Breast Revision Surgery to Recover a Youthful Breast Contour

        Over time, even the most successfully placed implants may rupture or leak, and should be replaced. Typically, both silicone and saline breast implants last between ten and fifteen years. After the estimated implants’ useful time has expired, breast revision surgery will typically become necessary in order to maintain volume and shape. Also, many breast implants have a lifetime warranty on the actual implant device, but after ten years the costs associated with having surgery to replace the implants are no longer covered. Because of this, many women benefit from choosing to replace or update their breast implants at or around the 10-year time frame (1).

        Moreover, some women, for instance, had breast implants before they have started conceiving and now, after having children, their breast might be saggy, or smaller or they have gain some weight and they don’t want the implants anymore. As I usually tell my patients, as time goes by women’s bodies change around the implants and breast revision surgery is the best option to recover a youthful breast contour. Your self-confidence, as well as your breast’s wellbeing and appearance will profit from having an opportune breast implant and replacement surgery.  

 Breast implant replacement (from saline to silicone implants) performed by Dr. De La Cruz.

Breast implant replacement (from saline to silicone implants) performed by Dr. De La Cruz.

        Breast implant revision surgery should be performed by an aesthetic plastic surgeon who is well-trained and experienced in all different kinds of breast surgery and who will listen to the patient’s desires and expectations, since this surgery is not a standard procedure and requires to be customized to fit patient’s cosmetic goals and particular needs. Among the most common reasons why my patients opt for breast implant revision surgery are the following: 1) Saline breast implants have deflated or an X-ray or MRI suggests that silicone implant has a shell leak; 2) desire to change the implant/breast size; 3) pain from capsular contracture (tightening of the scar tissue around the implant) or concern about rupture or migration of implant; 4) breast tissue has changed as a result of skin stretching, or weight loss or gain; 5) change from saline to silicone implants, or different style of implant. The exact surgical procedure for breast implant and replacement varies depending on the particular reason for breast revision (2).

        Usually, the procedure to either replace or remove implants is more comfortable than the initial breast augmentation surgery, and the downtime is relatively short. Nonetheless, the amount of post-operative discomfort depends mostly on whether the scar tissue is removed along with the implant (3). My patients typically return to work and their normal daily activities within a week after revisionary breast surgery. Healing will continue for several weeks as swelling decreases. For a successful recovery, patients should follow their plastic surgeon’s post-operative instructions to the letter and attend follow-up visits as scheduled.



(1) “Breast Implant Revision”. American Society of Plastic Surgeons.

(2) “Breast Revision”. The American Society for Aesthetic Plastic Surgery.

(3) “Breast Revision FAQs”. Einstein Medical.

Leading Minimally-Invasive Procedures in America

        Much have change since I started my clinical practice and enduring partnership with patients in cosmetic and reconstructive plastic surgery, back in 2010. Technological advantages in the surgical process and new developments and improvements in devices and techniques have revolutionized the field of aesthetic procedures. Nowadays, risk for post-operative complications have been considerably minimized, as well as the downtime after surgery has been reduced. Without a doubt, there has never been more customized choices readily available for patients who desire to enhance their appearance. Nonetheless, there is a triad of aesthetic surgeries who managed to remain among the top five most popular cosmetic procedures in America in the last decade, namely, breast augmentation, liposuction and nose reshaping.

        Breast augmentation continues to be the most favored and frequently performed aesthetic surgery and has been since 2006, according to the American Society of Plastic Surgeons (ASPS). In 2016, more than 290,000 breast augmentation procedures were performed in the United States (1). Likewise, in Texas, breast enhancement surgery is the top cosmetic surgical procedure and has a long and successful track record in satisfying women who wish to enhance, regain or restore balance to their figures. Silicone implants, saline implants, and breast augmentation with fat transfer are the main choices I usually suggest my patients, depending on their medical history, body shape and aesthetic goals. 

         Breast augmentation with silicone implants performed by Dr. De La Cruz.

        Breast augmentation with silicone implants performed by Dr. De La Cruz.

