Brachioplasty
JOSEPH F. CAPELLA,
MATTHEW J. TROVATO, SCOTT WOEHRLE
CHAPTER 80
T
he rapid growth in bariatric surgery over the past decade has led to an increase
in demand for surgical procedures to address the contour deformities of the
arm following massive weight loss. According to the American Society of Plastic Sur-
geons, from 2000 to 2008 there was a 4059% increase in the number of brachio-
plasty procedures performed in the United States. Although weight loss affects the
entire body, the arms for many individuals are often of greatest concern because of
their visibility during everyday activities. The arm deformity associated with weight
loss is often dramatic and is influenced by multiple factors, including patient body
mass index (BMI); highest BMI ever obtained; change in BMI; age; and sex.
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Part XII Body Contouring
In a morbidly obese individual, fat deposits are usually most prominent along the
axilla and the anterior, posterior, and medial arm.
After weight loss, these regions of the arm manifest the greatest excess in soft tissue.
Patients with a lower BMI, particularly those who had reached a very high BMI be-
fore weight loss, are likely to have more soft excess than an individual who has had
a smaller change in weight.
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Chapter 80 Brachioplasty
Older patients, particularly women, perhaps because of attenuated connective tis-
sue, often have large amounts of excess tissue despite relatively small changes in BMI.
In men, the majority of their deformity tends to be limited to the proximal arm and
axilla. Women may have this appearance as well but are more likely to have a de-
formity that extends to the elbow and beyond.
Evolution of Technique
Before 2000, brachioplasty procedures were rarely performed by most plastic sur-
geons. The earliest descriptions of brachioplasty were relatively simple techniques
involving the removal of an ellipse of soft tissue. The axilla was not addressed, and
candidates for surgery were usually moderately overweight individuals. In the 1970s,
multiple articles were published that described different patterns of excision for soft
tissue of the arm. Several of these publications included techniques to avoid scar con-
2822
Part XII Body Contouring
tracture at the arm-axilla transition. Pitanguy described addressing deformities of
the axilla and lateral thoracic region concurrent with correction of excess tissue of
the arm. The first case report of a massive-weight-loss patient undergoing brachio-
plasty was published in this period. In the 1980s, articles appeared on performing
brachioplasty as part of an upper body lift and near-total body lift, and Goddio re-
ported on an innovative technique of burying soft tissue excess. Brachioplasty con-
tinued to evolve in the 1990s. Liposuction became a more integral component of
these procedures. Lockwood proposed that the posteromedial soft tissue of the arm
is suspended to the clavipectoral periosteum by means of the clavipectoral fascia and
axillary fasciae. He argued that when these structures loosen, they lead to a “loose
hammock” effect, or arm ptosis. Lockwood’s technique for brachioplasty described
securing the arm flap to the axillary fascia and incorporating a superficial fascial
system repair in wound closure to help reduce the incidence of wide scars and un-
natural contours.
In the past decade, many articles have been written on brachioplasty. In an effort to
minimize scar length, several authors have described excisional techniques limited
to the axilla and proximal arm in combination with liposuction. The majority of re-
cent articles on brachioplasty involve weight-loss patients almost exclusively, and
the size of the series analyzed has increased considerably from that of a decade ago.
Much of the discussion today in the literature is on scar position, the timing and use
of liposuction, and incorporation of short-scar techniques in the management of
postbariatric patients.
Scar Placement, Use of Liposuction, and Scar Length
Advantages and disadvantages can be proposed for the various recommendations
regarding scar placement, the use of liposuction, and short-scar versus traditional
scar techniques. Scar location in brachioplasty is often the most important consid-
eration for postbariatric candidates, and one of the most frequently discussed top-
ics among plastic surgeons. Traditional locations range from the bicipital sulcus to
the posterior aspect of the arm. Advocates of a more posterior approach argue that
scar visibility is diminished in this location. Proponents for the bicipital sulcus prefer
this location for the same reason.
The use of liposuction in brachioplasty is often debated. Some argue that liposuc-
tion should be performed before an excisional procedure. These surgeons advocate
a staged approach. Liposuction is performed first to “debulk” the arm, and at a later
date an excisional procedure is performed. Those recommending the concomitant
use of liposuction argue that liposuction reduces arm volume and provides greater
2823
Chapter 80 Brachioplasty
tissue mobilization without damaging nerves and other vessels. Various approaches
have been suggested to address the postbariatric arm deformity with a scar limited to
the axilla or extending only partially down the arm. Advocates argue that some post-
bariatric patients have limited arm deformities that can be effectively addressed with
scars only in the axilla or axilla and proximal arm, usually in combination with li-
posuction. The obvious advantage is that a scar is avoided in the far more visible
middle and distal thirds of the arm. Proponents of the classic approach, scar exten-
sion to the medial epicondyle, would argue that a limited approach to most post-
bariatric patients leads to suboptimal results.
Our Approach to Brachioplasty
We prefer to use a posteromedial approach with extension to the medial epicondyle
in combination with liposuction in the vast majority of massive-weight-loss patients.
In the first half of our series, our scars were placed along the bicipital sulcus. We have
not found that an approach limited to the axilla or proximal arm was effective for
a significant number of individuals in this patient population.
