Liposuction of the upper extremities

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Chapter 2 Liposuction of the upper extremities

Cemal enyuva, Hüseyin Güner

Key Points

• Patient selection is crucial and the skin quality of the target region should be assessed.

• Deformities should be classified, and simultaneous or late excisional surgery should be discussed with the patient.

• Conventional technique can be used or energy delivering technology can be used to get better skin retraction.

• Gentle surgical technique should be used and soft tissue thickness should be even and esthetic contours should be achieved at the end of the procedure.

• To get a smooth result the surgery should be extended to the entire esthetic unit of the arm.

Introduction

The basic principles of arm liposuction are no different from those for other parts of the body. A plastic surgeon should also assess the skin tone, quality, topographic mapping of fat deposits, retraction capacity of the skin, and the general health of the patient. The patient should be informed that a brachioplasty could be needed during the initial procedure or later on if the liposuction cannot produce acceptable results.

Preoperative Preparation

Patient Selection

Patients with fat deposits in their arms are candidates for arm liposuction. Body mass index is an important factor in liposuction, along with general health. Morbidly obese patients who need bariatric surgery are not candidates for arm liposuction.

The classification of Teimourian1 has been generally accepted for esthetic deformities of the arm (Table 2.1). Besides Teimourian, other classifications reported by El Kathib2 and Appelt3 can also be used. While liposuction can be used alone in class 2 deformities, it can be used alone or can be combined with a brachioplasty technique in class 3 deformities.

TABLE 2.1 Teimourian Classification

Group 1 Minimal to moderate subcutaneous fat with minimal skin laxity
Group 2 Generalized accumulation of subcutaneous fat with moderate skin laxity
Group 3 Generalized obesity and extensive skin laxity
Group 4 Minimal subcutaneous fat and extensive skin laxity

Chamosa’s cadaver study4 on fat deposits supports our clinical findings. Fat deposits in the arms are mostly located at the posterior area. Superficial fascia separates the fat layer into superficial and deep compartments and the storage of fat occurs in each compartment. Skin retraction is better in superficial liposuction technique. When combined with the use of internal ultrasonic and laser systems, better skin retraction is obtained due to increased dermal thermal energy.

Surgical anatomy may differ in fat and thin patients. In fat patients, increased fatty tissue is observed in the whole posterior compartment, part of the brachioradialis, deltoid, triceps and, rarely, the lateral head of biceps regions. In thin patients, there is more fat accumulation in the posterior compartment and less in the brachioradialis and triceps regions. Treatment of the whole fat accumulation, more or less, is important for a perfect result.

Surgical Technique

Preoperative drawings are done while the patient is standing. Deformities will be evident with the upper arm abducted 90° and lower arm flexed 90°. Photographs should be taken from front and back in this position and should involve both arms together and also separately. Arm circumferences should be measured at the proximal and distal 1/3 levels of the arms. Anterior and posterior arm pinch tests should also be applied to the proximal and distal 1/3 levels of the arms.

We usually use liposuction in the posterior half of the arm to avoid the irregularities caused by circumferential liposuction and because accumulation of fat occurs in the posterior arm. Lesser amounts of fat could be taken from the lateral region of the deltoid and triceps muscles, brachioradialis and sometimes from the posterior region of the lateral head of biceps. The brachial groove in the medial arm and the groove between the biceps and triceps in the lateral arm should be marked.

The procedure is performed under general anesthesia. Sedation with local anesthesia may be preferred if only liposuction is going to be performed. Multiple procedures may be started under local anesthesia and sedation; general anesthesia may be administered if needed from the beginning of the treatment.

The techniques currently being used are the conventional suction-assisted lipectomy (SAL), the third generation solid probe ultrasonic-assisted liposuction system (UAL; VASER), or laser-assisted techniques.

SAL

The Toomey or a vacuum-motored technique may be used. A stab incision located on the elbow should be sufficient. Rarely, a secondary stab incision located on the proximal arm is necessary for the cross tunnel technique. A wetting solution including 1/1 000 000 epinephrine (adrenaline) and local anesthetic is infiltrated with blunt cannulas. The amount of infiltration is calculated in accordance to soft tissue turgor or with a super wet technique (1 ml infiltration for 1 ml aspiration). Liposuction cannulas which are used parallel to the arm axis and skin surface and 2, 3, or 4 mm in diameter are preferred.

There are two basic operating positions during infiltration and liposuction. The arm should be held perpendicular and the forearm should be flexed into the first position (Fig. 2.1). In this way, the posterior arm can be kept stretched to ease the operation. In the second position, the surgical assistant should lift the arm to a 90° degree angle by holding the wrist. In this way, contours of the posterior arm become visible due to gravity. Using the pinch test, the thickness of adjacent esthetic units, which is the target thickness, can be gauged. The procedure should carry on until the desired thickness is achieved. After the desired thickness and esthetic contour has been achieved, four tests should be applied, which are similar to those applied to other body parts. After rubbing, pinch, active pinch and comparison tests, additional adjustments should be done to complete the procedure if needed. Stab incisions may be closed as two layers with separate 5/0 Monocryl sutures or kept open for drainage. A liposuction arm corset should be applied to the arm.

