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29 Brachioplasty (Arm Reduction)
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Fig. 29.20 A 58-year-old
before and after brachioplasty
and axillary reduction
445
it is carried down the lateral chest wall. Again, using the
pinch test, a good estimate of the skin to be removed is made
and the non-static line is marked. Meridians are again made
to simplify and orient closure (Figs.29.20, 29.21, and 29.22).
After tumescent, the areas for resection are, again, treated
to vigorous liposuction and an Avelar type removal of skin is
performed to disrupt as few lymphatic structures and nervous tissue as possible. Closure is the same using 2-0 Vicryl,
then 2-0 and 3-0 Monocryl with the nal closure of 3-0
Monoderm Stratax and Prineo. A closed suction drain is
placed in the axillae with the exit point at the most dependent
position.
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J. A. Swetnam
Fig. 29.21 A 48-year-old before and after extended brachioplasty with axillary reduction
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Fig. 29.22 A 44-year-old after gastric bypass. Class 3 downgraded to a class 2 after a breast lift with augmentation. Staging is always an option.
It is recommended the breast be done rst and match the axillary incision with the less variable horizontal breast incision
29.9 Class 3 Patients, Including theBreast
Class 3 patients can be the most challenging and yet the most
rewarding. You are essentially treating the entire upper quadrant which includes the arm, the axillae and by default the
upper back along with the breast in one procedure and
patients are very grateful (Fig.29.23). The class 3 joins a
brachioplasty with the axillary reduction and nally the
Weiss pattern breast lift or reduction. The markings for the
arm and upper axillae are essentially the same as for the class
2 patient. The Weiss pattern reduction or lift markings
(Figs. 29.24, 29.25, 29.26 and 29.27) are customized by
marking the new nipple position in the mid hemithorax at or
just above the old inframammary fold or crease. Rotation
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Fig. 29.23 Class 3: A 55-year-old female after gastric bypass and over
100-pound weight loss. Bilateral breast and nipple ptosis with axillary
ptosis and laxity in the arm
Fig. 29.24 Marked and ready for prepping. Note static line upper, estimated “non-static” lower line of resection, offset of incision crossing
the joint, and marking for liposuction upper forearm and avoiding
“straight” lines across the axillae
Fig. 29.25 Breast lift mostly complete after superior-medial pedicle,
elevation of breast mound with anchoring and closure of the medial horizontal incision. Aggressive liposuction was completed rst and before
making the “non-static” incision, towel clips were used to pull skin edges
together and re-mark. A more aggressive excision was done in the axillae.
Picture is post skin incision and avulsion of skin and fat. Of note is the
preferred approach to each side independently and placing a roll under
the scapula, toward the midline for better access. Foot access for IV’s is
preferred and the entire arm prepped allowing access and mobility
J. A. Swetnam
Fig. 29.26 Closure complete, Prineo applied and drain dressed
and elevation of the nipple during markings help identify the
extent of skin removal and the vertical limb distance is estimated (usually around a 6–10cm length). The horizontal is
marked based on the inframammary fold, established by
pushing the breast upward and marking the actual IMF.The
Weiss pattern is completed by connecting the vertical and
horizontal legs. Laterally, the upper horizontal marking is the
static mark and connects with the static mark in the anterior
axillae. The lower horizontal mark is carried out to meet the
non-static mark estimated by the pinch test. The amount of
skin to be removed laterally should not be underestimated.
Removal of this skin will make signicant changes, for the
better, in the upper back, upper abdomen, as well as the
axillae.
