COSMETIC Aesthetic Refinements in Body Contouring in the Massive Weight Loss Patient: Part 2. Arms Michele A. Shermak, M.D. Lutherville, Md.
Background: The literature has witnessed an evolution in brachioplasty technique since the procedure was introduced by Thorek in 1930. Aesthetic refinements in brachioplasty have been increasingly described in the literature, and this has paralleled the rise in the massive weight loss population. The aim of this review is to share the plastic surgery experience with this challenging body region and present different approaches to achieve the best results for a broad spectrum of patients. Methods: A literature review studying brachioplasty was performed through PubMed. Throughout the literature there has been debate about scar placement, scar length, application of liposuction, drain placement, and optimization of outcomes, and differences of opinion have been compared. Results: There is no definitive best method of brachioplasty, as evidenced by multiple classification systems which present algorithms for management depending on presentation. Not only does approach differ depending on degree of presentation, but there are also different approaches depending on author for similar manifestations. Approaches vary through incision length, incision placement, and use of liposuction. Outcomes studies similarly reveal lack of consensus. Conclusion: This literature review has elucidated multiple approaches to brachioplasty, and the pearls and pitfalls described may all be incorporated to produce excellent outcomes and patient satisfaction in an individualized approach. (Plast. Reconstr. Surg. 134: 726e, 2014.)
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rachioplasty has evolved since 1930, when surgical treatment of pendulous arm deformity for obesity was described by Thorek.1,2 The first description of aesthetic brachioplasty dates back to 1954, as reported by Correa Iturraspe and Fernandez.1,2 Modifications in patterns of skin excision and applications of a variety of adjunctive techniques navigate the evolution of brachioplasty, with improvements in contour, scar, versatility, and safety. The recent increase in prevalence of brachioplasty procedures parallels the growing patient population seeking out this technique, particularly those who have sustained massive weight loss. Statistics collected by the American Society of Plastic Surgeons demonstrate a significant rise in the number of procedures performed between 2000 and 2012, with an increase of 4392 percent in 2012 relative to 20003 (Fig. 1). Individuals interested in brachioplasty suffer from thinning, ptotic From the Plastic Surgery Center of Maryland. Received for publication December 10, 2013; accepted January 23, 2014. Copyright © 2014 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000000627
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upper extremity tissues associated with the natural aging process, or from pendulous skin with varying degrees of adiposity related to surgical and medical massive weight loss.
APPLIED ANATOMY The relevant anatomy of the arm with respect to brachioplasty lies along the ulnar aspect (Fig. 2). Skin in the arm is thin relative to the rest of the body. The subcutaneous fat of the arm is divided into superficial and deep layers, separated by a thin Scarpa fascia layer. Under the fat, the deeper layer of well-defined fascia protects the major neurovascular structures of the arm, and envelops the muscles. The thickness of the subcutaneous fat and the fixed dimensions of the core of the arm housed within the deep fascia need to be considered when marking the brachioplasty design, as they will limit the amount of skin that can be safely excised. A pinch test to account for subcutaneous Disclosure: The author has no financial interest to declare in relation to the content of this article.
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Volume 134, Number 5 • Brachioplasty after Massive Weight Loss
Fig. 1. American Society of Plastic Surgeons statistics for brachioplasty surgery demonstrate an increase in the number of procedures performed from 2000 to 2012.
Fig. 2. Applied anatomy of the arm relevant to brachioplasty includes the nerves and fascial planes. (Reprinted with permission from Shermak M. Body Contouring. Columbus, Ohio: McGraw-Hill Education; 2010.)
fat thickness assists in the evaluation of degree and location of skin excess and fat excess. This is the premise behind the double-ellipse technique described by Aly et al.4 Skin resection is best guided by segmental skin resection and tailor tacking.4,5 The sensory nerves of the arm have attracted the greatest attention in brachioplasty, as injury to them during brachioplasty is not uncommon. Hugging the superficial surface of the distal deep fascia layer are the cutaneous sensory nerves that are most vulnerable to damage during brachioplasty surgery: the medial brachial cutaneous nerves and medial antebrachial cutaneous nerves. The medial brachial cutaneous nerve originates from the medial cord of
the brachial plexus and passes medially and posteriorly to the ulnar nerve. It is posterior to the basilic vein, and terminal branches are found 2 to 3 cm proximal to the medial epicondyle. The medial antebrachial cutaneous nerve travels within the distal half to third of the arm, often in conjunction with the basilic vein. Anterior and posterior branches of the medial antebrachial cutaneous nerve originate at the medial epicondyle.6–10 Some authors recommend various strategies to reduce the risk of injuring sensory nerves, including performing adjunctive liposuction to minimize dissection and limit undermining, and leaving at least 1 cm of fat on the deep brachial fascia of the upper arm to prevent nerve damage.7,11 Reliably predicting the location of the sensory nerves has impacted incision choices in brachioplasty and limited depth of dissection. Accompanying the sensory nerves, the basilic and cephalic veins hug the deep fascia superficially. Lymphatics also accompany these major veins in the arm, and lymphatic basins exist at the antecubital region and axilla superficial to the deep fascia.12 Potential operative disruption of the lymph nodes makes seromas or lymphoceles and wound healing problems more common in brachioplasty, and these represent one of the top complication risks of brachioplasty. Knowledge of the locations of the lymphatics of the arm assists in protection against the risk of lymphatic drainage issues.11 Many surgeons apply liposuction to their brachioplasty technique to assist in atraumatic dissection of tissue planes to avoid injury to lymphatics and sensory nerves. Brachial fascia is another anatomical point of attention. Lockwood described loosening of the axillary and clavipectoral fascia of the arm with age and weight changes, resulting in a “loose hammock” effect of the arm.13 Defining the superficial fascial system of the arm informed Lockwood’s approach to anchoring the superficial fascial system fascia in the axilla to gain aesthetic improvement in the arm.
CLASSIFICATION SYSTEMS Classification systems have been developed to facilitate discussion of anatomical upper extremity presentations, particularly with regard to the degree of fat and skin excess. The utility of classification systems lies in their guidance for treatment. Teimourian and Malekzadeh described four categories of individuals desiring improvement of arm contour, groups 1 through 4. Group 1 comprises minimal to moderate adiposity and minimal skin laxity. Group 2 represents generalized skin laxity and generalized adiposity. Group 3 represents generalized obesity and extensive skin laxity. Group 4
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Plastic and Reconstructive Surgery • November 2014 Table 1. Classification System of Arm Deformities for Operative Management* Type
Skin Excess
Fat Excess
Location of Skin Excess
I IIa IIb IIc IIIa IIIb IIIc
Minimal Moderate Moderate Moderate Moderate Moderate Moderate
Moderate Minimal Minimal Minimal Moderate Moderate Moderate
n/a Proximal Entire arm Arm and chest Proximal Entire arm Arm and chest
n/a, not applicable. *From Appelt EA, Janis JE, Rohrich RJ. An algorithmic approach to upper arm contouring. Plast Reconstr Surg. 2006;118:237–246.
patients have minimal subcutaneous fat and extensive laxity. Treatments escalate from groups 1 to 4, from liposuction alone in group 1 to liposuction and axillary skin reduction in group 2, to treatment with brachioplasty using a brachial sulcus incision.14 Appelt et al. developed an analogous, more specific classification system with increasing degrees of skin excess and fat excess, with an additional variable of location of skin excess. Type I patients with moderate fat excess and minimal skin excess are excellent liposuction candidates, whereas type IIIC patients with moderate skin excess, moderate fat excess, and skin excess of the arm and chest qualify best for combined liposuction of the arm with extended brachioplasty15 (Table 1). Type II patients have moderate skin laxity with minimal excess fat, and those with proximal laxity alone qualify for minimal incision brachioplasty and patients with significant laxity of the arm and lateral chest wall are candidates for extended brachioplasty. El Khatib’s classification is more widely used, and is similarly based on adipose tissue deposits and ptosis of the skin. Stage 1 is minimal adipose tissue and no ptosis; stage 2a is defined by moderate adipose and ptosis less than 5 cm (grade 1 ptosis); stage 2b is defined as severe adipose and ptosis of 5 to 10 cm (grade 2); stage 3 is severe adipose and ptosis greater than 10 cm (grade 3); and stage 4 is minimal adipose with grade 3 ptosis. El Khatib performs liposuction on everyone, uses a posterior incision for brachioplasty, and places drains.16
EVOLVING INCISIONS AND TECHNIQUES Incisions have varied from quadrangular flaps to T-closures, Z-plasties, W-plasties, and sinusoidal S-shaped excisions. Other techniques described include fascial suspensions and liposuction. More contemporary literature promotes axillary extensions down the lateral chest wall, limited incisions, posterior incisions, and fish- and L-shaped incisions.
