One of the most common age-associated body contour problems is upper arm skin laxity. The so-called “batwing” deformity is characterized by an unsightly development of loose hanging skin of the posterior arm and is frequently accompanied by excess fatty tissues. The problem usually becomes a fashion concern in the late forties when concealment of the upper arm severely limits garment choices
However, even the most careful upper-arm tightening will result in a scar on the medial side of the arm, starting in the armpit and stretching as far as the elbow. The patient must therefore be informed accordingly because most patients want this procedure to be able to show their arms in public again
Patient Selection for Brachioplasty
The best candidates for brachioplasty are healthy individuals who have achieved a stable weight and a BMI of less than 28. Individuals with a BMI greater than 28 can obtain dramatic results; however, the final aesthetic result is less likely to be ideal.
The main indication of brachioplasty was either fatty tissue deposits (lipodystrophy) or excess skin in the upper arms. The extent of the fat deposits or excess skin then determined the types of brachioplasty that these patients needed.
To better understand and address the deformities found after massive weight loss, it is helpful to conceptualize the upper extremity based on four zones:
Zone 1 deformities
Our experience is that massive weight loss patients do not typically present with severe deformities of zone 1. When the deformity is present, it is most often characterized by a mild excess of subcutaneous fat without skin redundancy. This type of deformity can be well managed with suction-assisted liposuction alone.
Zone 2 deformities
The relative contribution of excess ptotic skin dictates the type of procedure that will achieve the best contour. Isolated zone 2 deformities can be divided into two types. Some patients present with excessive fat only, while others will have excessive fat and skin.
If such patients have good skin tone, they may be candidates for treatment with circumferential liposuction and not require direct excision. More commonly, patients have redundant ptotic skin far above the extent of excess fat. These patients may be treated with direct excision if restoration of upper extremity contour is achieved.
Deformities of zones 2 and 3
Most massive weight loss patients present with a deformity that spans zones 2 and 3, such as a wing or web is formed. In these cases, excess skin is present in abundance, while relatively little fat is present. Within zone 3, the excess skin of the axillary apex is present as the posterior axillary fold. Patients with deformities of zones 2 and 3 invariably require direct excision to restore a natural contour to both the arm and the axilla.
Deformities of zones 2–4
For those patients with deformities of joint zones 2, 3, and 4, direct excision is required to help restore contour to the arm, axilla, upper lateral chest wall, and the back. The four zones of deformities are offered four types of barachioplasty to address their deformities individually.
Type I patients had very little excess skin, most of it occurring in the upper arms. These patients had minimal lipodystrophy. These individuals were candidates for the less commonly used minimal incision Brachioplasty.
Type II patients had moderate excess skin in the upper arms and moderate fatty tissue collections. Many non-weight loss patients who fell into this category deserve a standard brachioplasty.
Type III patients had both excess skin and lipodystrophy. Most of these patients also had involvement in the lateral chest wall. Therefore, patients had a combination of brachioplasty and suction-assisted liposuction (SAL).
Type IV patients had excess arm skin and lipodystrophy and significant involvement of the lateral chest wall and upper body. This group had a combination of brachioplasty and thoracoplasty and an upper-body lift.
Who is Not a Good Candidate for Brachioplasty?
- High patient BMI and small BMI change from the highest weight.
- Problems related to bariatric surgery should be explored, for example, frequent vomiting, abdominal pain, weakness, light-headedness, and frequent bowel movements.
- A history of lymphedema and arterial or venous insufficiency.
- History of hyperpigmented or hypertrophic scars.
- Unrealistic patient expectations or individuals with a history of significant mental illness or acute mental illness are asked to be evaluated by a proper health professional.
- Individuals with a history of tobacco consumption are urged to stop as soon as possible—the risks of tobacco include impaired wound healing and thromboembolic phenomena.
Candidates for brachioplasty should undergo a thorough history and physical examination. Like all post-bariatric patients, special attention should be directed to weight history. Critical information includes the patient’s height, current weight, and maximum weight. The time interval between their maximum and current weight and length of time at the current weight should be documented.
Some discussion should occur for patients who have lost weight through lifestyle changes about how this was accomplished, i.e., exercise, diet, exercise, or medication.
