Introduction

There is an ever increasing demand, mainly in women, for correction of brachial dermatolipodystrophy. Most patients, however, are not willing to accept the traditional brachioplasty scar that extends, in various configurations, from the axilla, running along the inner arm to the elbow. Following the seminal paper by Pollock,¹ which described his technique for the treatment of hidradenitis suppurativa by excision of the involved axillary area followed by direct closure, I began to adapt this approach for esthetic brachioplasty. I now have 25 years of experience with this approach. There have been numerous refinements over the years.^1–8 The minimal incision brachioplasty (MIB) technique is the preferred approach for most patients that I see, save for those with excessively dependent dermatolipodystrophy of the upper arms (as commonly seen in massive weight loss patients). In all other cases, it provides predictably good results that are equal to those achieved in comparable patients with the traditional approach. I am most frequently asked how simply tightening the skin of the axilla, in the minimal incision approach, can replicate the result achieved when the customary extended incision method is employed. This is best demonstrated by referring to the mechanics of the classic bamboo finger trap (Fig. 6.1), which when pulled on just one end circumferentially tightens the entire length of the tube.

FIG. 6.1 The bamboo finger trap aptly demonstrates the principle of the transaxillary brachioplasty in which traction in the axilla narrows the circumference of the upper arm.

(A) Finger trap with no traction on it. (B) Traction on one end of finger trap narrows its entire circumference.

Preoperative Preparation

Patients are instructed not to shave their axillary hair for 48 hours before surgery. Standard preoperative laboratory testing is performed, as indicated by age and medical history.

Surgical Technique

Markings

1. Marking is performed in the preoperative holding area with the patient in the upright position. With arms against sides, mark the anterior and posterior shoulders at the junction of the axilla with the shoulder. The final scar should not be visible beyond these markings (Fig. 6.2A).

2. Mark longitudinal axis from central inner arm, through center of axilla, to the midlateral chest area (Fig. 6.2B).

3. Mark the transverse axis from anterior shoulder to posterior shoulder in the axillary crease or fold. This line should stop 1.5–2 cm medial to the anterior and posterior axillary crease–shoulder junction. This helps avoid a scar that will extend into a visible area of the shoulder (Fig. 6.2B).

4. Determine the longitudinal length of excision using the pinch technique. First, move the skin of the triceps towards the transverse axis line until the arm has a pleasing contour. Then move the lateral chest skin towards the transverse axillary line. It is important to advance the lateral chest skin towards the transverse axillary crease to fix and stabilize the upper arm correction (Fig. 6.2C, D).

5. Mark areas that require liposuction. These should include, if indicated, the area of lipodystrophy of the upper outer breast/anterior axillary area as well as the posterior shoulder/axillary area. Both of these areas of lipodystrophy – which patients frequently point out as being of concern – can be easily corrected during the MIB procedure by liposuction and the subsequent axillary skin tightening.

FIG. 6.2 (a) With the patient standing with arms at the side (adducted), the visible portions of the anterior and posterior axillary folds are marked with a triangle. This mark is used to determine the transverse diameter of the planned exposure, which extends 1 to 1.5 cm medial to the point of each triangle. (b) The arm is sufficiently abducted to mark the axillary hollow or crease apex. This line is then shortened so that it stops about 1.5 cm before hitting the axillary fold marks. The line is bisected and carried up the arm and down the chest wall to mark the meridian of the axilla. (c) The arm is abducted 90°, and the excess skin of the triceps area is forcefully advanced toward the axillary crease and marked as point A. (d) Next, the skin of the chest wall is next similarly advanced toward the axillary crease with force adequate to balance the tension (point B). The points are connected to make an oval area of proposed resection.

The Procedure

1. Place patient on operating room table with arms outstretched.

2. Circumferentially prep arms and chest and apply appropriate draping.

3. Infiltrate tumescent solution into the areas to be liposuctioned (approximately 1 : 1).

4. Infiltrate dilute local anesthesia (1% Xylocaine plain 50 ml and 0.25% Marcaine 50 ml, 1 ml 1 : 1000 epinephrine (adrenaline) plus 150 ml normal saline) into areas of planned surgical resection.

5. Carry out liposuction on both upper arms.

6. Use the tailor tack method to check the accuracy of the preoperative markings. It is important to check the tailor tack closure with the patient in the upright position and the arm at 90° to the lateral chest. Make any revisions necessary in the initial preoperative markings. At this time also check for any abnormal folds or rotations in the skin of the arm. Adjust the tailor tack suture placements to correct these as well. After necessary adjustments have been made, remark the planned surgical site (Fig. 6.3A).

7. Remove the tailor tack sutures or Adairs, and with the patient in the recumbent position, excise the involved area with just a thin layer of fat attached (Fig. 6.3B).

8. Clean area with 5% Betadine and mark out the area of the axillary crease (Fig. 6.3C).

9. Wound closure:

a. First layer 1 Vicryl which incorporates the base of the wound in the area of the axillary fold (Fig. 6.4)

b. Two layered closure with 2-0 14×14 PDS Quill suture

c. Final layer running 3-0 plain gut vertical mattress suture.

