WHAT IS ARMS LIPOSUCTION?

Arms liposuction is appropriate for younger patients with fatty collections and good skin quality. Women request arms liposuction more than men. Skin is thin in the arm, so skin retraction is less likely in the standard patient than abdomen or back. Arm liposuction may result in skin laxity and if this is anticipated, it is best to discuss the potential need for second-stage skin removal.

Arms Liposuction treatment is often weighed against arm lift with the possibility of a visible scar. While liposuction reduces bulk and improves the contour of the arm, it cannot treat skin redundancy. Arms Liposuction is challenging, finding the balance between removing subcutaneous fat to uncover a more muscular physique without removing so much that there is resulting skin redundancy.

Today, non-invasive options are performed as an adjunct to arms liposuction to enhance the completeness of fat removal and the evenness of the result and aid in skin tightening and smoothing. Arms Liposuction is challenging, finding the balance between removing subcutaneous fat to uncover a more muscular physique without removing so much that there is resulting skin redundancy.

General Considerations of Arms Liposuction

Liposuction (suction lipectomy, liposculpture, lipoplasty, and lipostructure) contouring the body shape by removing excess fat using suction cannulas through small incisions. It is rarely a procedure for weight loss. Over the past two decades, liposuction has grown from a procedure that removes localized fatty tissue deposits to be an irreplaceable tool in circumferential body contouring.

Several innovations and modifications to the standard suction-assisted liposuction or SAL have progressively refined the procedure. Today liposuction in tumescent local anesthesia is the most performed cosmetic procedure worldwide.

Basic science and Anatomic Considerations of Arms Liposuction

Due to current trends in liposuction, anatomic considerations of the fatty layers of the body are Subcutaneous essential fat is arbitrarily divided into superficial, intermediate, and deep layers. These separate layers’ have relative consistency, and thickness varies for different anatomic areas. Liposuction is done in the intermediate and deep layers. 

The areolar layer (superficial) is located directly beneath the skin and is composed of fat cells with vertical organization separated by vertical septa of connective tissue. It holds blood vessels and lymph vessels. Superficial fat is less prone to changes in the diet. Suctioning fat from the superficial layer fat layer will result in skin draping and tightening, resulting in a more aesthetic result. We call it Liposculpture. However, the superficial layer holds the vascular structure, and when it is treated, it increases the risk for contour irregularities. Therefore, liposculpture or superficial liposuction should be conducted by an experienced surgeon.

The lamellar layer (deep) is composed of fat cells positioned in an elongated horizontal layout and a large amount of connective tissue forming trabeculae through which blood vessels pass. This is the fat that is suctioned when you gain weight; this is called liposuction. The deep layer is more prone to store or lose fat whenever a change in diet is made.

Twenty-five years of experience performing liposuction has convinced me that I need to be able to work superficially and in the deeper plane if I am to obtain greatest results.

Who is a Good Candidate for Arms Liposuction?

Since the1980s, surgical treatments for arms included liposuction, excisional surgery, or a combination of these techniques in a single session or as a staged procedure. Arms Liposuction can remove the excess fat and contraction of the skin, resulting in a better cosmetically appearing arm.

We can see that a well-defined arm in all genders is not flat or straight but has curves. Although the deltoid and the biceps muscles clearly define the curves in the anterior and lateral arm, the contour of the posterior arm is more difficult to define and create due to the unique fat distribution

The arm is one of the most challenging areas in body contouring because of the substantial risk of contour irregularities. Each patient’s muscular disposition figures out arm shape.

Three main muscles handle the arm shape: the deltoid, triceps, and biceps. In men, more pronounced musculature is considered more athletic and healthier. Slender curves and toned, smaller muscle masses are considered aesthetically pleasing for women.

Today, preoccupation with fitness has made muscular definition in the female a sought-after goal. Well, proportioned arms and upper Back with muscular development are the goal of today’s physically fit women and are prominently featured in today’s fashion.

The increase in bariatric surgery for the morbidly obese has added to the group interested in the aesthetic improvement of their arms. Rejuvenation of the upper arms continues to challenge both the surgeon and patient.

The aging of the upper arm is highly variable. It depends on numerous factors, the most important of which are genetics, the consistency of upper body toning exercises, obesity, and the variations in weight throughout life.

The net result is an unaesthetic appearance with skin laxity and lipodystrophy of various degrees, with the most severe form often named the “batwing” deformity.

Requests for rejuvenation of the arms are increasing, particularly by young and middle-aged women, who are often well-educated and physically fit. They receive a psychological boost from the appearance of well-proportioned muscular arms. Early efforts to prevent, delay, or even halt skin degeneration and ptosis may include exercise, weight loss, and massage.

After these first conservative efforts fail, individuals seek consultation for surgical correction. Women are often trying to prevent the development of “batwing” deformity that they see in their mothers and grandmothers.

