Pectoral Augmentation and Recovery

ONLY A REALLY GOOD PLASTIC SURGEON  KNOWS A MAN’S BODY REALLY WELL

This letter is addressed to you, the prospective client who wants to change his or her life today. It was written by Ray Gapuz to inspire you to take the first step.

Hi,

I’m Ray A. Gapuz, a certified regular client for aesthetic surgery and one of the many satisfied clients of DR. ANGELES.  So let me reassure you that you are in good hands if you have chosen Dr. Angeles to perform your surgery. In my case, I have undergone 10 procedures (including BLEPHAROPLASTY, LIPOSUCTION, CHEEK AND PECTORAL IMPLANTS, ETC.) 

Here are some helpful hints for those who are preparing for PECTORAL IMPLANT SURGERY. These helped me recover fast. I was able to return to my office meetings within 3 days after surgery. I hope this regimen will help you, too.

(Signed, Ray A. Gapuz)

PERSONAL THINGS TO PREPARE:Although valuables are looked after during your procedure, the clinic is not expected to   take responsibility for these items, so it’s best to only bring necessities. The following personal things are what I prepared for my personal use after the procedure.

·         Polo with buttons all the way to the front for ease of wearing after the surgery·         Bathrobe which you may prefer to use at discharge
·         Extra large sleeveless shirts ( sando) for everyday use after surgery

·         ‘Garterized’ shorts for a comfortable adjustment to the swelling

·         Bactidol gargle to counteract sore throat

·         Stretchable Corset (THAT SERVES AS ADDITIONAL SUPPORT TO THE COMPRESSION BANDAGE OR VEST) to minimize edema and pain when moving·         Battery-operated handheld mini massage machine helps minimize swelling

·         Call bell to facilitate communication with care provider

Preparations before surgery

Eat a  well-balanced diet

·         A well-balanced, healthy diet  aids healing and strengthens your immune system,leading to a faster recovery.

·        Take one  vitamin C a day which improves wound healing but avoid vitamin E intake for about two weeks prior to undergoing surgery, as it can interfere with blood clotting.

Do regular Exercise

·        By exercising, you increase your metabolic rate and build muscle mass which assists in avoiding weight gain during the recovery time. Check with your doctor which drugs are safe to take.From my personal readings I learned the following 

·        Two weeks prior to surgery: Stop vitamin E intake. Wheat germ, nuts, and some vegetable oils contain the largest amounts of vitamin E so avoid these for the two weeks before your surgery.

·        Seven days prior to your operation: Stop taking aspirin, clopidogrel (eg. Plavix, Iscover), dipyridamole (eg Asasantin, Persantin) and NSAIDs (non-steroidal anti-inflammatory drugs). The use of birth control pills, hormone replacement therapy and some forms of post-cancer treatment medication may also involve an increased risk of complications during or after surgery. Use of these types of medications may produce an increased risk of developing dangerous internal blood clots that can, in rare cases, lead to embolism.

·        Five days prior: Stop taking warfarin medications (Coumadin, Marevan). However, for high risk patients, stopping warfarin can lead to life-threatening blood clots and daily injections with low molecular weight heparin may be required. High risk patients most commonly include those with artificial heart valves or those who have suffered myocardial infarctions. Your doctor can advise if you are in the high risk category. Low risk patients stopping warfarin may require no course of action.

·        Stop eating at least six (6) hours before your procedure. However, you may continue drinking water and clear apple juice (and only clear apple juice) up to two (2) hours prior to your procedure.

·        On the day of your procedure: Shower and wash yourself with mild soap and shampoo your hair. Remove all jewelry.

·        Your own maintenance medication can be taken with a sip of water on the morning of surgery.

What to wear in the hospital

·        On the day of surgery, wear loose-fitting clothes (which do not have to be put on over your head).

·        Avoid using  aftershave, face cream or other cosmetics.

·        As contact lenses cannot be worn in the operating theatre, wear glasses, if required.

·        Please refer to the list of personal things needed in the aforementioned paragraph.

After Surgery

·        Dr. Angeles  will check you   after your surgery to ensure everything is going well. You will be able to go home a few hours later.

·        Some post-operative pain (varying from quite severe to mild or moderate) will occur on the first day. This gradually improves over the next few days and is usually well-tolerated by patients taking the prescribed painkillers. Increasing pain that is unresponsive to painkillers should be brought to the attention of Dr  Angeles as this may be an indication that complications are developing.

