The type IIB procedure is for patients with redundancy of their entire upper arm, from the elbow to the chest wall (though not inclusive). There are two groups present in this subset of patients, depending on whether the patient has excessive isolated vertical redundancy in the axilla or a combination of horizontal and vertical redundancy. For patients with isolated vertical redundancy, a horizontal excision can be performed along the brachial groove. The superior aspect of the horizontal resection is then marked 3 to 4 cm superior to the brachial sulcus. The inferior aspect can be estimated, but the actual extent of resection is decided in the operating room (Fig. 4).
For patients with moderate horizontal combined with vertical excess, an L-shaped excision is performed in the axilla (Fig. 5). The lax arm tissue is displaced medially to determine the extent of vertical resection necessary to correct the ptosis of the arm.12,13 The length of the incision distally is dependent on the amount of redundant tissue around the elbow. Occasionally, the incision must extend distal to the elbow. We have found that the best results are obtained when the vertical axillary excision is performed first, followed by the horizontal excision. The vertical incision is temporarily closed, and then the horizontal excision is performed by making the incision along the superior marking and dissecting the flap just superficial to the deep brachial fascia. This flap is then pulled superiorly and marked so as to provide the most aesthetic correction of the deformity, and the resection is then performed. Lockwood believes that anchoring the superficial fascia of the arm to the axillary fascia with permanent sutures decreases the incidence of recurrence and difficulty with scarring.12,13 With this technique, we have used polydioxanone suture (absorbable) with good results. The amount of undermining superiorly and inferiorly is kept to a minimum, and the wound is closed over a suction drain.
For patients who have had massive weight loss, laxity may also be present on the lateral chest wall. For these patients, an extended brachioplasty onto the chest wall, as initially described by Pitanguy,19,20 is the procedure of choice. The markings for this technique start by delineating the superior aspect of the anticipated resection 3 to 4 cm above the brachial sulcus. This line marking the extent of superior resection is curved inferiorly into the axilla, where the incision is interrupted by a “Z” to avoid straight line scar contracture (Fig. 6). The marking then continues along the anterior axillary line and ends in the inframammary fold. Sometimes this procedure is performed concomitantly with a mastopexy or reduction mammaplasty. For patients with redundancy around the elbow, it is sometimes necessary to extend the incision past the elbow onto the forearm to remove the excess. However, extension should be avoided, if at all possible, distal to the elbow, because the scar is more noticeable in this location. The wound is closed in layers over a drain.
Closed suction drains are used in all patients undergoing traditional or extended brachioplasty. The drains remain in place until the output is less than 30 cc in a 24-hour period. The arms are circumferentially covered with nonadhesive foam and compression garments are placed. Patients should wear these garments for at least 4 weeks postoperatively. This amount of time is longer than that when liposuction alone is used. After the garments are discontinued, the suture line is supported with paper tape, and compression bandages are wrapped around the arm for an additional 4 weeks.
Type III patients have both lipodystrophy and redundant lax skin in the arm (pinch test, >1.5 cm). Liposuction for arm contouring will not provide enough skin retraction to obtain a good aesthetic result. Excisional techniques, on the other hand, have a higher incidence of complications in this patient population, because the amount of excess fat provides bulk that results in greater tension across the incision. Furthermore, the weight of the flap pulls on the incision postoperatively.
Several options are available for these patients. First, further weight loss can decrease the amount of subcutaneous fat, subsequently downstaging these patients. Second, patients with moderate, but not severe, skin laxity can be treated in a staged fashion beginning with ultrasound- and suction-assisted liposuction.15,16 These patients must understand that liposuction likely will not provide enough skin retraction and that a revisional brachioplasty (using excisional techniques) will likely be required to give the best aesthetic result. Lastly, these patients can be treated with combined single-stage liposuction and resection.8–9,14 Liposuction is performed first, as previously described. After completion of the liposuction, markings are made and the resection of redundancy is performed. Performing the liposuction as part of the procedure can shorten the length of the brachioplasty incision. Postoperatively, these patients are cared for in the manner previously discussed.