There is evidence that early arms liposuction in these categories one patients prevents progressive fatty tissue collection lipodystrophy, which results in ptosis of the superficial fascia resulting in skin ptosis and flaccidity.

Arms liposuction patients often present with a variety of expec­tations, concerns, and complaints. As a rule, liposuction is performed in healthy patients who keep realistic goals and expecta­tions.  Studies have shown that patients who undergo proper long-term lifestyle changes will achieve the highest postoperative satisfaction from their arm liposuction procedure.

A successful Arms Liposuction patient must satisfy four key elements to achieve and keep optimal results:

1. Lifestyle change
2. Regular exercise
3. Well-balanced diet
4. Body contouring.

Appropriate candidates for arms liposuction are not morbidly obese, are of stable weight, and have incorporated the above lifestyle changes into their preoperative regimen. Preoperative consultation with a dietician may prove benefi­cial for long-term patient satisfaction.

Who is Not a Good Candidate for Arms Liposuction?

Arms liposuction is contra­indicated in patients who are pregnant or in poor general medical health. Patients with morbid obesity, cardiopulmo­nary disease, body image belief issues, unrealistic expectations, wound healing difficulties, or who have exten­sive or poorly located scars should be excluded from consid­eration for arm liposuction.

Using the BMI, the surgeon can objectively classify a patient’s obesity as one of the following:

• Class I: Lean range (18.5–19.9)
• Class II: Optimal (average) (20–25)
• Class III: Overweight range (25.1–29.9)
• Class IV: Obese range (30–34.9)
• Class V: Morbidly obese range (35–39.9)
• Class VI: Extremely obese (40 or greater)

During the initial and follow up visits of arms liposuction , height and weight with calculating body mass index (BMI) are of paramount importance to patient safety as morbid obesity (BMI > 35) impart a threefold to fourfold risk of significant respiratory depression from sedative drugs, perhaps because sleep apnea is more common in that group. BMI calculation is vital in follow-up visits to gauge long-term results.

Grading of Arm Deformities for Arms Liposuction

Treatment approaches of the arms vary according to the grade of the arm deformity, which is derived from the amount of fat excess and the location and severity of skin redundancies. Patient Classification. Patients are classified according to the scheme proposed by Teimourian and Malekzadeh.

Category 1: Minimal to moderate subcutaneous fat with minimal skin laxity: Patients have a circumferential increase in fat volume but good skin tone and elasticity. These patients do well with circumferential arms liposuction and para-axillary area. Relatively insignificant amounts of fat are removed.

Category2: Generalized accumulation of subcutaneous fat with moderate skin laxity: Patients have an increased volume of fatty tissue circumferentially and a noticeable loss of skin elasticity with ptosis. Circumferential arms liposuction encourages skin tightening. Power-assisted arms liposuction can encourage enhanced skin retraction, often reducing the need for skin excision. Mini-Brachioplasty may be required.

Category 3: Generalized obesity and extensive skin laxity: Patients have more significant lipodystrophy and skin laxity. Obese patients accumulate a large fat volume in the para-axillary region and upper arm. Power-assisted circumferential arms liposuction maximizes the potential for adequate skin retraction. Mini- Brachioplasty confided to the axilla is often needed for Group 3 individuals. The larger the volume of fat removal, the better the prognosis for skin retraction with arm liposuction and the shorter the Brachioplasty scar if required.

Category 4: Minimal subcutaneous fat and extensive skin laxity: These individuals show marked skin laxity and depletion of subcutaneous fat. Full Brachioplasty can produce an aesthetically pleasing contour of the arm and straight inferior brachial border.

Preoperative Assessment of Arms Liposuction

During this first interaction of arms liposuction , the cosmetic surgeon must assess the patient’s goals of surgery and be able to determine if the patient has realistic expectations regarding the outcome and postoperative body image.

It may be helpful to have the patient prioritize the body regions that they are most concerned with while focusing on specific com­plaints within these areas.

A detailed medical history of patients who seek arms liposuction should be obtained, including any medications, allergies, and tobacco use. Critical are notations in the medical history of diabetes, massive weight loss, earlier surgery, previous liposuction, and a complete detailed list of medications and supple­ments.

• No aspirin or any products holding aspirin (salicylic acid) should be taken for at least two weeks before.
• Do not take a non-steroidal anti-inflammatory such as brufen, Voltaren
• Do not take any vitamins, especially vitamins C and E, for two weeks before surgery and for one week after surgery
• Discontinue all estrogens (check with your physician first) 4 weeks before surgery and two weeks after surgery
• Discontinue all benzodiazepines, such as Xanax, etc. These drugs slow lidocaine metabolism by inhibiting cytochrome P450 3A4. Lidocaine toxicity may ensue

Any concerns about a patient’s medical suitability to undergo anesthesia and an operative procedure should result in a referral for preoperative clearance with either an internist or cardiologist.

