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29 Brachioplasty (Arm Reduction)
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Fig. 29.5 Class 1 subclass C.A 39-year-old female after gastric bypass
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procedures. The arm and axillae combination will change the
appearance of the upper back and chest/breast area and may
alter the patients plans for future body contouring.
Fortunately, the alterations are in a good way and usually
eliminate other procedures. The axillary part of the lift, when
done properly, usually eliminates the need for a back lift.
29.3.3 Class 3: Arms, Axillae, Breast
Patients with a class 3 issue (Figs.29.10, 29.11 and 29.12)
have involvement of the arm contiguous with the axillae and
breast. The classic “bat wing” deformity exists with the
largest amount of draping in the upper arm. The draping
travels into the axillae with skin laxity there too. There is
nipple and breast ptosis as seen with massive weight loss
and in class 3 patients, a Weiss pattern lift is combined with
the axillary lift and arm reduction to correct the entire
“quadrant.” For these patients, placement of an implant can
be perilous for a number of reasons. The biggest reason is a
high rate of complications in the perioperative and early
postoperative period. Some studies quote an up to 60% rate
of implant malposition within the rst year of the initial surgery. The same study quotes a 16.7% rate of early onset ptosis in the massive weight loss patient [2]. Breast lifts alone
are difcult in this population due to excessive skin laxity,
nutritional deciencies, ill-dened boundaries of the breast,
and poor contour [3].
There are a number of other risks involved when mixing
breast, axillary, and upper arm procedures such as hematoma
or infection. In these procedures, a drain is highly recommended due to the high incidence of seroma reported when
operating in the axillary region and the large amount of dead
space created. Implant exposure to seroma uid and a for-
Fig. 29.6 Class 1 subclass C,
bordering on class 2. A
42-year-old female after
gastric bypass
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Fig. 29.7 Class 2, arms and
axillae. A 61-year-old female
after gastric bypass
Fig. 29.8 Class 2 down
staged from a class 3 after
breast lift with augmentation,
a 44-year-old female after
gastric bypass and breast lift
with augmentation
J. A. Swetnam
eign body, even when implant placement is in the total submuscular position places the implant at risk for infection. For
all of the above reason’s simultaneous placement of a breast
implant is not recommended. If one is requested, the recommendation would be to place it remotely after at least a four
month or longer period after the larger procedure.
29.3.4 Class 4: Breast andAxillae
Not included in detail in this chapter is the class 4 patient.
The class 4 patient has excess skin in the axillae combined
with breast and nipple ptosis and in many cases macromastia. These patients are not dealing with skin laxity in the arm
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Fig. 29.9 Extended class 2. A 43-year-old female with
stable weight, no desire for weight loss surgery or breast
surgery. This patient could be classied as a class 3.
Mastopexy with axillary component would sufce on
the right but not on the left. This is an excellent example
of how exibility is required to manage patients with
great disparity from one to the next and even from side
to side
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Fig. 29.10 Class 3. A
55-year-old female after
gastric bypass
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J. A. Swetnam
Fig. 29.11 Class 3. A 41-year-old female after gastric bypass
and the problem usually is associated with larger breast
reductions where the Weiss pattern used must be extended in
to the axillae laterally and superiorly to avoid a large “dog
ear” deformity. The arm is not involved in these cases and the
area of resection stops there, in the upper axillae.
Fig. 29.12 Class 3. A 49-year-old male after gastric bypass
29.4 Preconditions toTreatment
Brachioplasty is an elective procedure, therefore a baseline
can be established for general health prior to entertaining
options for treatment. For weight loss patients and patients
who have undergone a weight loss procedure, weight stability
for at least 6months improves outcomes and is recommended.
A BMI of 30 or less is preferred. Patients with a higher BMI,
even when stable, will have a less satisfactory result. A higher
stable BMI is the nal result for many weight loss patients
and is not a contraindication however. In these cases, management of expectations is key to having an acceptable result.
Selection of patients with good baseline health for all cosmetic procedures is preferred. Many massive weight loss
patients have a dismal past history and most or all problems
resolve after the loss and stabilization of their weight. Any
Subclavian
Palmar venous arche
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unresolved medical issues should be evaluated and optimized
for surgery. If unable to satisfactorily treat an underlying
medical problem, it may be cause to eliminate surgical treatment. Other potential causes for elimination from surgical
treatment are lymphedema, prior axillary dissection, prior
radiation to the axillae, or vascular diseases such as Raynaud’s.
