History

Inner arm longitudinal brachioplasty was introduced by Correa-Iturraspe and Fernandez in 1954. Twenty years later Pitanguy justified a visible arm and lateral breast scar for only the most severe cases of lipodystrophy of the upper arm through the lateral thorax. A fellow Brazilian, Baroudi then described the classic dermolipectomy of the upper arm with a scar along the brachial sulcus. Juri in 1979 advocated an inferiorly based long quadrangular flap rotated towards the axilla with a T-closure to avoid hypertrophic scars and dog ears. That same year, Guerrero-Santos removed excess axillary tissue followed by a Z-plasty. Regnault also sculptured the axilla, incorporating a fish-tail excision. She advocated varying the extent of excision to the deformity up to a thoracoplasty for the massive weight loss patient. Lockwood in 1994 described a T-shape excision across the axilla with permanent suture anchoring of the arm flaps to the axillary fascia.

Attempts at limiting the length of the arm scar began with Teimourian in 1997. He recommended circumferential liposuction followed by skin resection of the medial upper one-half of the arm. Then a purse string suture closure resulted in a shorter T-shaped scar along the medial sulcus. Alternative short scar techniques were published by Richards in 2002 and Abramson in 2004 that included lipoplasty, wide-axillary and upper-arm skin excision, and dermal suspension of the upper-arm skin to superior axillary fascia. With poor skin elasticity, short scar techniques have a limited role in the massive weight loss patient.

In 2004, Strauch planned two sinusoidal flaps to interdigitate along the posterior margin followed by an axillary excision and Z-plasty closure. Pascal also favors the axillary Z-plasty, but recommended aggressive subexcision liposuction of the skin to preserve lymphatics and thereby avoid the occasional lymphoceles and rare prolonged edema. The L-brachioplasty for the severe arm, axillary and chest deformities seen after massive weight loss was described by Hurwitz in 2006.

Physical evaluation

Technical steps

With the patient sitting, the arm and forearm are abducted 90 degrees with the palm forward. Dot the mid-point of the arm slightly posterior to the medial bicipital groove. An anterior line is drawn from the medial elbow through this dot to the deltopectoral groove across the dome of the axilla (Fig. 67.1). By gathering and pinching excess skin and fat posterior to the initial mark, the width of mid-arm excision is determined and a second dot is made near the posterior border (Fig. 67.2). A straight line is drawn from that point to meet the medial elbow termination of the first line (Fig. 67.3). Then by pinching posterior arm skin towards the superior axilla, a critical point is picked and marked along the inferior border of the medial arm that can be advanced to the deltopectoral groove at the proximal termination of the anterior line (Fig. 67.4). Approximation of these points should raise the posterior axillary fold, and equalize the lengths of the anterior and posterior lines. The line then acutely angles to descend inferiorly through the axilla, skirting the posterior axillary fold (Fig. 67.5). A parallel line descends from the deltopectoral groove through the axilla (Fig. 67.6). The distance between these last two lines removes the excess skin of the axilla and lateral chest.

Fig. 67.1 An anterior line is drawn from the medial elbow through this dot to the deltopectoral groove across the dome of the axilla.

Fig. 67.2 The width of mid-arm excision is determined by gathering and pinching excess skin and fat posterior to the initial mark. A second dot is made near the posterior border.

Fig. 67.3 A straight line is drawn from that point to meet the medial elbow termination of the first line.

Fig. 67.4 By pinching posterior arm skin towards the superior axilla, a critical point is picked and marked along the inferior border of the medial arm that can be advanced to the deltopectoral groove at the proximal termination of the anterior line.

Fig. 67.5 Approximation of these points should raise the posterior axillary fold, and equalize the lengths of the anterior and posterior lines. The line then acutely angles to descend inferiorly through the axilla, skirting the posterior axillary fold.

Fig. 67.6

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