10. Concealing the scar: In many cases the closure of the surgical site can cause the final scar to extend into the visible portions of the anterior or posterior shoulder, or both. This should be addressed at the time of closure using the purse string technique:

a. Undermine the involved area and defat if necessary (Fig. 6.5)

b. Use a 2-0 7×7 Quill suture anchored in the axillary fold to bring the visible portion of the scar back into the axillary fold. This will leave some bunching and a dog-ear. These largely disappear in 3–6 months (Figs 6.6 and 6.7)

c. After the purse string correction, complete the closure in the standard fashion (Fig. 6.8).

11. Selective use of bolster dressing. In those cases where it is felt that the axillary fold may be difficult to recreate or there is obvious tension, use a bolster dressing made from a rolled up ABD pad.

FIG. 6.3 (a) Final determination of the amount of tissue to be removed is made during surgery, using the tailor tack method. (b) Intraoperative view of axillary area of resection measuring 17 × 9 cm. (c) This intraoperative view demonstrates the amount of tissue removed as well as the remarking of the axillary crease with methylene blue. Note the presence of subcutaneous fat remaining on the axillary fascia.

FIG. 6.4 After the axillary tissue is excised, the axillary crease is marked again. The fold is recreated during closure, incorporating the fascia into each stitch, using 1.0 Vicryl.

FIG. 6.5 The extended visible portion of the incision is first undermined and then defatted to the dermis before executing the purse string closure.

FIG. 6.6 After the incision is defatted at its ends in the subdermal plane, it is closed with a purse string stitch, using 2.0 Quill suture, thus pulling the wound edges further back into the axilla. This bunched tissue usually settles in 3 to 6 months.

FIG. 6.7 Area of gathered skin at the wound after the purse string suture closure. This area usually settles out after 3 to 6 months.

FIG. 6.8 View of final closure with purse string correction of elongated anterior axillary incision.

Prior to beginning closure of the wound, place four #1 retention sutures, placed 3 cm from the wound edges. These sutures should pass carefully through the base of the wound. After the final closure, these sutures will be used to snug the bolster dressing in place. The bolster is normally left in place from 2 to 4 days. No drains are used. Bacitracin and gauze are placed on the surgical sites. No arm wraps or surgical arm garments are used (Fig. 6.9).

FIG. 6.9 Bolster dressing in place at end of procedure helps to recreate axillary fold.

Optimizing Outcomes

Postoperative Care

Complications

Complications in a series of 650 cases have included two infections, both of which responded to conservative antibiotic therapy. In 8% of patients small wound separations (1–2 cm) occurred, usually after 14 days. All healed by secondary intention after wet-to-dry dressings and topical antibiotic ointments.

Two complete wound dehiscences; both after an arm was fully extended above the shoulder, occurred at 7 and 10 days post operation. These were corrected on the days of the injuries and went on to uneventful, satisfactory healing.

In 10% of patients, hypertrophic or unacceptable scarring occurred. All revisions on nonacute surgical complications are carried out at 1 year.

There may be bow-stringing or “bat wing” deformity secondary to tension. This is treated with a Z plasty or other skin lengthening technique with scar release. We use bolster dressings for 3–5 days. The more commonly seen presentation is bow-stringing or “bat wing” deformity secondary to distraction or separation of the axillary skin from the base of the wound. One can check for distraction by seeing how easily the involved area of skin can be pushed up into the axillary hollow. This is treated with scar excision only. Place sutures for the bolster dressing and tack the edges of the wound to the axillary base in line with the axillary fold. Close the incision and leave the bolster dressing in place for 3–5 days. The bow-string deformity is not uncommonly seen in patients with macromastia or heavy pendulous breasts. For these patients, wearing a good, supportive bra will lessen or eradicate the bow-string presentation. A reduction mammoplasty should also be considered. It is important to recognize this phenomenon and discuss these options with the patient during the initial consultation.

No hematomas or seromas were observed. No neurovascular, lymphatic, or musculoskeletal problems occurred.

Conclusion

The minimal incision transaxillary brachioplasty should be the procedure of choice for all those patients requesting recontouring and rejuvenation of the upper arm who do not have excessively dependent dermatolipodystrophy. Please refer to Figs 6.10–6.14 for a representative selection of before and after surgery results. It is a simple procedure that delivers predictably good results, comparable to those results achieved with the traditional approach, while confining the scar to the axillary area.

FIG. 6.10 (A–D) Views of 63-year-old woman before surgery and 4 months postoperatively.

FIG. 6.11 (A, B) Views of 47-year-old woman before surgery and 6 months postoperatively.

FIG. 6.12 (A, B) Views of 32-year-old woman before surgery and 11 months postoperatively.

FIG. 6.13 (A, B) Views of 43-year-old woman before surgery and 5 months postoperatively.

FIG. 6.14 (A, B) Views of 43-year-old woman before surgery and 5 months postoperatively.