Introduction

Individuals that have experienced massive weight loss will often present with significant upper arm deformities. As with the other areas of the body such as the breasts, abdomen, buttocks, and thighs, significant fat reduction in the upper arms results in excess hanging skin and varying amounts of remaining fat. Many patients will call these their “bat wings.” These deformities can lead to embarrassment, rashes, and discomfort in clothing. Patients are unhappy with this stigma of their previous obesity, which has led to the authors’ development of the presented technique.

In the development of the presented technique, the senior author had to recognize the basic nature of the deformity in the upper arm of the massive weight loss patient. The excess was noted to be located within the posterior axillary fold as it extends from the axilla to the upper arm. Thus, since the posterior fold traverses from the upper arm to the axilla and onto the lateral chest wall, the excess also involved the upper arm, axilla, and the lateral chest wall (see Fig. 4.1). This was a major advancement in knowledge, which led to the authors’ technique of crossing the axilla with the resection. Other authors have since developed other methods of resection, but they are all based on the need to cross the axilla with the resection onto the chest wall.

FIG. 4.1 The typical “bat wing” deformity in a massive weight loss patient.

The yellow mark demonstrates how the excess crosses from the upper arm onto the lateral chest wall.

Another important concept that the senior author introduced to brachioplasty surgery is the understanding of the anatomy of the arm as it relates to the dynamics of surgery. The arm is a cylindrical structure with a hard non-compressible inner core made up of the musculoskeletal system. The inner core is covered by the skin–fat envelope, which makes up a small percentage of the entire cross-sectional area of the arm. This creates a potentially dangerous situation because the skin–fat envelope cannot tolerate even a moderate amount of swelling, as the hard inner core will not compress to accommodate that swelling. Thus this led to the discovery that allowing the arm to develop any significant amount of swelling while performing a brachioplasty can lead to one of two bad outcomes. First, if the technique allows adjustment for intraoperative swelling then less tissue is resected than ideal. Second, if the surgeon commits to the proposed amount of resection and swelling is allowed to occur in the skin–fat envelope, then the wound will not close.

The technique presented here accounts for these two major discoveries: the resection should cross the axilla and minimal to no swelling should be allowed to occur during the procedure.^1,2

Preoperative Preparation

Included in the initial evaluation of the patient is a thorough examination of the arms. The upper arm meets the chest wall at a junction bordered by the anterior and posterior axillary folds and the hair-bearing axilla. The degree of horizontal and vertical excess is noted as well as the degree of skin laxity. The quality of the skin envelope is analyzed in relationship to the overall bulk of the arm.

Photographs of the patient should be taken with the arms abducted at 90° from the lateral chest wall, with elbows straight and then bent at 90°. Anterior and posterior views should be obtained. Lateral views with the elbows at 90° are also advisable. A careful assessment of the arms will reveal the redundant tissue is in the posterior axillary fold, which, as discussed above, crosses the axilla onto the lateral chest wall.

Patients may be categorized into three subsets. The first group of patients is those with significantly deflated arms and a thin layer of remaining subcutaneous fat. These patients are ideal candidates for excisional brachioplasty. The second group of patients presents with a large amount of persistent subcutaneous fat in their arms following massive weight loss. These patients should be treated in a staged fashion with aggressive liposuction of the upper arms as the first procedure. Then in 3 to 6 months they can undergo an excisional procedure, as a second stage. The third group of patients presents with an intermediate amount of subcutaneous tissue. These patients may choose between undergoing excisional brachioplasty with a less-than-ideal result or a staged procedure with liposuction first.

The goals of the brachioplasty procedure are to remove the horizontal upper arm soft tissue and skin excess that occur from massive weight loss and create a smooth transition from the lateral chest wall to the upper arm. The authors prefer placing the scar on the most inferior aspect of the arm in the abducted position because, when facing an observer and animating the arms, this area is least visible. Final scar position will differ based on surgeon preference.

