Sunday, February 27, 2011

Facts You Need to Know about RADIESSE

What do you need to know about Radiesse?

Fast Facts about Radiesse
  • Radiesse is an injectible filler made of calcium hydroxylapatite microspheres, which has the same chemical constituent of teeth and bone.
  • Radiesse has been approved by the FDA on December of 2006 for correction of moderate to severe facial wrinkles and folds, such as the nasolabial fold.
  • When Radiesse is injected into soft tissue, such as the dermis, this causes fibroblasts proliferation and new collagen formation. 
  • Pre-clinical studies have shown that Radiesse was shown to be non-toxic, non-mutagenic, non-antigenic and non-irritating.
  • The clinical outcome of Radiesse is expected to last up to 12-24 months.  

Potential Complications of Radiesse
  • The most common adverse event requiring clinical intervention after injection with Radiesse was the development of nodules of the lip.  This typically occurs within 6 to 12 weeks after injection into the lips.
  • 12.4% of patients in one study developed lip nodules after injection for lip augmentation.
  • Treatment of the nodules can range from massage therapy, steroid injection to surgical excision of the nodules.
  • Injection into the tiny vessels of the face may occur with any dermal filler.  Although this complication is rare, intraarterial embolization of any dermal filler may cause necrosis of the face, and even blindness.  
  • Lumps may occur after Radiesse injection, especially after intramuscular injection such as the orbicularis oculi (muscles around the eye.)

Before one undergoes a simple non-invasive procedure, such as a Radiesse injection, one should be informed about the possible adverse outcomes that can potentially happen.  I recommend asking your plastic surgeon for any questions about Radiesse prior to undergoing this procedure.

Emmanuel De La Cruz MD

Jansen et al. Evaluation of Calcium Hydroxylapatite-Based Implant (Radiesse) for Facial Soft Tissue Augmentation.  Plastic Reconstructive Surgery. 2006 Volume 118, 3S: 22-30s
Lemperle et al. Avoiding and Treating Dermal Filler Complications. Plastic Reconstructive Surgery. 2006 Volume 118 3S: 92-106S

Saturday, February 26, 2011

Smile Train of The Week

Smile Train of The Week

I encourage the readers of this blog to help support SMILE TRAIN, one of the non-profit Cleft Charity Organizations.  "Smile Train is the world's leading cleft charity with thousands of partners and programs operating in 78 countries, including some of the world's poorest. "  The organization's mission is to help the millions of children in developing countries who are suffering with unrepaired clefts.  Please visit their facebook website SMILE Train.

Sunday, February 20, 2011

Causes of Gynecomastia

So What are the Possible Causes of gynecomastia?

  • Persistent pubertal gynecomastia – 25%
  • Drugs – 10-25%
  • No detectable abnormality – 25%
  • Cirrhosis or malnutrition – 8%
  • Primary hypogonadism – 8%
  • Testicular tumors – 3%
  • Secondary hypogonadism – 2%
  • Hyperthyroidism - 1.5%
  • Chronic renal insufficiency – 1%

Emmanuel De La Cruz M.D.

Braunstein GD. Gynecomastia. N Engl J Med. Feb 18 1993;328(7):490-5
Mahoney CP. Adolescent gynecomastia. Differential diagnosis and management. Pediatr Clin North Am. Dec 1990;37(6):1389-404
Carlson HE. Approach to the patient with gynecomastia. J Clin Endocrinol Metab. Jan 2011;96(1):15-21

Friday, February 18, 2011

Let's help support SMILE TRAIN

One of the plastic surgery procedures I enjoy is cleft lip/palate repair.  I would like to ask the visitors of this blog to help support The SMILE TRAIN, a non-profit Cleft Charity Organization.  Please visit their facebook website:  SMILE TRAIN