Patient history can often suggest problems; however, a thorough laboratory workup is critical for finding existing deficiencies or abnormalities. Abnormal laboratory values are acted on as they are made available. Individuals found to be malnourished with a total protein of less than six g/dL and albumin less than 3 mg/dL may be referred to their bariatric surgeon for re-evaluation and possible nutritional supplementation. Protein-depleted patients may prove difficulty healing wounds. Those findings may be corroborated by edema on physical exam.
Severely anemic patients with hemoglobin less than ten g/dL are referred to their primary physician and hematologist. Patients with hemoglobin above ten g/dL are recommended to continue on iron, folate, and B12 supplementation and to have their blood cell count repeated in a week. Our preference is for patients to have hemoglobin above 12 g/dL before surgery.
Medications that should be avoided before surgery are reviewed; these include medications that increase the risk of bleeding (aspirin and non-steroidal anti-inflammatory agents) and those that increase the risk for deep vein thrombosis (oral contraceptives or hormone replacement therapy). Patients are advised not to take either drug two weeks before or after surgery.
Patients with a BMI of greater than 32 are given 5000 units of heparin subcutaneously before surgery. Individuals with risk factors other than obesity are treated on a case-by-case basis
Examination of the post-bariatric brachioplasty candidate should be thorough, with particular attention directed towards the upper body. The degree of the soft-tissue excess present along the forearm, arm, axilla, the breasts, lateral thoracic region, and back.
Patients rarely have an ultimate sense of their deformities. A dynamic exam in front of a large mirror should help educate the patient and surgeon about aging and tissue excess features and which surgical approaches are indicated. Highlighting existing asymmetries, existing scars, transverse armbands, and striae along the upper extremity should be noted. The fat content of all these areas should be noted.
A series of photos and an exam in front of a large mirror are vital in evaluating and instructing prospective patients about their deformities and explaining how the planned procedure or procedures will address their deformities.
Once a clear plan is made, details of that procedure are proven and described. In general, depending on the assessment, one of the following options is chosen:
These procedures can be done with or without liposuction, depending on the extent of existing lipodystrophy. As previously noted, a select group of patients is candidates for liposuction
A determination is also made about added procedures included with the arm recontouring. These might be breast procedures or upper body lifts. A failure to discuss the full spectrum of scar quality can lead to a disappointed patient despite an excellent result in contour. Restrictions and recovery guidelines are reviewed
The technical, artistic, and philosophical approach to arm recontouring is clearly explained at this meeting.
Accurate preoperative marking is a stepping-stone for an organized and efficient operative approach for brachioplasty. The patient is marked while standing with her arms abducted at the shoulders to 90 degrees. The e elbows are flexed to 90 degrees.
The intended scar position is marked. Reference points for this line are the medial elbow to the apex of the axilla. Another longitudinal line is placed 2 to 3 cm above the intended scar position. Likewise, another lower longitudinal line is marked. Transverse reference lines are marked on the skin to assist with skin alignment during closure.
The minimal incision brachioplasty (group I) will leave a scar between the anterior and posterior extent of the axilla. The linear incision of the complete brachioplasty procedures (group II-IV) is the best place in the posterior medial position.
We undertake a very detailed review of the informed consent paperwork at this visit. Each patient receives an information booklet that summarizes and describes the preoperative, operative, and postoperative elements of their procedure.
As with all surgical procedures, a clear and concise transmittal of information is paramount in setting up a healthy medical and psycho-emotional relationship between the patient and the physician.
Typically, local anesthesia with sedation (monitored anesthesia care [MAC]) is used. The patient is supine, with the arms abducted, and is circumferentially prepped from the fingertips to the lateral chest wall. Apply appropriate dressings that permit full circumferential access to the arms and shoulders.
All patients undergoing brachioplasty have activated lower extremity sequential compression devices in place before surgery, during surgery, and until ambulation is regular. Following surgery, patients are encouraged to ambulate shortly after the conclusion of the procedure.
Each arm is rotated up to approximately 135 degrees during the resection. This maneuver helps establish some tension for the eventual excision.
The area underneath the resection area is infiltrated with a local anesthetic and a vasoconstrictive solution using an infiltration cannula (1: 1 ratio, infiltration to expected aspiration volume).
The purpose of liposuction is to remove fat while preserving the blood and lymphatic vessels and cutaneous nerves of the arm. After the necessary time has elapsed, a liposuction device of choice is used to suction out the subcutaneous fat under the proposed area of resection.
