Introduction

The female arm has a smoothly full but adherent skin covering that reflects the underlying musculature. The sensuous and undulating axillary hollow is created by retention of strands of fascia emanating from the chest wall to the clavipectoral fascia.

Aging as well as weight loss lead to undesirable excess skin and fat. When severe, the hanging skin is hard to cover and painful during waving. There is a canopy-like sagging of the posterior upper arm, which can be weighted down further by excessive adipose. The posterior arm junction to the chest descends, creating a broad wing-like attachment. The lateral chest has transversely oriented sagging rolls of skin lateral to the breast.

The operative strategy relates to the magnitude of deformity.¹ For the vast majority of presentations, arm skin reduction surgery is needed from the axilla to elbow.^2–4 Experience with severe arm and upper body deformity after massive weight loss (MWL) led to the design of the inclusive L-brachioplasty, so named for the L shaped pattern of excision with the long limb from the elbow to the axilla and the short limb extending at right angles through the axilla and along the lateral chest.^5,6

Preoperative Preparation

Suitable candidates for L-brachioplasty desire correction of their excess skin and fat of the arm and axilla and at times the upper lateral chest. These patients accept the possibility of long, possibly hypertrophic scars, asymmetry, inadequate resections, scar contracture across the axilla, delayed wound healing, and the general medical risks inherent in this operation. Poor candidates have excessive adiposity. Arms distended by adiposity, or chronic swelling due to lymphatic and/or venous incompetence are contraindications.

Meticulous surgical markings permit expeditious conservative excision of the excess skin and fat, leaving symmetrical closures. The free hand markings are followed by linear distance measurements, creating equal lengths of anterior and posterior incision lines. Thus, there should be little need for intraoperative skin adjustment, except for the heavier, adipose laden arms, requiring considerable liposuction (see video demonstration). At the time of closure, if the resection proves to be inadequate then another centimeter excision along either resection line perimeter can be performed.

The L-brachioplasty marking begins with a hemi-elliptical skin excision of the medial arm, with the anterior straight line at or slightly above the bicipital groove and the descending curved line along the posterior arm. The six critical points are found with the patient’s arm abducted and the forearm flexed 90°. Ink dots are made at point 1 at the deltopectoral groove, point 2 at the widest portion of the mid arm near the bicipital groove, and point 3 the termination of the brachioplasty about the medial elbow or beyond. The straight or slight bowed line connecting these points is the anterior incision line (Fig. 5.1). The width of the mid-arm excision is determined next by gathering and pinching excess skin and fat posterior to the mid-arm point 2 to mark point 4 along the mid-posterior margin of the arm (Fig. 5.1, upper). With the arm raised and the skin put on stretch, a straight line is drawn from that widest posterior arm point 4 to meet the anterior line termination at point 3. The proximal portion of the posterior incision line is then drawn by finding the critical point 5 that can be advanced to the deltopectoral point 1. Pinching the approximation of point 5 to the deltopectoral groove point 1 advances the posterior axillary fold to tightly suspend the posterior arm (Fig. 5.1, lower). So far an incomplete hemi-ellipse has been drawn. The anterior incision from deltopectoral groove point 1 to the elbow point 3 is measured by tape measure to confirm it is equal in length to the curved posterior incision from elbow point 3 to the advancement point 5. With the arm extended, the posterior line continues across the axilla, staying several centimeters away from the posterior axillary fold to descend to a tapered lateral chest point 6 as the posterior incision line of the lateral chest. The length of this line (points 5 to 6) will vary according to the skin laxity and rolls of the lateral chest. A line roughly perpendicular to 1–3 descends from the deltopectoral groove through the axilla and posterior to the lateral pectoral fold to taper to point 6. The skin excision between these last two lines (5–6 and 1–6) removes the excess skin of the axilla and lateral chest (Fig. 5.2).

FIG. 5.1 These are color-coded preoperative markings for the L-brachioplasty.

The ink dots 1–6 are placed sequentially freehand as described in the text. The dots are connected to create upper arm hemi-elliptical and lateral chest elliptical excisions. After the lines are drawn the linear distances are measured and adjusted so that 1–3 equals the distance from 3–5, and the distance 5–6 equals the distance from 1–6. Inset shows that the outstretched arm better demonstrates these relationships. If the arm deformities are symmetrical then these measured distances, as well as the width from point 2 to point 4, will be the same or otherwise adjusted.