        Breast augmentation surgeries are followed very closely by liposuction procedures in the ranking of well-liked cosmetic surgical interventions (with 235,237 procedures performed in 2016). Among the wide range of liposuction techniques available nowadays, I favor VASER liposuction for its remarkable advantages over traditional liposuction. VASER liposuction is an advanced body contouring procedure that selectively remove unwanted body fat. This method uses minimally-invasive ultrasound technology to emulsify fat while leaving all other important tissues intact, resulting in significant desirable effects with minimal damage to surrounding tissues. Consequently, patients recover considerably quicker as they suffer reduced bleeding, bruising and swelling in the treated areas (2). The shorter recovery time needed for VASER liposuction makes it more convenient and appealing to my patients, who may return to their regular lives and activities 1-2 weeks after the surgery. Furthermore, VASER liposuction is clinically proven to cause 53% more skin retraction relative to traditional liposuction (3).

        Lastly, nose reshaping holds third place in the ranking of most popular aesthetic surgeries, with a total of 223,018 procedures performed in 2016. Nose reshaping, also known as rhinoplasty, can reshape, reduce or augment a person’s nose to achieve facial harmony and boost self-confidence. It may be performed as a reconstructive procedure to correct a birth defect or an injury such as a broken nose. Many of my patients also opt for rhinoplasty surgery in view of functional reasons rather than solely cosmetic purposes. For instance, certain breathing problems can be effectively treated by combining nose reshaping with septoplasty or endoscopic sinus surgery.



(1)  “Plastic Surgery Statistics Report 2016”. American Society of Plastic Surgeons.

(2)  Garcia, O., Jr., Nathan N. 2008. “Comparative Analysis of Blood Loss in Suction-Assisted Lipoplasty and Third-Generation Internal Ultrasound-Assisted Lipoplasty”. Aesthetic Surgery Journal, 28(4): 430-435

(3)  Lewis, Linda W. “Taking Shape”. MedEsthetics.


Custom-Built Choices for Breast Augmentation

Breast augmentation continues to be the most popular and frequently performed aesthetic surgery and has been since 2006, according to the American Society of Plastic Surgeons (ASPS). In 2016, more than 290,000 breast augmentation procedures were performed in the United States (1). These statistics issued in the 2016 Plastic Surgery Statistics Report reflect a 37% growth relative to the number of breast augmentation surgeries reported in 2000. Similarly, in Texas, breast enhancement surgery is the top cosmetic surgical procedure and has a long and successful track record in satisfying women who wish to enhance, regain or restore balance to their figures. Most of the consistently popularity of breast augmentation is due to the technological innovations and improvements in procedural techniques, which resulted in the myriad of options available nowadays to women looking to add volume to their chest. My work is based on the philosophy that every patient is unique. Therefore, depending on their medical history, body shape and aesthetic goals, there are three main choices I typically discuss with my patients: Silicone implants, saline implants, and autologous fat transfer.

In 2016, silicone implants were used in 84% of all breast augmentations in America, as stated by the ASPS, and are the leading option among my patients. There are two principal categories of silicone implants: silicone gel-filled breast implants, and cohesive gel silicone gel-filled breast implants. The traditional silicone gel-filled breast implants are filled with soft, elastic gel and are available in a wide range of shapes, sizes and profiles, making them quite appealing and convenient to many of my patients. However, an alternative classification of silicone implants are filled with a cohesive gel made of cross-linked molecules of silicone, which makes them thicker and firmer than traditional silicone implants. These innovative prosthetic implants are denominated cohesive gel silicone-gel filled breast implants, and are commonly known as “gummy bear” implants. Although more costly than their conventional counterparts, women tend to like gummy bear implants due to their tendency to have a superior natural look and feel and because the risks of complications, like capsular contracture and gel migration in the case of implant rupture, are considerable reduced. One downside to consider while choosing breast implants is that all silicone-gel prosthesis are pre-filled and may require a longer incision for implant placement (2).

 Breast augmentation with silicone implants performed by Dr. De La Cruz.

Breast augmentation with silicone implants performed by Dr. De La Cruz.


