What GLP-1 Medications Are Really Doing to Your Face, Body & Buttocks

One in eight Americans is now on a GLP-1 medication like Ozempic, Wegovy, or Zepbound. The weight loss can be life-changing, but there is a side of this story that rarely gets talked about openly: what these medications are doing to your face, your skin, your muscle mass, your bone density, and your body contour.

In this episode, board-certified plastic surgeons Dr. Sam Jejurikar (Dallas, TX) and Dr. Sal Pacella (San Diego, CA) bring a combined four decades of surgical experience to one of the most pressing topics reshaping their practices today.

They break down the predictable patterns of facial volume loss they are seeing, including hollowing of the cheeks, temporal wasting, dark circles from mid-face descent, and loss of skin elasticity that goes beyond what you would expect from weight loss alone. They discuss why fat grafting results in GLP-1 patients may not be as durable as expected, and why GLP-1 receptors expressed on fat cells themselves may be to blame.

The episode features a lively disagreement on Sculptra: Dr. Pacella is firmly in the skeptic camp, calling it a reverse ATM machine, while Dr. Jejurikar makes the case that conservative, layered treatments delivered every six to eight weeks can serve as an effective volumizing foundation for the right patient. They also explore the promise and limitations of AlloClae cadaveric fat grafting, currently FDA approved for the breast and body but generating serious interest for facial applications.

The conversation then shifts to the body, covering the underappreciated impact of GLP-1s on muscle mass and bone density, why resistance training is now a clinical conversation happening in plastic surgery offices, and why brachioplasty and thigh lift volumes have increased fivefold in recent years. They also tackle Ozempic butt directly, explaining the combined role of fat loss, muscle atrophy, and pelvic structural changes, and why excisional lifting procedures are increasingly replacing the Brazilian Butt Lift for this growing patient population.

GLP-1 medications are not going anywhere. Newer agents, oral formulations, and triple-mechanism drugs like Retatrutide are already in the pipeline. For patients and surgeons alike, understanding the downstream effects is no longer optional.

Dr. Sam Jejurikar is a board-certified plastic surgeon and President of Dallas Plastic Surgery Institute. Dr. Sal Pacella is a board-certified plastic surgeon in private practice in San Diego, California. Together they host Beauty and the Beasts, a podcast dedicated to honest, unfiltered conversations about plastic surgery, aesthetics, and the science behind looking and feeling your best.

Follow Dr. Jejurikar on Instagram: @samjejurikar Follow Dr. Pacella on Instagram: @sandiegoplasticsurgeon

Transcript

SPEAKER_01 0:00

So I'm going to say something very controversial. I do not believe in sculpture whatsoever. I think it is a reverse ATM machine. Takes your money, doesn't give you anything back. I have found that in order to get a marginal effect of sculpture, you sometimes have to use three, four, five syringes in order to get anywhere close to any kind of volume. It's incredibly expensive. It's very unpredictable. I don't think it does what the company thinks it does.

SPEAKER_00 0:30

Well, welcome everyone to another episode of the Beauty and the Beast podcast. As always, I am Sam de Juricar from Dallas, Texas, and I'm joined by Salvatore Pachella, illustrious plastic surgeon from San Diego, California. Today we are going to talk about a topic that virtually all of our audience knows about, and that's Ozempic face or Ozempic butt or Ozempic body. It's not an obscure topic. Recent data shows that about one in eight Americans are now on GLP1s. And it permeates even, I think, even more so in the plastic surgery population. Knowing that you see a large number of patients who are on GLP1s, whether it's on Zempic or ZEP bound or reditry tide, what are the things that you're seeing in the face? What are the predictable patterns you're seeing? And what are your general approaches to it? Sure.