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Fig. 3. Preoperative and postoperative frontal views of a weight loss patient who underwent a brachioplasty in the style of Lockwood, with a T-incision in the anteromedial arm with axillary anchoring.
Early brachioplasty innovations focused on incision conformation. In 1979, Juri et al. advocated for a quadrangular flap with T-flap closure in the axilla.17 Baroudi performed a longitudinal elliptical excision, placing the scar in the brachial sulcus.18 Borges described a W-plasty incision.19 In 1989, Goddio described deepithelializing the posterior skin flap that is typically discarded and tucked the dermis under the anterior arm flap, a technique Guerrerosantos applies to secondary brachioplasty.20,21 De Souza Pinto et al. use the double-S–shape molded incision for brachioplasty.22 Popularization of modern brachioplasty was ushered in by Lockwood in 1995. He described a T-incision approach based on the techniques described by Juri and Regnault, with removal of tissue along the axilla and along the length of the arm. Axillary anchoring of the superficial fascial system of the arm to the clavipectoral fascia treated arm ptosis13 (Fig. 3). Many authors describe the T-incision with removal of axillary tissue continuing along the length of the arm, including Teimourian and Malekzadeh, who
Volume 134, Number 5 • Brachioplasty after Massive Weight Loss modified the arm incision by applying a purse-string suture to reduce the scar length, and Chandawarkar and Lewis with the fish-incision brachioplasty.14,23 In 2005, Pascal and Le Louarn described a posterior longitudinal incision with Z-plasty to deepen the axillary dome, like the T-pattern, but with a “Z” in the axilla.11 Cannistra et al. describe a very similar pattern with Z-plasty to deepen the axillary dome.24 More contemporary publications include the posterior sinusoidal scar described by Strauch et al., created for decreased linear scar contracture, decreased wound tension, and preventing hypertrophic and widened scars.25,26 Aboul Wafa described an S-shaped incision, designed to reduce arm tissue both horizontally and vertically.27 Bracaglia et al. described the “Kris knife” or “V-flap” with axillary ellipse removal, resembling an S-pattern along the medial arm surface to minimize scar retraction, and using liposuction as an adjunct to ease dissection and minimize neurovascular risk.28 Aly et al. describe the double-ellipse marking pattern, which may be extended from the arm down the lateral chest wall.4,5 This results in a straight-line scar, with axillary Z-plasty recommended to minimize axillary scar contracture. Different suspension techniques have been described, with El Khatib16 and Reed and Hyman29 tacking the skin flaps to deep fascia and Lockwood’s suspension deep in the axilla.13 This blind axillary suspension bite has drawn criticism for postoperative neurologic problems. Anterior Bicipital Groove versus Posterior Incision One of the major controversies debated with regard to brachioplasty includes scar placement, either posteriorly or within the brachial sulcus more anteriorly, and the shape of the scar, straight or undulating. The medial scar is in the bicipital groove and the posterior scar is in the brachial sulcus. Those who advocate for the posterior approach describe a more acceptable scar location, not visible from the front view, with better skin quality and thickness, and decreased likelihood of injury to sensory nerves. Proponents of the posterior scar include Aly et al., with their double-ellipse approach, and Pascal and Le Louarn, whose scar extends across the axilla as a Z-plasty with circumferential liposuction.4,5,11 Strauch et al.’s approach to correction of bat-wing deformity characteristic of massive weight loss has an undulating sinusoidal flap with a Z-plasty in the axillary dome to restore the axillary dome and minimize scar contracture.25,26 Makhlouf notes the benefit of the posterior scar, which does particularly well if it is between the medial epicondyle and the olecranon.30
Knoetgen and Moran note that despite the proposed benefit of avoiding nerve injury, there still may be injury to a posterior crossing branch of the medial antebrachial cutaneous nerve with the posterior approach. This can lead to painful neuroma and paresthesia of the elbow pad. Furthermore, the posterior branch of the medial brachial cutaneous nerve runs posterior to the ulnar nerve and basilic vein.7,28 Those who prefer the anterior scar note that the posterior scar has a greater tendency to become hypertrophic, is extremely visible from behind, and requires cumbersome positioning in the operating room.31 The most significant drawback of the medial incision is closer proximity to sensory nerves and the risk of lymphoceles at the elbow.32 Samra et al. performed a survey assessing observer opinion about the appearance of the anteromedial versus posterior scar. The four scars assessed included medial straight, medial sinusoidal, posterior straight, and posterior sinusoidal. The medial straight scar was the preferred scar, followed by the posterior straight, posterior sinusoidal, and medial sinusoidal scars. There was consistency in the order of preference across the different observer groups surveyed: public (male and female), plastic surgeons, and brachioplasty patients. Observers also preferred a longer scar over a shorter scar with residual distal deformity. Although a medial scar is well hidden with the arm at rest, the posterior scar is almost always visible.32 Minimal Incision Brachioplasty Minimal incision brachioplasty may have originated with Pollock et al. in 1972 when they described closure of an axillary hidradenitis excision primarily.33 Although minimal incision brachioplasty is best applied to younger patients aged 40 to 60 years without a history of significant weight loss, application of minimal incision brachioplasty has been extended to weight loss patients who desire a shorter scar and who demonstrate understanding that the surgical result with minimal incision brachioplasty will be less effective than that of a more extensive brachioplasty. Various surgeons have described their technique of minimal incision brachioplasty (Fig. 4). Teimourian and Malekzadeh describe creation of an axillary ridge that may or may not be excised, in conjunction with circumferential liposuction.14 Reed and Hyman describe minimal incision brachioplasty using an oval excision within the axillary hollow, generally 6 to 8 × 13 to 18 cm. Liposuction of the triceps, deltoid, and anterior axillary regions is performed.29 Fifteen percent required a secondary procedure 1 year postoperatively, including scar revision, dogear revision, secondary skin laxity correction, bow
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Fig. 4. Preoperative and postoperative frontal views of a weight loss patient who underwent a minimal incision brachioplasty with an axillary excision only, to treat her ptosis and minimal skin excess.
stringing, and loss of the axillary hollow. Richards describes liposuction of the upper arm, with wide axillary and upper arm skin excision, and dermal suspension of the upper arm skin to axillary fascia.34 Trussler and Rohrich similarly describe minimal incision brachioplasty with adjunctive liposuction and limited axillary scar, particularly for patients with moderate excess skin and adiposity.35 Minimal incision brachioplasty with only an axillary component has limited applicability to massive weight loss patients. Pascal describes that the axillary excision reduces only the length and not the width of the arm. Surgeons such as Regnault report extending the incision of minimal incision brachioplasty short of a traditional brachioplasty to include segmental longitudinal resection of the arm, depending on skin involvement.36 Vogt modified the minimal incision brachioplasty with a T-incision in the bicipital groove, including liposuction of the anterior and posterior axillary folds.37 Abramson also described longitudinal and transverse components for minimal incision brachioplasty, with liposuction of the posterior arm.38
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Fig. 5. Preoperative (above) and postoperative (center) frontal views of a weight loss patient who underwent an extended brachioplasty with a longitudinal incision in the anteromedial arm extending down the lateral chest wall to address the ptotic axilla and bat-wing deformity. (Below) Oblique view demonstrating a Z-plasty in the axillary dome.