Indications and Contraindications
The best candidates for brachioplasty are healthy individuals who have achieved a
stable weight, have a BMI of less than 28, and who have lost substantial weight, gen-
erally more than 23 kg (50 pounds). Dramatic results can be achieved in individu-
als with a BMI greater than 28; however, the final aesthetic result is less likely to be
ideal. The value of performing a brachioplasty depends greatly on the extent of the
deformity to be corrected, which in turn usually depends primarily on the degree of
weight loss. Variables representing relative contraindications to brachioplasty are
high patient BMI and a small BMI change from the highest weight; significant pa-
tient reservations regarding arm scars; a history of poor scars, such as hypertrophic
or hyperpigmented scars; and unrealistic patient expectations, particularly with regard
to short-scar versions of brachioplasty. In our practice at present, absolute con-
traindications are a history of lymphedema and/or arterial or venous insufficiency
of the upper extremity. A high risk for developing one of these conditions, such as a
patient who has undergone axillary lymph node dissection or radiation, would also
represent an absolute contraindication for brachioplasty.
2824
Part XII Body Contouring
Patient Profiles
2825
Chapter 80 Brachioplasty
This 25-year-old woman, who lost 58 kg (128 pounds) as a result of bariatric sur-
gery, was an ideal candidate for brachioplasty. She presented 4 years after surgery at
a weight of 62 kg (137 pounds); her highest weight before bariatric surgery was 120
kg (265 pounds). Liposuction was performed along the posterior and medial aspects
of her arms immediately before tissue undermining and excision. No liposuction was
performed at the axilla. The scar was placed along the posteromedial aspect of the
arm in an effort to minimize visibility.
This 31-year-old woman lost 92 kg (203 pounds) following bariatric surgery. She
presented 4 years after surgery at a weight of 88 kg (195 pounds); her highest weight
before bariatric surgery was 181 kg (398 pounds). Liposuction was performed along
the posterior and medial aspects of her arms immediately before tissue undermin-
ing and excision. No liposuction was performed at the axilla. The scar was placed
along the posteromedial aspect of the arm in an effort to make it less conspicuous.
The patient had concerns about the constrictive band along the distal aspect of her
left arm. One option to address this band was to perform a Z-plasty along the band;
however, this option was not pursued, primarily because of the possibility of a scar
in a more visible location.
2826
Part XII Body Contouring
This 70-year-old woman lost 52 kg (115 pounds) as a result of bariatric surgery. She
presented 4 years after surgery at a weight of 61 kg (135 pounds); her highest weight
before surgery was 113 kg (250 pounds). She had a relatively large amount of excess
soft tissue despite moderate weight loss. She presented with concerns about her ax-
illae, arms, and forearms. We performed liposuction along the posterior and medial
aspect of her arms immediately before tissue undermining and excision. No lipo-
suction was performed at the axillae. The scar was placed along the bicipital sulcus,
our choice for scar placement at the time. Note that the scar continued onto the prox-
imal forearm in an effort to address contour concerns in that area.
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Chapter 80 Brachioplasty
This 55-year-old man had lost 68 kg (150 pounds) as a result of bariatric surgery.
He presented 2 years after surgery at a weight of 110 kg (242 pounds); his highest
weight before bariatric surgery was 178 kg (392 pounds). As is typical of men, his
arm contour deformity was primarily limited to the axillae and proximal half of the
arms. Liposuction was performed along the posterior and medial aspect of his arms
immediately before tissue undermining and excision. No liposuction was performed
at the axillae. The scar was placed along the bicipital sulcus, our choice for scar place-
ment at the time. Note that the scar does not extend to the medial epicondyle, re-
flecting the limited extent of his deformity.
2828
Part XII Body Contouring
2829
Chapter 80 Brachioplasty
When considering the posteromedial approach to brachioplasty, it is essential that
the surgeon identify several superficial anatomic landmarks for consistent scar place-
ment. Important surface anatomy includes the anterior and posterior axillary folds,
biceps and triceps muscles, medial epicondyle, medial bicipital furrow, and medial
cubital sulcus. A posteromedial approach to brachioplasty in virtually all instances in-
volves the axillary dome, the area between the anterior and posterior axillary folds.
An incision in this region should remain superficial, involving only skin and a small
amount of subcutaneous fat. Liposuction is not usually performed in this region. The
superficial-lying intercostobrachial nerve is sometimes encountered and inadvertently
cut, with resulting numbness along the proximal medial aspect of the arm. This con-
dition is well tolerated by patients and rarely noted. Liposuction before dissection
of the medial and posterior arm should provide an easily identifiable plane imme-
diately deep to the superficial fascial system and superficial to the deep fascia of the
arm. Along the entire arm and elbow, vital structures remain deep to the deep fas-
cia and are unlikely to be injured.
Anterior axillary fold
Posterior axillary fold
Vertical excess
Horizontal excess
Medial bicipital furrow
Medial epicondyle
Medial cubital sulcus
Biceps muscle
Triceps muscle
Pertinent Anatomy
2830
Part XII Body Contouring
Anterior brachial cutaneous nerve
Posterior brachial cutaneous nerve
Posterior antebrachial cutaneous nerve
Cephalic vein
Cephalic vein
Basilic vein
Medial brachial cutaneous nerve branches
Cross section through middle of humerus
MEDIAL
Biceps muscle
Brachialis muscle
LATERAL
Cephalic vein
Basilic vein
Deep fascia
Brachial artery
Ulnar nerve
Radial nerve
Median nerve
Medial antebrachial
cutaneous nerve
Medial brachial
cutaneous nerve
Posterior brachial
cutaneous nerve
Superficial fascia
Triceps muscle
Along the proximal two thirds of the medial and posterior aspects of the arm, lying
superficial to the deep fascia, are the medial and posterior brachial cutaneous nerves
and small superficial unnamed veins. The cephalic vein and anterior brachial cuta-
neous nerve should remain out of the field of sharp dissection. Prior liposuction and
careful dissection should spare the medial and posterior cutaneous nerves. Injury to
these nerves would result in corresponding numbness to these areas of the arm.
