Introduction

The female arm has a smoothly full but adherent skin covering that reflects the underlying musculature. The sensuous and undulating axillary hollow is created by retention of strands of fascia emanating from the chest wall to the clavipectoral fascia.

Aging as well as weight loss lead to undesirable excess skin and fat. When severe, the hanging skin is hard to cover and painful during waving. There is a canopy-like sagging of the posterior upper arm, which can be weighted down further by excessive adipose. The posterior arm junction to the chest descends, creating a broad wing-like attachment. The lateral chest has transversely oriented sagging rolls of skin lateral to the breast.

The operative strategy relates to the magnitude of deformity.¹ For the vast majority of presentations, arm skin reduction surgery is needed from the axilla to elbow.²^–⁴ Experience with severe arm and upper body deformity after massive weight loss (MWL) led to the design of the inclusive L-brachioplasty, so named for the L shaped pattern of excision with the long limb from the elbow to the axilla and the short limb extending at right angles through the axilla and along the lateral chest.^5,⁶

Preoperative Preparation

Suitable candidates for L-brachioplasty desire correction of their excess skin and fat of the arm and axilla and at times the upper lateral chest. These patients accept the possibility of long, possibly hypertrophic scars, asymmetry, inadequate resections, scar contracture across the axilla, delayed wound healing, and the general medical risks inherent in this operation. Poor candidates have excessive adiposity. Arms distended by adiposity, or chronic swelling due to lymphatic and/or venous incompetence are contraindications.

Meticulous surgical markings permit expeditious conservative excision of the excess skin and fat, leaving symmetrical closures. The free hand markings are followed by linear distance measurements, creating equal lengths of anterior and posterior incision lines. Thus, there should be little need for intraoperative skin adjustment, except for the heavier, adipose laden arms, requiring considerable liposuction (see video demonstration). At the time of closure, if the resection proves to be inadequate then another centimeter excision along either resection line perimeter can be performed.

The L-brachioplasty marking begins with a hemi-elliptical skin excision of the medial arm, with the anterior straight line at or slightly above the bicipital groove and the descending curved line along the posterior arm. The six critical points are found with the patient’s arm abducted and the forearm flexed 90°. Ink dots are made at point 1 at the deltopectoral groove, point 2 at the widest portion of the mid arm near the bicipital groove, and point 3 the termination of the brachioplasty about the medial elbow or beyond. The straight or slight bowed line connecting these points is the anterior incision line (Fig. 5.1). The width of the mid-arm excision is determined next by gathering and pinching excess skin and fat posterior to the mid-arm point 2 to mark point 4 along the mid-posterior margin of the arm (Fig. 5.1, upper). With the arm raised and the skin put on stretch, a straight line is drawn from that widest posterior arm point 4 to meet the anterior line termination at point 3. The proximal portion of the posterior incision line is then drawn by finding the critical point 5 that can be advanced to the deltopectoral point 1. Pinching the approximation of point 5 to the deltopectoral groove point 1 advances the posterior axillary fold to tightly suspend the posterior arm (Fig. 5.1, lower). So far an incomplete hemi-ellipse has been drawn. The anterior incision from deltopectoral groove point 1 to the elbow point 3 is measured by tape measure to confirm it is equal in length to the curved posterior incision from elbow point 3 to the advancement point 5. With the arm extended, the posterior line continues across the axilla, staying several centimeters away from the posterior axillary fold to descend to a tapered lateral chest point 6 as the posterior incision line of the lateral chest. The length of this line (points 5 to 6) will vary according to the skin laxity and rolls of the lateral chest. A line roughly perpendicular to 1–3 descends from the deltopectoral groove through the axilla and posterior to the lateral pectoral fold to taper to point 6. The skin excision between these last two lines (5–6 and 1–6) removes the excess skin of the axilla and lateral chest (Fig. 5.2).