FIG. 5.2 (A) The advancement point 5 is being dotted with a surgical marker, as it is found along the posterior incision line by pinch approximation to the deltopectoral groove. (B) Connecting the dots point 4 to point 5 completes the descending limb of the hemi-ellipse.

Surgical Technique (Fig. 5.3)

If brachioplasty is an isolated procedure, the arms, axillas and upper chest are prepped while the patient is sitting and then dressed in a paper surgeon’s gown. Lay the patient supine, and abduct the arms about 80° on arm boards. Under deep sedation of general anesthesia, sterile draping is completed. We avoid arm intravenous infusion. The width of resection is rechecked. About 150 ml of saline with 1 mg of epinephrine (adrenaline) and 30 ml of 1% Xylocaine per liter are infused through a thin multiholed, blunt tipped needle. If only excision site liposuction (ESL) is being done, limit the infusion to within the borders of the planned excision so the closure is not compromised. The subcutaneous fat within the arm excision site is suctioned as completely as possible, and the author favors preliminary application of ultrasonic energy. The remainder of the arm can have fat suctioned as needed, with care taken to minimize trauma to the closure margins (see video).

FIG. 5.3 Operative sequence for L-brachioplasty.

(A) The right arm has been marked and then circumferentially prepped. The patient was dressed in a paper surgeon’s gown, which was cut open after being positioned supine and the arm was placed on an arm board angled 80 ° from the operating room table. (B) Complete liposuction of the excision site is being completed as the 4 mm multiple holed suction cannula is pulled up against the dermis, revealing the thinned tissues. (C) The perimeter incision has been completed through the skin and subcutaneous tissue and with about a centimeter of undermining of the wound edges. (D) The full thickness skin and fat excision of the right lateral chest has been done. (E) The skin excision is completed with a scalpel assisted avulsion from proximal to distal. A lattice work of connective tissue with preserved neurovasculature lies in the wound bed. (F) The subcutaneous layer has been closed using a single Quill #1 PDO 30 cm long suture. A second layer of 3-0 Monoderm follows.

The final adjustment for the adequacy of the width of resection is aided by temporary staple or towel clip closure. Then the posterior arm incision is made through the skin and superficial fascia with traction anteriorly on the arm skin. Once through the fascia the incision pops open and then is undercut about 1 cm. The posterior incision is then continued across the axilla and along the lateral chest to the tapered end at point 6. The anterior straight line arm incision is similarly made, undermined, and continued across the axilla and descends as the anterior incision of the lateral chest to a depth of the serratus fascia. If breast augmentation or a spiral flap breast reshaping is to be performed, the anterior limb of the chest ellipse is not incised until the mastopexy/ augmentation is completed, because the recruitment of skin flaps in a breast augmentation reduces the need for lateral chest skin resection.⁷

The skin resection begins with thick full thickness skin and subcutaneous tissue resection from the chest and continues through the thin axillary tissues over the clavipectoral fascia. Stay immediately subdermal to avoid entering the axilla and damaging neurovasculature. Distal traction of the arm skin produces avulsion removal, assisted by scalpel along the exposed dermis. Little bleeding is encountered as the arm skin is removed like a full thickness skin graft. Superficial veins, lymphatics, and sensory nerves are preserved on the arm, within a latticework bed of connective tissue nearly empty of adipose tissue.

A nonundermined proximal posterior triangular flap is advanced to the deltoid fascia at the groove with the pectoralis using several 2-0 braided absorbable sutures. Undermining of this flap threatens the vitality of this precarious skin blood supply. Upon closure across the axilla there will be fullness that over time will recontour to a natural axillary hollow. Using the preoperative hatch marks as a guide, the incisions are then aligned with towel clamps. Excess skin can be resected along the wound edge if needed.

While any continuous horizontal running 2-0 absorbable suture could approximate the subcutaneous fascia, the author prefers the even and reliable long-term retention of the knotless, 0 or #1 PDO double armed barbed Quill (Angiotech Pharmaceuticals, Vancouver, British Columbia, Canada). The 24 cm long #1 barbed PDO comes on a 38 mm tapered needle that is passed through as a running horizontal mattress suture, starting from the center of the wound and advancing distally (elbow) and proximally (deltopectoral groove). To start the closure, two horizontal bites are taken away from the center with each needle and the Quill suture is pulled taut. After two passes of the suture on either side of the wound, the barbed suture is cinched and secured under the appropriate tension. As the suturing proceeds, the barbs keep the closure from slipping. Thus there is no segmental slippage as may occur with other running sutures. At the end of the wound, the barbed suture is returned back for several throws, forming a J, and the end is then cut. The series of dermal dimpling caused by the horizontal suture pull of the subcutaneous fascia to the dermis will disappear over several months. A second continuous barbed intradermal suture closure follows, using 3-0 Monodern Quill SRS. Dermal glue or taping completes the closure.