2831
Chapter 80 Brachioplasty
Anterior brachial cutaneous nerve
Cephalic vein
Basilic vein
Medial brachial cutaneous nerve branches
Medial antebrachial cutaneous nerve branches
Cross section through distal humerus
MEDIAL
Biceps muscle
LATERAL
Basilic vein
Deep fascia
Brachial artery
Ulnar nerve
Superficial fascia
Cephalic vein
Radial nerve
Median nerve
Medial antebrachial
cutaneous nerve
Brachialis muscle
Brachioradialis muscle
Triceps muscle
Along the distal third of the arm and in the elbow region, the basilic vein and me-
dial antebrachial cutaneous nerve lie superficial to the deep fascia and are vulnera-
ble to injury. Once again, liposuction before sharp dissection in this area is helpful
in visualizing these more important structures.
Zones of adherence along the arm are limited primarily to the lateral arm and el-
bow region. The posteromedial approach does not involve sharp dissection along the
lateral arm, and fat deposits in this area are not common. Liposuction along the me-
dial and posterior arm addresses the fat deposits commonly encountered along the
posterior elbow and facilitates sharp dissection along the medial elbow.
Zones of
adherence
Some liposuction
More liposuction
Preoperative Assessment
Candidates for brachioplasty should undergo thorough history-taking and physical
examination. Photographs of the areas of concern are obtained. As for all post-
bariatric patients, special attention should be directed toward the patient’s weight
history. Critical information includes the patient’s height, current weight, and max-
imum weight. The time interval between their maximum and current weight and
length of time at the current weight should be documented. If weight loss was
achieved through bariatric surgery, the technique and when surgery was performed
should be recorded. Other important weight-related information includes whether
the individual is being followed by a bariatric surgeon, the date of the last visit, and
whether supplemental medication has been prescribed and is being taken regularly.
Problems potentially related to bariatric surgery should be explored, such as frequent
vomiting, abdominal pain, weakness, light-headedness, and frequent bowel move-
ments. For patients who have lost weight through lifestyle changes, the surgeon
should determine how this was accomplished: through exercise, diet and exercise,
and/or medication, and whether the patient is being supervised by a professional.
Physical examination of a postbariatric brachioplasty candidate should be thorough,
with particular attention to the upper body. Along with the degree of soft tissue ex-
cess present along the forearm, arm, and axilla, an assessment should be made of
the breasts, flanks, and back. The fat content of all these areas should be noted.
A standardized examination form is helpful. The examiner should note whether in-
tertriginous dermatitis is present, potentially along the axilla. Lymphedema and/or
the stigmata of lymphedema should be documented, as should the presence of arterial
or vascular insufficiency. Existing scars, banding, and striae along the upper extremity
should be documented.
Patient Goals
For some individuals following weight loss, the appearance of the arms is their pri-
mary or only concern. More often, however, the arms are one of many concerns. The
average age in our postbariatric population is 39. Most of these patients are very ac-
tive and eager to minimize time off from work and time away from family obliga-
tions. It is therefore quite common for a patient to express concerns about multiple
areas of the body and to request that all areas be addressed as soon as possible. One
of the most important components of patient assessment is determining in what or-
der and with what other procedures a brachioplasty should be performed. The pa-
tient’s goals should be carefully considered in formulating a plan. With regard to the
arms, it is important to gain a clear understanding of the patient’s tolerance for scars
and of the degree of contour improvement he or she is expecting. A postbariatric pa-
tient anticipating an optimal result from a procedure with a scar limited to the prox-
imal arm is likely to be disappointed.
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Part XII Body Contouring
2833
Chapter 80 Brachioplasty
PREOPERATIVE ASSESSMENT FOR BRACHIO PLASTY
Patient name________________________________________________ Date____________________
ARM
Left:
Striae:
Yes
No
Skin excess:
None
Mild
Moderate
Severe
Lipodystrophy:
None
Mild
Moderate
Severe
Scars:
Yes
No
Constrictive band
Yes
No
Right:
Striae:
Yes
No
Skin excess:
None
Mild
Moderate
Severe
Lipodystrophy:
None
Mild
Moderate
Severe
Scars:
Yes
No
Constrictive band
Yes
No
AXILLA / FLANK
Left:
Lipodystrophy:
None
Mild
Moderate
Severe
Right:
None
Mild
Moderate
Severe
Left:
Skin excess:
None
Mild
Moderate
Severe
Right:
None
Mild
Moderate
Severe
BREAST
Current breast size:________________________ Desired breast size:___________________
Excess grams of breast tissue:
Left________ Right________
Diameter of nipple-areola complex:
Left________ Right________
Distance from sternal notch to nipple (normal 23-25 cm):
Left________ Right________
Distance from inframammary fold to nipple (normal 10-12 cm):
Left________ Right________
Distance from midline to nipple (normal 10-12 cm):
Left________ Right________
Scars:
Left:
Biopsy
Inverted T
Vertical
Periareolar
Inframammary
Axillary
Right:
Biopsy
Inverted T
Vertical
Periareolar
Inframammary
Axillary
Breast ptosis:
Left:
None
Grade I
Grade II
Grade III
Pseudoptosis
Right:
Biopsy
Inverted T
Vertical
Periareolar
Inframammary
Lymphadenopathy:
Left:
None
Axillary
Supraclavicular
Right:
None
Axillary
Supraclavicular
Palpable mass:
Left:
Yes
No
Right:
Yes
No
Nipple discharge:
Left:
Yes
No
Right:
Yes
No
Shoulder grooving:
Left:
Yes
No
Right:
Yes
No
Baker capsular
Left:
None
Mild
Moderate
Severe
contracture:
Right:
None
Mild
Moderate
Severe
Gynecomastia:
Left:
Type I II III IV
Hypertrophy: A B C
Right:
Type
I II III IV
Hypertrophy: A B C
Tuberous breast:
Left:
None
Mild
Moderate
Severe
Right:
None
Mild
Moderate
Severe
ABDOMEN
Striae:
Yes
No
Scars:
None Midline Epigastric Hypogastric Left subcostal
Right subcostal Chevron Left paramedian Right paramedian
Left inguinal Right inguinal
Hernia:
None
Ventral
Incisional
Umbilical
Left inguinal
Right inguinal
Skin excess:
Left:
None
Mild
Moderate
Severe
Right:
None
Mild
Moderate
Severe
Lipodystrophy:
Left:
None
Mild
Moderate
Severe
Right:
None
Mild
Moderate
Severe
Fascial laxity:
Left:
None
Mild
Moderate
Severe
Right:
None
Mild
Moderate
Severe
Intertriginous
Yes
No
dermatitis:
2834
Part XII Body Contouring
Preoperative Planning
The information gathered from the patient history and physical examination is in-
strumental in formulating a preliminary plan. For patients expressing concerns only
about their arms, the plan is clear. For these patients, it is important to clarify the
importance of addressing the axilla in rejuvenating the arm (see pp. 2821-2822).
