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 A parallel line descends from the deltopectoral groove through the axilla.

When the arm is fully raised, the equal lengths of the anterior and posterior incision lines of the upper arm are confirmed before continuing as zigzags across the axilla. An inferiorly based triangular flap of the proximal posterior upper arm has been formed as the inferior arm incision meets the lateral incision of the vertically oriented axillary ellipse. In essence, the long hemiellipse of the arm is connected to the short vertically oriented ellipse of the lateral chest by a chevron pattern excision through the axilla. Cross-hatching alignment lines are drawn.

The operation

With the patient supine, the arms are abducted about 80 degrees on arm boards. Arm intravenous infusion is avoided. The width of resection is rechecked. About 100 mL of saline with 1 mg of epinephrine and 20 mL of 1% xylocaine per liter are infused.

The arching posterior arm incision is made through skin to the superficial fascia, and then undermined by 1 cm. The anterior straight line arm incision is similarly made. Next, the outline of the shorter axillary-chest ellipse is incised. In the chest the incisions extend through fat to serratus fascia. If a “spiral flap” breast reshaping is to be performed, the posterior limb of the ellipse is not incised until the mastopexy/augmentation is completed.

The incision courses subdermal through the axilla and then is completed deeply over muscular fascia of the lateral chest. The clavipectoral fascia of the axilla is seen but not entered. The skin and underlying superficial fat are removed as a composite sheet, being sure to maintain a layer of deep subcutaneous fat.

A deep suture advances the PAF triangular flap to the deltopectoral groove. The anterior and posterior arm and chest incisions and are then aligned with towel hooks according to the hatch marks (Fig. 67.7). Only minor adjustments in incision length need be made, and if the excision was inadequate more skin can be removed. A continuous horizontal running 2-0 gauge braided absorbable suture approximates the subcutaneous fascia (Fig. 67.8). A second smaller caliber continuous monofilament intradermal closure follows. Dermal glue completes the operation, and drains are used. The operative time for both arms is approximately 90 minutes. The arms are wrapped in gauze and an ace wrap.

Fig. 67.7 The anterior and posterior arm and chest incisions and are aligned with towel hooks according to the hatch marks.

Fig. 67.8 A continuous horizontal running 2-0 gauge braided absorbable suture approximates the subcutaneous fascia.

For the last 20 cases, aggressive liposuction by ultrasonic assisted lipoplasty has removed most fat under and preliminary to resection of the arm hemiellipse. The skin is not resected until there is a depression under the pattern and the suction cannula can be visualized subdermal. Limited lipoplasty may be performed elsewhere (Fig. 67.9). Then the medial arm skin is sharply resected like a composite skin graft with adherent web like network of connective tissue and vessels (Fig. 67.10). Bleeding is minimal.

Fig. 67.9 The skin is not resected under there is a depression under the pattern and the suction cannula can be visualized subdermal. Limited lipoplasty may be performed elsewhere.

Fig. 67.10 The medial arm skin is sharply resected like a composite skin graft with adherent web like network of connective tissue and vessels.

Once the skin is removed the subcutaneous fascial network with accompanying vasculature and sensory nerves are seen (Fig. 67.11). When the liposuction is precise, the retained edge of subcutaneous tissue remains intact for closure.

Fig. 67.11 Once the skin is removed the subcutaneous fascial network with accompanying vasculature and sensory nerves are seen.

The next six figures are multiple pre- and postoperative views of a 59-year-old, 5 ft 6 in woman who lost 150 pounds after gastric bypass surgery. Two years previously she had a Wise pattern breast reduction. She had a total body lift (fleur de lys abdominoplasty, lower body lift, medial thighplasty and mons plasty) that included bilateral L brachioplasties (Fig. 67.12). Minor revision surgery around her breasts improved their definition from the chest wall. VASER® Ultrasonic Assisted Lipoplasty was liberally used throughout, with 250 mL removed from each arm with her brachioplasty modified as shown in Figs 67.10–67.12. Her result is seen 10 weeks later, with healing of all skin closures. Her new arm size is harmonious with her body. There is no redundant skin of her arm, axilla and lateral chests, and normal and pleasing contours are seen throughout her arms and torso.

Fig. 67.12 Pre- and postoperative views of a 59-year-old, 5 ft 6 in woman who lost 150 pounds after gastric bypass surgery. The patient had a Wise pattern breast reduction and a total body lift (fleur de lys abdominoplasty, lower body lift, medial thighplasty and mons plasty) that included bilateral L brachioplasties.

Postoperative care

The arm incisions are covered with gauze and then the arms are wrapped in 6-inch aces with care taken not to constrict across the triangular advancement flap. The arms are elevated on pillows. If distal swelling is excessive, the elastic wraps are removed. Otherwise the aces are exchanged for elastic sleeves in three days. Ischemic changes in the flap delays sleeve change. The sleeves are worn six weeks or longer if needed.

Complications

Tip necrosis of the V advancement flap occurred in about 20% of the cases, leaving a small wound in the axilla to heal secondarily. This may be due to excessive tension of its approximation to the deltopectoral groove. Pressure from an elastic sleeve or ace wrap may also incur necrosis. After debridement, secondary healing may progress to thickened and at times a contracting scar. This complication can be avoided by keeping the flap long and avoiding constricting pressure.

Debridement in the axilla and secondary closure was needed in three patients. Another patient required skin grafting for delayed healing of axillary and hip wounds. Further limited skin reduction after a year was performed in two patients.

One obese patient suffered chronic mild total arm swelling temporarily responsive to pressure therapy. Recurrent lymphoceles of 3–5 cm in the mid to distal medial arm occurred in about 20% of the patients. All lymphoceles responded to repeated aspiration and localized pressure. A few patients accept walnut-sized lumps. During the last 20 arms with preliminary UAL there have been no lymphoceles.

Complete maturation of the scars often takes longer than two years, so patients should be encouraged to wait extended periods for scar fade.