Expectations must be set regarding scarring as well. Most
Brachioplasty patients are excited to get rid of hanging fat
from the arms that is embarrassing when certain clothing is
worn. Patients must be aware they are trading this visible
hanging tissue for a visible scar. This must be made perfectly
clear to them to avoid surprise after surgery. Discussion about
postoperative scarring is important for all potential candidates but may be most important in candidates with smaller
arms and less skin. Those with a history of keloid or hypertrophic scar formation should be forewarned of the difculty
hiding this incision. Nutritional status should be evaluated if
in question. ERAS (early recovery after surgery) programs
are very helpful and in some cases require pre-operative protein loading. These programs are highly recommended,
numerous, available and will not be discussed in detail here.
29.5 Pertinent Anatomy oftheUpper Arm,
Axillae, andBreast
The anatomy of the upper extremity is complex with many
components in a relatively small area of real estate. Using the
technique described, however, much of the surgical risk to
vital structures can be minimized when treating the upper
extremity. Liposuction should be limited to the subcutaneous
layers of fat and great care should be taken to avoid injury to
deeper structures (Figs.29.13, 29.14 and 29.15). After safely
Axillary
Cephalic
Subscapular
Brachial
Basilic
Median cubital
Cephalic
Radial
Median
antebrachial
KEY
Deep veins
Superficial veins
Fig. 29.13 Venous anatomy of the upper extremity (photo courtesy of
Wikipedia)
Basilic
Ulnar
Digital
Fig. 29.14 Relevant
neuro-anatomy of the arm.
Medial antebrachial
cutaneous nerve is reported to
be the most injured in arm
reduction surgery (photo
courtesy of NYSORA)
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humoral circumfle
Anterior scalene muscle
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Fig. 29.15 Axillary anatomy
(courtesy of Frank Netter
illustrations)
Thoracoacromial artery
clavicular br.
acromial br.
pectoral br.
deltoid br.
and phrenic nerve
Superior theracic
artery
J. A. Swetnam
Brachial plexus
Subclavian vessels
Axillary nerve and
x arteries
Axillary artery
Lateral theracic artery
Long theracic nerve
Pectoralis minor muscle
performing liposuction on the involved areas, using the avulsion technique avoids many of the usual problems associated
with surgery in these areas. Lymphatic channels are more
preserved essentially eliminating seromas, neurologic structures are not exposed to surgical trauma limiting neurologic
issues and arterial structures are seldom even seen. The key
to doing avulsion properly is adequate liposuction. The area
to be removed should be down to essentially skin only with
all signicant fat being removed. The areas surrounding the
skin to be avulsed should also be liposuctioned aggressively,
but unlike the area of resection, leaving some adipose tissue
and creating a mobile ap, facilitating closure.
Subclavius muscle
Lateral
Medial
pectoral nerves
Pectoralis major
muscle
29.6 Treatment Options
Technology has advanced to the point where options are available to treat many patients with either a non-invasive technique
or a minimally invasive one. Classifying patients properly and
selecting the appropriate therapy requires training and experience (Fig.29.16). With the availability of internet research at
the patient’s ngertips, many patients present with a preconceived notion of what will work for them. It is critical to manage expectations rst and learn their language to steer them
towards the appropriate treatment for their problem. Using the
wrong technology or picking the wrong procedure leads to bad
feelings, bad results and ultimately bad reviews.
Fig. 29.16 Areas of resection for class 1-C (a) and class 2 (b). Class 3
adds a Weiss pattern breast lift to b (reference 4)
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29.6.1 Class 1-A Patients
Patients that fall into the class 1 category have the most
options. Skin quality is good with good elasticity, thickness,
and no stretch marks. Fat accumulation is mild-to-moderate
measured by the pinch test at less than 4cm fat thickness.
For selected patients in this group, non-invasive fat reduction
is an option. Arm treatment for many of these technologies is
an off-label use. Results are variable for some treatments and
different for some people. For class 1 patients averse to surgery, these are acceptable alternatives (Table29.3).