Most patients following massive weight loss express concerns about more than just
their arms; usually the breasts, flanks, back, abdomen, thighs, and buttocks are sources
of dissatisfaction as well. Multiple options are available to the plastic surgeon.
We prefer to perform a body lift first as a single procedure, then follow with a com-
bination mastopexy/lateral thoracoplasty/brachioplasty a minimum of 3 months
later. A medial thigh lift, if necessary, would be performed at least 3 months after
that. Our rationale for this sequence and combination of procedures derives from
the observation that the body-lift procedure greatly affects the rolls frequently pres-
ent along the upper and lower back (see p. 2835). In the vast majority of patients,
any remaining rolls along the back and flanks following a body lift can then be ad-
dressed by the combination mastopexy/lateral thoracoplasty/brachioplasty.
2835
Chapter 80 Brachioplasty
This 30-year-old woman had a 59 kg (130-pound) weight loss. She is shown 10
months after a body lift and 4 months after a medial thighplasty. Improvement to
the back contour is evident.
Although the upper body procedures may be performed before the body lift, it is of-
ten difficult to accurately estimate the appropriate amount of tissue to be excised in
the lateral thoracic region. The vast majority of postbariatric patients are candidates
for a body lift.
Before an individual can be considered for any procedure, certain criteria must be
met and issues addressed. The patient should be at a stable weight for several months;
this will vary, depending on the bariatric procedure. Operating during a period of
active weight loss may result in early recurrence of soft tissue laxity, and from a safety
perspective, the patient’s nutritional and metabolic status is unlikely to be optimal. Pa-
tients with symptoms that suggest problems related to bariatric surgery should be
evaluated by their surgeon, and patients are advised to maintain the supplemental
regimen prescribed by their bariatric surgeon. Individuals with a history of major or
acute mental illness are asked to undergo evaluation by an appropriate health pro-
fessional. Individuals with a history of tobacco consumption are urged to stop as
soon as possible. The risks of tobacco use are clearly established in the literature,
and patient education includes explanations of potential wound-healing problems
and thromboembolic disease. We ask patients who are on medications as part of
their weight-loss protocol to stop taking them. All patients are referred for medical
clearance. Although weight loss dramatically improves the health of morbidly obese
individuals, not all conditions are eliminated. A careful medical evaluation of their
health is imperative.
After discussing a possible plan with the patient, we review several topics. Many in-
dividuals are eager to lose more weight before surgery, feeling that their surgery will
be safer and that more skin can be removed if they are at a lower weight. We think
that most people whose weight is stable at the time of consultation are at the weight
they are most likely to maintain over the long term. Many weight-stable postbariatric
patients can lose additional weight for relatively brief periods of time—several months,
perhaps a year—but long-term sustained additional weight loss is difficult to achieve.
Weight loss over a short period of time can lead to several undesirable outcomes.
First, the individual may become nutritionally and metabolically unbalanced just at
the time contouring surgery is to be performed. Second, weight gain in the future
will in most instances diminish the aesthetic results of a procedure. We advise patients
to eat a balanced diet and maintain a stable weight. We also explain that a certain
amount of excess soft tissue will be removed during surgery. Their new weight after
surgery should be their current weight minus the weight of the tissue removed. A
3-month postoperative weight similar to their weight at consultation suggests a sig-
nificant weight gain. We also explain that the long-term results of this surgery are
best maintained by weight stability, minimizing exposure to sun (ultraviolet light),
and no tobacco consumption.
Laboratory Tests
The patient’s history can often suggest the presence of problems; however, a thor-
ough laboratory workup is essential to identify existing deficiencies or abnormali-
ties. It is not unusual for menstruating women to have few if any symptoms despite
having severe anemia as a result of bariatric surgery. Along with a complete blood
cell count and other studies, our routine includes a complete metabolic panel. Ab-
2836
Part XII Body Contouring
normal laboratory values are acted on as they are made available. Individuals found
to be malnourished (regarded as a total protein level less than 6 g/dl and/or albumin
less than 3 g/dl) may be referred to their bariatric surgeon for reevaluation and pos-
sible nutritional supplementation. Those findings may be corroborated by the pres-
ence of edema on physical examination. Protein-depleted patients may have difficulty
with wound healing. Severely anemic patients (those with a hemoglobin level less
than 10 g/dl) are referred to their primary physician and/or a hematologist. Patients
with a hemoglobin level above 10 g/dl are advised to continue taking iron, folate,
and B12 supplementation and to have their blood cell count repeated in 1 week. We
prefer that patients have a hemoglobin level above 12 g/dl before surgery. Patients
are advised of the possible need for a blood transfusion. We do not have patients
bank their own blood: in most institutions, blood can only be given within 1 month
of surgery, and 1 month may not be adequate time for an anemic patient to replen-
ish his or her blood levels.