Saline-filled implants rank second in popularity among women who opt for a breast enhancing procedure. In 2016, saline implants were used in 16% of all breast augmentation procedures performed in the U.S. Saline prosthesis may be sub-divided in two main categories. The first group, traditional saline-filled breast implants, are filled with sterile salt water. They may be prefilled at a predetermined size, or filled at the time of surgery to allow for minor modifications. The second classification of saline implants are the fairly new FDA-approved structured saline-filled breast implants, available in the U.S since 2015. These implants are also filled with sterile water, but contain a structure inside so they behave as if filled with soft, elastic silicone gel. This structure enables them to hold their shape better than traditional saline implants. Although saline-filled implants are not as popular as their silicone competitors, the former appeal to certain women due to the faculty to customize the sizing on a fairly pinpointed scale. Furthermore, in the case of a potential implant shell rupture, saline breast implants wouldn’t pose a risk as significant as silicone-gel implants, since they would release only salt water into the patient’s body.

Autologous Fat Transfer (AFT) is another option available for women who desire to improve the appearance of their breast. This procedure, also known as fat grafting, removes fat through liposuction from an specific area of your body in which there are abundant fat cells, such as thighs, abs and hips. After a process of purification, the autologous fat cells (from your own body) are injected into your breast. This breast enhancing procedure can be used independent from implants to achieve a small volume increase (about one bigger cup size), or combined with implants to accomplish a considerable augmentation in your breast size. While AFT procedures do not pose a risk of allergic reactions to foreign substances as both silicone and saline implants do, fat grafting is still undergoing clinical studies and research for safety and effectiveness (3).



(1)  “Plastic Surgery Statistics Report 2016”. American Society of Plastic Surgeons.

(2)  “Types of Breast Implants”. American Society of Plastic Surgeons.

(3)  “Breast Implant Complications”. U.S Food and Drug Administration.


Breast Implant-Associated Anaplastic Large Cell Lymphoma

There are approximately 10 million women who underwent breast augmentation with breast implants in the whole world.  Currently, breast augmentation is the number 1 cosmetic procedure performed in the United States with approximately 500,000 implants placed every year.

 Before & After Photos of Breast Augmentation using the Dual-Plane Technique performed by Dr. Emmanuel De La Cruz. 

Before & After Photos of Breast Augmentation using the Dual-Plane Technique performed by Dr. Emmanuel De La Cruz. 

Breast implant-associated anaplastic large cell lymphoma (ALCL) is a dinstinctive type of T-cell lymphoma that occurs after breast augmentation or enlargement.  This occurs around the breast implants itself.  Fortunately, this is a rare condition with approximately 258 cases that has been documented since 1997 (as of September 2015.) 

Clinical Findings and Symptoms of Patients who may potentially have ALCL:

  • Persistent Seroma
  • Seroma associated with breast pain or swelling
  • Occurs an average of 9 years after breast augmentation
  • All reported cases of breast implant-associated ALCL have involved textured breast implants

What are your risks for developing ALCL (Anaplastic Large Cell Lymphoma)?

  • incidence varies from 0.1 and 0.3 per 100,000 women with breast implants per year.
  • One in 100 million women per year in the general population (based on the data from the Surveillance, Epidemiology and End Results Program of the National Cancer Institute.)
  • Lifetime prevalence was 33 per 1 million women with a textured breast implant or 1 per 30,000 women with a textured breast implant.

I recommend discussing your risks for development of ALCL with your plastic surgeon prior to having breast augmentation.


Doren, et al.  US Epidemiology of Breast Implant-Associated Anaplastic Large Cell Lymphoma.  Plastic and Reconstructive Surgery. Volume 139 Number 5May 2017 pp104-1049

Emmanuel De La Cruz MD, PLLC

Plastic & Reconstructive Surgeon (Houston, TX)


Reducing Capsular Contracture Rate during Surgery for Breast Augmentation

Plastic surgeons have tried reducing capsular contracture rate through different means during surgery.  Routinely, antibacterial lavage with topical antibiotics is performed during surgery prior to placement of the breast implants to possibly reduce the infection rate and possibly the occurrence of capsular contracture (CC) in breast augmentation.