The patient was a 38-year-old woman who was unhappy with the size of her arms. She reported no recent changes in weight. Physical examination showed that she had excess fat but minimal laxity of her upper arm.
She was classified as a type I patient who would benefit best from ultrasound- and suction-assisted liposuction of the upper arm. This was performed with removal of 350 cc of fat on each side. Her 9-month results are shown (Fig. 7). Her postoperative course was uncomplicated, and she was pleased with the results.
The patient was a 58-year-old woman who had undergone numerous other cosmetic procedures. She complained of “floppy” upper inner arms and desired a more youthful appearance. She reported stable weight but increased laxity of her upper arms as she aged. On examination, she had a mild amount of laxity of her upper proximal arm. There was only horizontal laxity on examination, with no excess fat as determined by the pinch test.
This patient was classified as a type IIA. A vertical upper arm brachioplasty was performed. Her 10-month postoperative result is shown (Fig. 8). Her postoperative course was uncomplicated, and she was pleased with the results.
This patient was a 46-year-old woman with numerous complaints, including lax upper arms. She reported that in her thirties she had fluctuations in her weight of up to 100 pounds. After her abdominal lipodystrophy was treated, a separate procedure involving her upper arms and a medial thigh lift were performed. On examination, this patient had laxity of her upper arms to the elbow and moderate excess fat.
This patient was classified as a type III. She was initially treated as a type IIB patient, and a traditional brachioplasty was performed. Her 7-month postoperative result is shown (Fig. 9, center). She was dissatisfied with her scars and revision was performed after her incisions had healed completely (Fig. 9, below). Ultrasound- and suction-assisted liposuction was performed at the same time as her scar revision, with much improved results.
This 57-year-old woman presented after gastric bypass surgery. She had lost 180 pounds and had significant upper arm laxity with minimal excess fat extending onto the chest wall and distally onto the forearm.
She was classified as a type IIC patient who would benefit most from an extended brachioplasty. Because her laxity extended to her elbow, the incision was extended distal to this point to remove the excess fat. Her results are shown (Fig. 10). She was pleased with the postoperative result and did not desire scar revisions.
Brachioplasty is a procedure that is avoided by many surgeons because of the historically high complication rate. However, more patients are presenting to our clinics desiring correction of this deformity. By properly selecting the procedure based on the type of deformity, an optimal aesthetic result can be obtained.
Previous articles in the literature have focused on modifying the original technique to decrease the potential complications. The majority of these articles describe only one method of brachioplasty for all patients. We believe, as do Teimourian and Malekzadeh,9 that the best results are obtained by altering the procedure based on the anatomic analysis of the arm. The upper extremity rejuvenation surgeon should possess knowledge of a variety of techniques to provide the best possible result for the patient.
The algorithm presented in this article is meant to provide a guideline to help select an appropriate technique to use for upper arm contouring. None of the surgical methods described in this article are new. The algorithm is a compilation of techniques that can be used for upper extremity contouring that, when properly selected, can give the most aesthetic outcome.
The usual postoperative course includes edema and ecchymosis. The ecchymosis usually resolves in 3 to 4 weeks, but edema can sometimes take up to 6 months to resolve. If it is present after use of compression garments and continuous Ace bandages has been discontinued (8 weeks), the edema can be treated by Ace bandage compression for 3 hours a day, usually in the morning. Patients can usually return to work after 2 weeks. However, with liposuction or limited proximal brachioplasty, patients may return to work as early as 1 week postoperatively.
Regardless of the procedure used, scars from brachioplasty are often wide or hypertrophic and frequently require revision. All patients scheduled for these procedures should be counseled about the limitations of brachioplasty and the possible need for scar revision, especially in patients needing a resection that mandates the use of a long horizontal incision.
The authors extend special thanks to William P. Adams, M.D., for allowing the use of one patient’s photographs and treatment plan.
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©2006American Society of Plastic Surgeons
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