Preoperative Visit
At the preoperative visit, usually 2 weeks before surgery, we review the planned sur-
gical procedure in detail with the patient, as well as the potential complications. Any
requested consultations and recommendations are discussed at this time. Another
critical function of the preoperative visit is to review the photographs taken at the
first consultation. Patients rarely have a completely accurate sense of their deformi-
ties. Key elements of this discussion are to highlight existing asymmetries, the pres-
ence of constrictive bands (which in many cases cannot be completely corrected), re-
view the extent of their deformities, and to explain the degree to which the planned
procedure or procedures will address these deformities. We prefer not to morph pa-
tient images on the computer but rather to show preoperative and postoperative
examples of individuals with similar body types who have had the same procedure.
Perhaps more than any other postbariatric body-contouring procedure, candidates
for brachioplasty must have a very clear understanding of the scar involved. The
process of scar maturation must be discussed, as should the potential risks for hy-
pertrophic and hyperpigmented scars. Failure to discuss the full spectrum of scar
quality can lead to a disappointed patient despite an excellent contour result. Re-
strictions and recovery guidelines are reviewed. Patients often have the sense that re-
covery from surgery should involve significant bed rest; instead, we emphasize the
importance of early and frequent ambulation. Medications that should be avoided
before surgery are reviewed: those that increase the risk for bleeding, such as aspirin
and NSAIDs, and medications that increase the risk for deep venous thrombosis
(DVT), such as birth control pills or hormone replacement therapy. Patients are ad-
vised not to take either for 2 weeks before or after surgery. We conclude the consul-
tation with an explanation of the plan for DVT prophylaxis.
2837
Chapter 80 Brachioplasty
Thromboembolic Disease Prophylaxis
Thromboembolic disease has been very rare in our brachioplasty series. All patients
undergoing brachioplasty have activated lower extremity sequential compression de-
vices in place before surgery, during surgery, and until they are regularly ambulat-
ing. After surgery, patients are encouraged to walk shortly after the procedure. Pa-
tients with a BMI above 32 are given 5000 units of heparin subcutaneously before
surgery. Individuals with risk factors other than obesity are treated on a case-by-case
basis. Thromboembolic disease prophylaxis for patients undergoing brachioplasty
and additional procedures, particularly abdominoplasty, is outside the scope of this
chapter but is discussed in detail in Chapter 79.
PERIOPERATIVE MANAGEMENT
Preoperative Planning
The goal of our technique is for the scar to lie along the posterior medial arm, ap-
proximately at the level of the triceps muscle. At the axilla, the scar should lie within
the axillary dome.
2838
Part XII Body Contouring
Restrictions and Recovery Guidelines
1. Dressings are removed 2 days postoperatively. Showering is permitted at this time. You
should keep your underarms dry at all times when not showering.
2. No special garments are required.
3. Avoid perspiring excessively for 2 weeks.
4. Deodorants or antiperspirants may be applied 2 weeks after surgery. (Many patients
report that they have no need or less need to apply these products, because in most
cases a significant number of sebaceous glands and hair follicles have been removed.)
5. Avoid lifting your arms (not the forearms) above shoulder level for 2 weeks after sur-
gery (the forearms and hands may be used for grooming).
6. Vigorous activities involving the lower body may be resumed 2 weeks after surgery.
Vigorous activities of the upper body, including the arms, may be resumed 6 weeks
after surgery.
Marking begins with the patient standing and the arm extended perpendicular to
the body. A line is drawn along the lateral inferior border of the pectoralis major
muscle from point A, the superior portion of the axillary dome to point B, the infe-
rior portion of the dome. A point C is found, usually at the level of the triceps muscle
that can be advanced easily to a point D at the most superior portion of the axillary
dome. The points at A, B, and C are connected to complete the ellipse at the axilla.
These steps determine the soft tissue excess to be excised from the axillary dome.
A dashed line is then drawn from the medial epicondyle, point E, to the lateral aspect
of the axillary dome over the triceps muscle, point F. In heavier individuals, the pos-
terior portion of the arm may need to be grasped to determine the location of the
triceps muscle. Finally, area G above the dashed line E-F is identified, corresponding
to the region of maximum soft tissue excess on the posterior aspect of the arm. Mod-
erate downward traction is placed on the area using multiple digits, typically the in-
dex, long, ring, and small fingers, to identify level H, which descends to the height
of point E, or the medial epicondyle. A line is then drawn from point E through H
and onto the lateral aspect of the ellipse, point I. The line from E through point H
should mirror the corresponding soft tissue excess of the posterior arm in that re-
gion. Typically the line rises gradually over the distal arm and rises more as it reaches
the proximal arm.
2839
Chapter 80 Brachioplasty
A
I
E
B
C
D
F
Area G
Level H
2840
Part XII Body Contouring
Operative Technique
Draping for bilateral brachioplasty, performed
with lateral thoracoplasty and mastopexy
Sterile drapes are placed on the operative table and arm boards. With the patient
supine, a sequential compression device is placed on one leg and a blood pressure
cuff on the other. An intravenous catheter is placed in the dorsal aspect of the hand
or wrist. Intravenous antibiotics are given, typically a first-generation cephalosporin.
A pulse oximeter sensor is placed on the ear. Following administration of general
anesthesia, often with a laryngeal mask, the forearm, arm, axilla, flank, and chest
are prepared with povidone-iodine solution (Betadine). A sterile towel is wrapped
around each hand and proximal forearm and secured to itself and the patient with
staples. An ether drape is stapled to the patient along the upper chest and over the
midclavicular portion of the shoulders. Sterile drapes are placed over the patient’s
body from the lower chest and inferiorly.
