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:  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.

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