The patients need to be asked specifi­cally about herbal and over-the-counter medications because these are frequently omitted.

Non-essential medications should be dropped at least three weeks before surgery. Herbal remedies and supplements, including bleeding or hypercoagulability, should be avoided in the perioperative period.

Avoiding aspirin, NSAIDs, and hormonal therapy can help prevent such com­plications as well. Of course, if there is a medical indication and necessity for these drugs, consultation with the primary physician or appropriate specialist should be completed before discontinuation of the medical therapy. We strongly recommend that oral contraceptives and estrogen these medications be discontin­ued a month before the operative procedure.

A preoperative evaluation by a primary care doctor, internist, or cardiologist may be warranted in selected patients. This typi­cally includes anyone with a significant medical history or patients older than 50 years of age.

Massive weight loss patients who seek arms liposuction should undergo the same preoperative evaluation, and clearance for arm liposuction is the same as for any excisional-type body contouring procedure (including nutrition, hemoglobin, iron, vitamin B₁₂, etc.). It is safest to refrain from operations until these lab results are normalized.

Physical Exam of Arms Liposuction

A detailed physical exam is performed at the first visit and consultation. Specific attention to prior scars, presence or absence of hernias, evidence of venous insufficiency, and presence of pre-existing asymmetry or contour irregularity should be discussed and noted in the chart.

For arms lipo­suction candidates, six key elements are documented

• Evaluate fatty tissue deposits and deformities
• Skin tone and quality
• Asymmetries
• Dimpling and cellulite
• Myofascial support
• Zones of adherence.

A detailed exam of the subcutaneous fat distribution is essential if superficial arms liposuction or “liposculpture” is planned. Attention must be paid to “gender ideal” muscular shape/ mass and fat distribution. Additionally, dynamic areas must be examined and marked in the full range of muscular contrac­tion to yield natural results

The physical exam is best performed before a full-length mirror, allowing an open dialogue between patient and physician.

High-quality medical images should be obtained with anterior, posterior, lateral, and oblique views, documenting the results and objective evaluation of outcomes by both patient and physician. Find­ings may be challenging to interpret in more prominent individuals, males, or patients with multiple scars.

A follow-up visit after arms liposuction is typically scheduled 2–3 weeks after the first consultation. During this visit, computer images are reviewed, which allows the patient to set up realistic expectations. These true-to-life images portray the advantages, disadvantages, and limitations of body contour­ing surgery. The second visit allows further dialogue between the patient and physician so that all questions may be answered, and issues addressed.

Arms Liposuction Preoperative Instructions

• You do not gain weight before surgery
• If you have any doubt about the surgery, do not have it done
• If you have had problems with drug or alcohol abuse at any time, notify the surgeon before scheduling the surgery
• Absolutely no smoking for at least two weeks before and two weeks after surgery
• Report to the physician any history of excessive bleeding or bruising
• Report all prior mental disorders or psychological problems to your surgeon
• If you have high blood pressure, report this to your surgeon
• If anticoagulants (blood-thinning) medication is being taken, this must be stopped at least five days before surgery, and blood tests must be taken before surgery
• Try not to schedule surgery on a day close to your menstrual period. It is preferable not to do surgery during the first five days of menstrual bleeding
• Take a shower daily with Betadine for three days before surgery and also in the morning on the day of surgery

Preoperative Marking of Arms Liposuction

Marking is done in front of a mirror, thus allowing the patient to contribute to the process and further confirming precisely what will be addressed during the procedure. Areas to be suctioned are marked with a circle; areas of adherence and avoidance are marked with hash marks.

The body is not symmetric, and the markings will be slightly different on the two sides. The apparent length of obese arms is usually shorter than the actual length because of obese axillary and back areas. In addition, the shoulder looks more comprehensive than the actual body frame due to deltoid convexity.

I use a topographic type of marking with more circles in areas that will need more suction. The central ring is the most area to liposuctioned and at a deep level; as I move to the peripheral ring, the aspirate less and move more superficial to blend nicely with the surrounding areas.

Access incisions of arms liposuction are also marked at this setting. The surgeon should not hesitate to place more incisions if access is insufficient with the existing markings.

Preoperative markings of arms liposuction divide the arm and contiguous para-axillary regions into nine zones. The arms were marked in the abducted position with 90° flexion at the elbow.

Different markings were made for men versus women. The addition of the patient arm moves in the marking process resolved the problems going with natural asymmetries and yield natural results. The dynamic marking can achieve athletic and natural results that can match the gender, age, body type, and wishes of the patient.

Infrequently a puncture site is marked in the middle third of the posterolateral arm. Preoperative marks were checked with the arms in the adducted relaxed position to ensure right placement for minimal delectability.

