Arm contouring has traditionally been addressed with liposuction alone or with skin excision procedures. More specifically, liposuction is offered to individuals with mild skin laxity and good skin quality while all others are considered candidates for brachioplasty. Given the scar burden that accompanies brachioplasty, may individuals with moderate or severe skin laxity defer surgery leaving a relatively large treatment gap. In this chapter, we offer our treatment algorithm for patients based on skin laxity and skin quality. Through the addition of radiofrequency-assisted liposuction (RFAL), we are able to treat patients with excess fat and moderate to severe skin laxity without necessarily committing these patients to the scar burden of traditional brachioplasty. To that end, we offer our technique to provide safe and reproducible results using this technology. RFAL is a powerful tool for thermal contraction of the soft tissues in properly selected cases.
18 Radiofrequency-Assisted Liposuction for Arm Contouring
Contouring of the arms has always posed a distinct challenge to plastic surgeons due to the dependent nature of the underlying skin and its non-adherence to the underlying structures. Although brachioplasty has been an effective procedure for patients with massive weight loss and severe laxity it entails a long unsightly scar that often heals poorly. The reason being that these wounds are subject to a combination of gravity-induced tension, weighted flap design, and the nature of non-adherence of the area. The number of patients asking for a solution to this deformity far supersedes the number of patients settling for a brachioplasty operation. Even though there have been classifications of arm deformities in the past (there have never really been clear treatment pathways other than brachioplasty offered for advanced ptosis). 1 , 2 As such, arm contouring is defined to an extent by a treatment gap in our existing armamentarium of solutions offered to patients.
Technology-based solutions have been offered up in the past. Older treatment modalities such as ultrasound-assisted liposuction and superficial subdermal liposuction have been reported to have some effect on skin retraction in this area. 3 However, the first comes with questionable results and the second carries significant risks for contour deformities. Radiofrequency-assisted liposuction presents a novel approach to arm contouring with reproducible results. 4 This is achieved via the generated electromagnetic energy of a bipolar device designed to heat the soft tissues and cause contraction and collagen formation.
18.1 Anatomical RFAL Arm Landmarks
The patient is marked in the standing position with his or her arms to the side touching the lateral thighs. This is a perfect position to mark the deltoid fat pad (DFP) and its projection as well as the fat overlying the triceps. The arm is then positioned with the elbow flexed at 90 degrees in order to allow proper examination of the underlying soft tissues that are inferior to the bicipital groove. The bicipital groove is then marked (▶Fig. 18.1).
18.2 No Man’s Land
The area between the bicipital groove and the DFP border is outlined as “no man’s land”. This area, as the name implies, is not treated. It carries significant treatment risk due to the underlying neurovascular structures (▶Fig. 18.2).
18.3 Zone 1 and Zone 2
The dependent portion of the arm is further subdivided into two treatment zones. The proximal one third “zone 1” and the distal one third “zone 2”. Zone 1 typically contains more fat and contributes to the majority of the laxity seen in most cases that require arm contouring. This zone in turn will be the recipient of the majority of the RF energy (▶Fig. 18.3).
18.4 Deltoid Fat Pad
The DFP has often been overlooked in arm contouring. It not only has medical ramifications (as in inoculation injections) but also aesthetic implications. The more lateral projection of the DFP the more disconcerting it tends to be for female patients. They present with the common complaint of being too “wide” accompanied by the feelings of personal embarrassment when wearing short sleeve shirts or dresses. We call this the “linebacker” look. Modern day aesthetics of the arm beckon for a more sculpted toned appearance for both men and women. The treatment of the DFP is critical in this respect as it typically translates into high patient satisfaction 5 (▶Fig. 18.4).
18.4.1 Deltoid Fat Pad Marking
A longitudinal line is drawn along the length of the arm starting at the acromion of the scapula intersecting the deltoid muscle insertion. A transverse line intersecting the longitudinal one marks the point of maximal projection. The access point is marked at approximately 3 cm distal to this point at the junction of the deltoid muscle insertion and the biceps. The natural shadow cast by the confluence of these two muscles tends to be less conspicuous of a scar (▶Fig. 18.5).