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January 15th, 2018


As stated by the American Society of Plastic Surgeons, Botulinum Toxin Type A injections are the leading cosmetic minimally-invasive procedures in America, nowadays1. Botulinum Toxin Type A is a neurotoxin, also called neuromodulator, which is used in the cosmetics industry to prevent the movement of facial muscles by blocking nerve impulses. Since 2002, neurotoxins are successfully used to temporarily remove wrinkles in the brow, forehead, and around the eyes. The first neurotoxin available in the market was Botox, followed 7 years later by Dysport and, ultimately, Xeomin made his appearance in America in 2011. Officially, these three neurotoxins are the only US Food and Drugs Administration approved for the treatment of glabellar lines.

Although Botox, Dysport and Xeomin are all neuromodulators formulated to fulfill the same functions, there are some particularities in their nature and composition that distinguish them from each other. In my quest for always offering my patients the best quality medical service and cost-effective products, I will share the conclusions of my research on those differences. For starts, it is a well-known fact that Botox is the most popular among the neurotoxins and the one with the longest trajectory in the US marketplace. However, the next neuromodulator to entry the aesthetic treatments’ arena, Dysport, presented a remarkably advantage over Botox. Dysport has a smaller protein carrier than Botox, which translates in a higher spread of toxin after injection. Consequently, Dysport offers a faster onset of action than Botox (1-2 days versus 3-5 days), and it requires less injection sites for larges areas such as the forehead or under the arms for hyperhidrosis. Accordingly, less injection sites turns on gains on patient’s comfort. However, Dysport injections are much less convenient to apply in small zones. Owing to its higher diffusion characteristic, instilling it in small muscles, as in the brow or around the eyes, would increase the risk of side effects like drooping of the eyelid, for instance.

But better advantage than having a smaller protein carrier is no having a protein at all. That’s the case of Xeomin, the newest and more affordable Botox competitor. Xeomin is derived from the same parent molecule as Botox, but unlike Botox, it does not have a preservative protein. When Botox and Dysport are injected, the Botulinum molecule must free itself from its protein carrier before bonding with the facial muscles and, as a result, eliminate the wrinkles. On the contrary, Xeomin has no preservative protein, therefore it is immediately available to the muscle receptors2. Cost-effectiveness is another benefit of Xeomin, popularly known as the “Naked Botox”. Xeomin does not required refrigeration, making its transportation more convenient than any other neuromodulator. For its part, Botox and Dysport are both transported in dry ice, which represents an additional expense for distributors, injectors and, ultimately, for patients.



1Plastic Surgery Statistics Report 2016. American Society of Plastic Surgeons.


2Gart, Michael. “Aesthetic Uses of Neuromodulators: Current Uses and Future Directions”. Journal of the American Society of Plastic Surgeons.


Post-Operative Abdominoplasty Complications

January 3rd, 2018

Post-Operative Abdominoplasty Complications

One of the most common cosmetic surgeries patients are interested in when they come to my office is the abdominoplasty. This procedure, generally known as tummy tuck, can flatten your abdomen by removing loose, excess fat and skin and tightening muscles in the abdominal wall. One benefit that patients appreciate the most is that it can also remove the stretch marks in your lower abdomen. It is popular following pregnancy, massive weight loss or whenever a saggy abdomen with weak muscles impairs body contour.
When performed by an experienced board certified plastic surgeon, the abdominoplasty will result in flatter, firmer abdominal contour with narrower waistline that wouldn’t be achieved by liposuction procedures only. All in all, abdominoplasty is a very safe operation. Unfortunately, as with any other cosmetic surgeries, there are post-operative complications that should be addressed by a specialist in a time manner. The most likely possible complications after abdominoplasty are: swelling, infection, wound separation and fluid collections (seromas and hematomas).
The swelling is manifested in the upper thighs and in some cases in the lower legs. The abdominal skin flap can stay swollen due to lymphatic blockage weeks after surgery. This type of swelling requires compression, because swollen tissues themselves can cause more scarring. To prevent the swelling that can occur following a tummy tuck procedure, I prefer the Lockwood technique because separates less tissues than the standard technique. Moreover, one significant thing you can do to control the swelling after the surgery is to wear the post-op compression garment 24/7 for at least eight weeks. Have in mind that tissues heal better and faster when there is minimal swelling.
Infection is another possible complication that can occur after abdominoplasty. Usually, I prescribe patients antibiotics during their final pre-operative visit to prevent wound infection. It is important that patients make sure they are not allergic to the antibiotics prescribed by their surgeons. Oral temperature over 100.4 degrees, yellowish or greenish drainage from the incisions and/or foul odor are among the indicators of a possible infection. A suture abscess is typically not dangerous and it’s easily taken care of by lancing the area under a local anesthetic, and packing the small puncture with a medicated gauze. However, infections can also be life threatening, like those of MRSA (Methicillin Resistant Staph Aureus). It’s always best for patients to contact their doctor promptly if they have any sign of infection. Therefore, I facilitate my cell phone number to all of my post-op patients so they can communicate immediately if any problems or concerns arise.
Wound separation can also be a possible complication after an abdominoplasty. Excess skin tension if too much skin was taking out during the procedure can cause the wound to separate. Small wound separations are easily taken care of by packing the wound with medicated gauze. Slightly larger wound separations can be taken care of by a suction device called a “Vac Dressing”. Large wound separations caused by poor blood supply may need revision and re-approximation of the wound edges in a procedure room.