There are many classifications of arm areas or zones. Prof. Moawad follows the following treatment zone:

• Zone 1: anteromedial/anterolateral arm
• Zone 2: the bicipital triangle. The apex of the bicipital triangle is approximately 3 cm proximal to the medial epicondyle, and the base is at the axilla.
• Zone 3: posteromedial/posterolateral arm
• Zone 4: para- axillary region formed the para-axillary region (i.e., the lateral pectoral zone and the upper Back).

A detailed exam of the subcutaneous fat distribution is essential if superficial arm liposuction or “liposculpture” is planned. Attention must be paid to “gender ideal” muscular shape/ mass and fat distribution. Additionally, dynamic areas must be examined and marked in the full range of muscular contrac­tion to yield natural results

For individuals with excessive skin laxity, in addition to lipodystrophy, a mini-Brachioplasty is designed. Distal forearm, upper Back, deltoid, axilla, and lateral pectoral extensions are included for regional harmony.

Puncture sites are marked at the anterior and posterior axillary folds, medial, and lateral distal arm 1.5 cm proximal to the olecranon. The crease marking the junction of the medial arm with the axilla is located. The skin to be excised is marked with an asymmetric ellipse of tissue measuring 4–6 by 12–15 cm in length.

Patient Education and Informed Consent of Arms Liposuction

The patient has sufficient information about the proce­dure, postoperative course, and long-term results to make a truly informed decision. The patient and physician should discuss the procedure, alternative treatments, financial obligations (including further surgeries if required), and complications and risks.

Informed consent is vitally important in evaluating and managing arms liposuction patients to protect the surgeon and the patient from unexpected outcomes or patient dissatisfaction. The operative surgeon should perform this vital process (not a nurse or staff) and be documented in the medical record.

Perioperative Notes of Arms Liposuction

We are supporting Core body Temperature

The patient is placed in a warming blanket 30–60 min before the procedure. The wetting solutions should be warmed and not administered cold. Also, calf compression devices are applied to the lower legs as preoperative precautions to assist in DVT prophylaxis and prevent the patient from becoming cold during the procedure.

Patient positioning of Arms Liposuction

Each area is treated with the body in a specific position on the operating table. With the patient in the lateral position, the flanks and lateral thighs, the gluteal fold, and the “banana” fold are treated. We treat the dorsal region, arms, flanks, dorsal and medial thighs, and the knees in the prone position. The abdomen, medial thighs, calves, ankles, and axillary region are treated in the supine position. By bending and separating the patient’s knees, the medial thighs, calves, and ankles are treated.

Will I have General Anesthesia for Arms Liposuction

It is up to the surgeon to determine the optimal surgical setting for each patient undergoing liposuction. Factors that influence this decision are the amount of expected lipoaspi­rate, length and extent of the procedure, patient positioning, operating surgeon preference, anesthesiologist preference, and overall health of the patient.

Small-volume arms liposuction cases can be performed with local anesthesia, with or without mild seda­tion. Complex, large-volume arm liposuction, and combined cases should be performed under general anesthesia.

Four different terms describe infiltration of local anesthesia (wetting techniques): dry, wet, superwet, and tumescent. These terms are based on the volume of infiltrating as a ratio of the volume suctioned. The dry technique uses no wetting solution and has few indications in liposuction.

The wet technique involves pre-infiltrating two hundred–300 mL of solution per region to be treated, regardless of the anticipated amount to be aspirated.

The superwet tech­nique employs an infiltration of 1 mL of solution per estimated 1 mL of expected aspirate.

Finally, the tumescent infiltra­tion, popularized by Klein et al., involves extensive infiltration of solution that infiltration significant tissue turgor and results in total infiltration of ~3 mL of wetting solution per 1 mL aspirated.

I believe that tumescent infiltration should be carried out until the tissue has firmness and a slight “orange peel” appearance, which will help stabilize the tissue during the arm liposuction phase. The volume of infiltrating is typically eight hundred– 1,500 mL/arm.

Regardless of the technique used, the infiltrate should be allowed for 30 – 60 min before suctioning because the anesthetic’s estimated onset of action and the solution’s vasoconstrictor effect reach maximum. Following a 30–60 min permeation of local anesthesia will result in the homogenization of the adipose tissue. This effect is essential to facilitate the suction process and get regular postoperative results.

The strict application of the current technology allows us to carry out extensive arm liposuction procedures at ambulatory facilities with no risk. Using the accurate tumescent method, blood loss is less than 1 % of the total extracted volume. Major aspirations of 8–10 L imply a blood loss of no more than 80–100 mL, which in no way compromises the patient’s safety.

While waiting for the real action of tumescent anesthesia, we use external ultrasound energy to liquefy fatty deposits. This will help in superficial arm liposuction and final contouring of the arm. This is important in male patients or secondary procedures.