Superficial liposuction is then performed to empty the subcutaneous tissues under the area for excision. There is no feathering or liposuction of the adjacent medial inner arm. In this case, 100 mL of lipoaspirate was removed from each side.
The skin and superficial subcutaneous tissue are sharply incised along with the planned markings down to the level of the underlying muscular fascia of the arm, leaving a thin layer of fat on the fascia. As with the other technique, care is taken to leave a healthy layer of brachial fascia and subcutaneous fat on the floor of the resection
There are two essential brachioplasty techniques. The staple approximation technique is used for thinner arms with copious skin excess. The sequential resection and approximation technique is often used with liposuction for arms with an excess fat collection.
With inferior traction, a bloodless and loose fibrous remnant of the area of liposuction is opened from the elbow to whatever extent the lateral wall has been previously figured out, marked, and aspirated. The lower or flap is advanced systematically and segmentally up to the committed line, and excess skin is found, marked, and incised. Each excised segment is temporarily closed with staples. It is wise to set up hemostasis so that this will be the final reapproximating before the closure of the defect. Types of Brachioplasty
The Length and Location of the Final Scar Location will determine the name of brachioplasty
Minimal Incision Brachioplasty
Patients who present with skin laxity of the proximal upper arm and mild to moderate lipodystrophy are candidates for minimal incision brachioplasty. Minimal incision brachioplasty can be done with or without liposuction, depending on the extent of lipodystrophy of the proximal upper arm.
This standard operation is proper for a large group of patients with a significant excess of the skin of the upper area with” bat wing deformity.” This operation addresses skin laxity and can also be done with or without liposuction, depending on the presenting lipodystrophy. The extent of the excision is generally limited to the upper arm.
Patients with excess not simply limited to the upper arm and who have laxity of skin and lipodystrophy of the proximal forearm or proximal chest wall will require an extensive brachioplasty. The extension of the excision will depend on the presenting magnitude of excess in both the proximal forearm and the chest wall. This group will also be evaluated for the possibility of SAL as an adjunct to arms recontouring.
This extensive operation is reserved for patients with a dramatic excess of the skin and significant excess on the lateral chest wall. This group often complains of excessive “bra rolls” and will need an overall recontouring of the arm and chest wall, breast, and back and will undergo an upper body lift
As scar widening and thickening is a significant sequella of brachioplasty, meticulous low-tension closure is paramount and a prerequisite for a good outcome.
Once symmetry and hemostasis are confirmed, closure of the arm is done to reduce tension on the scar and alleviate the need for drains. The 3-pointed closure is a technique that grabs the SFS of the upper and lower resection lines and includes the floor of the arm fascia eliminatinge any dead space, is the first step in setting up a good scar line. It is imperative to use caution to identify, preserve, and use the superficial facial layer (SFS) in this closure.
Brachioplasty can be done concomitantly with other operations, the most common and vital being liposuction. Liposuction has been determined to be a safe adjunctive operation. Other logical concomitant procedures include an upper body lift.
Brachioplasty is nearly always performed in an ambulatory setting. Ambulation is encouraged as soon as possible after surgery. Discharge home is usually within several hours of the conclusion of the procedure. No drains or arm garments are used. Patients are instructed not to bend at the elbow for the first 24 hours and are highly encouraged not to engage in any strenuous activity for the first two weeks after the operation.
They are all cautioned that edema is specific and are instructed to avoid wearing rings or any compressive ornaments for the first two weeks after the operation. As edema is fading, a compression garment is advised. Garment wear necessitates patients to wait until the cool weather months of the fall and winter to perform this surgery.
Postoperative care is mainly based on conforming to proper wound healing and starting a controlled protocol of postoperative scar control.
For the first two weeks, the incisions are covered with a steri-strip. For the third week, micropore brown tape is used. Subsequently, a rest period is recommended to allow the scar to dry and verify that there are no separations of the incision.
At this point, silicone gel sheeting is begun and continued for six months. It is imperative to compress the sheeting with the garment. Given the difficulty of placing strips on a moving arm, occasional silicone gel spray is provided to patients to improve compliance.
Patients are given the go-ahead to start their exercise regimen simultaneously and are cleared for any activity at six weeks.
Standardized photography to capture postoperative results is done at three months. Still, given the prolonged maturity of brachioplasty scars, the patient is asked to follow up 6 to 9 months after the operation for a final photo.