Extended Brachioplasty In 1975, Pitanguy described brachioplasty involving the lateral thorax, upper arm, and elbow.39 In contrast to minimal incision brachioplasty, extended brachioplasty techniques have been endorsed far more by surgeons performing
Volume 134, Number 5 • Brachioplasty after Massive Weight Loss brachioplasty for post–bariatric surgery patients. Longer scars provide more effective results in the massive weight loss population for most body regions, and the arm is no different (Fig. 5). Brachioplasty is often performed concomitant with surgery on other body regions, some of which are adjacent to the arm. Extending the brachioplasty excision from the axilla down the lateral chest wall is described by Strauch et al., Hurwitz and Jerrod, Aly et al., Nguyen and Rohrich, and Gusenoff et al., among others.1,5,25,26,40,41Although some authors endorse the benefit of Z-plasty in the axilla to avoid scar contracture, others deem it unnecessary. The benefit of the extended
technique is improvement not only of the ptotic arm but also the ptotic axilla and lax skin along the lateral chest wall. The lateral chest wall takeout should be performed posterior to the breast in the female patient to avoid distortion of the breast.42 The lateral chest wall incision may be continued anteriorly onto the thoracic region to achieve mastopexy and upper (reverse) abdominoplasty (Fig. 6). This presents a comprehensive approach to the upper body, addressing the arm, bat-wing deformity, upper back, and breast and upper abdomen (an anterior upper body lift). Hallock and Altobelli described simultaneous brachioplasty,
Fig. 6. (Above) Preoperative views of a weight loss patient who underwent an extended brachioplasty, with excess tissue along the length of the arm, extending down the lateral chest wall, with deflation and ptosis of the breast and inframammary fold, and upper abdominal laxity. She also has significant upper back skin excess. (Below) Postoperative views of the patient after brachioplasty, lateral chest wall takeout, and mastopexy with suspension of the inframammary fold.
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Plastic and Reconstructive Surgery • November 2014 thoracoplasty, and mastopexy in 1985 (an upper extremity L-plasty combined with Wise pattern mastopexy).43 I have incorporated an analogous approach in my practice. This body lift is a powerful tool that I use to approach the upper body lift in the massive weight loss patient, and I have been particularly impressed with the improvement of the minimal to moderate upper back rolls without a direct scar. The effect of the axillary approach cinches in and reduces the torso in a circumferential manner more than an isolated horizontal incision can. This indirect benefit to the upper back is also described by Soliman et al. in their discussion of female pattern type II upper body lift, which eliminates minimal upper body horizontal excess with the axillary takeout, although their lateral takeout is contiguous but separate from the breast-lift pattern and treatment.42 Baroudi and Ferreira describe elbowplasty, discontinuously extending the brachioplasty effect distally down the arm. This technique uses an elliptical excision along the lower border of the elbow with a scar that is hidden in a crease, improving elbow laxity.44 Adjunctive Liposuction in Brachioplasty Liposuction has been used in conjunction with brachioplasty, from minimal incision brachioplasty to extended brachioplasty, to facilitate tissue undermining, minimize injury to nerves and lymphatics, and improve contour.14,21,29 Gilliland and Lyos discussed their liposuction-only approach to arm contouring in 1997 because of their anticipation of skin retraction.45 Liposuction is gaining increasing attention in brachioplasty, analogous to increasing use of liposuction with abdominoplasty. Nguyen and Rohrich described their technique of liposuction-assisted
posterior brachioplasty. In this procedure, ultrasound-assisted liposuction and subsequent liposuction with a 4.6-mm cannula is performed on the tissue planned for excision, which may extend to the lateral chest wall. This tissue is ultimately removed with traction off of the arm. Compressive dressing is placed. The ideal candidate is one with excess skin and fat along the entire arm1 (Fig. 7). There has been a debate about performance of liposuction within the tissues marked to be excised, versus within adjacent tissues to the resected area, versus circumferential, comprehensive liposuction. Many authors suction the skin planned for resection to ease dissection of the tissue off of the arm. Aly argues an elevated risk for poor outcomes in brachioplasty performed with liposuction caused by change in circumference of the arm with edema associated with liposuction, presenting the risk of difficulty closing the incision or performing inadequate resection making the final result too loose.46 Not long ago, it was advocated that liposuction be performed in the first stage of an at least twostage brachioplasty, to allow satisfactory results in arms with significant adipose tissue. Now, liposuction is increasingly performed in the arm at the time of brachioplasty, adjacent to the excisional region, within the excisional region, or diffusely throughout the arm. This later study authored by Bossert et al reported Level III evidence demonstrating healing issues with the use of liposuction in the arm, but this predates another study from the same group that shows a lack of detrimental outcomes from liposuction in the arm.41,47 This later study reported Level III evidence evaluating outcomes of brachioplasty performed in conjunction with liposuction performed on the posterior arm, not within the region of excision.47 In this
Fig. 7. Preoperative and postoperative frontal views of a weight loss patient who underwent a liposuction-assisted posterior brachioplasty in the manner of Nguyen and Rohrich.
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Volume 134, Number 5 • Brachioplasty after Massive Weight Loss study, 44.7 percent of the brachioplasty patients (64 patients) underwent concurrent liposuction. With an overall complication rate of 46 percent, there was no significant difference in complication rates of those patients with and without liposuction. Operative times increased approximately 30 minutes with the additional liposuction. Minimally Invasive Technologies for Arm Contouring Radiofrequency-assisted liposuction has been described by Duncan to treat lax arms typically treated with surgical brachioplasty. Using the BodyTite device (Invasiz, Inc., Yokneam, Israel), mean surface area reduction of the arm was 33.5 percent bilaterally, and mean degree of ptosis reduction was 50 percent bilaterally. Five of the 13 patients studied sustained massive weight loss. Duncan advocates this approach most optimally for El Khatib’s stages 2b and 4. Category 3 required minimal incision brachioplasty.48 Drains and Postoperative Compression There is only one study that has Level IV evidence demonstrating that drains do not prevent seromas.2 Many authors use drains with compressive dressings in traditional and extended brachioplasty, but not in minimal incision brachio pla sty.7,13,15,25,26,47 Compressive dressings are generally applied in the acute postoperative period, typically with elastic bandage wrapping, but also with tubular compressive dressings to limit seroma and scarring.13,25,26,28,47,49
OUTCOMES STUDIES Studies of brachioplasty surgery have been performed by investigators interested in determining variables that impact outcomes. Knoetgen and Moran evaluated their brachioplasty experience, using an anterior incision. Seventy-six percent of their study group sustained massive weight loss, and 85 percent had additional procedures. There was an overall 25 percent complication rate, with 95 percent being minor, including scarring, seroma, wound dehiscence, and nerve injury. The surgical revision rate was 12.5 percent.7 Symbas and Losken50 retrospectively evaluated their brachioplasty outcomes in 31 patients, using an L-shaped incision described by Hurwitz and Jerrod or double ellipse described by Aly et al.5,40 The complication rate was 22 percent, mostly minor, with a revision rate of 16 percent for dog-ears, scar band contracture, scar, and