External Ultrasound with no suction is the noninvasive treatment of localized fat deposits of volume smaller than 300 ml by increasing the intracellular volume and rupturing the cellular membrane. I note that if fat grafting is considered, either ultrasound is not used or, if used, fat extraction can be done elsewhere.

For volumes more significant than 300 mL, we can combine external Ultrasound with either syringe liposculpture in small cases or power-assisted in large ones. External Ultrasound produced significant physician and patient benefits both operatively and postoperatively. Now the anesthesia has reached its peak. The skin looks blanched and firm.

Arms Liposuction Techniques 

The lateral decubitus position allows for circumferential treatment. Although arm contouring can be performed in the prone and supine position, access to the para-axillary region is limited

In the beginning, Cefazolin, 1 g, is administered intravenously. The skin is prepped with Betadine from the wrists to the shoulders, including the axillae, and sterilely draped. The hands are wrapped with sterile towels.

The arms are placed on arm boards at 85° abduction, never more than that (to prevent accidental stretching of the brachial plexus and traction nerve injury). The arms should not be strapped to the table since mobility may be necessary.

Three 5-mm incisions were made at (1) the posterior axillary crease, (2) the anterior axillary fold, and (3) in the elbow, at the olecranon tip. Only two incisions were made in women—at the posterior axillary crease and the olecranon tip—except for obese women, in whom the anterior axillary fold incision was also made.

The tumescent solution was used to uniformly infiltrate the layers of fat, starting in the deep layer and ending in the superficial layer. The solution consisted of 1000 mL of normal saline and a vial of 1:1000 epinephrine. Tumescent solution is injected through a small incision in the posterior portions of both upper arms just proximal to the elbow (olecranon process).

Be very careful that the incision is not made medially since the ulnar nerve is medial to the olecranon. The infiltration ratio to suction was 2:1. The elbow wound was left open for drainage and covered with a sterile gauze pad.

Factors that influence selecting a particular type of treatment include surgeon preference, target area, expected aspirate, and history of the previous liposuc­tion. The traditional SAL remains the most common and popular modality for liposuction among plastic surgeons. The author prefers syringe reduction techniques in localized fatty tissue deposits of small volume or when fat grafting is required later.

Multiple access points are utilized using a crisscross technique to cover the sizeable arm surface, including ant-lateral, ant-medial, and post-lateral. Incisions are small, no more than 2 mm, and do not need suturing at the end.

Traditional arms liposuction has failed to meet the expectations of our patients. Commonly reported undesired sequelae of the arms’ liposuction include worsening of skin laxity and wrinkling, central over resection on the inferior brachial border, and the lack of regional harmony.

Brachioplasty procedures improve contour but are frequently unacceptable to our patients because of the undesired sequelae of widened, misplaced, or hypertrophic scars, contour irregularities, numbness, and skin necrosis.

Circumferential arms liposuction and para-axillary region creates a subcutaneous confluence (lattice)of collagen deposition during healing, promoting regional harmony. Circumferential liposuction permits excess skin of the posterolateral arm to be moved and redistributed to the anterior side.

The redraping of the skin of the upper arm on the x-axis and the y -axis results in a decrease in the diameter of the upper arm. The area of suction can be extended around the shoulder girdle (the axillar and scapular area), and retraction of the adjacent skin of the upper arm causes skin redraping of the upper arm in the z-axis

To maximize skin contracture and redraping, I applied different suction techniques depending on the degree of fat accumulation; if necessary, the operation area was extended around the axillary and scapular region (Zone 4) to overcome the traditional method’s limitations and achieve optimal effects.

Arms Liposuction begins using the syringe for harvesting fat for later grafting. Once enough fat is obtained, arm liposuction starts in the post-lateral arm, where many fat deposits are found. Liposuction is at a deep plane using 3 mm multi holes cannulas. 

Ensure that the cannula does not enter the axilla except in a very superficial fashion and complete control of the cannula tip with the non-dominant hand. The indiscriminate cannula used in liposuctioning the axilla will frequently result in serious injury to nerves and vessels.

The tissues are checked with pinching to compare each side, and any areas of excess fat remaining can then be identified and liposuctioned. The amount of aspirate from each arm is measured separately to remove nearly equal amounts

Suction-assisted Arms Liposuction

Suction-assisted liposuction uses a two-stage technique. The site is infiltrated with a predetermined wetting solution and then evacuated after allowing time for the solu­tion to set and take effect. Advantages of this technique include ease of use, mal­leable cannulas, a wide variety of cannulas, and decades of experience and results.