Surgical Technique

Regardless of the brachioplasty technique chosen, the surgeon must strike a balance between resecting enough skin and soft tissue to create an attractive contour and over-resecting at the risk of not being able to close the wound. As mentioned above, the upper arm should be thought of as a cylinder with a hard, noncompressible inner core composed of bone and muscle mass, surrounded by soft tissue and skin. Aggressive resection will result in compression of soft tissues against the hard, noncompressible inner core, leading to increased risk of neurovascular compromise and possibly even inability to close the defect. To avoid this complication we employ the “double ellipse marking technique”. The outer ellipse is based on anatomic reference points that outline the extent of the upper arm deformity including the lateral chest wall and, if necessary, across the elbow. The inner ellipse is based on the outer ellipse but adjusted to allow closure of the wound around a cylindrical core.

Preoperative Markings: Double Ellipse Technique

1. Patient seated with arms abducted to 90° and elbows flexed at 90°.

2. At the axillary crease, located at the junction of the arm with the chest wall, excess skin and subcutaneous tissues are pinched just below the musculoskeletal complex. The anterior and posterior margins of this pinch are marked.

3. This process of pinching just below the musculoskeletal system is repeated at multiple points along the entire upper arm. In some patients the excess will have to be followed past the elbow.

4. The pinching of excess tissue is continued onto the lateral chest wall.

5. The marks are then all connected, both anteriorly and posteriorly, to create the first ellipse. This ellipse does not account for the distance between the pinching fingers and if used to resect tissues will not allow enough skin to be left behind to close the arm.

6. A second ellipse is created, based on the first ellipse, which accounts for the distance between the pinching fingers. Thus at multiple points along the upper arm, this pinch is repeated and the distance between the pinched fingers is noted. Marks that move in from the original ellipse edges by half the distance of the pinch are then made.

7. This process is repeated along the extent of the arm but not the lateral chest wall, since the resection is not around a cylinder at this point.

8. The second set of marks is then connected to create the inner ellipse.

9. Horizontal hatch marks are made at varying distances along the length of the ellipse to assist with final closure (see Fig. 4.2).

FIG. 4.2 The double ellipse markings.

The outer ellipse is based on the pinch of the soft tissues just below the musculoskeletal anatomy of the arm. The inner ellipse is created as an adjustment of the outer ellipse, based on the need to leave enough skin behind to account for the distance between the pinched fingers. Note that once the resection moves onto the lateral chest wall, the outer ellipse is reverted to.

Postoperative Care

At the conclusion of the procedure the arms are elevated on multiple pillows with a slight bend at the elbow. No compression sleeves or wrappings are used. The arms are kept elevated above the heart for 2 to 3 weeks but patients are allowed to lower them for brief periods of time to perform necessary activities. Swelling in the arms and hands is not uncommon and typically resolves in 1 to 2 weeks. Patients can usually return to normal vigorous activity 3 to 6 weeks after surgery.

It is not unusual for patients to experience small areas of wound separation, especially in the axilla. The authors prefer to leave a few external skin staples around the axilla, to help reduce that risk.

Optimizing Outcomes

Because of the nature of closing around a cylinder the resultant healing scar often has a scalloped appearance that tends to resolve over a 6 to 12 month period. Patients are often concerned about scalloping unless they are counseled about its likely presence for a period of time after surgery. It is also the authors’ experience that scar quality takes longer to reach maturity than most scars in the body. The technique described in this chapter leads to a more posteriorly positioned scar when compared to the previously more popular bicipital groove scar. The position of the scar in brachioplasty is a matter of surgeon preference, with no right or wrong position. The authors’ preference for a posterior scar is based on a number of issues. First, the most visible aspect of the arm during normal animation of an individual facing an observer is the bicipital groove. The posterior scar is essentially invisible in that situation. Second, resections that are centered on the bicipital groove may injure the medial antebrachial cutaneous nerve, as well as a relatively lymph-rich area of the arm. The potential negative aspect of a posterior scar is that an observer standing behind a patient may see part of the scar.

The technique described in this chapter is quite effective in reducing upper arm access, reducing axillary laxity, and because of the lateral chest wall component of the excision, can also be utilized to decrease horizontal thoracic excess. In the authors’ experience the technique is far more effective than the previously popular “T” type brachioplasty technique, especially when the excess is of a severe nature.^3,4 A typical early postoperative result of the technique discussed in this chapter is shown in Fig. 4.3.