reexcision. Ninety-four percent of the patients were satisfied, with increased self-esteem and goals met.50 Zomerlei et al. retrospectively studied their 96 patients who underwent brachioplasty by one of nine surgeons. Fifty-five percent had concomitant procedures and 53 percent had liposuction. Major complications occurred 17.7 percent of the time, and minor complications occurred 44.8 percent of the time. Common complications included hypertrophic scar and infection. The revision rate was 23 percent, primarily for scar and residual contour. Concomitant liposuction and concomitant other procedures were not associated with a significant increase in complications. Prior bariatric surgery significantly increased the risk of major complications relative to nonsurgical weight loss patients and patients who did not lose significant weight. The absence of a drain did not increase the risk of seroma.2 Gusenoff et al. reported on the group’s prospective registry of all weight loss patients, with regard to brachioplasty being performed concomitant with other excisional procedures. Ninety-six percent of the brachioplasties were associated with performance of procedures on other body regions. The scar was placed anteriorly in the bicipital groove, with identification of the medial antebrachial cutaneous nerve by its location adjacent to the basilic vein in the distal arm; 23.8 percent of the 100 patients had liposuction as well. There was a 40.4 percent complication rate in the arm, and the majority were seromas. Longer operative time (>8 hours) was associated with increased overall surgical complications, including dehiscence, infection, and hematoma. Arm liposuction tended to increase arm-related complications in this study.41
CONCLUSIONS Aesthetic refinements in brachioplasty have been increasingly described in the literature, paralleling the increasing prevalence of the public’s pursuit of brachioplasty. One of the best innovations is the increasing versatility brachioplasty affords in treating a broad range of presentations by means of the heterogeneity of approaches available: minimal incision brachioplasty, traditional brachioplasty limited to the arm, extended brachioplasty along the lateral chest wall, and extension of brachioplasty into neighboring body regions. The adjunctive application of liposuction at the time of brachioplasty assists in dissection, complication avoidance,
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Plastic and Reconstructive Surgery • November 2014 and optimization of contour, without evidence of detrimental healing. Although debate continues with regard to scar placement, the survey by Samra et al.32 provides convincing evidence of the benefit of the medial scar over the posterior scar. Many authors have cast doubt over the necessity of sinusoidal scars and Z-plasties in protecting against contracted and hypertrophic scar, and the study by Samra et al. indicates that the scars are not as aesthetically pleasing as straight scars.21,31,38 The literature has provided expanding education to surgeons on ways to better approach brachioplasty, increasing its safety and improving its outcomes. The horizon holds potential for nonsurgical skin-tightening technologies. The other uncharted territory is modulation of scar outcome in brachioplasty, as there has not yet been a satisfactory answer to hypertrophic scarring in brachioplasty. Although it is the most common hindrance to undergoing brachioplasty, optimization of scarring is a key area that would benefit most from future advancements. Michele A. Shermak, M.D. The Plastic Surgery Center of Maryland 1304 Bellona Avenue Lutherville, Md. 21093 [email protected]
references 1. Nguyen AT, Rohrich RJ. Liposuction-assisted posterior brachioplasty: Technical refinements in upper arm contouring. Plast Reconstr Surg. 2010;126:1365–1369. 2. Zomerlei TA, Neaman KC, Armstrong SD, et al. Brachioplasty outcomes: A review of a multipractice cohort. Plast Reconstr Surg. 2013;131:883–889. 3. American Society of Plastic Surgeons. 2010 Plastic Surgery Procedural Statistics. Available at: http://www.plasticsurgery. org/news-and-resources/2012-plastic-surgery-statistics.html. Accessed December 8, 2013. 4. Aly A, Pace D, Cram A. Brachioplasty in the patient with massive weight loss. Aesthet Surg J. 2006;26:76–84. 5. Aly A, Soliman S, Cram A. Brachioplasty in the massive weight loss patient. Clin Plast Surg. 2008;35:141–147; discussion 149. 6. Chowdhry S, Elston JB, Lefkowitz T, Wilhelmi BJ. Avoiding the medial brachial cutaneous nerve in brachioplasty: An anatomical study. Eplasty 2010;10:e16. 7. Knoetgen J III, Moran SL. Long-term outcomes and complications associated with brachioplasty: A retrospective review and cadaveric study. Plast Reconstr Surg. 2006;117: 2219–2223. 8. Lowe JB III, Maggi SP, Mackinnon SE. The position of crossing branches of the medial antebrachial cutaneous nerve during cubital tunnel surgery in humans. Plast Reconstr Surg. 2004;114:692–696. 9. Masear VR, Meyer RD, Pichora DR. Surgical anatomy of the medial antebrachial cutaneous nerve. J Hand Surg Am. 1989;14:267–271.
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10. Race CM, Saldana MJ. Anatomic course of the medial cutaneous nerves of the arm. J Hand Surg Am. 1991;16:48–52. 11. Pascal JF, Le Louarn C. Brachioplasty. Aesthetic Plast Surg. 2005;29:423–429; discussion 430. 12. Yu HL, Chase RA, Strauch B, eds. Atlas of Hand Anatomy and Clinical Implications. St. Louis: Mosby; 2004. 13. Lockwood T. Brachioplasty with superficial fascial system suspension. Plast Reconstr Surg. 1995;96:912–920. 14. Teimourian B, Malekzadeh S. Rejuvenation of the upper arm. Plast Reconstr Surg. 1998;102:545–551; discussion 552. 15. Appelt EA, Janis JE, Rohrich RJ. An algorithmic approach to upper arm contouring. Plast Reconstr Surg. 2006;118:237–246. 16. El Khatib HA. Classification of brachial ptosis: Strategy for treatment. Plast Reconstr Surg. 2007;119:1337–1342. 17. Juri J, Juri C, Elias JC. Arm dermolipectomy with a quadrangular flap and T closure. Plast Reconstr Surg. 1979;64:521–525. 18. Baroudi R. Dermolipectomy of the upper arm. Clin Plast Surg. 1975;2:485–494. 19. Borges AF. W-plastic dermolipectomy to correct bat-wing deformity. Ann Plast Surg. 1982;9:498–501. 20. Goddio AS. A new technique for brachioplasty. Plast Reconstr Surg. 1989;84:85–91. 21. Guerrerosantos J. Brachioplasty. Aesthet Surg J. 2004;24:161–169. 22. de Souza Pinto EB, Erazo PJ, Matsuda CA, et al. Brachioplasty technique with the use of molds. Plast Reconstr Surg. 2000;105:1854–1860; discussion 1861. 23. Chandawarkar RY, Lewis JM. ‘Fish-incision’ brachioplasty. J Plast Reconstr Aesthet Surg. 2006;59:521–525. 24. Cannistra C, Valero R, Benelli C, Marmuse JP. Brachioplasty after massive weight loss: A simple algorithm for surgical plane. Aesthetic Plast Surg. 2007;31:6–9; discussion 10. 25. Strauch B, Linetskaya D, Baum T, Greenspun D. Brachioplasty and axillary restoration. Aesthet Surg J. 2004;24:486–488. 26. Strauch B, Greenspun D, Levine J, Baum T. A technique of brachioplasty. Plast Reconstr Surg. 2004;113:1044–1048; discussion 1049. 27. Aboul Wafa AM. S-shaped brachioplasty: An effective technique to correct excess skin and fat of the upper arm. Plast Reconstr Surg. 2013;131:661e–663e. 28. Bracaglia R, D’Ettorre M, Gentileschi S, Mingrone G, Tambasco D. “Kris knife” brachioplasty after bariatric surgery and massive weight loss. Aesthetic Plast Surg. 2013;37:640–642. 29. Reed LS, Hyman JB. Minimal incision brachioplasty: Refining transaxillary arm rejuvenation. Aesthet Surg J. 2007;27:433–441. 30. Makhlouf VM. Brachioplasty incision. Plast Reconstr Surg. 2011;128:97e–98e. 31. Huemer GM. Some thoughts on the posterior brachioplasty. Plast Reconstr Surg. 2011;127:2516–2517; author reply 2517. 32. Samra S, Samra F, Liu Y-J, Sawh-Martinez R, Persing J. Optimal placement of a brachioplasty scar. Ann Plast Surg. 2013;71:329–332. 33. Pollock WJ, Virnelli FR, Ryan RF. Axillary hidradenitis suppurativa: A simple and effective surgical technique. Plast Reconstr Surg. 1972;49:22–27. 34. Richards ME. Minimal-incision brachioplasty: A first choice option in arm reduction surgery. Aesthet Surg J. 2001;21:301–310. 35. Trussler AP, Rohrich RJ. Limited incision medial brachioplasty: Technical refinements in upper arm contouring. Plast Reconstr Surg. 2008;121:305–307. 36. Regnault P. Brachioplasty, axilloplasty, and pre-axilloplasty. Aesthetic Plast Surg. 1983;7:31–36. 37. Vogt PA. Brachial suction-assisted lipoplasty and brachio plasty. Aesthet Surg J. 2001;21:164–167.
