80 Brachioplasty

Rod J. Rohrich and Paul D. Durand

Abstract

With a growing massive weight loss population, upper arm contouring continues to rise in popularity. Refinements in technique, such as modification of skin excision patterns and the adjunct use of liposuction, have allowed for safe and reproducible results. Patient selection remains of utmost importance in selecting the best approach for upper arm contouring. In this chapter, a clinical algorithm is presented that can be used to select the best surgical method based on careful aesthetic analysis of the upper arm. This is followed by detailed descriptions of the operative steps involved in each type of procedure.

Brachioplasty – limited-incision brachioplasty – extended brachioplasty – upper arm contouring – body contouring

80 Brachioplasty

Key Points

With a growing massive weight loss population, upper arm contouring continues to rise in popularity.
Refinements in technique, such as modification of skin excision patterns and the adjunct use of liposuction, have allowed for safe and reproducible results.
Patient selection is of utmost importance in selecting the best approach for upper arm contouring.

80.1 Preoperative Steps

Proper preoperative analysis is key in determining the best method for upper arm contouring for each patient.
A pinch test can be used to determine excess fat; it will usually account for more than 1.5 cm of additional tissue thickness that should be factored into the resection.
Skin laxity is a separate issue that can be present alone or in combination with excess fat; it can be measured by pinching excess skin between fingers and measuring the length of excess skin.
Redundant tissue has to be evaluated in at all locations of the upper arm: proximal, middle, and distal aspects.

A classification system can serve to stratify patients and narrow down what technique would be effective for each (Table 80.1).

**Table 80.1** **Classification system for the brachioplasty patient**
Skin laxity		Location of redundant skin	Treatment
Type I	No	No skin laxity	UAL/SAL
Type II
A	Yes	Minimal medial lower arm laxity	Lib-Medial brachioplasty
B	Yes	Moderate medial lower arm laxity	Extended medial brachioplasty
Type III
A	Yes	Entire lower arm	Inferior or medial brachioplasty
B	Yes	Entire lower arm and lateral chest wall	Extended inferior brachioplasty
Abbreviations: SAL, suction-assisted liposuction; UAL, ultrasound-assisted liposuction.

80.2 Operative Steps

See Video 80.1.

80.2.1 Liposuction Alone

Access incision are made along radial aspect of distal humerus and proximally along posterior aspect of the arm.
Areas of liposuction are infiltrated using a superwet technique with a solution of 1 L of lactated Ringer’s solution, 30 cc of 1% lidocaine, and one ampule of 1:1000 epinephrine.
Excess fat is removed from intermediate and superficial with ultrasound-assisted liposuction (UAL) or suction-assisted liposuction (SAL) alone.
Superior to the brachial groove the authors use SAL exclusively, whereas inferiorly better skin retraction has been noted if SAL is combined with UAL.

80.2.2 Limited-Incision Brachioplasty

Ideal in patients with proximal skin laxity and limited fat excess.

Markings

With the arm in repose, the anterior and posterior limits of the axillary incision are marked in the axillary skin crease; limiting the incision between these points ensures that the scar will be hidden within the axilla.
The arm is then abducted to 90 degrees and the two points are connected in the axillary fold.
The amount of skin excision is marked in a semi-elliptical fashion; it usually measures 3 to 5 cm in vertical distance at the most central point.
With the arm in the abducted position, areas of liposuction are then marked, with the bicipital groove as the most anterior point for liposuction.