Only late lymphoceles, rather than early seromas, can be a problem. As such, suction drains are unnecessary and we believe are contraindicated as negative pressure encourages flow from damaged lymphatics. The operative time for each arm is approximately 40 minutes. The incisions are covered with foam dressing and then wrapped in ace bandages with the hands elevated. Before and after photographs are seen in Figs 5.4–5.6. The result of an L-brachioplasty with circumferential liposuction is seen in Figs 5.7–5.9. Please see the accompanying video for this chapter for this surgical technique.

FIG. 5.4 Before and 7 months after L-brachioplasty frontal views with a 7 kg (15 pound) weight gain for the 51-year-old patient (BMI 28) seen in the operative sequence in Fig. 5.4. The preoperative drawings are seen. The hanging posterior skin is gone. The incompletely faded scar curves from the axilla down to the mid arm and then slightly ascends to the elbow.

FIG. 5.5 Before and 7 months after L-brachioplasty posterior views for the patient seen in the operative sequence in Fig. 5.4. Despite her 7 kg (15 pound) weight gain, her arms are smaller and better shaped.

FIG. 5.6 Before and 7 months after L-brachioplasty left oblique views for the patient seen in the operative sequence in Fig. 5.4. The full course of the brachioplasty scar is seen as it crosses the axilla and descends on the chest. The arm, axilla and lateral chest are well shaped and reduced.

FIG. 5.7 Before and 1 year after frontal views of a L-brachioplasty with circumferential liposuction in a 48-year-old MWL patient with a BMI of 35.5. The upper arm sagging skin has been improved.

FIG. 5.8 Before and 1 year after left oblique views of a L-brachioplasty with circumferential liposuction in the same 48-year-old MWL patient with a BMI of 35.5. The axillary and chest wall improvement is seen.

FIG. 5.9 Before and 1 year after posterior views of a L-brachioplasty with circumferential liposuction in the same 48-year-old MWL patient with a BMI of 35.5. The overall arm and arm to chest attachment improvement is seen.

Optimizing Outcomes

Postoperative Management

The arms are elevated on pillows for 3 days. The sponge and ace bandages are removed and replaced with securely fitting elastic sleeves at 3 days. Complete maturation of the scars with massage and a variety of topical agents takes over 2 years.

Complications and Their Management

While under-resection results in inadequate treatment, partial recurrence can result even with adequate resection, from inherent tissue laxity, which is common after MWL. Over-resection of skin is difficult to close and can lead to incision line dehiscence or vascular compromise to the hand. Skin edge necrosis and delayed wound healing may lead to widened and hypertrophic scars, and contractures across the axilla. Chronic swelling, lymphoceles, sensory loss and muscular paralysis due to radial nerve and musculocutaneous nerve injury and pain are recognized but uncommon complications.

Since using the modifications described here, complications have been reduced and satisfaction improved. The markings are more precise, leading to expeditious surgery. The anchoring to deltopectoral fascia is more secure with less distal drifting of the axillary scar. Over the past 4 years, there were 13 women and 2 males treated. There have been no seromas or lymphoceles. Appreciable swelling has resolved in all cases within a month, with no cases of prolonged edema.

Incision dehiscence was limited to less than 1 cm in five patients. Tip necrosis of the V advancement flap occurred in three arms, leaving small wounds in the axilla to heal secondarily. Secondary skin reduction was not needed. There were no contractures across the axilla in this group of patients.

Conclusion

The originally designed L-brachioplasty is commonly used for the MWL arm deformity.⁵ With our better understanding of the esthetics and the four modifications described herein, we have improved our results and lowered complications.⁶ We have gone beyond the concept of arm reduction surgery to sculpturing a region to esthetic beauty.⁷ It is better to leave a little extra tissue than compromise shape or hazard serious complications. Already a commonly accepted procedure,⁸ with the improvements in shape, scar placement, and reduced complications, L-brachioplasty can take its place as the optimal cosmetic operation for moderate to severe skin and fat redundancy of the upper arm.