Volume 134, Number 5 • Brachioplasty after Massive Weight Loss 38. Abramson DL. Minibrachioplasty: Minimizing scars while maximizing results. Plast Reconstr Surg. 2004;114:1631–1634; discussion 1635. 39. Pitanguy I. Correction of lipodystrophy of the lateral thoracic aspect and inner side of the arm and elbow dermosenescence. Clin Plast Surg. 1975;2:477–483. 40. Hurwitz DJ, Jerrod K. The L-brachioplasty: An innovative approach to correct excess tissue of the upper arm, axilla, and lateral chest. Plast Reconstr Surg. 2006;117:403–411; discussion 412–413. 41. Gusenoff JA, Coon D, Rubin JP. Brachioplasty and con comitant procedures after massive weight loss: A statistical analysis from a prospective registry. Plast Reconstr Surg. 2008;122:595–603. 42. Soliman S, Rotemberg SC, Pace D, et al. Upper body lift. Clin Plast Surg. 2008;35:107–104; discussion 121. 43. Hallock GG, Altobelli JA. Simultaneous brachioplasty, thoracoplasty, and mammoplasty. Aesthetic Plast Surg. 1985;9:233–235.
44. Baroudi R, Ferreira CA. Arm contouring. Aesthet Surg J. 2003;23:290–292. 45. Gilliland MD, Lyos AT. CAST liposuction: An alternative to brachioplasty. Aesthetic Plast Surg. 1997;21:398–402. 46. Aly A. Discussion: Liposuction of the arm concurrent with brachioplasty in the massive weight loss patient: Is it safe? Plast Reconstr Surg. 2013;131:366–367. 47. Bossert RP, Dreifuss S, Coon D, et al. Liposuction of the arm concurrent with brachioplasty in the massive weight loss patient: Is it safe? Plast Reconstr Surg. 2013;131: 357–365. 48. Duncan DI. Improving outcomes in upper arm liposuction: Adding radiofrequency-assisted liposuction to induce skin contraction. Aesthet Surg J. 2012;32:84–95. 49. Filobbos G, Chapman T. Compression dressing for brachioplasty. J Plast Reconstr Aesthet Surg. 2012;65:127. 50. Symbas JD, Losken A. An outcome analysis of brachioplasty techniques following massive weight loss. Ann Plast Surg. 2010;64:588–591.
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Background: The literature has witnessed an evolution in brachioplasty technique since the procedure was introduced by Thorek in 1930. Aesthetic refinements in brachioplasty have been increasingly described in the literature, and this has paralleled the rise in the massive weight loss population. The aim of this review is to share the plastic surgery experience with this challenging body region and present different approaches to achieve the best results for a broad spectrum of patients. Methods: A literature review studying brachioplasty was performed through PubMed. Throughout the literature there has been debate about scar placement, scar length, application of liposuction, drain placement, and optimization of outcomes, and differences of opinion have been compared. Results: There is no definitive best method of brachioplasty, as evidenced by multiple classification systems which present algorithms for management depending on presentation. Not only does approach differ depending on degree of presentation, but there are also different approaches depending on author for similar manifestations. Approaches vary through incision length, incision placement, and use of liposuction. Outcomes studies similarly reveal lack of consensus. Conclusion: This literature review has elucidated multiple approaches to brachioplasty, and the pearls and pitfalls described may all be incorporated to produce excellent outcomes and patient satisfaction in an individualized approach. (Plast. Reconstr. Surg. 134: 726e, 2014.)
B
rachioplasty has evolved since 1930, when surgical treatment of pendulous arm deformity for obesity was described by Thorek.1,2 The first description of aesthetic brachioplasty dates back to 1954, as reported by Correa Iturraspe and Fernandez.1,2 Modifications in patterns of skin excision and applications of a variety of adjunctive techniques navigate the evolution of brachioplasty, with improvements in contour, scar, versatility, and safety. The recent increase in prevalence of brachioplasty procedures parallels the growing patient population seeking out this technique, particularly those who have sustained massive weight loss. Statistics collected by the American Society of Plastic Surgeons demonstrate a significant rise in the number of procedures performed between 2000 and 2012, with an increase of 4392 percent in 2012 relative to 20003 (Fig. 1). Individuals interested in brachioplasty suffer from thinning, ptotic From the Plastic Surgery Center of Maryland. Received for publication December 10, 2013; accepted January 23, 2014. Copyright © 2014 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000000627
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upper extremity tissues associated with the natural aging process, or from pendulous skin with varying degrees of adiposity related to surgical and medical massive weight loss.
APPLIED ANATOMY The relevant anatomy of the arm with respect to brachioplasty lies along the ulnar aspect (Fig. 2). Skin in the arm is thin relative to the rest of the body. The subcutaneous fat of the arm is divided into superficial and deep layers, separated by a thin Scarpa fascia layer. Under the fat, the deeper layer of well-defined fascia protects the major neurovascular structures of the arm, and envelops the muscles. The thickness of the subcutaneous fat and the fixed dimensions of the core of the arm housed within the deep fascia need to be considered when marking the brachioplasty design, as they will limit the amount of skin that can be safely excised. A pinch test to account for subcutaneous Disclosure: The author has no financial interest to declare in relation to the content of this article.
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Volume 134, Number 5 • Brachioplasty after Massive Weight Loss
Fig. 1. American Society of Plastic Surgeons statistics for brachioplasty surgery demonstrate an increase in the number of procedures performed from 2000 to 2012.
Fig. 2. Applied anatomy of the arm relevant to brachioplasty includes the nerves and fascial planes. (Reprinted with permission from Shermak M. Body Contouring. Columbus, Ohio: McGraw-Hill Education; 2010.)
fat thickness assists in the evaluation of degree and location of skin excess and fat excess. This is the premise behind the double-ellipse technique described by Aly et al.4 Skin resection is best guided by segmental skin resection and tailor tacking.4,5 The sensory nerves of the arm have attracted the greatest attention in brachioplasty, as injury to them during brachioplasty is not uncommon. Hugging the superficial surface of the distal deep fascia layer are the cutaneous sensory nerves that are most vulnerable to damage during brachioplasty surgery: the medial brachial cutaneous nerves and medial antebrachial cutaneous nerves. The medial brachial cutaneous nerve originates from the medial cord of
the brachial plexus and passes medially and posteriorly to the ulnar nerve. It is posterior to the basilic vein, and terminal branches are found 2 to 3 cm proximal to the medial epicondyle. The medial antebrachial cutaneous nerve travels within the distal half to third of the arm, often in conjunction with the basilic vein. Anterior and posterior branches of the medial antebrachial cutaneous nerve originate at the medial epicondyle.6–10 Some authors recommend various strategies to reduce the risk of injuring sensory nerves, including performing adjunctive liposuction to minimize dissection and limit undermining, and leaving at least 1 cm of fat on the deep brachial fascia of the upper arm to prevent nerve damage.7,11 Reliably predicting the location of the sensory nerves has impacted incision choices in brachioplasty and limited depth of dissection. Accompanying the sensory nerves, the basilic and cephalic veins hug the deep fascia superficially. Lymphatics also accompany these major veins in the arm, and lymphatic basins exist at the antecubital region and axilla superficial to the deep fascia.12 Potential operative disruption of the lymph nodes makes seromas or lymphoceles and wound healing problems more common in brachioplasty, and these represent one of the top complication risks of brachioplasty. Knowledge of the locations of the lymphatics of the arm assists in protection against the risk of lymphatic drainage issues.11 Many surgeons apply liposuction to their brachioplasty technique to assist in atraumatic dissection of tissue planes to avoid injury to lymphatics and sensory nerves. Brachial fascia is another anatomical point of attention. Lockwood described loosening of the axillary and clavipectoral fascia of the arm with age and weight changes, resulting in a “loose hammock” effect of the arm.13 Defining the superficial fascial system of the arm informed Lockwood’s approach to anchoring the superficial fascial system fascia in the axilla to gain aesthetic improvement in the arm.
