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 Teimourian ¹ 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 study ⁴ 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.