Thursday, February 17, 2011

The Use of Sunscreens in Facial Plastic Surgery

The Use of Sunscreen in Facial Plastic Surgery

The use of sunscreen after undergoing a facial plastic surgery procedure, such as LASER skin resurfacing and facial chemical peels, is probably one of the most effective moisturizer additive. Inflammation from a facial plastic surgery procedure can cause hyperpigmentation, especially with sun exposure.  Sunscreen is an effective moisturizer additive since it has the ability to prevent and reverse photoaging.  It is also an important part of facial post-surgical skin care since it can prevent skin hyperpigmentation (darker skin pigmentation).    Hyperpigmentation may occur since the presence of UVA radiation can stimulate the production of melanin by melanocytes (cells producing pigment in skin.)
Fast Facts about Sunscreen
  • Chemical ingredients found in sunscreen undergo a chemical transformation that absorbs UV radiation and turn it into heat.  This process is irreversible, rendering the sunscreen inactive once it absorbs UV radiation.
  • Thus, the frequent use of sunscreen is important.
  • Sunscreen ingredients can be divided into UVA (320-360nm) and UVB (290-320nm) absorbers.
Kim Kardashian's Facial Sunburn (Photograph Courtesy of
 UVA Absorbers
  • Proper UVA protection is important since it is this spectrum of radiation that is responsible for photoaging, skin pigmentation, and photocarcinogenesis (causes skin cancer.)  UVA as in Aging.
  • UVA absorbers: oxybenzone, avobenzone & menthyl anthranilate.
UVB Absorbers
  • UVB ingredients contribute to the sun protection rating, called SPF.  UVB as in Better Sun Protection for sunburns.
  • UVB radiation causes sunburn, as well as photocarcinogenesis.
  • UVB absorbers: Salicylates, such as octisalate & homosalate,octyl methoxycinnamate.
Based on the Colipa (European) Suncreen Regulation:
  • For SPF 15, 93% of the harmful UVB rays are blocked
  • For SPF 20, 95% of the harmful UVB rays are blocked
  • For SPF 30, 97% of the harmful UVB rays are blocked
  • For SPF 60, 98% of the harmful UVB rays are blocked
I recommend asking one of your Facial Plastic Surgeons their protocol with regards to the usage of sunscreens after your facial plastic surgery procedure.

Emmanuel De La Cruz M.D.
Woodlands Plastic Surgery

Tuesday, February 15, 2011

Liposuction for Arm Lymphedema after Breast Cancer Surgery

Liposuction for Arm Lymphedema Following Breast Cancer Surgery

Fast Facts about Lymphedema and Breast Cancer Surgery
  • Lymphedema is swelling of the limbs caused by abnormal build up of fluids in the body.  This may occur after breast cancer surgery, such as a mastectomy (removal of the breast) and axillary node dissection (surgery to remove the lymph nodes at the arm pit area.)
  • Extensive surgery of the axilla (arm pit area) increases risk for lymphedema of the arm.
  • Radiation therapy to the axilla also increases risk for arm lymphedema.
  • Up to 38% of patients who undergo axillary dissection for breast cancer and radiation therapy may develop lymphedema (swelling) of the arm
  • Most patients can be treated with no need for surgery.
  • Patients with lymphedema are at increased risk of developing an infection of the arm, such as cellulitis.
Precautions to take to avoid an infection of the arm when one has lymphedema :
  • Make every attempt to avoid cuts, scratches, hangnails, insect bites and burns.
  • No blood pressures or venipunctures on the arm with the lymphedema.
  • Wear protective garments when gardening or pruning, dishwashing, baking/cooking or sewing.
  • Contact your physician immediately if there are any signs of infection of your arm (more swelling, redness, fever, pus drainage, more pain.)
  • Carry heavy parcels or purses on the unaffected limb (no lymphedema.)
  • Avoid wearing jewelry on the arm with the lymphedema.
Treatment of Severe Lymphedema of the Arm after Breast Cancer Surgery
  • Dr. Brorson, a Swedish Surgeon, had shown the effectiveness of reducing lymphedema in patients who previously had breast cancer surgery by performing liposuction of the arm lymphedema. 
  • According to the study, liposuction of the lymphedema arm reduced the arm edema volume by 115% versus 53% when compared with Controlled Compression Therapy (p=0.008).
  • Circumferential liposuction is currently the preferred method to treat severe lymphedema that is not responsive to conservative therapy.
  • There's an associated 4-fold decrease incidence of infection of the arm with the lymphedema after liposuction treatment.
  • After liposuction of the arm, the patient will need to wear a compression bandage more or less permanently to prevent the lymphedema from coming back.
  • Note that liposuction does not correct the inadequate lymphatic drainage found in lymphedema.
  • Combined Decongestive Therapy (CDT) may be recommended initially as treatment for lymphedema after breast cancer surgery.
  • CDT is a lymphedema therapy consisting of manual lymph drainage, compression bandaging, skin care, exercise and self care instruction. 