CLASSIFICATION SYSTEMS Classification systems have been developed to facilitate discussion of anatomical upper extremity presentations, particularly with regard to the degree of fat and skin excess. The utility of classification systems lies in their guidance for treatment. Teimourian and Malekzadeh described four categories of individuals desiring improvement of arm contour, groups 1 through 4. Group 1 comprises minimal to moderate adiposity and minimal skin laxity. Group 2 represents generalized skin laxity and generalized adiposity. Group 3 represents generalized obesity and extensive skin laxity. Group 4
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Plastic and Reconstructive Surgery • November 2014 Table 1. Classification System of Arm Deformities for Operative Management* Type
Skin Excess
Fat Excess
Location of Skin Excess
I IIa IIb IIc IIIa IIIb IIIc
Minimal Moderate Moderate Moderate Moderate Moderate Moderate
Moderate Minimal Minimal Minimal Moderate Moderate Moderate
n/a Proximal Entire arm Arm and chest Proximal Entire arm Arm and chest
n/a, not applicable. *From Appelt EA, Janis JE, Rohrich RJ. An algorithmic approach to upper arm contouring. Plast Reconstr Surg. 2006;118:237–246.
patients have minimal subcutaneous fat and extensive laxity. Treatments escalate from groups 1 to 4, from liposuction alone in group 1 to liposuction and axillary skin reduction in group 2, to treatment with brachioplasty using a brachial sulcus incision.14 Appelt et al. developed an analogous, more specific classification system with increasing degrees of skin excess and fat excess, with an additional variable of location of skin excess. Type I patients with moderate fat excess and minimal skin excess are excellent liposuction candidates, whereas type IIIC patients with moderate skin excess, moderate fat excess, and skin excess of the arm and chest qualify best for combined liposuction of the arm with extended brachioplasty15 (Table 1). Type II patients have moderate skin laxity with minimal excess fat, and those with proximal laxity alone qualify for minimal incision brachioplasty and patients with significant laxity of the arm and lateral chest wall are candidates for extended brachioplasty. El Khatib’s classification is more widely used, and is similarly based on adipose tissue deposits and ptosis of the skin. Stage 1 is minimal adipose tissue and no ptosis; stage 2a is defined by moderate adipose and ptosis less than 5 cm (grade 1 ptosis); stage 2b is defined as severe adipose and ptosis of 5 to 10 cm (grade 2); stage 3 is severe adipose and ptosis greater than 10 cm (grade 3); and stage 4 is minimal adipose with grade 3 ptosis. El Khatib performs liposuction on everyone, uses a posterior incision for brachioplasty, and places drains.16
EVOLVING INCISIONS AND TECHNIQUES Incisions have varied from quadrangular flaps to T-closures, Z-plasties, W-plasties, and sinusoidal S-shaped excisions. Other techniques described include fascial suspensions and liposuction. More contemporary literature promotes axillary extensions down the lateral chest wall, limited incisions, posterior incisions, and fish- and L-shaped incisions.
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Fig. 3. Preoperative and postoperative frontal views of a weight loss patient who underwent a brachioplasty in the style of Lockwood, with a T-incision in the anteromedial arm with axillary anchoring.
Early brachioplasty innovations focused on incision conformation. In 1979, Juri et al. advocated for a quadrangular flap with T-flap closure in the axilla.17 Baroudi performed a longitudinal elliptical excision, placing the scar in the brachial sulcus.18 Borges described a W-plasty incision.19 In 1989, Goddio described deepithelializing the posterior skin flap that is typically discarded and tucked the dermis under the anterior arm flap, a technique Guerrerosantos applies to secondary brachioplasty.20,21 De Souza Pinto et al. use the double-S–shape molded incision for brachioplasty.22 Popularization of modern brachioplasty was ushered in by Lockwood in 1995. He described a T-incision approach based on the techniques described by Juri and Regnault, with removal of tissue along the axilla and along the length of the arm. Axillary anchoring of the superficial fascial system of the arm to the clavipectoral fascia treated arm ptosis13 (Fig. 3). Many authors describe the T-incision with removal of axillary tissue continuing along the length of the arm, including Teimourian and Malekzadeh, who
Volume 134, Number 5 • Brachioplasty after Massive Weight Loss modified the arm incision by applying a purse-string suture to reduce the scar length, and Chandawarkar and Lewis with the fish-incision brachioplasty.14,23 In 2005, Pascal and Le Louarn described a posterior longitudinal incision with Z-plasty to deepen the axillary dome, like the T-pattern, but with a “Z” in the axilla.11 Cannistra et al. describe a very similar pattern with Z-plasty to deepen the axillary dome.24 More contemporary publications include the posterior sinusoidal scar described by Strauch et al., created for decreased linear scar contracture, decreased wound tension, and preventing hypertrophic and widened scars.25,26 Aboul Wafa described an S-shaped incision, designed to reduce arm tissue both horizontally and vertically.27 Bracaglia et al. described the “Kris knife” or “V-flap” with axillary ellipse removal, resembling an S-pattern along the medial arm surface to minimize scar retraction, and using liposuction as an adjunct to ease dissection and minimize neurovascular risk.28 Aly et al. describe the double-ellipse marking pattern, which may be extended from the arm down the lateral chest wall.4,5 This results in a straight-line scar, with axillary Z-plasty recommended to minimize axillary scar contracture. Different suspension techniques have been described, with El Khatib16 and Reed and Hyman29 tacking the skin flaps to deep fascia and Lockwood’s suspension deep in the axilla.13 This blind axillary suspension bite has drawn criticism for postoperative neurologic problems. Anterior Bicipital Groove versus Posterior Incision One of the major controversies debated with regard to brachioplasty includes scar placement, either posteriorly or within the brachial sulcus more anteriorly, and the shape of the scar, straight or undulating. The medial scar is in the bicipital groove and the posterior scar is in the brachial sulcus. Those who advocate for the posterior approach describe a more acceptable scar location, not visible from the front view, with better skin quality and thickness, and decreased likelihood of injury to sensory nerves. Proponents of the posterior scar include Aly et al., with their double-ellipse approach, and Pascal and Le Louarn, whose scar extends across the axilla as a Z-plasty with circumferential liposuction.4,5,11 Strauch et al.’s approach to correction of bat-wing deformity characteristic of massive weight loss has an undulating sinusoidal flap with a Z-plasty in the axillary dome to restore the axillary dome and minimize scar contracture.25,26 Makhlouf notes the benefit of the posterior scar, which does particularly well if it is between the medial epicondyle and the olecranon.30
Knoetgen and Moran note that despite the proposed benefit of avoiding nerve injury, there still may be injury to a posterior crossing branch of the medial antebrachial cutaneous nerve with the posterior approach. This can lead to painful neuroma and paresthesia of the elbow pad. Furthermore, the posterior branch of the medial brachial cutaneous nerve runs posterior to the ulnar nerve and basilic vein.7,28 Those who prefer the anterior scar note that the posterior scar has a greater tendency to become hypertrophic, is extremely visible from behind, and requires cumbersome positioning in the operating room.31 The most significant drawback of the medial incision is closer proximity to sensory nerves and the risk of lymphoceles at the elbow.32 Samra et al. performed a survey assessing observer opinion about the appearance of the anteromedial versus posterior scar. The four scars assessed included medial straight, medial sinusoidal, posterior straight, and posterior sinusoidal. The medial straight scar was the preferred scar, followed by the posterior straight, posterior sinusoidal, and medial sinusoidal scars. There was consistency in the order of preference across the different observer groups surveyed: public (male and female), plastic surgeons, and brachioplasty patients. Observers also preferred a longer scar over a shorter scar with residual distal deformity. Although a medial scar is well hidden with the arm at rest, the posterior scar is almost always visible.32 Minimal Incision Brachioplasty Minimal incision brachioplasty may have originated with Pollock et al. in 1972 when they described closure of an axillary hidradenitis excision primarily.33 Although minimal incision brachioplasty is best applied to younger patients aged 40 to 60 years without a history of significant weight loss, application of minimal incision brachioplasty has been extended to weight loss patients who desire a shorter scar and who demonstrate understanding that the surgical result with minimal incision brachioplasty will be less effective than that of a more extensive brachioplasty. Various surgeons have described their technique of minimal incision brachioplasty (Fig. 4). Teimourian and Malekzadeh describe creation of an axillary ridge that may or may not be excised, in conjunction with circumferential liposuction.14 Reed and Hyman describe minimal incision brachioplasty using an oval excision within the axillary hollow, generally 6 to 8 × 13 to 18 cm. Liposuction of the triceps, deltoid, and anterior axillary regions is performed.29 Fifteen percent required a secondary procedure 1 year postoperatively, including scar revision, dogear revision, secondary skin laxity correction, bow
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Fig. 4. Preoperative and postoperative frontal views of a weight loss patient who underwent a minimal incision brachioplasty with an axillary excision only, to treat her ptosis and minimal skin excess.