In any case, I highly recommend patients to schedule an in-person visit to get the wound treated promptly and prevent further complications such as getting the wound infected or extending the recovery period.
Lastly, fluid collections (namely seromas and hematomas) are among the possible complications after a tummy tuck procedure. A seroma is a collection of wound fluid. Sometimes it occurs when patients do not wear the compression garment adequately or he/she has a lot of activity in the post-operative period. For its part, a hematoma is a collection of blood in the dead space. It usually needs to be evacuated because it can be painful, can lead to infection or cause excessive scarring. Although seromas and hematomas can be easily treated with a needle aspiration, the best remedy against fluid collections is prevention. The proper use of compression garments and foam pads (Topifoam pads) over areas of potential fluid accumulation are significantly beneficial to prevent these post-operative complications.

PRP (Platelet-Rich Plasma) Facial Rejuvenation The Woodlands|Houston

October 20th, 2017

Autologous platelet-rich plasma or PRP has attracted attention in various medical fields recently, including orthopedic, plastic surgery and dermatology for its wound healing ability.  Various growth factors, including platelet-derived growth factor (PDGF), transforming growth factor (TGF), vascular endothelial growth factor (VEGF), and insulin-like growth factor (IGF), are secreted from the α-granules of concentrated platelets. Due to the presence of high concentrations of these growth factors, PRP has been used in a wide variety of surgical procedures and clinical treatments, including skin rejuvenation and hair loss treatment.













Since PRP secretes various growth factors with roles in skin regeneration, PRP may induce collagen synthesis and other matrix components by stimulating the activation of fibroblasts, thus, rejuvenating the skin.  Studies have shown that PRP stimulates dermal fibroblast proliferation, and thus can promote the remodeling of aged and photoaged skin.

Cosmetic Application of PRP (Platelet-rich Plasma)

  • Hair Loss Treatment
  • Facial Rejuvenation

I recommend consulting with your plastic surgeon if you’re interested in PRP.  PRP in combination with fat transfer for facial rejuvenation has been shown to have longer lasting results.


Emmanuel De La Cruz MD, PLLC

Plastic Surgeon, Houston | The Woodlands  Texas


Kim et al.  Can Platelet-rich plasma be used for skin rejuvenation? Evaluation of effects of Platelet-rich plasma on human dermal fibroblast.   Ann Dermatol. 2011 Nov; 23(4): 424–431.

Published online 2011 Nov 3. doi:  10.5021/ad.2011.23.4.424


October is Breast Cancer Awareness Month

October 15th, 2017

One in 8 women will be diagnosed with breast cancer in their lifetime.  It is very important to examine your breasts daily, as well as obtain your screening mammogram annually.

Screening Mammogram Recommendations:

  • Previously, it was recommended to start annual screening mammogram at the age of 40.  Currently, women ages 40 to 44 should have the choice to start annual breast cancer screening with mammograms (x-rays of the breast) if they wish to do so.
  • Women age 45 to 54 should get mammograms every year.
  • Women 55 and older should switch to mammograms every 2 years, or can continue yearly screening
  • If one has a strong family history of breast cancer, annual screening mammogram may be recommended at an early age.

Emmanuel De La Cruz MD, PLLC
Plastic Surgeon, Houston Texas

Cellulite Removal

July 20th, 2017

So what is Cellulite? Cellulite is the herniation of subcutaneous fat within fibrous connective tissue that manifests topographically as skin dimpling and modularity, typically affecting the buttocks and the thighs.   Approximately 85 to 98% of women have cellulite which indicates that it is physiologic rather than a pathologic condition in women.

