INTRODUCTION
Arm contouring for lipodystrophy and ptosis
are increasing in demand with age and especially
after massive weight loss following bariatric surgeries
where aesthetic arm contouring is one of
the most requested surgeries to those patients [1].
Various deformities can occur in the arm either
with excess skin laxity or excess and heterogeneous
fat deposition, multiple classification systems were
described to give a proper assessment to those
patients, which include assessment of fat excess,
skin excess, and location of the deformity (proximal
arm, entire arm, and extension to lateral chest
wall).
Management to those cases varies between
liposuction, skin excision or combination of liposuction
and skin resection, or possibly the use of
newer energy based skin tightening devices [2].
Multiple methods had been described for arm
rejuvenation, yet none of them has provided full
satisfaction to both the patients and surgeons;
among these methods are excess skin resection of
the arm with the scar oriented horizontally placed
in the brachial sulcus, W-plasties, and T closure
and the de-epithelialized rolled-up flap, fascial
suspension technique, and lipoaspiration. The focus
of the modifications has been mainly to improve
the aesthetic result of the scar and reduce possible
complications [3].
One of the most undesirable sequelae is visible
scarring either due to widening or migration of the
scars. An ongoing, unresolved debate regards the
optimal placement of the scar, with some authors
supporting a posterior arm location, and others
favoring medial placement in the bicipital groove
also the most recently reported poster-medial scar
[4].
Another issue that concerns patients seeking
arm contouring is the presence of undesirable fat
deposits, especially in the distal arm above the
olecranon [5].
PATIENTS AND METHODS
This study was conducted on 15 patients who
presented seeking arm contouring in the period
from October 2017 to May 2019.
Demographic information, including age, sex,
associated comorbidities, method and rate of weight
loss and current body mass index, were gathered
from all patients enrolled in the study.
A detailed pre-operative counseling with consents
was done to all patients who were part of the
study. The consent included the proposed treatment
options, details of the pre-operative pictures, markings,
proposed surgical intervention, scars position
and possible post-operative complications. Patients
approved enrolment in the study and publication.
Standardized photographs were taken with the
patient's arm abducted at 90 degrees, using a 50mm
lens at 1m. photographs were taken preoperatively
and at each follow-up visit, at 2 weeks, 1 month
and 3 months.
Inclusion criteria were as follows:
• Individuals between the age of 20-50 years,
presenting for arm contouring requiring surgical
excision.
• Body mass index less than or equal to 30kg/m2.
• Minimum one year following bariatric surgery
and 6-months of weight stabilization.
Exclusion criteria include:
• Patients with severe uncontrolled comorbidities
that may limit surgery and affect proper healing.
• Patients presenting with arm lipodystrophy requiring
liposuction only.
• Patients presenting with excess skin along the
chest and upper body roll that will require upper
body lift.
• Previous history of deep vein thrombosis and/or
pulmonary embolism.
• Heamoglobin value less than 10g/dl.
• Smoking habit (>5 cigarettes a day).
84 Vol. 44, No. 1 / Single Flap Upper Medial Vector Brachioplasty
Pre-operative markings:
With the patient standing and the arm abducted
at 90 degrees, a horizontal line was drawn along
the bicipital groove extending from the axillary
crease proximally till a point two fingers above
the medial epicondyle; another line was drawn 1
finger breadth posteriorly which is the site of the
incision to end in a postero-medial scar. A perpendicular
extension of the line is marked along the
axillary crease posteriorly, marking the modified
scar placement along the axillary crease. The decision
of the length of both the distal incision at
the medial epicondyle and the proximal posterior
extension along the axillary crease were kept for
intra-operative decision according to the extent of
the excision of the skin excess; with no extension
beyond the elbow in the horizontal element of the
scar, and the posterior axillary fold as the cutoff
point that the axillary crease incision doesn't extend
beyond, to avoid visibility of the scar. Areas requiring
liposuction were marked as well in standing
position with arm abducted and adducted.