stringing, and loss of the axillary hollow. Richards describes liposuction of the upper arm, with wide axillary and upper arm skin excision, and dermal suspension of the upper arm skin to axillary fascia.34 Trussler and Rohrich similarly describe minimal incision brachioplasty with adjunctive liposuction and limited axillary scar, particularly for patients with moderate excess skin and adiposity.35 Minimal incision brachioplasty with only an axillary component has limited applicability to massive weight loss patients. Pascal describes that the axillary excision reduces only the length and not the width of the arm. Surgeons such as Regnault report extending the incision of minimal incision brachioplasty short of a traditional brachioplasty to include segmental longitudinal resection of the arm, depending on skin involvement.36 Vogt modified the minimal incision brachioplasty with a T-incision in the bicipital groove, including liposuction of the anterior and posterior axillary folds.37 Abramson also described longitudinal and transverse components for minimal incision brachioplasty, with liposuction of the posterior arm.38
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Fig. 5. Preoperative (above) and postoperative (center) frontal views of a weight loss patient who underwent an extended brachioplasty with a longitudinal incision in the anteromedial arm extending down the lateral chest wall to address the ptotic axilla and bat-wing deformity. (Below) Oblique view demonstrating a Z-plasty in the axillary dome.
Extended Brachioplasty In 1975, Pitanguy described brachioplasty involving the lateral thorax, upper arm, and elbow.39 In contrast to minimal incision brachioplasty, extended brachioplasty techniques have been endorsed far more by surgeons performing
Volume 134, Number 5 • Brachioplasty after Massive Weight Loss brachioplasty for post–bariatric surgery patients. Longer scars provide more effective results in the massive weight loss population for most body regions, and the arm is no different (Fig. 5). Brachioplasty is often performed concomitant with surgery on other body regions, some of which are adjacent to the arm. Extending the brachioplasty excision from the axilla down the lateral chest wall is described by Strauch et al., Hurwitz and Jerrod, Aly et al., Nguyen and Rohrich, and Gusenoff et al., among others.1,5,25,26,40,41Although some authors endorse the benefit of Z-plasty in the axilla to avoid scar contracture, others deem it unnecessary. The benefit of the extended
technique is improvement not only of the ptotic arm but also the ptotic axilla and lax skin along the lateral chest wall. The lateral chest wall takeout should be performed posterior to the breast in the female patient to avoid distortion of the breast.42 The lateral chest wall incision may be continued anteriorly onto the thoracic region to achieve mastopexy and upper (reverse) abdominoplasty (Fig. 6). This presents a comprehensive approach to the upper body, addressing the arm, bat-wing deformity, upper back, and breast and upper abdomen (an anterior upper body lift). Hallock and Altobelli described simultaneous brachioplasty,
Fig. 6. (Above) Preoperative views of a weight loss patient who underwent an extended brachioplasty, with excess tissue along the length of the arm, extending down the lateral chest wall, with deflation and ptosis of the breast and inframammary fold, and upper abdominal laxity. She also has significant upper back skin excess. (Below) Postoperative views of the patient after brachioplasty, lateral chest wall takeout, and mastopexy with suspension of the inframammary fold.
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Plastic and Reconstructive Surgery • November 2014 thoracoplasty, and mastopexy in 1985 (an upper extremity L-plasty combined with Wise pattern mastopexy).43 I have incorporated an analogous approach in my practice. This body lift is a powerful tool that I use to approach the upper body lift in the massive weight loss patient, and I have been particularly impressed with the improvement of the minimal to moderate upper back rolls without a direct scar. The effect of the axillary approach cinches in and reduces the torso in a circumferential manner more than an isolated horizontal incision can. This indirect benefit to the upper back is also described by Soliman et al. in their discussion of female pattern type II upper body lift, which eliminates minimal upper body horizontal excess with the axillary takeout, although their lateral takeout is contiguous but separate from the breast-lift pattern and treatment.42 Baroudi and Ferreira describe elbowplasty, discontinuously extending the brachioplasty effect distally down the arm. This technique uses an elliptical excision along the lower border of the elbow with a scar that is hidden in a crease, improving elbow laxity.44 Adjunctive Liposuction in Brachioplasty Liposuction has been used in conjunction with brachioplasty, from minimal incision brachioplasty to extended brachioplasty, to facilitate tissue undermining, minimize injury to nerves and lymphatics, and improve contour.14,21,29 Gilliland and Lyos discussed their liposuction-only approach to arm contouring in 1997 because of their anticipation of skin retraction.45 Liposuction is gaining increasing attention in brachioplasty, analogous to increasing use of liposuction with abdominoplasty. Nguyen and Rohrich described their technique of liposuction-assisted
posterior brachioplasty. In this procedure, ultrasound-assisted liposuction and subsequent liposuction with a 4.6-mm cannula is performed on the tissue planned for excision, which may extend to the lateral chest wall. This tissue is ultimately removed with traction off of the arm. Compressive dressing is placed. The ideal candidate is one with excess skin and fat along the entire arm1 (Fig. 7). There has been a debate about performance of liposuction within the tissues marked to be excised, versus within adjacent tissues to the resected area, versus circumferential, comprehensive liposuction. Many authors suction the skin planned for resection to ease dissection of the tissue off of the arm. Aly argues an elevated risk for poor outcomes in brachioplasty performed with liposuction caused by change in circumference of the arm with edema associated with liposuction, presenting the risk of difficulty closing the incision or performing inadequate resection making the final result too loose.46 Not long ago, it was advocated that liposuction be performed in the first stage of an at least twostage brachioplasty, to allow satisfactory results in arms with significant adipose tissue. Now, liposuction is increasingly performed in the arm at the time of brachioplasty, adjacent to the excisional region, within the excisional region, or diffusely throughout the arm. This later study authored by Bossert et al reported Level III evidence demonstrating healing issues with the use of liposuction in the arm, but this predates another study from the same group that shows a lack of detrimental outcomes from liposuction in the arm.41,47 This later study reported Level III evidence evaluating outcomes of brachioplasty performed in conjunction with liposuction performed on the posterior arm, not within the region of excision.47 In this
Fig. 7. Preoperative and postoperative frontal views of a weight loss patient who underwent a liposuction-assisted posterior brachioplasty in the manner of Nguyen and Rohrich.