Causes of Cellulite

1)Hormonal - the hormone estrogen maybe the culprit for the development of cellulite in women.  Although there’s no clinical evidence that estrogen may cause cellulite.

2)Genetics – There’s a genetic predisposition of cellulite.  Some women have more cellulite than others.  Scientists were able to trace the genetic component of cellulite in angiotensin converting enzyme (ACE) and hypoxia-inducible factor 1A (HIF1a) genes.

3)Lifestyle - A high-stress lifestyle will cause an increase in the level of catecholamines, which have also been associated with the development of cellulite.  Thus, reducing stress, such as during exercise, may improve cellulite.

Treatment of Cellulite

1)Cellulaze – it’s the first FDA-approved treatment of cellulite.  Although it may improve the appearance of cellulite, it’s not a guarantee to completely remove it.



Prevention and Treatment of Double-Bubble Deformity with Dual Plane Technique for Breast Augmentation

May 24th, 2017

The double-bubble deformity is a widely recognized complication of breast augmentation.

Prevention of Double-Bubble Deformity
• This deformity can be avoided with selection of a subglandular or dual plane (type II or III) placement, a sufficient implant volume or projection and anatomic prosthesis
There are several techniques one can employ to treat and correct the double-bubble deformity. These techniques include:
• Use of a dual-plane pocket
• Form-stable shaped implants
• Capsulorrhaphy
• Pocket plane conversion
• Use of acellular dermal matrices


Handel N. The double-bubble deformity: cause, prevention, and treatment. Plast Reconstr Surg. 2013 Dec;132(6):1434-43. doi: 10.1097/01.prs.0000434405.91316.96.

Emmanuel De La Cruz MD, PLLC
Plastic & Reconstructive Surgeon
Houston, Texas

Reduction of Seroma in Abdominoplasty

May 22nd, 2017

Seroma is the most common complication of abdominoplasty (tummy tuck.)  There are certain modifications to abdominoplasty that may reduce the risk of seroma.

A recent meta-analysis involving 1824 patients revealed the following:

  • Abdominoplasty with preservation of Scarpa’s fascia reduced incidence of seroma compared with that of standard abdominoplasty (P < 0.0001)
  • Abdominoplasty with placement of progressive tension sutures was associated with a significantly reduced incidence of seroma compared with that of standard abdominoplasty (P < 0.0002,).
  • Application of fibrin glue has no impact on seroma formation.  It does not reduce seroma formation in abdominoplasty.


Ardehali, et al.  A Meta-Analysis of the Effects of Abdominoplasty Modifications on the Incidence of Postoperative Seroma. Aesthet Surg J. 2017 May 6. doi: 10.1093/asj/sjx051.

Emmanuel De La Cruz MD, PLLC
Plastic & Reconstructive Surgeon
Houston, Texas


Brazilian Butt Lift Fat Transfer vs Gluteal Implant Buttock Augmentation

May 22nd, 2017

Buttock augmentation has been performed more frequently in the past decade.  There’s approximately over 21,000 procedures performed in the past year alone. The most popular methods for buttock augmentation involve silicone implants and autologous fat grafting.

So which Buttock Augmentation Procedure is safer and have lesser risks and complications?

The most commonly reported complications in 2375 patients receiving silicone implants has an overall complication rate of 21.6 percent (n = 512).
• Wound dehiscence (9.6 percent)
• Seroma (4.6 percent)
• Infection (1.9 percent)
• Transient sciatic paresthesias (1.0 percent

The most commonly reported complications in 3567 patients receiving autologous fat injection has an overall complication rate of 9.9 percent (n = 353).
• Seroma (3.5 percent)
• Undercorrection (2.2 percent)
• Infection (2.0 percent)
• Pain or sciatalgia (1.7 percent)

Sinno, et al. Determining the Safety and Efficacy of Gluteal Augmentation: A Systematic Review of Outcomes and Complications. Plast Reconstr Surg. 2016 Apr;137(4):1151-6

Emmanuel De La Cruz MD, PLLC
Plastic & Reconstructive Surgeon
Houston, Texas

Preventing Fat Embolism in Brazilian Butt Lift

May 19th, 2017

Brazilian Butt Lift involving fat transfer to the buttocks had been recently become very popular. As in any surgery, there are risks and complications, especially when combined with fat injection. There had been numerous case reports of fat embolism that have been documented. The possible explanation for these cases may be attributed to the puncture and tear of gluteal vessels during the procedure, especially when a deep injection is planned.

