October 07, 2026 | Body Contouring, Patient Planning, Weight Loss
“It’s true, the skin doesn’t know how you did it. 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.”
I said that on the This Is My Journey podcast in August. A few weeks later Everyday Health quoted me in a guide to buying Saxenda online. I was happy to answer the pharmacology. This is the part of the answer that belongs on a surgical site.
Why I Care Which GLP-1 You Are On
Here is what I told Everyday Health about why anyone is still on Saxenda: “For many patients, this is the medication that their insurance covers, and sometimes that’s why they’re on it versus the other newer ones.”
Saxenda is liraglutide, a shot every day. Semaglutide and tirzepatide are a shot every week and hold their level all week. I do not see many patients on Saxenda and I do not recommend it as a first choice. Our program at Southwest Plastic Surgery prescribes compounded semaglutide, compounded tirzepatide and, for some patients, retatrutide. The full post on the program, and the comparison between the three, is on the Southwest Plastic Surgery site.
What I See in the Operating Room
From the podcast:
“Obviously the GLP-1s have changed everything, but weight loss has been happening for ages, with bariatric surgery or diet and exercise.”
“Skin stops producing elastin after puberty, so it just doesn’t contract like it does during puberty. 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.”
“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. Some patients have it in the inner thighs, the arms, the back. It’s a 360 thing. It’s the whole body, not just the tummy like most people expect.”
The Timeline Has Changed
“We had everything standardized for bariatric surgery: a sleeve or a bypass, they would lose weight for a year or a year and a half, stabilize, and then we would wait six months. With GLP-1s, patients are losing the weight a lot faster, getting to goal faster, and plateauing faster. 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.”
“We also see that GLP-1 patients are healthier than bariatric patients, because bariatric patients also have the nutritional deficit; we’re taking out intestinal parts that absorb nutrients. So the complications are lower and the healing is better.”
“The timing is shorter now with the GLP-1s, but it’s still cooking. We don’t know exactly how it’s going to work. 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.”
The Warnings Every GLP-1 Carries
Everyday Health asked me about safety, and I did not single Saxenda out: “It still carries the big warning about thyroid C-cell tumors just like semaglutide and tirzepatide, and the serious, but rather rare, risks of pancreatitis and gallstone disease.”
And on who should not take it: “Just like the other GLP-1s, Saxenda needs to be avoided [by] anyone who has a personal history or family history of medullary thyroid carcinoma or MEN2. It should also be avoided by women who are pregnant or trying to conceive.”
When the Scale Stops Moving
Not every patient gets to goal. I dictated this for an upcoming post on BMI and surgery, and it belongs here too:
“I am always an advocate for patients to continue their weight loss journey to get to a healthier weight and BMI to decrease complications. But the fact of the matter is that some patients have just plateaued and are no longer able to lose more weight. They continue to diet and exercise and use GLP-1s, or they may have already had a bariatric procedure. But the fact that they are not moving the scale is frustrating and sometimes causes psychological distress, resulting in bounce backs and weight gain, almost a vicious cycle of a yo-yo effect.”
“At this point, if the patient agrees that the benefits will outweigh the risks, and it gets them motivated to a healthier weight and lifestyle, I agree to proceed.”
“At high BMIs, we also consider staging. The ideal is to keep a surgery under six hours, and at higher BMIs each procedure can take longer than usual. Many times we will opt to perform liposuction first and the excisional surgeries later.”
Realistic Expectations
“Realistic expectations. We have to set that from the beginning, otherwise nobody’s going to be happy. I’m not going to be happy, the patient’s not going to be happy, it’s going to be a sad story.”
“Some patients bring wish photos and you have to coach them. You have to tell them, this patient you’re showing me is 20 years old, you’re 40. Or this patient’s BMI is 20 and you’re still at 30. You look much better than you did before, but we can’t compare apples to oranges.”
“Patients who have lost a lot of weight, we do these surgeries and we’re pulling as tight as we can, but the skin, because it’s lost that elastin, is going to give again. We lose some of the result over the first six months. Another realistic expectation is that a lot of times, six months later, we have to do a little nip and tuck to tighten things up and get them right.”
Why Choose Dr. Agullo
I am certified by the American Board of Plastic Surgery and the American Board of Surgery, trained in plastic surgery at the Mayo Clinic, and teach as Clinical Associate Professor of Plastic Surgery at Texas Tech University Health Sciences Center. Castle Connolly has named me a Top Doctor every year from 2014 through 2026. I prescribe these medications and I do the surgery afterward, so the conversation about the skin starts at the first visit, not the eighteenth month.
Ready to talk?
Call (915) 590-7900, text 1-866-814-0038, or book a consultation online. #StayBeautiful
Find me at @RealDrWorldWide on Instagram, TikTok, and Snapchat, @Agullo on X, or @AgulloPlasticSurgery on Facebook.