EXPECT DISCOMFORT DURING THE FIRST 24 HOURS

·         Pain-Take the prescribed pain medications and communicate a need for dose adjustment  to Dr. Angeles, if necessary

·         Muscle Fatigue-Massage the joint affected. Ensure that the extremity is properly positioned after the surgery.

·         Oozing-Apply additional gauze if necessary

·         Constipation – Increase fluids and fiber in the diet and move around as soon as you can.

AFTER 24 HOURS

·         Itchiness of the skin at the back due to the bandage, I used calamine lotion to manage it.

·         Swelling, I used the massage machine, cold compress in the first 48 hours and warm compress there after to lessen it.

·         Bruising , The SINECCH I bought at the clinic helped a lot.There was very minimal bruising because I took it as prescribed.

·         Numbness , I did squeezing exercises using a rubberball to minimize numbness of the arms and fingers.
·         Sometimes you may feel a lot of pressure on the chest area, as I did. This is due to the augmentation. Deep breathing may help.

·         It’s normal to feel burning, sharp shooting pain and soreness during the recovery.·         I was told that I will be swollen for a few months.which may affect the abdominal area and the legs. I am told that It’s normal for this to happen, it takes days for the swelling to go away, says Dr. Angeles.

DURING DRESSING TIME

·         Skin Irritation may result from the hypersensitivity of the skin after surgery especially when the anesthesia has worn off.

·         Dried wound tissues that attached to the gauze may cause pain. I used hydrogen peroxide to prevent unnecessary detachment of dried skin.

WOUND CARE PARAPHERNALIA

·         Hydrogen peroxide- facilitates changing of gauze

·         Lactcyd blue- used to wash the skin

·         Micropore tape- keeps the gauze in place

·         Fucidin antibacterial ointment-applied before the gauze is taped over the wound to prevent infection

·         Gauze protects the wound

CALL DR. ANGELES  IF ANY OF THE FOLLOWING DEVELOPS

·         Allergic Reaction

·         Pain that is not relieved by medications


·         Continuous bleeding

·         Dizziness

·         Feeling light headed

·         Abnormal temperature

·         Fever and chills

Before-and-after pics of another pec implant patient

ANY OF THESE MANIFESTATIONS MAY INDICATE THE DEVELOPMENT OF COMPLICATIONS

MANEUVERS THAT HELP DECREASE PAIN WHEN GETTING IN AND OUT OF BED

1.   Ensure that your care provider is there to assist you.

2.   Ask your care provider to place one hand at your back and the other hand will be for you to hold onto as you try to sit up.

3.   Flex one of  your legs

4.   At the count of 3, or any agreed signal,  push and step on your flexed leg as you hold onto your care providers’ arm and hold your upper body up.

5.   Sit and dangle your legs for a while before you stand up. This will help you stabilize your circulation first before you move as the anesthesia may cause your blood vessels to dilate that may cause dizziness when you abruptly change your position.

DO’S AND DONT’S DURING RECOVERY

DO’s

·         Sleep in an upright reclined position for 1-2 weeks. Elevate the head and shoulder on 2-3 pillows. This will help decrease the swelling.

·         Please take the medications as directed.  Never on an empty stomach and always space out the medications as instructed.

·          Start taking something to help prevent constipation 2-3 days post surgery.


DONT’s


·         Driving for 2-3 weeks post surgery or until off narcotic pain medication completely.

·         Reaching out or above  your head for at least 3-4 weeks.

·         Taking showers for 2-3 weeks post surgery or until drains are removed. No swimming for 12 weeks post surgery or until the incisions are fully healed.

·         Upper body exercising for 8-12 weeks post surgery.

·         Tanning or sun exposure to the incision until the incision has healed completely.·         Scar creams or ointments on the incision immediately after surgery, you may irritate the area or cause an allergic reaction.

·         Applying deodorant at the axillary area for at least 2 weeks or if the area looks red or is in the healing process.

AFTER EVERYTHING

·         Now, I’m enjoying my new chest

·         Wearing shirts is never the same. Shirts always shows my muscular cleavage now.

·         Flexing my pecs enhances the form

·         The feel and movements are all so natural

·         I show off my chest topless at pools and gym with confidence

·         More than anything else, this was a good decision and worth every spent.  I never could have had this chest doing gym exercises with my busy schedule.

More about me

Dr. Arnold Angeles, MD,
FPSGS, FPAPRAS, FPCS

Dr. Arnold Angeles is a graduate from the University of the East Ramon Magsaysay Memorial Medical Center (UERM) and trained as a General Surgeon at the same institution. He accomplished training in Plastic and Reconstructive Surgery , Consortium 1 (2005-2008). Dr. Arnold Angeles is now an Assistant Prof in General and Plastic surgery in UERM Medical Center.