Syringe Reduction Arms Liposculpture

Four steps are required:

• Removal of the excess fatty tissue in a crisscross fashion.
• Remodeling of the remaining crisscrossed fatty tissue.
• Redistribution of the skin after a wide peripheral mesh undermining the neighboring normal fatty tissue has been done with a cannula with no extraction (like subcision).
• Adequate immobilization of the treated area until shrinkage and healing proceed satisfactorily.
• The left hand is the “brain hand” with liposculpture, and the right is a mere piston.

The surgeon must remember that closed liposculpture is an artistic, three-dimensional, architectural body contouring technique. It is essentially a tactile operation with the surgeon working almost blindly. The results are different from those of traditional liposuction.

Superficial arm liposuction is frequently applied to lax skin and excess fat patients. The surgeon needs to make a smooth transition between different treated areas of the arms. However, he should emphasize the differing aesthetic difference between males and females.

Power-assisted Arms Liposuction

Power-assisted liposuction uses an externally powered cannula, variable in size and flex, and oscillates in a 2–3-mm reciprocating motion at 4000–6000 cycles/ min. Advocates of PAL contend that it is best used for large volumes, fibrous areas such as the Back, and revision liposuctions

Because the PAL cannula breaks up fibrous fat much more readily, the procedure is significantly faster and less labor-intensive for the surgeon than traditional SAL. The most advantageous of power-assisted liposuction is its usage in superficial layers with or without suction for tunneling and promoting skin redraping and skin tightening.

We always combine power-assisted, suction-assisted, and syringe-reduction liposuction. At first, a 3 mm spatula or multi-hole reciprocating cannula without suction (pre-tunneling) is applied. The tunnels are made in a crisscross fashion. Refinement is carried out in the superficial plane using small 2.0-mm or smaller cannulas.

Anteromedial Arms Liposuction

Pretunneling is performed from the olecranon and axillary sites longitudinally. Cross tunneling and deep suctioning are performed from the middle third of the arm to create a 10–15 mm final pinch test. If the pinch test is 10 mm or less, only pretunneling is done. No liposuction is performed under thin, anteromedial skin due to the propensity for wrinkling, especially near the axilla.

Anterolateral Arms Liposuction

Superficial liposuction from the anterior axillary site, dorsoradial arm, and mid-arm is performed with a three × 20-mm Mercedes cannula. The final pinch test should be 9–14 mm.

Posterolateral Arms Liposuction

Power-assisted is used through the posterior axillary incision as described. All-layer liposuction is performed with frequently required deep, superficial, and subdermal liposuction. A 3 × 20-mm Mercedes cannula is used initially. For more extensive volume extractions, a four × 30-mm cannula enables access to the entire length of the posterolateral compartment. Avoid over-resection centrally (Zones 2 and 3) by checking the pinch test frequently.

Para-Axillary Arms Liposuction

Power-assisted is particularly useful for the deltoid region and upper Back (Zones 7 and 8). The fat is evacuated with 3- and 4-mm Mercedes cannulas. More aggressive liposuction is performed with a 3 mm Gasparotti to encourage the formation of a confluent layer of collagen forming circumferentially around the arm connecting to the trunk. The axilla, deltoid, and lateral pectoral extensions are treated with a 3 mm Mercedes to minimize wrinkling.

Circumferential arms liposuction is performed most aggressively in the posterolateral one-third, less aggressively in the anterolateral one-third, and least aggressively in the anteromedial one-third

The quantity of fat removed can be moderate, but improved results are often observed with the release of fibrous attachment of superficial fat to deeper tissue. The larger the volume of fat removed, the greater the potential for skin retraction.

Fat Grafting in Arms Liposuction

Zone 2 comprised the bicipital triangle, characterized by a contour depression. Fat grafting can be added to achieve better results in patients requiring volumetric enhancement and places upward tension on zone 3, thereby supporting and redraping ptotic skin and restoring a pleasing contour of the arm in patients with grade 2 or 3 ptosis. Between 50 and 100 mL of fat was injected.

Surgical Endpoints of Arms Liposuction

Longstanding endpoints have been established for traditional liposuction, such as skin pinch, final contour, and volume of aspirate. The endpoint of the procedure was determined by pinching to have similar skin thickness in each region. The anteromedial thickness was made the reference point of pinching.

Measured volume aspirated is a good indicator for bilateral procedures to judge symmetry and contour, comparing each side to the opposite. Other indicators such as treatment time, blood in aspirate, and amount of aspirate are essential factors to consider.

Post Operative Notes of Arms Liposuction

Sutures are not applied to the entry points. This allows for easy dripping of the fluids. When all tumescent solution is drained from the surgery site postoperatively, gradual adherence and shrinking of the subcutaneous wound are initiated, resulting in a global three-dimensional wound contraction and a horizontal subcutaneous scar.

The patient or caretaker should call the doctor if there is bright red bleeding through the dressings, drainage of pus, increasing pain, or other unusual symptoms (shortness of breath, abdominal pain, chest pain, mental confusion, etc.). Some pink drainage, not bright red, is expected and maybe pretty profuse the first night. If fainting or collapse occurs, notify your surgeon immediately.