Surgical technique:
General anesthesia was used in all patients.
Procedure started with tumescence infusion for
liposuction. The Tumescence was composed of
20cc of 0.1% lidocaine in an epinephrine/saline
1:1000,000 concentration. The liposuction was
performed deep to the superficial fascia and addressed
the entire circumference of the arm with
a special concern on the proximal postero-lateral
aspect of the arm, the planned flap to be resected
and distally at the area above the olecranon. The
procedure ended with superficial liposuction to
eliminate irregularities and to enhance skin retraction.
An incision was placed at the previously drawn
line posterior to the bicipital groove; the incision
was then deepened to the honeycomb plane that
was created by the liposuction cannula. Dissection
proceeded inferiorly to the desired extent which
always reached the anterior border of the triceps
muscle with undermining between the superficial
fascia of the skin and the deep fascia of the muscle.
The undermined flap was then pulled completely
in an upper medial vector towards the axillary
crease, this vectors helps eliminate excess skin
especially at the elbow in a homogenous way, and
prevents the presence of bands. Excess skin was
excised in a tailor tucking manner from distal to
proximal to prevent any risk of skin over resection.
The fascia of the undermined flap was tacked and
fixed to the deep axillary fascia in the axillary
crease with multiple interrupted 2/0 PDS sutures
Egypt, J. Plast. Reconstr. Surg., January 2020 85
in the same fascial suspension technique previously
described by Elkhatib in 2013 [3]. The upper medial
vector pull of the skin flap directs the excess dog
ears towards the axillary crease marking which
was planned pre-operatively. Excess skin can be
removed along the axillary crease incision directed
posteriorly as an L-shaped scar or with a small Tscar
if a small extension anteriorly is needed along
the axillary crease. Layered closure was performed
with absorbable sutures. Compression garments
were instructed to be used by all patients for 6
weeks post-operatively.
Fig. (1): Pre-operative marking where the arm is abducted 90 degrees, the above dotted line is at the bicipital groove (A) while
the solid line is one finger breadth posteriorly (B), and also there is another line along the axillary crease.
Fig. (2): Showing pulling the undermined flap in an upper medial vector towards the axilla, (A) the right arm and
(B) the left arm.
Fig. (3): Immediate post-operative picture after closure of the
wound.
(A) (B)
RESULTS
Fifteen patients underwent brachioplasty with
the described technique in this study. Nine patients
had bariatric surgeries with massive weight loss,
four patients complained of arm redundancy as a
consequence of weight fluctuation and aging, and
two patients complained of excess arm skin laxity
after a previous procedure of liposuction. Mean
age at of the patients in the study was 38 years
(range between 24 to 57 years). The mean body
mass index was 27.5kg/m2 (range between 24 to
30kg/m2).
For early complications; one patient had a 2-
cm wound dehiscence at the junction of the horizontal
and vertical wounds and was treated in
outpatient setting through repeated dressing and
follow-up. Neither thromboembolic events nor
major systemic complications were experienced.
No hematoma, seroma, infection or skin necrosis
occurred in any of the patients.
For late complications; five patients experienced
hypertrophied scar and were treated with topical
therapy (silicone gel sheets), four patients complained
of scar pigmentation and were instructed
to use skin lightening creams (containing both
Vitamin C and glutathione). Neither scar widening
nor axillary contractures nor lymphedema presented
as complains in this study.
(A) (B)
DISCUSSION
Brachioplasty was first described in 1930s as
a reduction procedure of pendulous arms in obese
women. However, the first aesthetic brachioplasty
was described by Correa-Iturraspe and Fernandez
in the 1950s, and since that time, brachioplasty
has become a standard procedure for upper limb
aesthetic contouring. The most frequent causes
leading to arm redundancy are the natural aging
process, massive weight loss due to diet and exer-
86 Vol. 44, No. 1 / Single Flap Upper Medial Vector Brachioplasty
cise, and weight loss following bariatric surgeries
[6].