Arnold Angeles is also a loving husband to his wife and a warm father to his children.

Meanwhile, the following is found in my website's About the doctor page:

Dr. Arnold Angeles, MD, FPSGS, FPAPRAS, FPCS, completed his formal training in Plastic Surgery and Reconstructive Surgery at UERMMMCi, Quezon City in the Philippines. Soon after, he applied and was awarded the raredouble board certification for General Surgery and Plastic & Reconstructive Surgery by Philippine Board of Plastic & Reconstructive Surgery (PAPRAS) and the Philippine Society of General Surgeons, Philippine College of Surgeons. Although he is more than capable as a general surgery, Dr. Arnold Angeles found his calling

With boxer Manny Pacquiao

in Plastic, Cosmetic, Aesthetic and Reconstructive Surgery. It is his personal belief that beyond vanity, his craft empowers those that have no power and lifts up those that have been put down all their life. He gives men and women a chance to start-over, move-on or continue with the lives they already have or wish they had. That is why to continue providing the best individualized and affordable services to all his clients, Dr. Angeles continues to learn and use new techniques, methods and products while combining it with traditional and time-tested alternatives. His constant desire to excel in his craft drove him to continue learning, writing and teaching for various lectures, talks and conventions all over the world from Singapore to the United States and of course the Philippines.

Facelifting

Doing face lifts may be easily reckoned as a little nip here and a little tuck here. It takes more than that because achieving correct facial rejuvenation leads to a naturally appearing, younger you, and it lasts. I believe this is the main reason why, in doing a facelift, certain anatomic areas should be touched while others should be avoided. The end result is not only a nip/tuck procedure, but a good camouflage of the aging changes. That is good facelifting!

And more often than not, it also requires some eyelid surgery: You don't want to look like an 18-year old with grandma eye bags!

Breast Reconstruction

With breast reconstruction, I have no idea how it feels to be 'unbreasted,” nor will I assume that I can understand completely what they are going through." All I know is how to create results.

Fillers and Injectables

About fillers and injectables Any loss of volume, especially on the face, is always related to loss of innocence and youthfulness. It may also be a birth defect such as overbite or a lack of chin.

Fillers can also be used as a form of "putty clay" used for sculpting the face to a semblance of perfection. The photos above show the difference! Notice how the overbite was corrected?

Fillers may also be used to create plumper lips.

Fillers and Injectables

About fillers and injectables


Any loss of volume, especially on the face, is always related to loss of innocence and youthfulness. First, lines begin to appear. Then the lines become deeper. What was plump becomes thinner and flat. Then more lines appear, growing in numbers. Like rubber bands that have been constantly pulled, fibroelastins and dermal supports begin to soften and stretch. Now, structures begin to follow gravity, creating the illusion of sadness and aging.

Volume lost should be replaced. One of the new developments in achieving volume replacement is by using fillers.

What are fillers? I think this has become a common household name. Just mentioning it doesn’t need any other explanations. It’s a filler, used to fill up a defect, correct a skin depression or a deep facial line or something. It is used to replenish lost volume, enhancing something that a client feels minutely or noticeably lost that is brought about by our normal aging and gravity. Our own body unfortunately degrades after time. Although our body continuously replaces our cells, some parts are not replaced as youthfully as we would expect. Proteins degrade and fibrin connections loss elasticity creating unwanted furrows and wrinkles.

But we have to agree on one thing. Fillers are just one of the many aesthetic tools that can address the same problem. Funny thing is, from the start of the 21st century, filler materials have boomed into the market, not only in South America and Europe, but also in Asia and America. Due to these numerous products, sometimes it is really confusing which one to use. The good thing here is that with numerous fillers, numerous specialists have also used them. This effect has resulted in the development of reports about their use and experiences, and right now, it has been an abundant array of data. Hence, our knowledge about indications, techniques and complications has been increasing, making us more able to deal with what kinds of result we can deliver to our clients’ desire. For more information about Fillers, the book on “Injectable Fillers in Aesthetic Medicine,” by Mauricio de Maio & Berthold Rzany (pub by Springer) is really fantastic and educational to read (http://bit.ly/bC2HAJ).