If you or your family has a history of arm lymphedema after breast cancer surgery, I recommend to ask one of your Houston Plastic Surgeons whether liposuction of the arm with lymphedema is right for you.

National Lymphedema Network.
Brorson, H. Liposuction in Arm Lymphedema Treatment. Scand J Surg. 2003;92(4):287-95.
Brorson, et al. Liposuction Reduces Arm Lymphedema Without Significantly Altering the Already Impaired Lymph Transport. Lymphology. 1998; 32:156-172 
Koul, et al. Efficacy of Complete Decongestive Therapy and Manual Lymphatic Drainage on Treatment-Related Lymphedema in Breast Cancer.  Int. Journal of Radiation Oncology Biol. Phys. 2007: 67 (3):841-846 
Williams, et al. A Randomized Controlled Crossover Study of Manual Lymphatic Drainage Therapy in WOmen with Breast Cancer-related lymphoedema. European Journal of Cancer Care. 2002. 11:254–261 

Monday, February 14, 2011

Tuesday, February 8, 2011

Medications That Cause Gynecomastia

Medications That Cause Gynecomastia
There are several pharmacologic agents or medications that could cause gynecomastia.  Although the risk of male breast enlargement secondary to certain medications are very low, one should be aware of which drugs can cause gynecomastia.  

The following drugs  are associated with  gynecomastia:
  • Marijuana (Cannabis sativa)
  • Androgens as found in anabolic steroids
  • Estrogen containing medications
  • Stilbestrol - medication used to treat prostate cancer
  • Anti-androgen medications
  • Chorionic gonadotropin
  • Diazepam
  • Digitalis
  • Ergotamine
  • Hydantoin
  • Hydroxyzine
  • Isoniazid
  • Lunesta
  • Methyldopa
  • Meprobamate
  • Pepcid
  • Tagamet
  • Reserpine
  • Spironolactone
I recommend consulting your primary care physician regarding these medications if gynecomastia is a major concern for you.  If your medical doctor decides to stop the medication, the breast enlargement may go away.  One should not stop taking their medications without the consultation of your physician.

Emmanuel De La Cruz M.D.


Ersek RA, Schaefenele M, Salisbury MA, et al. Gynecomastia: A clinical review. Aesth Surg J. 2000;20(5):381-6.

Sunday, February 6, 2011

Breast Implant ALCL Lymphoma

Fast Facts About ALCL and Breast Implants
  • The incidence of ALCL of the breast is very low according to a European study:  0.1 to 0.3 per 100,000 women with breast implants per year. 
  • There is currently no consensus regarding the treatment protocol for ALCL of the breast since there has been very few cases worldwide.  The prognosis has been excellent based on the study conducted at the University  of Texas M.D. Anderson Cancer Center.
Feel free to read more about ALCL and Breast Implants.

Saturday, February 5, 2011

Mesotherapy or Lipodissolve

FDA Status of Lipodissolve as of April 2010
Being an informed patient is critical prior to any procedure. I recommend to visit for the current FDA status of this procedure.

The Woodlands Plastic Surgeon

Friday, February 4, 2011

Dermal Filler Injection Before After Photos

Hyaluronic Acid Dermal Filler Injection Before & After Photos
 Houston Cosmetic Surgeon

Disclosure:  Dr. De La Cruz has no financial disclosure or association with Allergan.  These photographs were included to educate patients about hyaluronic acid dermal fillers.  Photograph courtesy of Allergan.

Emmanuel De La Cruz M.D.