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Volume 134, Number 5 • Brachioplasty after Massive Weight Loss study, 44.7 percent of the brachioplasty patients (64 patients) underwent concurrent liposuction. With an overall complication rate of 46 percent, there was no significant difference in complication rates of those patients with and without liposuction. Operative times increased approximately 30 minutes with the additional liposuction. Minimally Invasive Technologies for Arm Contouring Radiofrequency-assisted liposuction has been described by Duncan to treat lax arms typically treated with surgical brachioplasty. Using the BodyTite device (Invasiz, Inc., Yokneam, Israel), mean surface area reduction of the arm was 33.5 percent bilaterally, and mean degree of ptosis reduction was 50 percent bilaterally. Five of the 13 patients studied sustained massive weight loss. Duncan advocates this approach most optimally for El Khatib’s stages 2b and 4. Category 3 required minimal incision brachioplasty.48 Drains and Postoperative Compression There is only one study that has Level IV evidence demonstrating that drains do not prevent seromas.2 Many authors use drains with compressive dressings in traditional and extended brachioplasty, but not in minimal incision brachio pla sty.7,13,15,25,26,47 Compressive dressings are generally applied in the acute postoperative period, typically with elastic bandage wrapping, but also with tubular compressive dressings to limit seroma and scarring.13,25,26,28,47,49
OUTCOMES STUDIES Studies of brachioplasty surgery have been performed by investigators interested in determining variables that impact outcomes. Knoetgen and Moran evaluated their brachioplasty experience, using an anterior incision. Seventy-six percent of their study group sustained massive weight loss, and 85 percent had additional procedures. There was an overall 25 percent complication rate, with 95 percent being minor, including scarring, seroma, wound dehiscence, and nerve injury. The surgical revision rate was 12.5 percent.7 Symbas and Losken50 retrospectively evaluated their brachioplasty outcomes in 31 patients, using an L-shaped incision described by Hurwitz and Jerrod or double ellipse described by Aly et al.5,40 The complication rate was 22 percent, mostly minor, with a revision rate of 16 percent for dog-ears, scar band contracture, scar, and
reexcision. Ninety-four percent of the patients were satisfied, with increased self-esteem and goals met.50 Zomerlei et al. retrospectively studied their 96 patients who underwent brachioplasty by one of nine surgeons. Fifty-five percent had concomitant procedures and 53 percent had liposuction. Major complications occurred 17.7 percent of the time, and minor complications occurred 44.8 percent of the time. Common complications included hypertrophic scar and infection. The revision rate was 23 percent, primarily for scar and residual contour. Concomitant liposuction and concomitant other procedures were not associated with a significant increase in complications. Prior bariatric surgery significantly increased the risk of major complications relative to nonsurgical weight loss patients and patients who did not lose significant weight. The absence of a drain did not increase the risk of seroma.2 Gusenoff et al. reported on the group’s prospective registry of all weight loss patients, with regard to brachioplasty being performed concomitant with other excisional procedures. Ninety-six percent of the brachioplasties were associated with performance of procedures on other body regions. The scar was placed anteriorly in the bicipital groove, with identification of the medial antebrachial cutaneous nerve by its location adjacent to the basilic vein in the distal arm; 23.8 percent of the 100 patients had liposuction as well. There was a 40.4 percent complication rate in the arm, and the majority were seromas. Longer operative time (>8 hours) was associated with increased overall surgical complications, including dehiscence, infection, and hematoma. Arm liposuction tended to increase arm-related complications in this study.41
CONCLUSIONS Aesthetic refinements in brachioplasty have been increasingly described in the literature, paralleling the increasing prevalence of the public’s pursuit of brachioplasty. One of the best innovations is the increasing versatility brachioplasty affords in treating a broad range of presentations by means of the heterogeneity of approaches available: minimal incision brachioplasty, traditional brachioplasty limited to the arm, extended brachioplasty along the lateral chest wall, and extension of brachioplasty into neighboring body regions. The adjunctive application of liposuction at the time of brachioplasty assists in dissection, complication avoidance,
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Plastic and Reconstructive Surgery • November 2014 and optimization of contour, without evidence of detrimental healing. Although debate continues with regard to scar placement, the survey by Samra et al.32 provides convincing evidence of the benefit of the medial scar over the posterior scar. Many authors have cast doubt over the necessity of sinusoidal scars and Z-plasties in protecting against contracted and hypertrophic scar, and the study by Samra et al. indicates that the scars are not as aesthetically pleasing as straight scars.21,31,38 The literature has provided expanding education to surgeons on ways to better approach brachioplasty, increasing its safety and improving its outcomes. The horizon holds potential for nonsurgical skin-tightening technologies. The other uncharted territory is modulation of scar outcome in brachioplasty, as there has not yet been a satisfactory answer to hypertrophic scarring in brachioplasty. Although it is the most common hindrance to undergoing brachioplasty, optimization of scarring is a key area that would benefit most from future advancements. Michele A. Shermak, M.D. The Plastic Surgery Center of Maryland 1304 Bellona Avenue Lutherville, Md. 21093 [email protected]
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10. Race CM, Saldana MJ. Anatomic course of the medial cutaneous nerves of the arm. J Hand Surg Am. 1991;16:48–52. 11. Pascal JF, Le Louarn C. Brachioplasty. Aesthetic Plast Surg. 2005;29:423–429; discussion 430. 12. Yu HL, Chase RA, Strauch B, eds. Atlas of Hand Anatomy and Clinical Implications. St. Louis: Mosby; 2004. 13. Lockwood T. Brachioplasty with superficial fascial system suspension. Plast Reconstr Surg. 1995;96:912–920. 14. Teimourian B, Malekzadeh S. Rejuvenation of the upper arm. Plast Reconstr Surg. 1998;102:545–551; discussion 552. 15. Appelt EA, Janis JE, Rohrich RJ. An algorithmic approach to upper arm contouring. Plast Reconstr Surg. 2006;118:237–246. 16. El Khatib HA. Classification of brachial ptosis: Strategy for treatment. Plast Reconstr Surg. 2007;119:1337–1342. 17. Juri J, Juri C, Elias JC. Arm dermolipectomy with a quadrangular flap and T closure. Plast Reconstr Surg. 1979;64:521–525. 18. Baroudi R. Dermolipectomy of the upper arm. Clin Plast Surg. 1975;2:485–494. 19. Borges AF. W-plastic dermolipectomy to correct bat-wing deformity. Ann Plast Surg. 1982;9:498–501. 20. Goddio AS. A new technique for brachioplasty. Plast Reconstr Surg. 1989;84:85–91. 21. Guerrerosantos J. Brachioplasty. Aesthet Surg J. 2004;24:161–169. 22. de Souza Pinto EB, Erazo PJ, Matsuda CA, et al. Brachioplasty technique with the use of molds. Plast Reconstr Surg. 2000;105:1854–1860; discussion 1861. 23. Chandawarkar RY, Lewis JM. ‘Fish-incision’ brachioplasty. J Plast Reconstr Aesthet Surg. 2006;59:521–525. 24. Cannistra C, Valero R, Benelli C, Marmuse JP. Brachioplasty after massive weight loss: A simple algorithm for surgical plane. Aesthetic Plast Surg. 2007;31:6–9; discussion 10. 25. Strauch B, Linetskaya D, Baum T, Greenspun D. Brachioplasty and axillary restoration. Aesthet Surg J. 2004;24:486–488. 26. Strauch B, Greenspun D, Levine J, Baum T. A technique of brachioplasty. Plast Reconstr Surg. 2004;113:1044–1048; discussion 1049. 27. Aboul Wafa AM. S-shaped brachioplasty: An effective technique to correct excess skin and fat of the upper arm. Plast Reconstr Surg. 2013;131:661e–663e. 28. Bracaglia R, D’Ettorre M, Gentileschi S, Mingrone G, Tambasco D. “Kris knife” brachioplasty after bariatric surgery and massive weight loss. Aesthetic Plast Surg. 2013;37:640–642. 29. Reed LS, Hyman JB. Minimal incision brachioplasty: Refining transaxillary arm rejuvenation. Aesthet Surg J. 2007;27:433–441. 30. Makhlouf VM. Brachioplasty incision. Plast Reconstr Surg. 2011;128:97e–98e. 31. Huemer GM. Some thoughts on the posterior brachioplasty. Plast Reconstr Surg. 2011;127:2516–2517; author reply 2517. 32. Samra S, Samra F, Liu Y-J, Sawh-Martinez R, Persing J. Optimal placement of a brachioplasty scar. Ann Plast Surg. 2013;71:329–332. 33. Pollock WJ, Virnelli FR, Ryan RF. Axillary hidradenitis suppurativa: A simple and effective surgical technique. Plast Reconstr Surg. 1972;49:22–27. 34. Richards ME. Minimal-incision brachioplasty: A first choice option in arm reduction surgery. Aesthet Surg J. 2001;21:301–310. 35. Trussler AP, Rohrich RJ. Limited incision medial brachioplasty: Technical refinements in upper arm contouring. Plast Reconstr Surg. 2008;121:305–307. 36. Regnault P. Brachioplasty, axilloplasty, and pre-axilloplasty. Aesthetic Plast Surg. 1983;7:31–36. 37. Vogt PA. Brachial suction-assisted lipoplasty and brachio plasty. Aesthet Surg J. 2001;21:164–167.
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