The previously made markings along the axilla, points A to B, up to C, and back
to A are scored with a knife blade. Similarly, the line from E through H and onto the
lateral limb of the axillary ellipse, point I, is scored. Beginning with the right arm
and using a No. 15 blade, the surgeon makes four stab wounds: along the medial
forearm, just distal to the medial epicondyle, the proximal and midposterior arm,
and the distal lateral arm. Through these stab wounds tumescent fluid (1 L of saline
solution, 1 ml of 1:1,000 epinephrine, 50 ml of 1% lidocaine) is injected into the
subcutaneous tissues of the medial and posterior arm. If fatty deposits are to be ad-
dressed along the anterior and lateral arm, fluid should be injected into these areas
as well. Our preference is to inject at a 1:1 ratio, fluid injected equaling effluent re-
moved. Excessive fluid injection may compromise control over the excision. While
the tumescent fluid is setting, the ellipse at the axilla is excised. Only a small amount
of subcutaneous fat is removed with the skin to avoid any deeper structures.
6
80-1 Brachioplasty
Liposuction is then performed with a 3 to 4 mm cannula, beginning through the stab
wound along the proximal medial forearm. By this approach, the medial arm is suc-
tioned with particular attention to the distal area, where the skin is more firmly ad-
herent to the underlying fascia. The arm is typically resting on the arm board dur-
ing this maneuver. Suction is then performed along the posterior and posterolateral
arm through the stab wound along the distal lateral arm. The surgeon is standing
and the forearm is elevated off the arm board by an assistant. Finally, the entire pos-
terior arm is liposuctioned through the posterior stab wounds. The arm is rotated
medially over the patient’s chest. With the arm resting on the arm board, the sur-
geon incises the skin from points E to I. The subcutaneous tissues are divided to
reach the honeycomb-appearing plane produced by the liposuction. In this plane,
dissection is readily performed to the posterolateral aspect of the arm.
2841
Chapter 80 Brachioplasty
A
I
E
B
C
D
F
Area G
Level H
2842
Part XII Body Contouring
The supporting ligaments to the skin in the region of the elbow are thicker and slightly
more difficult to divide. With the dissection complete, a towel clamp or an Adair
clamp is used to approximate the lateral skin edge of the axillary ellipse, point I, to
a point directly across the ellipse along the medial axillary skin edge. Towel clamps
are then used to approximate the lateral skin edge at a point beginning below E to
point I, already approximated. The correct point whether C or a point between C
and B, is the point that creates the desired contour of the proximal arm but avoids ex-
cessive tension. Once the desired point is found, the skin edges of the axillary ellipse
have been approximated. Attention is then directed toward the arm. Towel clips are
placed along the upper divided skin edge, E to I.
Beginning in the region of greatest tissue excess of the arm, typically slightly proxi-
mal to the mid-arm, a Pitanguy long skin demarcator is secured to a towel clip. The
surgeon and assistant then apply upward traction on the entire lower skin flap edge.
Advancement of the demarcator posteriorly toward the lower flap will cause it to
glide posteriorly for 1 cm or more before stopping. The lower flap is drawn into the
jaws of the demarcator under moderate tension. Once mild resistance is reached, the
lower flap is released by approximately 1 cm. This point is then marked.
The appearance of the subcutaneous tissues after li-
posuction to the medial and posterior arm is shown.
The plane of dissection is readily visible.
The same technique is repeated along the arm three or four times to develop an out-
line of the flap to be excised. The dots are connected and the flap excised. Hemostasis
is carefully restored. No drain is placed. Towel clamps are used to approximate the
flap edges along the axilla and arm. At the axilla, 2-0 Vicryl interrupted sutures are
used to approximate the superficial fascial system and deep dermis, approximately
0.5 cm from the flap edge. Incorporated in this approximation is a superficial bite
of the deeper tissues to help eliminate dead space. A 3-0 Monocryl intracuticular su-
ture is then placed. A similar closure with 2-0 Vicryl and 3-0 Monocryl is used along
the arm; however, the deeper tissues are not incorporated in the closure. ABD pads are
placed on the wounds of the axilla and arm, followed by a loosely applied elastic
wrap to the arm. To support the dressings at the axilla, an upper pole breast binder
is placed, or if breast surgery is being performed concomitantly, a bra is placed.
In our practice, the lateral thoracic region is often addressed in combination with a
brachioplasty and mastopexy. The sequence of procedures in these cases is for the
mastopexy to be performed first. From the lateral extent of the inframammary wound
closure, the tailor-tacking technique is then used to assess the excess skin and soft
tissue along the lateral thoracic region and to the dome of the axilla. Next the ex-
cess skin and a small amount of subcutaneous fat from the lateral thoracic region
and axilla are removed. The arm portion of the brachioplasty procedure can then
begin as described previously from the step in which liposuction is performed. The
remainder of the procedure is the same, except for the final wound closure, which
extends inferiorly from the axilla to the lateral thoracic region and terminates at the
lateral extent of the mastopexy inframammary wound closure. If large areas of skin
and soft tissue have been removed from the lateral thoracic region, the dermal su-
tures can be placed to incorporate a superficial bite of the tissues at the base of the
wound, or a drain can be left in place for several days. These efforts may diminish
the likelihood of a seroma or persistent fluid drainage from the axilla.