SPEAKER_01 1:22

And, you know, I think you'll agree with me when I say that, you know, GLP1 medications are probably the most transformative weight loss drugs that have ever been created in the history of humankind. I mean, it has done remarkable success in reducing morbidity, reducing mortality in general in the population, but it doesn't come without a price tag, right? And I think the the benefit of losing weight, particularly central weight, central obesity, it, you know, which chokes off your organs, causes insulin resistance, et cetera, is beneficial. But we're seeing a lot going on in other parts of the body and the face. And years ago, the treatment for massive weight loss was surgery, right? Um, you'd have a gastric bypass, you'd lose 100, 200 pounds. And those operations were also transformative, but it's a general surgery operation. So we're seeing kind of the same effect, which is loss of volume in the face, loss of volume in the temporal region. I even in doing a tremendous amount of eyelid surgery, I also see patients with a lot of hollowing out in and around the orbit and the lower eyelids. We see it in the face, we see it in the jowl area. And, you know, it's a it's a little bit of buyer's remorse, too. Now, let's kind of think about this for a second here. When you look at fat in the face, okay, I when I when I do these talks across the country or across the world, I show this photograph of my daughter, Ellie, who was two years old at the time, and she's sitting on the lap of my 92-year-old grandmother, right? And I have this beautiful picture of them looking at each other's eyes. And Ellie's face is a big round cherub-like face, right? A very youthful face. And and Nana's face is all hollowed out, right? 92 years old. And so you see that when someone has weight in their face, it's a very youthful phenomenon. And those those patients that you see that are portly or obese in their 50s, uh, facial aging is not necessarily a huge issue in them, right? They look very youthful. And so, so again, a bit of buyer's remorse that we see with patients. And I think it's a huge challenge for us to restore that youthful fat in the face.

SPEAKER_00 3:36

Yeah. I think um when you talk about fat loss in the face, it's different than the fat loss that you experience just when you lose weight. So typically we store our fat in what's called the subcutaneous fat or the superficial layers of the fat uh of you know, just uh underneath the skin. And you definitely experience that kind of fat loss with GLP1s. But what's different with GLP1 medications are the fact that you're also losing deeper fat. So this, you know, where it's really prominent is in the central malar, the central cheek fat where you lose this. In addition, what we're seeing as more and more patients have been on GLP1s is that there are changes in skin elasticity that happen with high doses of GLP1s that's more significant than what you would get just from regular weight loss. So you take loss of deep fat, loss of superficial fat, you lose skin elasticity. And there are predictable patterns of aging now that we're seeing in patients, particularly, you know, in your expert area of expertise, the periocular region, you'll see the midface pull down from the lower eyelid. That leads to dark circles in the lower eyelids, that leads to a hollowness in the cheek and actually over the cheek bones as well. And so fat grafting or large volume filling of some kind really becomes important to try to restore some of that loss, that that volume loss. I don't see a lot of regret from patients, though. They're still love these medications, and they want to figure out how to get treated while simultaneously being on these medications. Right.

SPEAKER_01 5:14

And it kind of begs the question, too. So we know that you know these medications recess fat, right? But when we're when we're taking fat from other parts of the body, let's say I'm doing a facial rejuvenation case in a patient who was on Ozempic for a number of years, and I'm redistributing that fat. Maybe I'm taking it from the abdomen or the arms or the legs, and I'm putting it in other parts of the face. Well, when you do BBLs, right, one of the things you want to avoid is losing fat during that process, right? So you could easily be in a situation where you're injecting that fat, but you're gonna lose it. You're gonna have a higher rate of loss when patients kind of go back on that. So, how does that temper your treatment? Um, obviously, these patients need to be off of Ozempic and stuff for surgery, but what do you say afterwards after a fat transfer case?

SPEAKER_00 6:06

So my answer has changed in the last six months than it was before. Um, I used to tell people once, you know, you know, if you get back on a GLP1 and you're on more of a maintenance dose and you're trying to actually stay at a stable weight, my thought is that after you do the fat transfer, you'll hold on to that fat. And I told people that for a year, two years, but then I saw them losing the fat, regardless, even with them being at a stable weight. And what we're seeing is that GLP1 receptors are actually expressed on adipose cells, adipose-derived stem cells, so that the ongoing exposure still causes, still causes fat loss, even if the patient's weight isn't going down as much. So it's a problem. Don't have a great solution for it yet, at least involving um your own fat, which leads to a bigger question. And it's an area where you and I oftentimes have some form of controversy, and that's the use of fillers that are not your own fat. So, for instance, for a patient who we're, let's say we're talking about their face, what are your thoughts on something like sculpture or polyal lactic acid to try to add volume instead of fat, particularly if this patient is deficient in fat, or you're worried there's going to be ongoing fat loss.