Let us not forget, however, that “one session only” filler delivery session is still a dream. Currently, achievement of happiness in its aesthetic form takes at least 2 to 4 sessions of filling delivery. Personally, I feel awkward in delivering substantial amount of fillers in one session, creating a super-enhanced look that sometimes can be frightening during the recuperation phases of healing. Of course, it is always safe to use these biodegradable fillers, especially if you are a beginner, or if it’s your first time to undergo (or do) the procedure, because after sometime, it gets resorbed and any unwanted result can dissipate. On the other hand, if its beautifully done, it will not last too. But if you like what you see, then go for the permanent fillers so that you don’t have to keep on coming back.

It’s also depressing to be putting in very small amounts in one session resulting in no result at all. There has to be a substantial amount invested here in order to see an effect. But don’t get confused in delivering little vs delivering too much. I get confused also, but I guess, too little is never appreciated and too much of anything is always bad. How will you know if you placed in just the right amount of filler?...a mirror is a best friend…well, also experience.

Let us start understanding the composition of a filler, how it reacts with our body, and how it achieves the goal on “filling.” There might be other preferences with other filler materials by other Plastic Surgeons or Dermatologists, but I just want to discuss some of my own choices here. The choice should always be a resolution based on the common understanding between patient and specialist regarding the purpose of filling, the effect it can produce and how long it will last.

Safety first.
Historically, silicone injection in the form of oil (silicone oil) was popularly used to correct volume loss or augment specific body parts. Unbelievably, it was cheap and easy to perform…anybody can do the injection, like a “fly-by-night” thing. After a few years, complications begin to appear. These complications include dermal hyperpigmentation (“rose spots”), abscess formation, gravitating fibrosis and loss of aesthetic form. These complications are irreversible and permanent since the human body cannot degrade the silicone that was injected. More often, surgical resolution is needed, but resolves into a more morbid and sometimes debilitating outcome. Personally, silicone oil injection is not safe and is bound to develop complications.

Some concerns include allergic reactions after dermal filling. Earlier generations of fillers were developed from pigs. Bovine fillers like Endoplast-50 and Zyderm/Zyplast gave pleasing results in the management of fine to deep wrinkles and facial volume rejuvenation. Unfortunately, since these fillers are bovine in origin, it’s always safe to do some form of skin testing prior to the actual injection. But skin testing has been quite tasking and requires a lot of time and retesting; and quite sadly, clients lose their enthusiasm entirely about the procedure.

Biodegradable or non-biodegradable; cross-linked or not.
Biodegradability determines the longevity of the effects of the fillers. Different components determine their lasting effects. Some fillers are composed of calcium hydroxylapatite (Radiesse), which is like bone and therefore gets eliminated slowly…meaning, it provides a longer dermal filling/volume replacement result. Others have poly-L-lactic acid (Sculptra) that stimulates expansion of our own collagen which also provides lasting results. Lastly, dermal fillers with hyaluronic acids have many brands, each brand is different in its composition of HA, cross-linking and molecule size…just to cater the different indications and needs of the client and plastic surgeons as well.

Hyaluronic acid is a naturally occurring substance that is both biodegradable and biocompatible with the human body. HA is manufactured variably by cross-linking its molecules. Those without cross-linking are easily degraded by our body’s enzymes, but they are the thinnest and more viscous. These are “thin” fillers that usually take care of fine wrinkles without causing bulk and unwanted bumps. It cannot resolve volume loss.

Some fillers are cross-linked while others are not or in moderation. Cross linking creates a mesh, which also creates volume to the filler. Some are moderately cross-linked, while others are heavily cross-linked. Just like any other mesh, the heavier cross-linked dermal fillers tend to last longer and replace volume better. “Heavy” fillers take a longer time for our enzymes to degrade; and they are usually injected deep to avoid noticeable bumps or nodulations

Non-biodegradable or permanent fillers like Polyacrylamide hydrogel (Aquamid) have met some resistance in its use because of the possibility of long term infections and granuloma formations. But in the recent prospective RCT study by Michaela Ryan in a 5 year assessment of facial application of polyacrylamide hydrogel, showed good aesthetic outcomes with limited complications.

Micro or macromoleculeThis is one manufacturing technology that is an added feature. Micromolecules can seep into small spaces in the dermis correcting fine to moderate wrinkles primarily over volume. Macromolecules, on the other hand, the bigger version tends to correct volume primarily. Giving back the volume eliminates the lines created by the loss of it. In addition, macromolecules do not migrate.

Below are some of the dermal fillers I use. Again, other plastic surgeons may have different preferences and reasons, but these are just my own tools.