The proximal forearm, in addition to the arm, may be a concern for some patients,
particularly women in their fifth decade and beyond. Management of the proximal
forearm begins with the routine brachioplasty, as described previously, up to the
point just before the final intracuticular layer of 3-0 Monocryl is placed. With the
2-0 Vicryl suture in place, the tailor-tacking technique is used to assess the excess
skin and soft tissue along the proximal forearm beyond the medial epicondyle. The
skin and a small amount of subcutaneous fat from the pattern created along the prox-
imal medial forearm are removed. The final closure begins with 2-0 Vicryl in the fore-
arm, followed by 3-0 Monocryl along the forearm, arm, and axilla.
2843
Chapter 80 Brachioplasty
2844
Part XII Body Contouring
Postoperative Care
Ambulation is encouraged as soon as possible after surgery. Brachioplasty is nearly
always performed in an ambulatory setting, particularly if it is the only operation
being performed. The patient is usually discharged several hours after the procedure.
Dressings are removed 2 days later, and the patient is then allowed to shower.
Patients are encouraged to take narcotic analgesics as needed but to taper them as
soon as possible. They are reminded to avoid elevating their arms above shoulder
level. Routine follow-up visits are planned for 1 week, 6 weeks, 3 months, 6 months,
and yearly thereafter. Images are usually taken at the 3-month follow-up.
Problems and Complications
Major complications are very few following brachioplasty. In our review of 350 bra-
chioplasty cases (700 arms), skin dehiscence was the most frequent complication at
25%. None of the instances of dehiscence occurred acutely; that is, within the first
24 to 48 hours after the procedure. Rather, dehiscence began to become evident ap-
proximately 2 weeks after the procedure. Nearly all (95%) instances occurred at the
intersection of the closure of the axillary dome and the arm.
As in many skin flaps that are triangular, the tip of the flap has a compromised blood
supply. In the days after the procedure, the tip can become increasingly ischemic, tak-
ing on a dusky appearance, and at 2 weeks actual skin separation occurs. Most skin
dehiscences (over 90%) were less than 2 cm in size.
Avoiding this complication is challenging, because some form of Z-plasty must be
used for the closure to extend from the axilla to the arm to prevent scar contracture.
Although advising the patient to limit extension of the arm may be helpful, it is un-
likely to entirely prevent this problem. Dehiscences are treated with dressing changes.
In some instances, hypergranulation tissue may arise in the area of skin dehiscence.
Application of nitrate is very effective.
Seromas are the second most frequent problem (10%). Approximately 90% occur
along the distal medial third of the arm, immediately beneath the scar. Most become
evident at about 3 weeks postoperatively and range in diameter from 1 to 4 cm. Ini-
tially we manage them by needle aspiration; unfortunately, this technique has a very
high recurrence rate.
Marsupialization, which consists of incising the skin over the seroma, draining the
seroma, and suturing the seroma cavity to the skin, is 100% effective but results in a
scar that may be wider than the adjoining scar and can prolong wound healing. Cur-
rently we prefer to drain the seroma through the scar and place a secured Penrose
type of drain into the seroma cavity. This technique has also proved very effective.
Patients receive antibiotics while the Penrose drain is in place.
Infections have had been very infrequent, as have bleeding and hematomas. Com-
plaints of dysesthesia beyond 3 months have been few, and rare beyond 6 months.
Skin necrosis has also been very infrequent despite liposuction being performed in
virtually all cases.
We have had only one documented instance of DVT in a patient who underwent bra-
chioplasty. The patient presented with a palpable cord extending from the forearm
to the arm. There have been no instances of pulmonary embolism.
2845
Chapter 80 Brachioplasty
Complication Rates Associated With Brachioplasty
(N 350 cases; 700 arms)
Complication
Percentage
Skin dehiscence
25.0
Seroma
10.0
Infection
2.6
Hematoma
0.6
Skin necrosis
0.6
Deep venous thrombosis
0.3
Pulmonary embolism
0.0
Results
The following cases have been selected to represent the broad range of postbariatric
patients following brachioplasty.
2846
Part XII Body Contouring
This 25-year-old woman presented 4 years after bariatric surgery that resulted in a
weight loss of 58 kg (128 pounds). Her current weight was 62 kg (137 pounds) with
a BMI of 25. Her highest weight had been 120 kg (265 pounds) with a BMI of 48.
She is seen 6 months after brachioplasty with concomitant liposuction and postero-
medial scar placement. Note the improvement of the axilla, a critical component of
an effective brachioplasty. Scars placed in this position are less noticeable than those
along the bicipital sulcus.
2847
Chapter 80 Brachioplasty
This patient was a good candidate for brachioplasty. She was 31 years old and had
undergone bariatric surgery 4 years earlier. As a result, she had lost 92 kg (203
pounds). Her current weight was 89 kg (195 pounds) with a BMI of 35. The high-
est weight and BMI she ever reached were 181 kg (398 pounds) and 71, respectively.
She is seen 3 months after brachioplasty and concomitant liposuction, with scar
placement along the posteromedial arm. Although the results are dramatic, the aes-
thetic level achieved is not the same as for the preceding ideal candidate. Note the
constrictive band along the left arm that could not be eliminated.
This 70-year-old woman presented 4 years after bariatric surgery that had produced
a weight loss of 52 kg (115 pounds). Her current weight was 61 kg (135 pounds)
with a BMI of 25. Her highest weight had been 114 kg (250 pounds) with a BMI of
46. She is seen 6 months after brachioplasty and concomitant liposuction, with scar
placement at the bicipital sulcus. Note that her deformity extends from the axilla
and arm to the proximal forearm; this is typical of older women. In addition, her
deformity is greater than might be expected from her degree of weight loss.
