Figure 1. The relative sag in the skin in the triceps area. This illustrates a moderately fatty arm with good skin elasticity.
Figure 2. This is a posterior view showing skin excess extending to the olecranon.
Prior to the introduction of safe, effective weight loss surgery, brachioplasty was a relatively uncommon procedure. That has all changed due to the recent epidemic of obesity in the United States, which has led to many patients losing 50% or more of their excess weight. As a result, a large pool of men and women want to make their external appearance match their new BMI.
The traditional long upper arm incision with its resultant scar may not be acceptable, and the excess skin of weight loss may be much greater than the prior aging-related skin sag seen in individuals with lifelong low BMI. Thus, what you find today are combination procedures including skin resection, liposuction, and laser- or radiofrequency (RF)-based energy sources to facilitate skin contraction.
Avoiding injury to the sensory and motor nerves of the upper extremity during the performance of brachioplasty is essential and requires the knowledge of anatomy. Attention to both contour and scar visibility are, likewise, essential for a satisfactory result and require patient education and careful preoperative planning in order to individualize the treatment.
The historical evolution of brachioplasty emphasizes short elliptical resections, satisfactory for low-BMI patients with skin laxity only. These incisions involve the proximal and middle thirds of the upper arm. With the introduction by Lockwood of the superficial fascia system, better tension distribution made additional contour correction possible, and, in combination with liposuction, transformed the brachioplasty into a multistep procedure, able to address the complex deformities that accompany massive weight loss.
Once relatively rare, brachioplasty can now be considered an important procedure in the cosmetic surgeon’s armamentarium.
PREOPERATIVE EVALUATION
Figure 3. This image shows the elongation of the distance between the anterior and the triceps radius from the humerus in the aging arm.
The first step to surgical care requires a clear understanding of the contraindications for the intended procedure. In brachioplasty, these include both factors related to patient history and current physical findings.
Unrealistic expectations should be the first warning. If the patient has been unhappy with abdominal or breast scars, they’ll tolerate the arm incision even less. Drawing the proposed scar should be part of any informed consent, especially in brachioplasty as the scar will almost inevitably be visible. Even if only liposuction is proposed, possible skin laxity may require secondary surgery and should be part of the discussion.
The presence of preexisting vascular, neurological, or lymphatic drainage problems should be red flags in surgical planning. These conditions include connective tissue disorders such as Reynaud’s disease, Ehlers-Danlos Syndrome, and rheumatoid arthritis, as well as previous axillary dissection.
Once it has been determined that the patient is a candidate for the procedure, an analysis of the problem is essential to selecting the most appropriate procedure. Several different classification systems exist, but they all have several poin4ts in common.
Evaluation of the arm should determine the quality of the skin, amount of subcutaneous fat present, and the relative proportions of each. Extreme skin laxity in the absence of subcutaneous fat will require surgical excision, while slight skin laxity might be approached with RF- or laser-type energies to tighten the skin. Good skin tone with fat may respond to liposuction only, whereas laxity and fat together will probably best respond to a combined procedure. Extreme weight loss may be associated with skin laxity that extends along the lateral thorax, requiring an incision extended across the axilla with the upper arm skin resection.
Table 1 demonstrates the different presurgical brachioplasty components. An excellent reference for brachioplasty classification can be found in the article by Kahtib.1
ANATOMY OF THE UPPER ARM
Figure 4. Marking the antebrachial fold in planning surgery.
Figure 5. Here is the planned areas of liposuction, and skin resection, crossing the posterior axillary fold.
Aging affects upper arm proportions and contour. In youth, the distance between the humerus and the skin is equal both anteriorly and posteriorly. As the patient ages, the distance on the posterior triceps side elongates, with a differential accumulation of fat. Removal of that fat improves contour, restoring that more youthful ratio.
Attention to the location of the brachiocutaneous, lateral antibacterial cutaneous and ulnar nerve, and the basilica and cephalic veins, are key features during any skin resection.
The primary aesthetic components of the upper arm include attention to contour of the axillary fold, the triceps skin fold, upper arm subcutaneous fat volume, and transition across the elbow to the forearm. Recognition of which of these issues are primary form the basis of surgical treatment planning. If upper arm volume alone is a concern and skin tone is good, liposuction alone may be sufficient (Figures 1 and 2).
Younger patients generally may be the best candidates for this approach. If liposuction in combination with laser, RF, or ultrasound to promote skin contraction is proposed, possible further surgery needs to be part of the preoperative discussion.