Meticulous postoperative care is vital to obtaining good results. After arm liposuction, patients are placed in a compression garment, customized based on surgeon preference, and performed the procedure. Compression is essential to achieve accurate redraping of the skin. Most frequently, the skin is loose and sagging posteriorly. Pulling the skin anterolaterally to smooth any wrinkles anterior medially and then fixing it with Reston foam facilitates re-draping and stabilizing the skin.

The sterile padded dressing is applied with Micropore tape. On top of this, an elastic bandage is applied, followed by pressure garments when finishing. It helps diminish bruising and edema in our hands.

At the end of the surgery, the patients remain 1–2 h more before returning home by their means. Prof. Moawad always insists the patients must be accompanied by another person (friend or relative).

The French tape and gauzes are removed on the second postoperative day. This makes lymphatic drainage easier and a quicker reduction of inflammation. The patient is instructed to keep the arms elevated on pillows when reclining for the first three days. She will wear the garment 24 h per day, removing it only to shower for the first week. The garment will then be worn for the second week, 18 h per day, and for the third week, 12 h per day.

Patients are asked to ambulate on the day of the surgery. Walking is encouraged immediately. Full mobility of the arm was encouraged after 24 hours. Light activity is allowed two weeks after surgery. Heavy physical activity (including gym, jogging, and extreme physical exercise) is strongly recommended after one month

The patient is instructed to take showers daily and change the dressings after each shower

The severity and duration of skin hardening were directly proportional to the subdermal release performed to obtain skin retraction. Stretching exercises were prescribed from 1 to 6 months postoperatively.

External Ultrasound is used starting the following week after the surgery to improve the arm contour further and provoke a quicker reduction of inflammation. Ultrasonic therapy will be continued for skin hardening, irregularity, and ecchymosis. Bruising should be minimal and dissipate by 7–10 days after surgery.

Patients should expect to initially gain weight after arm liposuction due to volume shifts and postopera­tive swelling. Edema tends to peak from 3 to 5 days after surgery.

Patients were evaluated at 24 to 48 hours, one week, and then 1, 3, and 6 months and one year after surgery

Patients should begin to see contour changes in their arms by two weeks, and at six weeks should be able to appreciate significant changes in their shape. Maximum shrinking is usually seen after four months. As patients’ activity levels improve and necessary lifestyle changes proceed, further changes may be noticed. Depending on the patient, the final aesthetic result can be seen 3–6 months after surgery. The total wound healing time continues for 18 months.

Complications of Arms Liposuction

In our experience, arms liposuction complications are rare when performed by experienced surgeons. The most common complication is under-correction of the deformities and the need for a secondary “revision” procedure.

Hyperpigmentation at the incision site is common, especially in Hispanic and black patients. This pigmentation is often post-inflammatory hyperpigmentation and resolves over four to six months.

Postop­erative complications occur in three different windows. These are the perioperative period (0–48 h), early postoperative period (days 1–7), and late postoperative period (1 week to 3 months).

Perioperative complica­tions can include anesthesia and cardiac complications, cannula trauma to the skin, and volume loss/overload from bleeding or excess fluid administration

Liposuction surgery, especially when it involves multiple areas, places the patient at risk for hypothermia. Preventative measures include warming the wetting solutions and prep, increasing the ambient room temperature, and use of preoperative and intraoperative warming.

Pre-warming the patient for one h has also significantly reduced hypothermia incidence. It should be considered, particularly for longer body contouring cases and those involving multiple areas.

In the perioperative period, fluid shifts occur, which, if improperly managed, can lead to hypovolemia or volume overload. As a rule, we require our patients to obtain preoperative medical clearance when they are over 50 years of age or have any concomitant risk factors, such as cardio­pulmonary disease.

Careful management of intraoperative and postoperative fluids and an intraoperative datasheet helps prevent volume-related complications from liposuction.

Other early postoperative complications include venous thromboembolism, infection, and skin necrosis. The incidence of DVT in liposuction has been reported at <1%, but a marked increase in this percentage is demonstrated when liposuction is combined with other surgery.

Wound infections, including necrotizing fasciitis, are serious complications known to occur in liposuction. Fortu­nately, these types of complications are rare. Complaints of persistent postoperative fevers or cellulitis should be closely monitored and aggressively treated.

As a preventative measure, first-generation cephalosporins are administered perioperatively within 30 min of the incision. There is no indication for routine postoperative antibiotics after the perioperative dose in stan­dard liposuction.

Late liposuction complications include delayed seroma formation, edema and ecchymosis, paresthesia, hyperpig­mentation, and contour irregularities. A loose closure of cannula sites, postoperative compression garments, and expression of residual fluid over liposuction areas at the end of the procedure can potentially reduce the incidence of seroma formation.