Cryolipolysis is the technology with the largest number
of treated patients. Gradual cooling is used to destroy the fat
cell without any long-term damage to skin, nerve or muscle.
It is safe, has very few long-term negative effects, quick, and
totally non-invasive. The most important aspect to this treatment is requiring enough cycles to adequately treat the area
and making sure the “cup” on the machine adequately ts the
area being treated. Arms can be tricky and the head may not
t properly. If this occurs, other options should be
considered.
Laser lipolysis is the use of skin surface laser technology
to destroy fat cells. With laser, heat, instead of cold, is used
to cause lipolysis. As with all other non-invasive fat reduction technology, patient selection is critical.
Radiofrequency technology is another method to reduce
fat under the skin in a non-invasive way. RF technology, as
with laser, uses heat to lyse fat cells.
Ultrasound energy is also available for use on the
arms.
Liposuction has been, and will continue to be, the workhorse of this area. For the class 1-A patient in the market for
a “one and done” solution, liposuction is extremely effective
and safe. Using tumescent technique (Table29.4), the arms
can be done with no sedation in selected patients, oral seda-
Table 29.3 The type of energy used in the various technologies as an
adjunct to Liposuction
Energy source Energy type Brand Names
Cryolipolysis Cold CoolSculpting
Laser lipolysis Heat Sculpsure
Radio frequency Heat Vanquish
Ultrasound Heat Ultrashape, Liposonix
Table 29.4 Constituents of the tumescent solution
Standard Tumescent Solution
Saline 1000cm
2% plain lidocaine 50cm
1:1000 epinephrine 1ml
Sodium bicarbonate (awake
patients)
Tranexamic acid 1gm divided by number of bags
3
3
12.5ml
(optional)
tion, intravenous sedation, or general anesthesia for others.
In the class 1-A patient the skin will generally retract very
nicely without need for other sources of energy. Incision
placement is around the elbow being mindful of the ulnar
nerve. Liposuction in the medial arm should be minimal,
reserving a majority of the procedure for the posterior and
lateral arm. Sculpting of the deltoid laterally is also a nice
touch. For this area, smaller cannulas are recommended in
the class 1-A patient and, as with all liposuction, continuous
moving of the cannula, staying in deeper layers of fat, avoiding the dermis and subdermal fat, along with avoiding end
hits with the cannula are all good practice. Closure of puncture sites is optional but does decrease drainage and patient
anxiety. We use a compression garment after the procedure
that is connected in the back. We nd sleeves are difcult to
keep in place and are seldom worn properly. The garment
does help with immediate postoperative swelling and
improves comfort after liposuction but has not been shown to
affect the long-term result. Final results for fat resorption and
skin retraction can be expected in 3–6months.
29.6.2 Class 1-B Patients
• Liposuction with adjuncts for skin tightening in the
class 1-B patient have made signicant advances in effectiveness and safety. We now have many sources of energy
to heat the subdermal attachments resulting in skin contracture. Of course, the most important part of all of these
procedures is the liposuction itself. All of these adjuncts
will not cover for poorly performed liposuction. The
energy forms available all produce heat. The heat lyses
some fat but most importantly, heat causes retraction of
subdermal attachments initially and over time. The
devices also cause repair and contracture/retraction of the
bro septal attachments between the skin and the underlying fascia and thickening of the skin due to collagen deposition in the healing process. These are all desired effects,
and when combined with well performed liposuction,
results can be very good when performed on the right
patient. The goal of heating the subdermal and connective
tissue comes at a cost however, and that cost is potential
damage to the skin. Here is a list of devices:
– Laser: Laser liposuction is one of the rst highly mar-
keted devices used. Most devices use a 1064 Yag laser
to impart laser energy into the area being treated. The
light energy heats the subdermal tissue using water as
the chromophore and causes skin retraction. Lasers can
use infrared temperature monitors to monitor external
skin temperature but they tend to be inaccurate. Heating
the subdermal tissue to an adequate temperature without creating skin damage can be challenging and intimidating, leaving areas undertreated with varying results.