For this procedure, the arm portion of the procedure and
axillary portion remain the same. Aggressive liposuction is
performed in the axillary area and around the upper back as
far as possible is recommended. This allows greater ap
movement and resection of more tissue with minimal tension and a better result (Figs. 29.24, 29.25, 29.26 and
29.27). The breast mound should be elevated and anchored
to the underlying pectoralis fascia during the lift to avoid
lateral shifting of the lift/reduction. As described by
Coombs [2] massive weight loss patients have little support
for breast tissue if it is present. In most cases, I choose to
use the superior-medial pedicle and, once created, tack the
pedicle to underlying pectoralis fascia to elevate the breast
pyramid. Experience shows the breast shape after the superior-medial pedicle to be much more durable than the inferior pedicle where “bottoming out” and the nipple elevation
after, seemed to be a constant problem. This pedicle is more
resistant to gravitational effects and, when anchored, in
many patients with adequate volume, maintains upper pole
fullness even without an implant. The usual order is,
aggressive liposuction to the arm and axillae, after injecting
tumescent solution rst, followed by the breast lift/reduction. The nipple, vertical and horizontal breast incision is
closed to just past the midline where liposuction began.
Again, towel clips or staples are used to pull skin together
and mark the exact non-static lines. Once marked, the incision is completed to the elbow and this tissue is avulsed.
Closure is the same, using 2-0 Vicryl to bring the meridian
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Fig. 29.27 Superior-medial pedicle for breast lift/reduction [6] Loskin
lines together then 2-0 and 3-0 Monocryl and the nal 3-0
Monoderm Stratax. Prineo Dermabond is then applied
and the garment and bra are applied. A closed suction drain
is placed on each side at the lowest point in the axillae. The
drain is pulled when output is 30 cm3 or less in a 24-h
period (Figs.29.28 and 29.29).
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Fig. 29.28 One-week postoperatively
Fig. 29.29 A 50-year-old male before and after. Gastric bypass with
signicant weight loss. Class 3 after arm, axillae, and breast lift
29.10 Common Complications
1. For non-invasive treatments, complications are rare. With
cryo-lipolysis and laser-lipolysis, the acute issue, though
rare, is skin damage due to excess cooling or heating.
Managing the area by slow re-warming or cooling and
then managing expectantly is advised. Topical treatment
is indicated with silver sulfadiazine or triple antibiotic
ointment for signicant thermal injuries and in some,
debridement may eventually be needed with grafting or
delayed closure. The other issues with non-invasive treatments usually revolve around managing expectations.
With Cryolipolysis, rebound lipo-hypertrophy can also
occur.
2. For minimally invasive treatments, thermal damage to the
dermis is a rare complication avoided by staying deeper
in the fatty layers, avoiding making tip contact with the
skin during treatment when using any of the technologies.
Infection is a rare occurrence and the wounds are very
small and heal well. Seroma formation does happen and
is treated with aspiration. Any other issues are usually
J. A. Swetnam
technique related, associated with liposuction and include
suction deformities, scar formation and irregularities or
“lumpiness.”
3. As with any actual body contouring procedure the most
common issues are with skin and scars. Small areas of
supercial wound dehiscence are common, especially at
the trifurcation of the upper and lower vertical incision in
the Weiss pattern breast closure.
– Infection is rare and usually supercial if it occurs.
Antibiotics and drainage are utilized when indicated.
– Hematomas should be drained and any hemorrhage
controlled.
– Seroma can occur but the incidence is lowered by
placing drains and using the avulsion technique
described. Aspiration is the treatment of choice initially and if persistent, the seroma may require replacement of a drain and seroma Desis. Long term problems
are generally related to scar formation.
– Hypertrophic scarring is not uncommon and is treated
with steroid injections (Kenalog 10), laser and micro
needling, and in the severe case, re-excision, usually
segmental.
– Ischemia in the distal arm is a rare cause of concern,
but the most feared. Patients complaining of a cold,
painful, numb hand should be seen and evaluated as
soon as possible. If distal pulses are diminished or
absent, you must assume it is related to the closure.
The wound should be released and the hand reevaluated. Return of ow conrms suspicions and the
wound must be left open. If ischemia is still a problem,
further vascular workup is indicated.
– Sensory changes that are minor can occur and nor-
mally will resolve over time. Any major neurologic
changes should be addressed by assessing any vascular issues rst, if none exist, nerve conduction studies
are in order.