SPEAKER_01 7:17

Right. So I'm going to say something very controversial. I do not believe in sculpture whatsoever. I think it is a reverse ATM machine. Takes your money, doesn't give you anything back. Okay. Um, I have found.

SPEAKER_00 7:31

Oh, I thought that was my wife.

unknown 7:33

Sorry.

SPEAKER_01 7:36

So I have found that in any in order to get a marginal effect of sculpture, you have sometimes have to use three, four, five syringes in order to get anywhere close to any kind of volume. It's incredibly expensive, it's very unpredictable. Um, I don't think it does what the company thinks it does. And I have been sorely um disappointed over the last 18 years on its use.

SPEAKER_00 7:59

So yeah, I completely disagree with that statement. But not for the, you know, but I will say that the way the company marketed it for years was in a way to basically just generate huge amounts of money from patients. So, where I think sculpture can be useful is to not inject it in the way that the company may have recommended to people. What they used to tell people is basically, sort of for every decade that you are, that's the number of vials you need for treatment. So if you're 40 years old, you're supposed to get four vials. How can we come from that? And that's really quite expensive. In addition, people look strange. When you put in that amount of sculpture, because the product does stick around for a long time, you can create an aesthetic that is very unnatural. What I think works better is very conservative layered treatments of it, where you would use one vial, split it between both sides of the cheek, you inject deep with it, and you wait. Because with what particularly with a product like sculpture, there's an initial inflammatory response where it's swollen and then it recesses a little bit, and you can actually tell how it's going to stick around. And if you inject deep and you layer it slowly over time, so the patients are coming in every six or eight weeks to get a vial of this. I think it can be very effective. It's not, you can't replace all of the volume that was lost with sculptor, but it can be a nice foundation, particularly as we are, you know, see no one, you know, GLP ones are not going away. Now we have Reditrutai, which are calling a GLP3, because it works through three different mechanisms. Um, and so this problem is going to be something we need to have a solution for.

SPEAKER_01 9:35

Right. And I think, you know, you're talking about products off the shelf. So I think one of the most exciting um products that is out there now and then hopefully will broaden its indication is the use of uh cadaveric fat graft, something called alloclay, marketed by a company, Centra. Currently only FDA approved for the breast and body, I believe, but not approved in the face. Um really has been a dramatic. And you want to talk about expensive a sculpture?

SPEAKER_00 10:05

Exactly.

SPEAKER_01 10:06

Massive expense, but but I think my patients will pay for that if it works, right? Yeah. Um, incredibly expensive. What is it for 10ccs?

SPEAKER_00 10:14

It's like uh I mean it ends up costing patients eight to ten thousand thousand dollars of treatment. Yeah. So so it is it is much more expensive. I mean, we're talking thousands of dollars as opposed to hundreds of dollars. Hasn't been tried in the face. And remember, there's no living fat cells in this. It's basically fat cell stroma that you're injecting. So I don't know. Uh I think the verdict is out on that still. I I think it it does sound exciting, but I have yet to see even one result in the face that that I think is uh, or I haven't seen any results in the face. Right.

SPEAKER_01 10:44

I mean, it's it's not FDA approved for the face. So I think unless you're injecting it off label, um, you know, it's not not indicated. But um, but it's it's really exciting on the reconstructive part of my practice, I would say. You know, as as I mentioned, you know, I do a lot of breast cancer reconstruction still as well. And, you know, we we have used the product in breast reconstruction uh to basically hide rippling around fat and things or around implants, uh particularly in patients who are very fit or very athletic. And that that gives us another arrow in our quiver, um, whereas, you know, we need a large volume of fat to hide some of these implant deformities and breast reconstruction.

SPEAKER_00 11:22

So you're using allocate in that indication instead of just the patients on back because they're fat deficient, or why they're fat deficient, they're just in too great a shape. Okay. Now we've talked about the effects of GLP1s on skin. We've talked about it on fat. What about the effect of GLP1s on muscle?