Radiesse (http://www.radiesse.com/) is one form of soft tissue injectable fillers that is composed of micro spheres of synthetic calcium hydroxylapatite (30%) that is combined with a common hydro gel (70%). Since the hydroxylapatite component has similar chemical and structural characteristic as bone and teeth, it doesn’t elicit any chronic inflammatory or immune response; and more importantly, it does not migrate. (Grabb & Smith Plastic Surgery. Ch 45, 2007). Initially, this was approved by the FDA for filling of oromaxillofacial defects, soft tissue depressions, and laryngeal augmentation. In 2006, FDA approval for Radiesse was extended to the treatment of deep nasolabial folds and lipoatrophy.

What happens after injection of Radiesse is that the carrier gel is gradually absorbed by the body and new collagen formation occurs around the calcium hydroxylapatite microspheres. Based on studies, this calcium hydroxylapatite has been found out to be biocompatible and non-antigenic, meaning, sensitivity testing is not necessary prior to delivery. This is a temporary filler but lasts quite long, about 12 – 18 months (but some reports up to 6 years). There has also been reports about formation of small submucousal nodules in the lip occurring after shallow delivery of the filler for lip augmentation, so better go a little deeper or use a finer filler if dealing with the lips instead. The manufacturer of Radiesse is Bioform Medical, Inc. at http://www.bioforminc.com/.

Sculptra (http://www.sculptraaesthetic.com/) consists of poly-L-lactic acid (PLLA) which is basically a biodegradable polyester derived from corn starch and sugar canes. This initiates the expansion of the body’s own collagen, resulting in a more lasting appearance. This was approved by the FDA in 2004 for the treatment of facial lipoatrophy secondary to HIV-associated medications. Now, Sculptra is being used to correct deep facial lines, frown lines, deep scars and deep nasolabial lines. This is usually delivered subdermally in a criss-cross (cross-hatch) pattern to minimize subdermal bumps later on. Sometimes, it’s best to dilute this filler to prevent the small bumps or papules from occurring which is usually not visible, but can be felt when pressing on the area injected. Some clinical trials showed that Sculptra can lasts up to 2 years.

Skinfill (http://www.webpromoitalia.com/) is based on a fluid Hyaluronic Acid gel that is stabilized with a new technological process called Coesix. Basically, this process decreases cell degeneration resulting in the longevity of result and durability of the “filling-up” effect we want to achieve. The same Coesix technology makes this filler very easy to introduce in the subdermal area It minimizes patient discomfort and some side reactions associated with crosslinked fillers.

Cross linked fillers are usually used to improve depth and volume and are generally viscous and dense. Cross linking creates a molecular mesh that increases its volume and therefore replaces “loss of volume” more adequately. Non-cross linked fillers are generally fluid and are usually used for facial hydration, fine wrinkle management and improves skin elasticity.
Skinfill is an affordable solution to lip augmentation and correction of moderate to deep facial wrinkling. Although this product is marketed by Promoitalia, it is distributed locally in the Philippines my Aemed, Inc.

Restylane (http://www.restylane.com/) is a partially cross-linked hyaluronic acid (HA) which can be used for correction of moderate to deep facial wrinkling and lip augmentation. Since HA occurs naturally in the body, there is no cross or allergic reaction. It is also naturally degraded within the body within at least 6months onwards. Restilane also works well with moderate wrinkles and depressions and once of the best results are with the use for lip augmentation.

Teosyal Ultimate (http://www.teoxane.com/) is a newly developed HA based dermal fillers. Teoxane has developed different filler viscosity that caters to the different types of wrinkles, depressions and volume replacement. This works well with depressed nasolabial folds, marionette lines and lip augmentation. Viability of the fillers may also reach the stability duration of Radiesse, almost approaching 2 years after final injection. Sadly, this is presently unavailable in the Philippines but can be ordered through their sister company in Korea or HK.

SiliconeIt is quite important to mention Silicone oil as a form of dermal filler. Historically, silicone injections were very popular because of its availability and low cost. Volume replacement using Silicone injection was amazing during its early use, but today, its use as a dermal filler should totally be abandoned. The complications and controversies that are presently occuring are numerous and sadly, almost all cases of Silicone oil injections are bound to develop some form of complication after time. Unlike HA, the body cannot degrade silicone; hence, instead of degrading the silicone, the body develops fibrosis, causing noticeable lumps that is observed to gravitate. Dermal reaction which is observed as hyperpigmentation (“redness”) may also be permanent and irreversible.

In the end, I really don’t know if this documentation about fillers added to the confusion of everything. It is always nice to know how things work and how we use this knowledge to accompany our expertise in providing the right kind of services to our clients.

Visit my website at arnoldangeles.com to learn more about dermal fillers and other cosmetic services.