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FIG. 2.1 The basic position with the arm held in vertical position and forearm held in flexion to ease the operation.

VAL (VASER)

Third-generation solid probe ultrasound liposuction systems that were introduced in 2001 for use in other body parts may also be used for the correction of arm fat deposits. In this procedure, fat fragmentation and emulsification is obtained by ultrasound energy in the first step. For this purpose, 2.9 or 3.7 mm diameter probes may be used. The 2.9 mm probes include three rings, which enable penetration and delicate shaping. The 3.7 mm probes may include one, two, or three rings. Probes with one ring have more penetration ability and the ultrasound energy is denser at the tip of the probe. The energy is higher at the sides in the probes with three rings. The same arm positions and stab incisions are used as for the SAL technique. Skin protectors should be used and should be sutured with 3/0 silk materials to prevent the incision edges from heat trauma. Klein solution is infiltrated. At least 100 ml wetting solution infiltration is recommended for each 1 minute of ultrasound application.

Probe choice is determined according to the fibrous content of the fat tissue and also the resistance to the probe. Energy amplitude (ranged 0–100) and mode of energy transfer (continuous or intermittent) is set. VASER application for the posterior arm usually lasts between 3 and 4.5 min. VASER is carried out with depletion of the resistance in fatty tissue and the second phase is initiated. Aspiration is made with 3, 3.7, and 4.6 mm blunt-windowed VentX® liposuction cannulas in the second stage.

Lipoaspiration is terminated when desirable esthetic contours are achieved and the pinch test thickness is equalized with adjacent esthetic units. Stab incisions may be closed as two layers with separate 5/0 monocryl sutures or kept open for drainage. A liposuction arm corset should be applied to the arm.

Laser-Assisted Liposuction (LAL) and Laser Tissue Interaction

The laser method has two main aims:

1. To selectively break down fat cells and separate fat lobules into small pieces.

2. To stretch and remodel the dermal collagen and the dense nondermal collagen, which is found in the connective tissue between muscle and dermis.

The distinctive features of laser treatments are their selectivity. Laser therapies are selective, unlike other techniques. There are two target chromophores in our area of liposuction: triglyceride and water. Fat cells and lobules are composed of 90% triglyceride and all other tissues are 60% water. With the wet technique, triglyceride concentration in fat cells decreases to 80% and water concentration in other tissues increases significantly to 80–90%. For the wet technique, there are two chromophores with the same concentrations subcutaneously.

According to the laser laboratory studies, it has been seen that although the 924 nm laser beam is absorbed very well by triglyceride, it is absorbed less well by water – the other chromophore in the operative area. This type of photothermal selectivity allows for the absorption of the light into the targeted adipose tissue, while leaving the adjacent tissue relatively undamaged. This type of selectivity is particularly useful when in the superficial layer of the tissue, near the dermal junction. As the dermal tissue contains a large amount of water, any water-only absorption-based system (YAG laser based) can present problems with burns or necrosis as a result of overheating.

The goal is to minimize thermal damage on the peripheral tissues while melting fat with 924 nm laser. This way, selective laser lipolysis can be done. By heating the water with 975 nm laser, the deep dermis and dense collagen tissue in the connective tissue are stimulated. Both acute and augmented dermal and subcutaneous retraction is targeted. There is an additional effect of the diffusion of the heat created in the adipocytes from the 924 nm laser by selective absorption into the triglyceride. As the connective tissue is 90% embedded in the fat cells, this type of diffusion allows for a more controlled method of collagen contraction. In the SlimLipo system, these two wavelengths are transferred to subcutaneous fat tissue by a 1.5 mm fiberoptic cable. The power may be set to 0–20 W for 924 and 975 nm, which is 40 W in total. We can accomplish a safe lipolysis and dermal subdermal retraction by using those two laser wave lengths separately or simultaneously with this laser liposuction system.

Surgical Technique for LAL on the Upper Arm

LAL resembles classic liposuction. It is important that the operation be done under slight sedation for the patient to maintain position. A good result in liposuction surgeries very much depends on good patient positioning. For the posterior upper arm, the best position is while the patient is lying down lateral supine, the shoulder is on 90° abduction and flexion, the elbow is flexed 90°, and the patient is holding the other forearm with the operative side hand. The entire operation can be done in this position. While the fat tissue on the deltoid or brachioradialis area is treated, the arm is simply adducted and the forearm is extended so that the operation can continue smoothly.

At the start of the operation, 1/500 000 epinephrine (adrenaline) and 0.8 g/l lidocaine Ringer’s lactate solution is infiltrated in such a manner that the lidocaine dosage is not over 55 mg/kg. Following the infiltration, laser is started by inserting a 1.5 mm fiber into the subcutaneous fatty tissue.