PHYSICAL EXAM, INFORMED CONSENT, AND PLANNING
The key elements of the exam should include evaluation of the patient’s overall health. Range of motion at the shoulder, elbow, and wrist should also be evaluated and recorded. Skin tone should be documented by the rebound test. The underlying subcutaneous fat should also be documented by the pinch test. If the pinch test shows less than 2 cm of fat and the skin tone is good, you have the ideal candidate for liposuction alone. If there is no fat but significant skin laxity, skin resection is indicated.
The most important contents of the informed consent include discussion of scars and of complications. Draw the scar, especially with red skin markers to emphasize the possible visibility of the incision.
Other complications that should be emphasized include skin numbness, transient neurophysiology and limitations in range of motion, and reduced mobility of the arm in the immediate postoperative period (which may limit the patient’s independence).
Hematology, infection, suture extrusion, and skin necrosis—though rare—should still be emphasized. Other postoperative care—such as the use of compression garments, foam padding, prolonged drainage, and edema—should also be included in the discussionIndication for surgical skin resection may be divided into scar type and location. It is important to remember that the skin of the upper arm is much thinner and more mobile than that of the thigh, and liposuction alone may not improve the contour.
An extended scar is necessary if there is significant skin excess and poor skin tone.
The short scar is an option if there is moderate skin excess and poor skin tone. An axillary scar will work only if there is minimal skin excess and skin tone is excellent.
An excellent algorithm for surgical planning can be found in the article by Appelt, Janis, and Rohrich.2
SURGICAL MARKING
Figure 6. Here, the surgeon is back cutting the elevated flap to determine the optimum posterior extent of the excision.
Marking the patient is done in the sitting or standing position, with the anterior incision placed within the bicipital groove (Figure 4). The extent of the incision may be limited to the upper one-third of the arm, or, if necessary, extend beyond the elbow. Crossing into the axilla requires care to angle the incision so that a contracture across the anterior or posterior fold will not develop.
Figure 5 shows a marking, at the axilla, that minimizes this risk. Some authors advocate an L-shaped incision; others suggest a straight-line excision across the axilla, modified by a Z-plasty after the initial closure.
The posterior incision is planned by pinching the skin to see the extent of the resection but is not incised until the anterior incision is completed and the skin flap is advanced. By making vertical cuts in the flap, the extent of resection can be assessed and closure without tension can be assured (Figure 6).
By progressing distal to proximal, the skin can be preserved as a flap and reinserted if the closure seems too tight as sutures are placed. Excessive skin excision can lead to distal edema, venous congestion, or even vascular compromise, requiring a delayed closure with the risk of a worsened scar.
POSTOPERATIVE CARE
Wound closure is very individual in cosmetic surgery, but, if possible, a subcutaneous closure with few, if any, retention sutures is ideal. A multilayer closure with attention to the superficial fascia, supporting the subcutaneous tissues, reduces skin tension for those cases of significant skin and fat resection. Distribution of tension along the whole axis of the arm may minimize scar hypertrophy.
Unless part of other procedures, antibiotics are not required following a brachioplasty. Compression garments are useful for patient comfort, but care should be taken to be sure they are not too tight. Distal pulses and signs of congestion should be checked prior to discharge from the recovery room or the office.
In our practice, compression is maintained for the patient as long as it is more comfortable to wear the garment than not—and often continues for several weeks. Drains are rarely required, and small lymphocoels may be safely aspirated in the days or weeks following surgery. Patients are instructed to call immediately for any symptoms of tingling or numbness in the fingers or hand, or for any sudden increase in pain.
CONCLUSION
Brachioplasty is a challenging procedure, especially in the post-weight-loss patient. Careful patient selection, a thoughtfully considered individualized procedure, and appropriate technical performance of that procedure make this a rewarding task for the surgeon—and will provide a satisfactory outcome for the patient. n
Jane Petro, MD, is a Boston-based board certified plastic and reconstructive surgeon; Fouad Ansari, MD, is president of Societe Francaise de Chirurgie Esthetique, the French society of aesthetic surgery; and Sharon C. DeChiara, MD, DDS, is a cosmetic surgeon based in New York.
References
- Kahtib HA. Classification of brachial ptosis: Strategy for treatment. Plast Recon Surg. 2007:119:1337-1342.
- Appelt EA, Janis JE, Rohrich RJ. An algorithmic approach to upper arm contouring. Plast Recon Surg. 2006;118:237-246.