FIG. 4.3 A patient is shown preoperatively (a) and early in the postoperative period (B) after brachioplasty performed utilizing the technique discussed in this chapter.

Complications and Their Management

General risks of surgery should always be discussed with the patient, including infection and bleeding. Specific to brachioplasty, superficial nonhealing areas tend to be the most common complication. They often occur in the region of the axilla and can mostly be allowed to heal by secondary intention. Deeper dehiscences are less frequent in the experience of the authors and may or may not require formal closures.

Patients should also be made aware of the risks of potential seromas, which tend to occur right above the elbow, but can be located anywhere. They are treated initially by repeated aspirations, progressing to the use of sclerosing agents, and finally they are exteriorized by opening the scar over the area of the seroma and leaving a wick in place to allow for drainage and closure from deep to superficial. Infections are uncommon but tend to occur in association with seromas. Initial treatment is decompression and antibiotic treatment and then exteriorization.

Historically, poor scarring has always been a problem with brachioplasty. Even with the use of deep sutures to support the superficial fascial system, scars often appear raised and cordlike. It is presumed that the etiology of poor scaring is tension on closure but it is not clear that this is more of a problem with the arms than other areas of the body. Thus it may also be related to the intrinsic nature of arm skin. Despite the poor quality of many arm scars, especially within the first year, it is the impression of the authors that they eventually mature, similar to other scars, but take considerably longer, up to 2 years, to mature.

A distal dog-ear can result distally if there is considerable forearm excess. In those instances, the authors do not hesitate to cross the elbow. This can be performed during the original brachioplasty operation or revised in a subsequent procedure. If the excess extends all the way to the wrist, the resection is limited to 8 to 10 cm below the elbow in the preliminary procedure. Subsequently, after the lymphatic drainage of the arm is re-established, a secondary final excision can be undertaken in a secondary procedure.

While the brachioplasty resection is performed superficial to the muscle fascia, thus sparing the deep vital structures, some skin sensory nerves are necessarily resected. This will cause some degree of sensory loss in the upper arm that is difficult to avoid.

The lymphatic drainage of the arm is often temporarily compromised after brachioplasty, which can lead to early postoperative edema. This usually resolves in 1 to 2 weeks. However, if extensive lymphatic interruption occurs, which is more likely to be associated with bicipital scar position, there is potential for permanent lymphedema. To help reduce the risk, leaving behind some intact lymphatics in the axilla is advantageous.

Inability to close a brachioplasty incision is a difficult problem. It may manifest as a very tight closure that compromises skin vascularity or loss of distal pulses. Once encountered, the area of greatest constriction has to be identified and the sutures in that segment released. An option at this juncture is to utilize some of the resected skin as a full thickness skin graft to bridge the gap. Another option, especially if the problem is felt to be secondary to intraoperative swelling rather than over-resection, is to lightly wrap the arm for a few days to allow the swelling to resolve, then attempt closing the arm without tension. Of course, it is best to avoid this problem in the first place by following some of the recommendations mentioned in this chapter.

Another problem with a brachioplasty closure that is overly tight is compression of the deeper motor nerves, particularly the ulnar nerve. This can create a scenario similar to compartment syndrome. Treatment of this requires release of the tension and close follow up to evaluate the extent of injury as well as to monitor return of function.

Conclusion

Massive weight loss patients often present with a “bat wing” deformity that extends to the lateral chest wall. This type of deformity requires that the resection cross the axilla from the upper arm onto the lateral chest wall to allow for maximal improvement. Multiple checks during the marking process and the surgical procedure allow for accurately approximating the amount to be resected and prevention of problems with under- or over-resection. Efficient surgical technique will also prevent intraoperative swelling leading to an inability to close the arm. Finally, although scar position in brachioplasty is a matter of surgeon preference, placing the scar in a posterior aspect of the arm effectively hides the scar during normal daily activities and avoids potential medial antebrachial cutaneous nerve injury and may lead to less injury of the lymphatics of the upper arms.