Introduction

Individuals that have experienced massive weight loss will often present with significant upper arm deformities. As with the other areas of the body such as the breasts, abdomen, buttocks, and thighs, significant fat reduction in the upper arms results in excess hanging skin and varying amounts of remaining fat. Many patients will call these their “bat wings.” These deformities can lead to embarrassment, rashes, and discomfort in clothing. Patients are unhappy with this stigma of their previous obesity, which has led to the authors’ development of the presented technique.

In the development of the presented technique, the senior author had to recognize the basic nature of the deformity in the upper arm of the massive weight loss patient. The excess was noted to be located within the posterior axillary fold as it extends from the axilla to the upper arm. Thus, since the posterior fold traverses from the upper arm to the axilla and onto the lateral chest wall, the excess also involved the upper arm, axilla, and the lateral chest wall (see Fig. 4.1). This was a major advancement in knowledge, which led to the authors’ technique of crossing the axilla with the resection. Other authors have since developed other methods of resection, but they are all based on the need to cross the axilla with the resection onto the chest wall.

FIG. 4.1 The typical “bat wing” deformity in a massive weight loss patient.

The yellow mark demonstrates how the excess crosses from the upper arm onto the lateral chest wall.

Another important concept that the senior author introduced to brachioplasty surgery is the understanding of the anatomy of the arm as it relates to the dynamics of surgery. The arm is a cylindrical structure with a hard non-compressible inner core made up of the musculoskeletal system. The inner core is covered by the skin–fat envelope, which makes up a small percentage of the entire cross-sectional area of the arm. This creates a potentially dangerous situation because the skin–fat envelope cannot tolerate even a moderate amount of swelling, as the hard inner core will not compress to accommodate that swelling. Thus this led to the discovery that allowing the arm to develop any significant amount of swelling while performing a brachioplasty can lead to one of two bad outcomes. First, if the technique allows adjustment for intraoperative swelling then less tissue is resected than ideal. Second, if the surgeon commits to the proposed amount of resection and swelling is allowed to occur in the skin–fat envelope, then the wound will not close.

The technique presented here accounts for these two major discoveries: the resection should cross the axilla and minimal to no swelling should be allowed to occur during the procedure.^1,2

Preoperative Preparation

Included in the initial evaluation of the patient is a thorough examination of the arms. The upper arm meets the chest wall at a junction bordered by the anterior and posterior axillary folds and the hair-bearing axilla. The degree of horizontal and vertical excess is noted as well as the degree of skin laxity. The quality of the skin envelope is analyzed in relationship to the overall bulk of the arm.

Photographs of the patient should be taken with the arms abducted at 90° from the lateral chest wall, with elbows straight and then bent at 90°. Anterior and posterior views should be obtained. Lateral views with the elbows at 90° are also advisable. A careful assessment of the arms will reveal the redundant tissue is in the posterior axillary fold, which, as discussed above, crosses the axilla onto the lateral chest wall.

Patients may be categorized into three subsets. The first group of patients is those with significantly deflated arms and a thin layer of remaining subcutaneous fat. These patients are ideal candidates for excisional brachioplasty. The second group of patients presents with a large amount of persistent subcutaneous fat in their arms following massive weight loss. These patients should be treated in a staged fashion with aggressive liposuction of the upper arms as the first procedure. Then in 3 to 6 months they can undergo an excisional procedure, as a second stage. The third group of patients presents with an intermediate amount of subcutaneous tissue. These patients may choose between undergoing excisional brachioplasty with a less-than-ideal result or a staged procedure with liposuction first.

The goals of the brachioplasty procedure are to remove the horizontal upper arm soft tissue and skin excess that occur from massive weight loss and create a smooth transition from the lateral chest wall to the upper arm. The authors prefer placing the scar on the most inferior aspect of the arm in the abducted position because, when facing an observer and animating the arms, this area is least visible. Final scar position will differ based on surgeon preference.

Surgical Technique

Regardless of the brachioplasty technique chosen, the surgeon must strike a balance between resecting enough skin and soft tissue to create an attractive contour and over-resecting at the risk of not being able to close the wound. As mentioned above, the upper arm should be thought of as a cylinder with a hard, noncompressible inner core composed of bone and muscle mass, surrounded by soft tissue and skin. Aggressive resection will result in compression of soft tissues against the hard, noncompressible inner core, leading to increased risk of neurovascular compromise and possibly even inability to close the defect. To avoid this complication we employ the “double ellipse marking technique”. The outer ellipse is based on anatomic reference points that outline the extent of the upper arm deformity including the lateral chest wall and, if necessary, across the elbow. The inner ellipse is based on the outer ellipse but adjusted to allow closure of the wound around a cylindrical core.

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