Hyaluronic Acid Injections for Tear Trough Deformities

Hyaluronic Acid Injections for Tear Trough Deformities

There are many options that are available to treat the tear trough deformities.  These include: fat injections, malar implant/prosthesis, pedicled fat, hyaluronic acid dermal filler injections, etc.  The advantages of using hyaluronic acid injections, such as Juvederm and Restylane, are that this method avoids the downtime of surgical options and is minimally invasive. 
Photograph by Biswarup Ganguly (File Courtesy of Wikimedia Commons)
Surgical & Non-surgical Options for Tear Trough Deformities
  • Autologous fat graft/transfer
  • Hyaluronic Acid Injections
  • Alloplastic Implants (such as, Silicone implants placed in front of the cheek.)
  • Release of the orbicularis oculi muscle origin (muscles around the eye), and transposition of pedicled orbital fat.
Fast Facts about Hyaluronic Acid Injections for Tear Trough Deformities
  • The dermal filler is injected at the level of the periosteum (tissue above the bone) to reduce the risk of palpability and surface irregularities.
  • Surface irregularities from dermal filler injections occur when these injections are done superficially, such as the superficial & deep dermis of the skin, subcutaneous (tissue under the skin) or suborbicularis oculi fat (fat underneath the lower eyelid muscle, orbicularis oculi).
  • Injection at the level of the periosteum improves the longevity of the filler since it is placed where the tissue is not mobile.
  • Like any dermal filler injections, the treatment of tear trough deformities using dermal fillers, such as Restylane, Juvederm or even Radiesse, may last for several months depending on which dermal filler is used.
  • According to a recent study, the results lasted from 6 to 12 months.
  • A dermal filler injection for tear trough deformities is not for everyone.  A transconjunctival blepharoplasty for the lower eyelid or other procedures may be necessary.
I recommend  these treatments to be performed by one of your Houston plastic surgeons who will determine whether a dermal filler injection is right for you.  Choosing a medical provider who has a solid knowledge of the anatomy of the face, and has good surgical judgment is essential to minimize the potential complications (such as blindness and facial necrosis) that may arise from a dermal filler injection.  Your plastic surgeon will guide and recommend you the best possible treatment option for your tear trough deformity problem.

Emmanuel De La Cruz M.D.
The Woodlands Plastic Surgeon

Flowers RS. Tear trough implants for correction of tear
trough deformity. Clin Plast Surg 1993;20:403-415.

Loeb R. Fat pad sliding and fat grafting for leveling lid
depressions. Clin Plast Surg 1981;8:757-776.
Kane MA. Treatment of tear trough deformity and lower eyelid bowing with injectable hyaluronic acid. Aesthetic Plast Surg. 2005 Sep-Oct;29(5):363-7.
Lambros VS. Hyaluronic acid injections for the correction of the tear trough deformity.
Plast Reconstr Surg. 2007 Nov;120(suppl 6S):74S-80S
Viana, et al.  Treatment of the Tear Trough Deformity With Hyaluronic Acid Aesthetic Surgery Journal February 2011 31: 225-231

Date Updated:  April 8, 2011

Thursday, February 3, 2011

Botox Injection Before & After Photos

Note:  Dr. De La Cruz has no financial disclosures and association with Allergan.  The photos are presented to educate patients who are interested in having an injection with BOTOX for facial rejuvenation.  Photographs courtesy of Allergan.

Emmanuel De La Cruz M.D. 

Wednesday, February 2, 2011

BOTOX Injection for the Wrinkles in Between the Brows (Glabellar Frowns)

BOTOX Injection for the Wrinkles in Between the Brows (Glabellar Frowns)
  • If your frown in between your eyebrows is visible only in motion, the result of treatment may well be a good one.
    • If the furrow is present at rest, then your wrinkles may not be completely eliminated.
    • If you have heavy brows (seen especially in men), treatment of your frown in between your eyebrows may increase the sagging toward the middle (medially).
    Are your brows not symmetric in motion?
    • If so, the results of your BOTOX treatment will be not be symmetrical too unless this is taken into account.
    Do you have an active frontalis (forehead muscles)?
    • If so, treatment of your vertical furrow alone may cause the lateral brow (brow on the side) to elevate, creating an unattractive peaking of the brows.   
    • You may need a different treatment or your full forehead  zone treated.
    BOTOX injection treatment requires a solid knowledge of the anatomy of the face, as well as good judgment by your medical provider.   I recommend asking one of your Houston cosmetic surgeons for any questions if you are a good candidate for BOTOX treatment.

    Emmanuel De La Cruz M.D.

    Other articles related to BOTOX
    1) The Truth About Botox
    3) BOTOX Treatment for your Crow's Feet (Wrinkles Around the Eyes)

    Are you a Good Candidate for BOTOX?

    Are you The Best Candidate for a BOTOX Injection?
    Being an informed patient is very important prior to having a procedure, even a minimally invasive procedure such as a Botox injection. 