In the study conducted by Giordano, patients in his retrospective study underwent breast augmentation with the same surgeon via the inframammary approach and dual-plane pocket. In group A, patients received a single perioperative dose of 1.5 g of intravenous cephalothin and 750 mg of oral cephalexin twice a day for 7 days after discharge. In group B, patients perioperatively received 750 mg of intravenous cefuroxime, and each implant and pocket were irrigated with 25 mL of a 10% povidone-iodine solution mixed with 750 mg of cefuroxime and 80 mg of gentamicin diluted in 15 mL of 0.9% sodium chloride solution. After discharge, patients received 500 mg of oral levofloxacin once a day for 5 days.

  • The postoperative superficial wound infection rate in their study was 1.8% and 1.2%; the seroma rate was 1.8% and 1.2%; and the hematoma rate was 0.6% and 1.2% in groups A and B, respectively. Ten Capsular contracture cases (Baker grade 3 or 4) in group A and 1 in group B were reported (6% vs 0.6%; P = .006).
  • Povidone-iodine and antibiotic irrigation in cosmetic breast augmentation yielded a lower capsular contracture rate than standard perioperative antibiotics.


Giordano, et al. Povidone-iodine combined with antibiotic topical irrigation to reduce capsular contracture in cosmetic breast augmentation: a comparative study. AestheticSurgery J. 2013 Jul;33(5):675-80. doi: 10.1177/1090820X13491490. Epub 2013 Jun 11.

Effects of Zafirlukast on Capsular Contracture

The most common complication of breast augmentation is capsular contracture. This a common matter of concern among most plastic surgeons and patients.  Surgical intervention usually is required.   In 2002, the use of zafirlukast, a leukotriene inhibitor (a drug used for asthma treatment), was reported for the treatment of capsular contracture, with good results.

Clinical studies and experimental studies showed that capsular contracture responds favorably to treatment with zafirlukast. 

  • Clinical findings according to some studies indicate that zafirlukast may reduce pain and breast capsule distortion for patients with long-standing contracture who either are not surgical candidates or do not wish to undergo surgery.
  • In Spano's evaluation of the effectiveness of Zafirlukast on capsular contracture, the investigation showed improvement of the thickness of capsule around the implants in the Zafirlukast group.  The mean total thickness of the capsule around the implants was 161.97 microm in the zafirlukast-treated group compared with 345.98 microm in the control group (p < 0.001). Outstandingly, the collagen fibers and fibroblast layer were reduced in the zafirlukast-treated group compared to the controls.   Their study confirmed the effectiveness of this compound in preventing fibrosis and putatively also in reducing the extent of collagen reaction when a capsule has been formed.
  • Another experimental study showed another leukotriene inhibitor, Montelukast, reduced the thickness, the inflammatory cell infiltrate and the myofibroblast content of the peri-implant capsules around silicone implants in their study. They lowered the expression of the fibrotic mediator, TGF-β, and inhibited the peri-implant capsular fibrosis.


Bastos, et al. Histologic analysis of zafirlukast's effect on capsule formation around silicone implants. Aesthetic Plastic Surgery. 2007 Sep-Oct;31(5):559-65.

Scuderi, et al. The effects of zafirlukast on capsular contracture: preliminary report.  Aesthetic Plastic Surgery. 2006 Sep-Oct;30(5):513-20.

Scuderi, at al.  Effects of zafirlukast on capsular contracture: controlled study measuring the mammary compliance.  Int J Immunopathol Pharmacol. 2007 Jul-Sep;20(3):577-84.

Spano, et alReduction of capsular thickness around silicone breast implants by zafirlukast in rats. Eur Surg Res. 2008;41(1):8-14. doi: 10.1159/000121501. Epub 2008 Mar 27.

Treatment of Capsular Contracture with "Dual Plane" Technique for Breast Augmentation

There has been very few clinical studies published regarding the treatment of patients with capsular contracture after a previous history of submuscular or subglandular breast augmentation.  Dr. Scott Spear conducted a 7 year retrospective study treating established capsular contracture after augmentation mammaplasty by relocating the breast implants to the "dual-plane" or partly subpectoral position.

In this study, the patients whose revision breast augmentation for capsular contracture were converted to the dual plane, 98 percent were free of capsular contracture and were Baker class I at follow-up, whereas 2 percent were judged as Baker class II.  There were no Baker level III or IV contractures at follow-up in their study. The dual-plane method of breast augmentation has proved to be a very effective technique for correcting established capsular contracture after previous breast augmentation.