Figure 1: 4D VASER Hi-Definition Liposuction with Fat Transfer to the Buttock (Before & After Procedure: 6 weeks after surgery) performed by Dr. Emmanuel De La Cruz

What are the risks of Fat Embolism during Brazilian Butt Lift?

  • Fat embolism with Brazilian Butt Lift is more common in South America (Columbia and Brazil- ~7%) than it is here in the US.
  • Twenty-five fatalities were confirmed in the United States over the last 5 years through of autopsy reports and interviews with surgeons and medical examiners. Four deaths were reported from 2014 to 2015 from pulmonary fat emboli in AAAASF facilities.

How to Prevent Fat Embolism in Brazilian Butt Lift

1)Knowing the Anatomy of the Perforators of Gluteus muscle is Key to Avoid iatrogenic injury the vessels
Cadaveric studies have shown that the area under the gluteus muscle where the superior gluteal vessels traverse the muscle was located 6.4 ± 1.54 cm from the intergluteal crease and 5.8 ± 1.13 cm from the superior border of the gluteus muscle. The inferior gluteal vessels were located 8.3 ± 1.39 cm from the intergluteal crease and 10 ± 2.24 cm from the superior border of the muscle.
Cadaveric studies have shown that the angle of fat injection is important in avoiding injury to the gluteal perforators.
A 30° angle allows for an injection into the muscle without passing into deeper structures, unlike a 45° injection angle.

2)The fat is injected ONLY when the cannula is being withdrawn. This minimizes the risk of vessel puncture.
3)Use of blunt cannula during fat injection. The blunt cannula is used to decrease the likelihood of penetrating a blood vessel.

4)Avoid downward slope injection of fat into the buttock since the likelihood of iatrogenic penetration of the gluteal perforators is higher.

5)Avoid injection of fat into the gluteus muscle.  Intramuscular gluteal lipoinjection was found to be associated with mortality caused by gluteal blood vessel damage allowing macroscopic and microscopic fat embolism


Preventing Fat Embolism Syndrome

1)The use of methylprednisolone as a “membrane stabilizer” would reduce the incidence of Fat Embolism Syndrome. Pooled analysis of 389 patients found that corticosteroids reduced the risk of FES by 78%.


Emmanuel De La Cruz MD, PLLC

Plastic & Reconstructive Surgeon  Houston, Texas

Bederman, et al. Do corticosteroids reduce the risk of fat embolism syndrome in patients with long bone fractures? A MetaAnalysis. Can J Surg 2009. Oct 52(5)386-93

Cardenas, et al. Deaths Cause by Gluteal Lipoinjection:  What are We Doing Wrong? Plast Reconstr Surg. 2015 Jul;136(1):58-66. doi: 10.1097

Mofid et al.  Report on Mortality from Gluteal Fat Grafting:  Recommendations from the ASERF Task Force. Aesthet Surg J. 2017 Mar 21. doi: 10.1093/asj/sjx004. [Epub ahead of print]

Ramos-Gallardo, et al. Prevention of Fat Embolism in Fat Injection for Gluteal Augmentation, Anatomic Study in Fresh Cadavers. J Invest Surg. 2017 May 9:1-6. doi: 10.1080/08941939.2017.1321703. [Epub ahead of print]

Schonfeld SA, Ploysongsang Y, DiLisio R, Crissman JD, Miller E, Hammerschmidt DE, et al. Fat embolism prophylaxis with corticosteroid: A prospective study in high-risk patients. Ann Int Med. 1983;99:438–43.

Sculptra Injection in The Woodlands, Texas

May 19th, 2017

Sculptra is a synthetic material containing poly-L-lactic acid.  This is an FDA-approved injectible that has been in use since 1999.  It’s a biocompatible and biodegradable product that is naturally absorbed by the body.  It’s a material that is frequently used in absorbable sutures.

What are the benefits of Sculptra?


  • It can last up to two years.
  • It can thicken your dermis up to 10-12 mm with progressive treatments.
  • It stimulates collagen growth which helps restore facial volume and the look of fullness to wrinkles and folds over time.

How many treatments does one typically would need?

  • Per session, one would need approximately 2 vials of Sculptra to treat the whole face.
  • One may require at least 2 to 3 treatments in 4 to 6 week intervals

How does Sculptra work?

Emmanuel De La Cruz MD, PLLC
Houston Plastic Surgeon