    Areas that can be treated with BOTOX:
    • Crow’s feet (wrinkles around the eye)
    • Vertical or Glabellar Frown (wrinkles in between the eyes)
    • Horizontal or Frontalis Frown (wrinkles on the forehead)
    • Wrinkles on the nose
    • Upper lip rhytids/wrinkles
    • Pebbly chin
    • Jaw line (platysma)
    • Turkey neck (vertical platysma bands)
    Are you a candidate for Botox?
    • If you have wrinkles that appear with smiling and frowning, then you may be a good candidate for Botox. 
    • If you have wrinkles at rest and is sun-damaged, Botox may reduce the lines or wrinkles around the eyes and forehead but will not eliminate them. 

        I recommend asking one of your Woodlands plastic surgeons if you're a good candidate for a BOTOX treatment.

        Feel free to read more about BOTOX.

         Emmanuel De La Cruz M.D.

        Other articles related to BOTOX
        1) The Truth About Botox
        2) BOTOX treatment for your Glabellar Frowns (Wrinkles in Between your Brows)
        3) BOTOX Treatment for your Crow's Feet (Wrinkles Around the Eyes)
        4) Dermal Fillers (Juvederm | Restylane | Radiesse)

        The Use of Botox to Relieve Pain after Breast Plastic Surgery

        One of my plastic surgery colleagues and friends from Loma Linda University, Dr. Allen Gabriel, recently conducted a study to determine whether the use of Botox could help alleviate the pain after undergoing a mastectomy (complete removal of the breast) and breast reconstruction in breast cancer patients.   The study showed that  patients who underwent Botox injections into the chest wall muscles after surgery were reportedly  more comfortable and experienced less pain post-operatively than those patients who only received saline injections.

        Fast Facts about Botox and Breast Pain after Breast Reconstruction
        • Botox to reduce breast pain after breast reconstruction were injected onto the chest wall muscles (pectoralis major) prior to surgery
        • Randomized clinical study involving patients who underwent mastectomy and breast reconstruction with tissue expanders  showed that  those women who received Botox were far more comfortable after surgery than those who received placebo.
        • No significant difference in the use of narcotic, muscle relaxants, or anti-inflammatory drugs were observed in patients who received Botox and the placebo group in the first 3 days after surgery.
        • Patients who received Botox had less pain, and used significantly fewer doses of narcotics and muscle relaxants 7 to 45 days after surgery (P<0.05).
        I recommend to ask one of your Houston Plastic Surgeons if they use Botox in their practice as an adjunct  to reduce post-operative pain after breast reconstruction with tissue expanders.

        Allen Gabriel.  International Society of Aesthetic Plastic Surgery (ISAPS) 20th Biennial Congress: Abstract 45. Presented August 17, 2010

        Other articles related to BOTOX:
        1) The Truth About Botox
        3) BOTOX treatment for your Glabellar Frowns (Wrinkles in Between your Brows)
        4) BOTOX Treatment for your Crow's Feet (Wrinkles Around the Eyes)

        Tuesday, February 1, 2011

        The Third Nipple

        Polythelia (Third nipple or Extra nipples) 

        Having extra nipples (often known as a third nipple) or polythelia  is often mistaken for moles by many.  Approximately 1 in 18 humans would have an extra nipple.   These extra nipples are usually found along the two vertical “milk lines” which can vary in number from one to as many as eight or more.  One should be aware that the presence of “extra nipples” or polythelia has a strong association with kidney disease.

        Supernumerary nipples from the work of Erik Strandberg (Wikimedia commons)

        Fast Facts about Polythelia
        • There may be a possible relationship with mitral valve prolapsed (heart valve problem).
        • Kidney abnormalities associated with polythelia include: cysts, duplications of the kidney, and kidney cancer
        • 14% of patients with no family history of polythelia have kidney abnormalities
        • 32 % of patients with a family history of polythelia have kidney abnormalities
        • 1-2% of general population may have kidney abnormalities.
        • 19% of patients who had kidney cancer had extra nipples.

        I recommend that physicians, families and friends of individuals who have "extra nipples" should be aware of the association of kidney abnormalities with polythelia.  Routine physical examination, a renal ultrasound and urinalysis may be recommended in these patients.

            Emmanuel De La Cruz M.D.

            Recommended reading:

            Leung AK, Robson WL. Renal anomalies in familial polythelia. Am J Dis Child. 1990 Jun;144(6):619-20
            Brown J, Schwartz RA. Supernumerary nipples and renal malformations: a family study. J Cutan Med Surg. 2004 May-Jun;8(3):170-2.

            Silicone Gel Breast Implant or Saline Breast Implant?