 Postoperative edema and ecchymosis occur to a varying extent in all patients. Significant ecchymoses may result in hemosiderin deposition and ultimately hyperpigmentation. This can be challenging to eliminate. Prolonged edema can occur up to 3 months post-surgery and is best treated with supportive care and lymphatic massage.

Postoperative paresthesia/dysesthesia can occur in all forms of liposuction. The sensory changes are usually reversible and can take up to 10 weeks to recover.

Other Techniques that Can be used in Arms Liposuction

Ultrasound-assisted liposuction utilizes ultrasonic energy to break down fat and facilitate suction-assisted removal. With this technique, fat is emulsified, which allows removal through traditional liposuction cannulas. Its mechanism of action is also primarily mechanical, but cavitation and some thermal effects are alleged to occur.

UAL com­prises three stages: (1) infiltration, (2) emulsification, and (3) evacuation and contouring. Skin protection may be utilized to help protect the skin from thermal injury.

Advantages of UAL include less surgeon fatigue. By utilizing ultrasound-assisted liposuction, advocates report a more uniform treatment of fat layers and improved contour with minor revision. Disadvantages include increased equipment cost, slightly more extensive incisions, longer operative times, and thermal injury.4

VASER-assisted arms liposuction employs a newer generation ultrasound-assisted liposuction device that incorporates less energy with more efficient, solid probes. The system uses less energy, decreasing its thermal component to the tissues. After either continuous or pulsed energy treatment, the fat broken down is then evacuated with a traditional liposuction cannula.

Laser-assisted arms liposuction has been at the forefront of marketing hype at present. The treatment involves the insertion of a laser fiber via a small skin incision. The most common available wave­lengths in the United States are 924/975 nm, 1064 nm, 1319/1320 nm, and 1450 nm. Most companies and physicians utilizing these devices employ a four-stage tech­nique: infiltration, application of energy to the subcutaneous tissues, evacuation, and finally, subdermal skin stimulation.

The laser fiber purportedly acts to disrupt fat cell membranes and emulsify fat. Evacuation then commences via traditional liposuction cannulas. The belief is that the heating of the subdermal tissue may provide a skin-tightening effect. Prof Moawad is e not convinced it yields clinical differences.

Water-Assisted arms Liposuction (WAL)

WAL burst onto the scene in 2007 for conscious liposuction, allowing improved contouring facilitated by an awake patient. First, the standard wetting solution is injected in the form of a fan-shaped spray by a waterjet approximating the force of a strong shower.

As anesthesia takes effect, a more dilute solution is substituted. This constant fluid flow increases adipose cell detachment and reduces the risk of adverse volume-related fluid-electrolyte shifts, circulatory overload, and postoperative edema. It also shortens the procedural time in large volume liposuction and has been shown to promote blood-sparing fat removal in lipedema.

Radiofrequency-Assisted Arms Liposuction (RFAL)

Radiofrequency-assisted liposuction (RFAL) utilizes diathermy-like bipolar radiofrequency energy to disrupt fatty cell membranes and encourage lipolysis. A beneficial secondary effect on skin contraction is also claimed, and much like LAL, it causes a thermal injury at the subdermal surface.

The uncontrolled and focally concentrated injury that besets LAL has been addressed using two electrodes. The internal one in the subcutaneous adipose tissue forms numerous tunnels similarly to SAL, but without the force required as RF energy itself produces lipolysis. Additionally, an external electrode channels the energy so that the effect is predominantly within the fat and focused on the subdermal surface.

IMPORTANT NOTES FOR THOSE WHO ADVOCATE THE USAGE OF THERMAL INJURY TO REMOVE FAT

Various technologies have facilitated fat removal over the past three decades. Many of these have used thermal injury. The thermal energy introduced with ultrasound-assisted, laser-assisted, and radiofrequency-assisted liposuction creates injury to fat cells, therefore facilitating aspiration. However, the thermal load imparted the creation of additional fibrosis, scarring, and contour irregularities. Therefore, using thermal devices designed to eliminate fat increases liposuction complications.

Conclusion of Arms Liposuction

Recent improvements in liposuction techniques have led more cosmetic surgeons to use arms liposuction procedures. Previously, surgeons had little indications for upper arm liposuction because skin laxity and irregularity were frequent and difficult to manage. Circumferential arms liposuction and para axillary and the para scapular area had overcome these shortcomings.

Therefore, the procedure leads to maximal three-dimensional skin retraction. Mini-Brachioplasty confined to the axilla can produce improvement of the upper arm with some residual skin laxity, particularly distally. Consequently, patients acquire straight inferior arm borders and slender upper arm contours.

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Arms HD Liposuction Results (before and after) 

HD Liposuction Results (before and after)