SPEAKER_01 11:40

So very, very interesting topic. And I think it's a it's a sleeper topic that I think patients really have to understand. There are some studies out there that show that when you're on some of these GLP uh medications, that you use you lose a disproportionate amount of muscle mass comparatively to fat. And if you're not actively resistance training and building your muscle, that is a big problem. There are even studies that show uh a depleted bone loss as well. And we don't know if it's related directly to the medication or related to perhaps some malnutrition component, loss of vitamin D, et cetera, uh, uh decreased transit times in the bowel. But I think it's fair to say that those muscle or that those medications have an effect on bone, they have an effect on muscle, and they have an effect on fat.

unknown 12:35

Yeah.

SPEAKER_00 12:36

And where muscle is concerned as a plastic surgeon, I will say that the number of patients that I have seen for both brachioplasty or arm lifts and thigh lifts has increased by a factor of probably 5x in the last couple of years. What you'll see is that combination of lessened skin elasticity or poor skin elasticity with then lack of resistance training, the skin just hangs off their arms. And what I'll tell those patients is you are a good candidate for a brachioplasty, provided you start doing some resistance training. Because much like we talked about with fat transfer, if you don't start getting on the pathway to resistance training, um, you will experience progressive and ongoing muscle wasting and the results of your surgery won't be as good. And that's just from a plastic surgery standpoint, not to mention a longevity standpoint. Uh you gotta get swole. Yeah. But, you know, if you lose your muscle mass and you get into your, you know, 60s, 70s, 80s, the likelihood of slipping and falling and breaking, you know, breaking your femur goes up. And there's a huge, there's a huge morbidity that goes along with that. Yeah, I agree. Um what about the buttock? Have you had patients complaining to you about sagging of the buttock with Ozempic? I mean, they there the term was Ozempic, but um, I don't think people refer to Ozempic quite so much anymore. But have you seen sagging of the buttock region from GLP1s?

SPEAKER_01 14:06

Absolutely. And I think I think that kind of goes along with what we were talking about. The, you know, there is there's a loss of fat, but there one of the biggest muscles in the body is the gluteus muscle, right? And and that reduces in size dramatically, particularly if not you're not working it and you're not uh resistance training. I I think there's also a component of uh bone loss to that as well, too. When you're standing straight and your pelvis is tilted a certain way, you know, you can potentially lose a little bit of structure in and around the pelvis, and that can contribute to the the loss of projection of of your um of your buttocks. So I think, you know, when you're talking, and and it kind of begs the question too, because you know, you're talking about doing a BBL, a Brazilian butt lift in a patient. You know, you may sometimes need 1500 cc's of fat. And if somebody's lost 100 pounds with the GLPs, where are you where are you going to find that fat, right?

SPEAKER_00 14:58

Yeah, I mean, I find that my treatment now uh relies less on fat grafting for these patients and more on excisional procedures. Where, you know, before there were Brazilian butt lifts, when we talked about a buttock lift, it was an excisional operation where basically you create an incision along the very top portion of the buttock and you lift upwards. And that's a big component for patients now to actually lift in that direction. There's another operation called the thong lift, and there's different variations of it where there might be an incision in the intergluteal cleft or in the lower pole of the buttock. But skin excision, it becomes a necessity because for the reasons that you're mentioning, there's just simply not enough fat um to make it look tight, or people may not want a butt that has 1500cc of fat in it. That's a pretty big butt. Thong, thong, thong, thong. It's a great song.

SPEAKER_01 15:47

So um it's the thong song. Yeah, Cisco.

SPEAKER_00 15:50

I remember. I don't'm sure I characterize it as a great song, but I remember the song for sure. Well, you know, I think GLP ones, for all the reasons that we've been mentioning along here, they're not going anywhere. Um they are um there's newer ones in the pipeline, oral versions of it, better versions of it. And so these problems are not going to go away. They're only gonna magnify. So it's important to know what effects it might have on your body. Any last closing thoughts for our viewers?

SPEAKER_01 16:16

Yeah, I think um for the viewers that are medical students, residents, plastic surgeons, I think this is a testament to keeping yourself educated on what's happening, not just in plastic surgery, but in general medicine, because it's absolutely going to affect your patient's healing and kind of how they're approaching problems in plastic surgery. So uh, well, thank you, Dr. J. As always, a pleasure.

SPEAKER_00 16:40

Always a pleasure until we meet again.