not a failure of technique. It is the price of the lift.
Which brings up the line he has been saying publicly for years, that fillers are a tax and a facelift is an investment. A tax recurs on a schedule that never gets shorter, and an investment gets paid once and then works for a decade or more. Filler also has a habit of overstaying, which is worth knowing before the fourth syringe rather than after it:
“Filler is going to make your nose bigger. All we do with filler is we cheat by adding to other places.”
“And the problem is that filler, what we see now, is that it doesn’t really go away. It spreads. So then in the end, it’s going to end up on the sides and make you look wide.”
None of that is an argument against ever having filler. It is an argument against paying the tax on a problem the tax was never designed to solve.
About Dr. Frank Agullo
Dr. Frank Agullo is the founder of Southwest Plastic Surgery in El Paso, Texas. He is double board-certified by the American Board of Plastic Surgery and the American Board of Surgery and a Fellow of the American College of Surgeons. He completed his plastic surgery fellowship at Mayo Clinic and trained in the endoscopic deep plane technique through the Ponytail Academy intermediate course in Pittsburgh and the advanced course in Santa Monica. He is a Clinical Associate Professor of Plastic Surgery at Texas Tech University Health Sciences Center Paul L. Foster School of Medicine and has been named a Castle Connolly Top Doctor for thirteen consecutive years.
Ready to Talk?
Come in, stand in front of the mirror, and do the thing with your fingers. The team will tell you honestly which side of the line you are on, and whether the Med Spa or the operating room is the right room for you.
Call (915) 590-7900, text 1-866-814-0038, or book online at agulloplasticsurgery.com/appointments. #StayBeautiful.
@RealDrWorldWide on Instagram, TikTok, and Snapchat, @Agullo on X, or @AgulloPlasticSurgery on Facebook.
Companion Reads
- Editorial version on drworldwide.com: Filling Is Not Lifting: The Mirror Test Every Patient Runs Without Knowing It
- Clinical patient-facing version on agulloplasticsurgery.com: The Fingers in the Mirror: Why Filling and Lifting Are Not the Same Operation