The number of performed brachioplasty procedures
increased in the past decade, for both massive
weight loss patients (39.8 percent) and the general
population (60.2 percent) as reported by the American
society of aesthetic surgery [7].
Despite being an effective treatment for arm
contouring, brachioplasty is associated with signif-
Fig. (4): A 42y old female patient where (A & B) are pre-operative photos while (C & D) are 6 months post-operative.
Fig. (5): A 25y old female patient where (A & B) are pre-operative photos while (C & D) are 4 weeks post-operative.
(A) (B)
(C) (D)
(A) (B)
(C) (D)
Egypt, J. Plast. Reconstr. Surg., January 2020 87
icant complication (25 to 40 percent) and revision
rates (3 to 25 percent) which can be considered
relatively high for an elective aesthetic procedure.
Commonly presented complications include widened
hypertrophic scar, visible scar, residual skin
laxity, wound dehiscence, and wound infection [8].
However, there is still controversy about what
would be the optimal location of the scar. In 2013,
Samra et al., surveyed plastic surgeons, the general
population, and former brachioplasty patients about
the optimal scar location. They found that the most
aesthetically acceptable location is the medially
placed scar [9].
The posteromedial scar approach is not visible
from behind, and compared with the classic medial
location, it is less visible from the frontal view
while the patient is abducting his/her arms [10] and
this is why it was the incision of choice in this
study.
Routine liposuction helped in dissecting the
flap between the superficial fascia and the deep
fascia of the muscle beneath, such technique was
also carried out by Nguyen and Rohrich, 2010 in
their work. Undermining the posterior flap till the
anterior border of the triceps muscle or further
posterior carried no risk since it was limited to a
plane between the superficial fascia and deep fascia
of the arm, this was evident also in the work of
Shermak, 2014. Such techniques reduced possible
risk of affecting skin vascularity [13,14]. No patients
suffered from skin necrosis or sloughing in the
study.
El-Khatib proposed a modification by adding
suspension of the anterior flap to the deep fascia
in an attempt to prevent tension at the suture line
thus improve scar quality, and reduce scar migration
in turn less visibility [2,3]. This is why in this study
we combined the idea of the postero-medial scar
with fascial suspension technique to prevent migration
or widening of the scars.
The idea of the pulling the undermined flap in
an upper medial vector, and placing the scar along
the axillary crease in a posterior direction, was to
limit the scar from crossing the axilla, for two
reasons, the first was to prevent the extension of
the scar on the chest wall reducing scar visibility
in non-indicated patients, and the second was to
prevent axillary contracture. Many patterns were
previously described including straight line scar,
a “T” shape scar, “W” shape, an “L” shape, and
“S” shape scar and sometimes including a Z-plasty
in the axilla to prevent contractures [11,12].
This upper medial vector helped in improving
the contour of the arm in a homogenous way,
eliminating skin excess especially in the area above
the olecranon in the distal arm and also avoids the
presence of bands while closure. The tailor tucking
excision of the skin prevented over resection of
the skin excess.
Conclusion:
The mentioned technique proved to be reliable
in achieving favorable arm contouring, with acceptable
scarring and a low incidence of complications.
The upper medial vector helped eliminate
excess skin, improve the contour of the arm in a
homogenous way and place the scar in a concealed
location.
Combining the postero-medial scar acceptance
to patients, with benefits of the fascial suspension
technique and the tailor tacking excision of the
skin helped reduce complications and overall patient
satisfaction.
Declaration of conflicting interests:
The authors declared no potential conflict of
interest with respect to the research, authorship,
and/or publication of this article.
Acknowledgement: None.
Funding:
The authors did not receive any funding for the
completion of this work.
Informed consent:
A detailed informed consent was obtained from
all patients who were part of the study. The consent
included details of the pre-operative pictures,
measurements, method of surgical intervention,
scars position and possible post-operative complications.
Patients approved enrolment in the study
and publication.