– Nipple ischemia or pedicle necrosis should be treated
as ischemia rst using topical vasodilators and releasing sutures around the nipple. Should the area necrose,
debridement may be in order depending on the extent.
Supercial necrosis should be treated topically.
Necrosis of the pedicle may require more extensive
debridement.
29.11 Conclusion
– Contouring of the arm and upper quarter of the body is in
high demand and the demand is increasing with the
advancements in laparoscopic weight loss surgery and its
better safety prole along with improving medical weight
loss. Most public and private health insurers are also recognizing the long-term health benets of surgical weight loss.
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– Classication of the upper quarter is necessary to tailor
treatments appropriately and should be simple and easily
remembered.
Classication Description
Class 1—Upper
arm only
Class 2—Upper
arm and axillae
Class 3—Arm,
axillae, breast
Class 4—Breast
and axillae
A.Mild and localized adipose tissue with good
skin elasticity and quality
B.Mild-to-moderate adiposity with some skin
laxity and good skin quality and elasticity
C.Mild-to-moderate adiposity with signicant
skin laxity and, or poor skin quality and
elasticity
Batwing deformity where there is no clear
demarcation between the arm and axillae or
axillary rolls are present
Signicant breast and nipple ptosis present with
a desire for a lift or reduction and axillae and
arm are also involved.
Breast and nipple ptosis with excess skin and
adipose tissue in the axillae, with or without
Macromastia.
– The arm should not be treated in a vacuum. The entire
upper quarter should be evaluated, and all options considered to maximize results with the minimum number
of surgical and anesthetic exposures. Choosing the correct procedure is critical and does require some artistry
and exibility on the part of the surgeon. Choosing the
correct procedure will often change the overall plan and
often eliminates procedures form the original plan. Plan
on changing your plan is a good motto when treating
weight loss patients who require larger “lifting”
procedures.
References
1. American Society of Plastic Surgeons 2018 statistics report.
2. Coombs DM, Srivastava U, Amar D, Rubin JP, Gusenoff JA.The chal-
lenges of augmentation mastopexy in the massive weight loss patient:
technical considerations. Plast Reconstr Surg. 2017;139(5):1090–9.
https://doi.org/10.1097/PRS.0000000000003294.
3. Losken APA, Albert MD.Breast reshaping following massive weight
loss: principles and techniques. Plast Reconstr Surg. 2010;126(3):1075–
85. https://doi.org/10.1097/PRS.0b013e3181e60580.
4. Han HH, Lee MC, Kim SH, Lee JH, Ahn ST, Rhie JW.Upper arm
contouring with brachioplasty after massive weight loss. Arch Plast
Surg. 2014;41(3):271–6. https://doi.org/10.5999/aps.2014.41.3.271.
5. Elkhatib H.Posterior Scar Brachioplasty with Fascial Suspension:
A Long-term Follow-up of a Modied Technique. Plast Reconstr
Surg Glob Open. 2013;1(6):e38. https://doi.org/10.1097/GOX.
6. Losken A, Funderburk CD, Duggal C. The extended superome-
dial pedicle: advancing mammaplasty techniques. Modern Plastic
Surgery. 2013;3(1):20–7. https://doi.org/10.4236/mps.2013.31005.
Circumferential Body Lift withBreast
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Procedures
ReneCalderon
30
30.1 Introduction
The eld of bariatric surgery has been growing dramatically
in the last few years. Morbidly obese patients who only
expected a temporary relief through nutritionists and specialists in medicine now have a chance to lose this excess weight
surgically with minimal or no complications. Use of laparoscopic procedures causing reduced postoperative discomfort
and recovery time helps these high-risk obese patients return
quickly to normal activity.
Losing large amounts of weight is the rst step of a morbidly obese person and the second step should include achieving an acceptable aesthetic body shape once the weight loss
has stabilized. This massive weight loss causes signicant skin
laxity in the abdomen, breasts, arms, and thighs which can
lead to a poor quality of life as well as reduced social acceptance. This dermatochalasis can additionally lead to intertrigo,
limitations in routine activities such as walking, sex, and passing urine along with associated loss of self-esteem and depression. Hence, it becomes very important to treat this loose skin
caused by deation which is usually generalized.