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J. A. Swetnam
Table 29.5 Comparison of various technologies
Technology Monitored Common Manufacturer name
Laser No Smart lipo
Ultrasound No Vaser
Radio frequency Yes Body Tite
Plasma No Renuvion J-plasma
– Ultrasound: Ultrasound is another technology that has
been around for some time. Using a wand inserted into
the subdermal fat, ultrasound energy is used to cause
very rapid vibrations that are imparted into the fat creating heat and cavitation that liquies fat and creates
heat with a secondary skin response and contraction.
– Radio frequency (RF): RF technology has also been
around for some time. It has been used topically to
tighten skin and over the past several years, this has
translated into use subdermally and combined with
liposuction. The newest RFAL (radiofrequency
assisted liposuction) systems have internal temperature monitoring to meet the temperature goals when
heating the subdermal tissue, and external temperature
controls that keep skin temperatures from reaching
dangerous levels. Combined with liposuction, RFAL is
one of the safer and consistantly successful methods of
using heat to cause skin contracture.
– Plasma: One of the newer technologies is plasma
combined with RF. Using plasma technology combined with RF and liposuction is a new approach
touting the ability to treat larger areas in much less
time. Plasma/RF works by heating subdermal tissue
but does it faster while limiting heat transfer to the
skin.
Table 29.5 shows the comparison between the vari-
ous technologies used during liposuction of arms.
The second is the posterior approach described by
Elkhatib [5]. This approach places the scar posteriorly along
the back of the arm.
The preferred method for my practice is a posteromedial
approach where the incision is placed halfway between the
medial grove and true posterior. The reasoning for this is to
have access to slightly thicker skin and a scar that is not easily visible from the front or back.
29.7 Brachioplasty Technique
During marking, the static line is placed in the posteriormedial aspect of the arm from the medial epicondyle to the
axillae. Using the pinch test, the variable line is estimated
and marked, creating the proposed ellipse to be removed
(Fig.29.17a, b). Lines of meridian are placed to help simplify closure. Another important note is to mark fat distal to
the incision for liposuction. This often is present on the upper
forearm and must be removed to have good transition.
After preparing the arms, tumescent anesthesia is injected
into both upper arms. The arms are rigorously liposuctioned
a
29.6.3 Class 1-C Patients
Patients falling in the 1-C category have too much skin laxity
for liposuction and even minimally invasive technologies are
inadequate to use as treatment. In general, skin quality is
usually compromised as well with decreased elasticity and
thinning common.
For patients in this category, a standard brachioplasty is
recommended.
There are 3 basic approaches to the brachioplasty. The
rst is the medial approach where the incision is made in the
natural groove in the medial aspect of the arm from the
medial epicondyle to the axillae.
b
Fig. 29.17 A 46-year-old female after weight loss surgery. (a) Static
line with meridian lines and marking for liposuction on the distal forearm. (b) Illustrates the proposed ellipse to be removed
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beneath the area of resection down to dermis only.
Liposuction around the areas is done leaving a fatty layer.
Towel clips are then used to pull the edges together and
verify or re-mark the non-static line. The skin edges are
incised and an avulsion technique is used to remove the skin.
This Avelar type technique for the arms is safer, causes fewer
nerve injuries and has fewer seromas because lymphatics are
Fig. 29.18 A 41years old
class 1B/C before and after
brachioplasty
left largely intact. The wound is then approximated with a
2-0 interrupted Vicryl suture at the Meridian lines followed
by 2-0 and 3-0 Monocryl and lastly a 3-0 Monoderm
Stratax. For a dressing we use Dermabond Prineo and then
place the compression garment. Figures29.18 and 29.19 are
clinical photographs of patients who have undergone the brachioplasty surgery to address the lax arm skin.
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Fig. 29.19 A 68-year-old
female. Before and after
brachioplasty
J. A. Swetnam
29.8 Class 2 Patients, Extended
Brachioplasty
The class 2 patient is one that has signicant excess skin
present not only in the arm, but in the axillae as well. These
are patients that may also have signicant breast ptosis but
do not want a breast lift at the same time. This procedure is
done much the same as the Brachioplasty except the markings are carried through the axillae and onto the lateral chest
wall to eliminate excess tissue in the axillae, lateral chest
wall and, by default, the upper back. The static line is carried
from the posterior-medial upper arm into the axillae where
the line is peaked towards the lateral edge of the pectoralis
muscle to eliminate skin tension across the joint. From there
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