Spear et al.  The correction of capsular contracture by conversion to "dual-plane" positioning: technique and outcomes.  Plast Reconstr Surg. 2003 Aug;112(2):456-66.

Treating Capsular Contracture After Breast Augmentation

Capsular contracture after breast augmentation is one of the most difficult problems faced by women who underwent breast augmentation.  Capsular contracture occurs when the collagen-fiber capsule shrinks, tightens and compresses the breast implant which may cause deformity of the breast implant.  When the capsule surrounding the breast implant contracts, the shape of the breast changes and may look deformed.  Often pain may occur after the formation of capsular contracture.  

Grading of Capsular Contracture after Breast Augmentation

  • Grade I — the breast is normally soft and appears natural in size and shape
  • Grade II — the breast is a little firm, but appears normal
  • Grade III — the breast is firm and appears abnormal
  • Grade IV — the breast is hard, painful to the touch, and appears abnormal

Reducing the Rate of Capsular Contracture

  • Placing the breast implant underneath the muscle either pure sub muscular or Dual-plane technique 
  • Using textured-breast implant may reduce capsular contracture
  • The use of antibiotic irrigation prior to placement of the breast implant may reduce the rate of capsular contracture
  • Minimal contact of the breast implant with the  skin of the patient during surgery before the insertion of the breast implant inside the breast.
  • Limiting the handling of the breast implant may reduce the capsular contracture rate.  The use of Keller Funnel to minimize the contamination of breast implants during surgery is promising but has not been clinically proven yet.

Zafirlukast as Treatment for Capsular Contracture

  • Zafirlukast (or Accolade at 20 mg po bid) appeared to soften capsular contracture in Baker's Grade III and IV capsular contracture.
  • Dramatic softening occurred after 1 or 3 months of treatment (1)
  • Reduced capsular contracture values are strictly related to the duration of drug intake. (2)
  •  A significant reduction and improvement of capsular contracture (complete or partial) was seen in a statistically significant proportion of treated breasts with Zafirlukast(75.7%, P < 0.05). This response was maintained on a long-term basis, with a mean follow-up of 16.5 months. (3)

Side Effects of Zafirlukast

  • Elevation of liver enzymes may occur after prolonged intake of Zafirlukast.  Although hepatitis is a rare side effect, one should notify your surgeon when this symptoms arises.  One should also stop taking this medication when abdominal pain occurs.  I recommend consulting your surgeon when one starts having symptoms with prolonged intake of Zafirlukast.


Emmanuel De La Cruz MD, PLLC

Plastic & Reconstructive Surgeon, Houston Texas


  1. Schlesinger, et al.  Aesthet Surg J. 2002 Jul;22(4):329-36. doi: 10.1067/maj.2002.126753. Zafirlukast (Accolate): A new treatment for capsular contracture.
  2. Mazzochi, et al.  Int J Immunopathol Pharmacol. 2012 Oct-Dec;25(4):935-44. Effects of zafirlukast on capsular contracture: long-term results.  
  3. Reid, et al.  Aesthet Surg J. 2005 Jan-Feb;25(1):26-30. doi: 10.1016/j.asj.2004.12.003.  The effect of zafirlukast (Accolate) on early capsular contracture in the primary augmentation patient: a pilot study.


Inverted Nipple Repair - Houston, Texas

Inverted Nipple Repair

Inverted nipples, or retraction of nipples, is a condition in which the nipple has the appearance of being tethered or pulled inwards.

The degree of inverted nipple can be a source of self-consciousness and breast feeding problems. This problem can occur in one or both breasts. 

Many women who experience this problem usually wear bras or clothing which do not emphasise the problem.  Nipple inversion is not rare, with reported prevalence ranging from 1.8 to 3.3%

 Inverted Nipple

Inverted Nipple


  • Breastfeeding
  • Born with the condition
  • Breast Cancer (Thus, one would need a mammogram if the inverted nipple is new onset)
  • Breast infection/inflammation
  • Pregnancy
  • Gynecomastia
  • Trauma

Mildly inverted nipples can be drawn out with physical stimulation, either sexually or for breast-feeding. 

Severely inverted nipples never project even when stimulated or in very cold water.