Recently, aesthetic surgery has begun to answer these
problems. There are many options to treat aesthetic requests
to tighten the loose skin post weight loss specially with an
experienced surgeon. The excess skin envelope and the associated contour deformity specially involving the abdomen,
anks, back, buttocks, and outer thighs can be very well
treated by belt lipectomy and lower body lift. Deated
breasts will need a mastopexy with or without an implant to
add volume to the empty breast envelope.
Postbariatric patients could began their aesthetic surgery
operations at least 12months after bariatric procedure. Loose
skin envelope secondary to weight loss is a complex condition and requires multiple sessions of treatment. On an average 4–8 operations may be required by every weight loss
patient to achieve acceptable aesthetic results [1].
30.2 Obesity Classication
Body mass index (BMI) of an individual is calculated as
weight in kilograms divided by the square of height in meters
(kg/m2). American Society for Bariatric Surgery has classied obesity as per BMI (Table30.1).
People having a BMI >35kg/m2 with major co-morbid
condition(s) like obesity-related hypertension, diabetes, etc.
are also classied as morbidly obese [2].
Table 30.1 Obesity classication by American Society for Bariatric
Surgery
BMI value (kg/m2) Category
18.5–24.9 Normal
25.0–26.9 Overweight
27.0–29.9 Mild obesity
30.0–34.9 Moderate obesity—Class I
35.0–39.9 Severe obesity—Class II
40.0–49.9 Extreme (morbid) obesity—Class III
50.0–59.9 Super obesity
60.0 + Super-super obesity
R. Calderon (*)
Tijuana, Mexico
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022
M. Thomas, J. D’silva (eds.), Manual of Cosmetic Surgery and Medicine, https://doi.org/10.1007/978-981-19-4997-5_30
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30.3 Contour Deformities After Massive
Weight Loss
A loss of 50% or more of excess weight is called as a massive weight loss (MWL). The sudden rapid reduction in
weight causes skin and soft tissue excess in association with
a poor skin tone. This phenomenon of skin excess causes a
diverse and unexpected manifestations that can involve multiple areas of the body. This causes a “deated appearance”
more pronounced in the breast, abdomen, buttocks, and the
face. The dramatic weight loss does not allow the overlying
skin and the soft tissues to shrink sufciently causing the
appearance of loose skin which collapses inferiorly and
inferomedially from the characteristic areas of fat deposition. Fat loss and thus loose skin from the axilla and anks
contribute to the back rolls and ank rolls In the upper trunk.
There is also varying degree of breast ptosis and loose skin
causing a bat wing appearance in the inner aspect of the
upper arm. In the lower trunk, the massive weight causes
signicant ptosis of the lower abdomen which covers the
pubic area. Moreover, ptosis of the pubic tissues is usually
towards the inner thighs and a combination of lax skin and
massive weight loss can produce an enormous overhanging
pannus that disrupts the silhouette (Fig.30.1). The drooping
of the redundant tissues from the lower abdomen, mons
pubis, buttocks as well as from the medial thigh itself contribute directly to the excess tissues around the waist and the
thighs resulting in both a vertical and horizontal tissue
excess. Often there is pain, irritation, and intertrigo under the
massive skin folds [2].
R. Calderon
Fig. 30.1 Massive weight loss patient
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30.4 Dening Terms
The MWL patient would have deliberately reduced her/his
body weight by 100 pounds or more in order to ght the
menace of morbid obesity. Bariatric surgery usually causes a
weight loss of this magnitude but similar situations are also
seen in people who have lost a lot of weight by maintaining
a calorie restricted diet and exercise. Patients who have
undergone gastric bypass procedure as part of bariatric surgery as compared to restrictive procedures (Lap band or
sleeve gastrectomy) have undergone more anatomical modications of their gastrointestinal tract and hence have a
higher tendency of nutritional imbalances and metabolic
complications due to the malabsorptive condition. The terms
“body contouring” or “post-MWL body contouring” is generally used for any surgical procedures that alters/tightens
the skin envelope, removes the loose subcutaneous tissue
and fascia, and encompasses a wide range of operations used
to treat the weight loss patient [3].