For arms with thick fat and sufficient turgor, 3040 W blend mode of 924 and 975 nm laser is used together in equal amounts or in different ratios. In total, 15–20 kJ is applied equally to the overall area. Following this, a sufficient amount of liposuction must be done by inserting a 2 mm suction cannula. As sufficient tissue heating and retraction may not always be achieved with the 924 nm wavelength alone, the 975 nm wavelength is also available to be combined or used independently. The 975 nm wavelength is highly absorbed by water, and as there is sufficient water content in the tissue adjacent to the adipocytes, this high absorption coefficient allows for some rapid heating. It is important to remember that this water-absorption based heating is rather hard to contain as there is high water content in much of the adjacent tissue. The 975 nm wavelength should not be used in high wattage in the superficial levels of tissue nearest the dermal tissue. External cooling can help with overheating.

Older patients or those with a medium amount of fat and diminished skin tone and who do not want an incision are generally difficult cases. Conventional liposuction will not produce a satisfactory outcome. For these patients no suction-only laser liposuction application or laser liposuction application with less suction will result in better outcomes. While the fat tissue is discharged in months, the skin will be retracted slowly. This application must be done very carefully. The 924 nm wavelength must be used at about 10–20 W and no tissue other than fat tissue must be harmed. If the fat amount in the arms is large, and for faster heating, 975 nm wavelength can be added in small doses. In careful and delicate applications there will be controlled fat necrosis and fat cell apoptosis. Since vascular and lymphatic tissues and connective tissue in the same compartment will stay intact, fat necrosis will be absorbed in weeks. It may take several months to produce the final outcome. These patients must be well documented photographically and must understand that results come over time.

The incisions are immediately sutured with 6/0 Prolene or Monocryl following the surgery and the patient dressed with an upper arm corset.

Forearm

A forearm application is rarely done. Most of these patients are over 60 years old. Their complaints are mostly not being able to wear a watch or jewelry.

While the patient is lying down supine, the forearm is placed on the surgical table and the wrist is flexed slightly. Following local solution infiltration with 1/500 000 epinephrine (adrenaline), laser liposuction is applied with 924 nm wavelength at about 10–20 W alone or with blending of the 975 nm wavelength, not exceeding 4–8 W. Following the application, suction from the forearm and/or dorsum of the hand is done with a 1.5 mm blunt-faced cannula. Incisions are closed with 6/0 Prolene and a hand wrist bandage with mild compression is applied to the dorsum.

Optimizing Outcomes

Patient selection is important. Also, the patient should have realistic expectations. The surgery should be performed smoothly and a gentle surgical technique should be used. To get skin retraction and a smooth surface without waviness the surgery should be performed on the whole esthetic arm unit extensively and soft tissue thickness should be even at the end of the operation (Figs 2.2–2.4).

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FIG. 2.2 Arm liposuction: preoperative and postoperative view of the patient.

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FIG. 2.3 Axillary lipodeposits before and after LAL.

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FIG. 2.4 Patient with lipodeposits on her forearms: preoperative and postoperative view after LAL.

Postoperative Care

A special arm corset should be applied to the arm postoperatively. If the patient has an intravenous line in the upper extremity, a corset on that side should be deferred until the removal of the intravenous line. In this case, the upper arm is wrapped with cotton and bandaged loosely. Except for showering, the arm corset should be used for 2 weeks continuously. Progressive soft tissue indurations and alterations in sensation regress after the third postoperative week. In the third postoperative month, a visit should be arranged for photographing, and arm circumference and tissue thickness measuring.

Complications and Their Management

Careful patient selection and accurate surgical planning is essential for a good esthetic result in arm liposuction. Complications such as bleeding, infection, prolonged soft tissue indurations, burns, or seroma may occur. However, in our clinical experience, seroma is the only complication that is observed in other parts of the body and none of those complications have been observed in our clinical experience on the arm. None of our patients who had arm liposuction necessitated or demanded additional brachioplasty.

Conclusion

In conclusion, liposuction in the arm region is a simple surgical procedure and anatomic structures are avoided as long as the procedure is applied to the suprafascial plane. SAL, VAL, or laser liposuction may be used alone for patients without soft tissue laxity and ptosis. Patients with minimal ptosis and loose skin may benefit from VAL or laser liposuction, which provide better skin retraction. In patients with ptosis, liposuction is used only to facilitate brachioplasty.

References

1 Teimourian B, Malekzadeh S. Rejuvenation of the upper arm. Plast Reconstr Surg. 1998;102:545–551.

2 El Khatib HA. Classification of brachial ptosis: Strategy for treatment. Plast Reconstr Surg. 2007;119:1337–1342.

3 Appelt EA, Janis JE, Rohrich AJ. An algorithmic approach to upper arm conturing. Plast Reconstr Surg. 2006;118:237–246.

4 Chamosa M, Murillo J, Vazquez T. Lipectomy of arms and lipograft of shoulders balance the upper body contour. Aesth Plast Surg. 2005;29:567–570.

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