Apart from cosmetic concern, severe inversion may have functional repercussions, such as the inability to breast feed, infection or irritation of the nipple when natural secretions become trapped.


  • Grade I - Inverted nipple may occasionally "pop out" without manipulation or pressure
  • Grade II - Inverted nipple retracts after the pressure is released
  • Grade III - Severely inverted nipples which cannot be pulled out physically and would require surgery


Many techniques have been reported for the correction of inverted nipples. However, the conventional methods may be insufficient, especially for moderate to severe inversions. The suspension technique is a simple, reliable method for correcting grade II and III nipple inversions. 


Jeong H-S, Lee H-K (2015) Correction of Inverted Nipple Using Subcutaneous Turn-Over Flaps to Create a Tent Suspension-Like Effect. PLoS ONE 10(7): e0133588. doi:10.1371/journal.pone.0133588

Call for a FREE Consultation with Dr. De La Cruz at 832-776-1134.  

The Perfect Breasts

In today's society, women are subconsciously bombarded with images of larger breasts overflowing out of low-cut dresses.  These images are reflected from magazines, reality TV shows and celebrities with enlarged breasts.  Because of our society's infatuation with large breasts, the tendency toward favoring larger breast volume with breast augmentation may result to a deviation from the natural shape of the breasts.  When the breast is excessively augmented with breast implants, the tear drop shape of the breast becomes more round which is not harmonious and looks unnatural.  But then again, the ideal breast is different for every woman.

Breast Symmetry

  • Ideally the perfect breasts would be symmetric.  Although this seldom comes to mind, perfect breasts aren't what one would expect. One study showed that breast asymmetry in women is a commonality amongst the population.
  • Nearly 80 % of women have asymmetric breasts.  Breast asymmetry is measured by several parameters, such as nipple areolar complex size & position, breast size/breast mound volume, breast/chest wall shape, degree of ptosis (sagging), and inframammary fold location. With this in mind, when one seeks a breast augmentation, any subtle difference of the breast may become more obvious after surgery.

What is the Ideal Breast Shape?

  • The nipple should be pointed outwards and parallel to the ground.
  • The upper pole of the breast should be full and not "deflated" as found in a "swooping breast."  The upper pole of the breast typically becomes "deflated" with aging, pregnancy or even with significant weight loss as seen in athletic women.
  •  The lower pole of the breast should be fuller than the upper pole of the breast.  The lower pole should also have a round shape.
  • The upper pole should have a slope from the upper chest down to the level of the nipple. 

Photograph courtesy of

Photograph courtesy of

Ideal Breast Dimension

  • According to a recent British Study by Dr. Malluci, the proportion of the upper to the lower pole should have a 45:55 ratio 
  • The angulation of the nipple should be pointing upwards at a mean angle of 20° from the nipple meridian
  • According to the study, the upper pole slope should be linear or slightly concave, and the lower pole should be convex.

With the advent and popularity of larger breasts, like Pamela Anderson in Baywatch, the perception of the perfect and ideal breasts have changed.  Mild to moderate fullness of the upper pole will produce a more youthful and more beautiful breasts as seen after a breast augmentation.  Excessive upper pole fullness due to an overly-sized breast implant will look unnatural, and thus will have an appearance of a more obvious "boob job."

 Figure 3: &nbsp;Ideal Breast Shape with Natural Slope. &nbsp;Before &amp; After Breast augmentation using the Dual-Plane Technique performed by Houston Plastic Surgeon Dr. Emmanuel De La Cruz MD.

Figure 3:  Ideal Breast Shape with Natural Slope.  Before & After Breast augmentation using the Dual-Plane Technique performed by Houston Plastic Surgeon Dr. Emmanuel De La Cruz MD.

With this in mind, what is the perfect breast?  The perception of the perfect breasts may vary from culture to culture and may vary individually.  The unnatural appearance of an overly-sized breast augmentation may be perceived as more beautiful.  Women who wants a "more natural look" may want the ideal "traditional" perfect breasts with a natural slope.  Regardless of what one perceives the perfect breasts to be, you should communicate with your plastic surgeon the ideal breast shape that you would want to achieve after your breast enlargement.


Clinics located in The Galleria in Houston and in The Woodlands.   Call us at 832-520-1844