30.5 Nutritional Considerations After
Massive Weight Loss
Anatomic and physiological modication of the gastrointestinal tract during bariatric surgery can cause a reduced capacity
for the absorption of essential vitamins, essential micro and
macronutrients, electrolytes, and also bile salts which in the
long run can cause multiple complications. Tests undertaken
a few months post-surgery can diagnose protein deciency,
reduced levels of fat-soluble vitamins, B12, iron, and folate.
Vitamin A, zinc, and selenium values may also be reduced. A
combination of these deciencies has a signicant impact on
the physiology of bone calcium deposit as well as in erythropoiesis. This is particularly obvious when obesity surgery
includes techniques which bypass the duodenum such as the
Roux-en-Y gastric bypass (RYGBP). Postoperative period
includes nausea and vomiting and dumping syndrome which
causes uid loss and Dehydration. Decreased production of
the lactate dehydrogenase can cause lactose intolerance associated with other protein deciencies.
After surgery, patients often have development of a food
intolerance to red meat and dairy products, which leads to
decits in protein intake. Protein consumption of 46 to 56g/d
is recommended, but many fail to comply for a variety of
reasons. One series reported that 4.7% of patients have
severe protein calorie malnutrition diagnosed at an average
18 months after RYGBP.Signicant wound complications
are possible due to protein deciency caused by
malabsorption.
Bypass of the duodenum and upper jejunum causes
reduced absorption of calcium, while bypass of jejunum and
ileum causes decreased vitamin D absorption which in the
long run causes osteopenia and osteoporosis. In 1998,
Gorman reported a 10years follow up with 348 patients who
had undergone gastric bypass, iron, vitamin B12, or folate
deciencies were found in 82% of patients, and 54% had
anemia. Sleeve gastrectomy as a form of bariatric surgery
also causes iron deciency due to reduced secretion of the
“Intrinsic Factor,” a necessary requirement for iron absorption. Oral supplements usually are not sufcient to reverse
the deciencies and injectable supplements may be required.
Other micronutrient deciencies may occur. Signicant
thiamine deciency can occur acutely after bariatric surgery
in patients with prolonged vomiting and can be associated
with severe and sometimes irreversible neurological symptoms [4].
30.6 Eective Nutritional andMetabolic
Screening
Nutritional concerns are usually most prominent in people
who have undergone massive weight loss secondary to bariatric surgery as compared to those who have lost through a
disciplined lifestyle and exercise; hence, it becomes important to take a thorough history at the initial consultation.
Some points to take into consideration are the following:
details about the weight loss technique, date of bariatric procedure, details about the weight loss month on month, highest weight before GBP/DE (Max BMI), goal weight, and the
last time the patient has met their bariatric surgeon/nutritionist. Weight loss changes in the last 3 months have to be
assessed so that there is conrmation of the stage of reaching
a plateau [5]. Patients should be assessed for symptoms such
as nausea, vomiting, and dumping syndrome. Prolonged
vomiting specially after a meal would indicate signs of
obstruction in the alimentary canal.
All nutritional supplementation including protein intake,
vitamins, minerals, and any hormonal medications should be
recorded as well as their blood levels checked. The goal for
protein intake should be at least 70–100g per day of highquality protein which is usually regularly consumed by people
who lose weight through natural means. Any surgical procedure should include preoperative blood work to assess complete hemogram, liver, and kidney function tests which should
include the complete protein panel including albumin and/or
prealbumin levels if concerns over malnutrition exists [3].
30.7 Preoperative Patient Screening
A safe outcome for a body contouring procedure involves
and is based on a combination of managing patient expectations and the right patient selection. The right patient selection involves the following key factors-
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