Treatment of Complications
Brachioplasty represents a challenge for many surgeons and has historically had a high complication rate. Patient complaints after Brachioplasty typically involve malpositioned, broad, or hypertrophic scars.
Wound dehiscence or necrosis of the flap edges may occur, and post-massive weight loss patients may be slow to heal due to previously subclinical nutritional deficiencies.
Seromas are the second most frequent problem, occurring in 10% of cases. The vast majority, approximately 90%, occur along with the distal medial one-third of the arm, immediately beneath the scar. Most become evident at about three weeks postoperatively and range in diameter from 1 to 4 cm. Initially, we manage seromas with needle aspiration.
If the tissues are not contoured symmetrically, contour irregularities, including depressions or folding of excess remaining tissues, could result. Contour irregularities are often due to overcorrection centrally or under resection proximally and distally if they do occur.
Secondary procedures for contouring irregularities following liposuction can be more challenging. A common area for over suctioning of fat is in the distal one-third of the arm, just proximal to the elbow. Treatment of this condition can involve liposuction alone or direct excision of the surrounding areas of the arm.
Nerve injury, major wound complications, and lymphedema are potential complications but have not been observed.
Outcomes, prognosis, and complications
The vast majority of patients following Brachioplasty are delighted with their results when proper screening and preoperative education have been performed. Patients most likely to approach an aesthetic ideal and to have a high level of satisfaction are those with a presenting BMI of less than 28.
Patients seeking improvement following Brachioplasty surgery typically have concerns about scar quality or location or overall upper limb contour. Complaints about scar quality include wide, pigmented, or hypertrophic scars. As noted of scars in general, arm scars of patients with a lower Fitzpatrick rating are likely to have a quicker and more complete dissipation of pigment than individuals higher on the scale
Perhaps one of the most critical scar maturity and outcome elements is time. Maturing of a scar of the arm lags the maturating of scars elsewhere in areas of the body contouring. Occasionally, secondary revisions of the scars are required, but with cautious advice, there are no grantees of improvement. This unavoidable reality should be explained to the patient to set realistic expectations.
Critical to achieving the best results with arm contouring surgery is addressing the upper body as a whole. Patients are unlikely to be satisfied with their arms if their forearms, axillae, or lateral thoracic region have not been addressed and contribute to their upper body concerns.
As with many other body contouring procedures, especially in the massive-weight-loss population, the longevity of the results can be limited. The arm is ever moving, has a thin circular sleeve of skin, and has variable levels of lipodystrophy.
This makes the results prone to a recurrence of laxity and redundancy despite execution with the best techniques. Secondary operations and revision must be a part of any preoperative discussion and informed consent process.
Two distinct anatomical features are challenging to treat. One is significant distal elbow lipodystrophy despite proper excision and liposuction.
Another is the restrictive bands of the upper arms tend to be inherent in the structural definition of the arms and tend to be resilient after brachioplasty. These bands are more noticeable among higher-BMI individuals and are typically found on the anterior aspect of the arm, proximal to the elbow. Brachioplasty may make the band appearance more noticeable. Patients should be warned about various anatomical limitations
Futures and Controversies
Some authors advocate staging the definitive Brachioplasty with an initial session of liposuction. The liposuction is performed 3–5 months before the Brachioplasty to reduce the excess subcutaneous fat: this is argued to maintain the skin’s elastic recoil properties and reduces the extent of dissection.
The use of brachioplasty is rapidly increasing. Patient selection, preoperative assessment, and a clear understanding of the arm’s anatomical features are paramount. Tremendous variability of presentations has led to different types of arms recontouring. Adding superficial liposuction will minimize the extent of brachioplasty.
Preoperatively designed markings of four major groups of brachioplasty-minimal incision, standard, extensive, and thoraco-brachioplasty—are based on the position and proximal and distal involvement of excess skin and fat on the preferred scar position in the posterior-medial axis.
As scarring continues to be a significant concern, intraoperative and postoperative measures are taken to reduce tension and create a better environment for the eventual mature scar. The use of longer-absorbing sutures and silicone products and the passage of time are primary factors in the mature scar’s appearance. Selective ancillary procedures can be a valuable adjunct to Brachioplasty, such as breast recontouring and upper body lifts.
Patients should be warned about elbow lipodystrophy, midarm constrictive bands, and the potential need for secondary operations with recurrent arm laxity. Occasionally, secondary revisions of the scars are required, but there are no grantees of improvement.