2848
Part XII Body Contouring
This 55-year-old man was initially seen when he requested brachioplasty 2 years af-
ter undergoing bariatric surgery through which he had lost 58 kg (128 pounds). His
weight at the first visit was 109 kg (240 pounds) with a BMI of 35. His highest weight
had been 177 kg (391 pounds) with a BMI of 58. He is seen 3 months after bra-
chioplasty and concomitant liposuction, with scar placement along the bicipital sul-
cus. As is typical of men, his deformity was primarily limited to the axilla and prox-
imal half of the arm. Although the erythema of his scar is quite typical for this
postoperative period, this degree of scar visibility influenced our decision to place
scars slightly more posterior along the medial aspect of the arm.
Concluding Thoughts
Increasing numbers of individuals are requesting arm contouring after massive weight
loss. It is important that plastic surgeons have a safe, effective, and reliable technique
to address upper extremity concerns. Careful preoperative evaluation with particu-
lar attention to weight history is the first step in creating the appropriate plan for
each individual. The preoperative evaluation should include a clear understanding
of patient expectations and their comfort level with scars. Examination of the pa-
tient should make note of the extent of the arm deformity, but also of surrounding
structures such as the forearm, axilla and lateral thoracic region. Once a patient has
been evaluated and a plan formulated, the brachioplasty procedure should proceed
2849
Chapter 80 Brachioplasty
in an organized, step-wise fashion. The technique described in this chapter has been
performed hundreds of times on a wide array of postbariatric patients. The outcomes
have been carefully evaluated and are associated with few significant complications
and a high level of patient satisfaction. The goal of the technique is to restore nor-
mal contour to the arm and adjacent structures, with scars placed in the least no-
ticeable locations. To achieve this in patients of varying BMIs, concomitant liposuc-
tion plays an essential role. Liposuction helps to create a safe plane for dissection
and remove excess fat, making it possible to safely remove more excess soft tissue.
Brachioplasty can be a consistently rewarding experience for both the plastic sur-
geon and postbariatric patient when careful attention is placed on preoperative eval-
uation and screening, scar placement, the treatment of the arm and adjoining struc-
tures, and the appropriate use of liposuction.
Clinical Caveats
Careful patient selection is critical for optimizing the outcome from brachioplasty
surgery.
In postbariatric patients, the arm contour deformity must be evaluated as a part of
the upper body and not as an isolated area.
Candidates for brachioplasty must have a clear understanding of scar visibility.
Upper extremity and upper body asymmetries, including the presence of con-
strictive bands, should be highlighted and discussed with patients before surgery.
Preoperative marking should be performed consistently, particularly with regard
to patient position.
The surgical plan and sequence of steps should be determined before the procedure.
The excisional component of brachioplasty must be performed in a methodical
and detailed fashion.
Liposuction should be considered for most postbariatric brachioplasty patients.
Annotated Bibliography
Abramson DL. Minibrachioplasty: minimizing scars while maximizing results. Plast Recon-
str Surg 114:1631-1634; discussion 1635-1637, 2004.
A short-scar brachioplasty or minibrachioplasty technique is described that limits the
scar to the axilla and proximal arm. Eight patients were treated with the technique. Bra-
chioplasty techniques with scars limited to the proximal arm are likely to have a lim-
ited scope of utility in massive-weight-loss patients.
2850
Part XII Body Contouring
Gusenoff J, Coon D, Rubin JP. Brachioplasty and concomitant procedures after massive
weight loss: a statistical analysis from a prospective registry. Plast Reconstr Surg 122:595-
603, 2008.
The authors analyze data from a prospective registry of massive-weight-loss patients
who underwent brachioplasty alone or with concomitant operations to identify statis-
tically significant complications (a total of 101 cases). Outcome measures included op-
erative time, time since the gastric bypass, need for revision, arm liposuction, and com-
plications such as seroma, dehiscence, hematoma, infection, and nerve injury. Patients
with a greater change in BMI had a higher likelihood of wound infection. Longer op-
erative time was associated with increased rates of surgical complications at the opera-
tive site. There was a trend toward increased complications when arm liposuction was
combined with brachioplasty.
Hallock GG, Altobelli JA. Simultaneous brachioplasty, thoracoplasty and mammoplasty.
Aesthetic Plast Surg 9:233-235, 1985.
A technique for combining brachioplasty with mammoplasty and lateral thoracoplasty
is described. The majority of women following massive weight loss can benefit from this
combination. Failure to treat the lateral thoracic region may lead to a suboptimal result
at the breasts or arms.
Lockwood T. Brachioplasty with superficial fascial system suspension. Plast Reconstr Surg
96:912-920, 1995.
Anatomic studies of five cases were reported by the author; these reveal that the pos-
teromedial soft tissue of the arm in youth is firmly suspended to the clavipectoral peri -
osteum by means of the clavipectoral and axillary fasciae. Loosening of these structures
leads to ptosis of the posteromedial arm. On the basis of this anatomic concept, the bra-
chioplasty technique proposed provides anchoring of the arm flap to the axillary fascia
and repair of the superficial fascial system to reduce the risk of scar widening or mi-
gration and unnatural arm contours.
Pascal JP, Le Louarn C. Brachioplasty. Aesthetic Plast Surg 29:423-429; discussion 430, 2005.
A technique for brachioplasty is described in which the scar is placed along the pos-
teromedial arm and concomitant liposuction is used to help preserve both deep and su-
perficial lymphatics, reduce damage to blood vessels and nerves, reduce volume, and al-
low better tissue mobilization. The series included 21 patients.
Suggested Readings
Aly AS, Capella JF. Staging, reoperation and treatment of complications after body contouring
in the massive-weight-loss patient. In Grotting J, ed. Reoperative Aesthetic and Recon-
structive Surgery, 2nd ed. St Louis: Quality Medical Publishing, 2007.
Aly AS, Cram AE, Pace D. Brachioplasty in the patient with massive weight loss. Aesthet Surg
J 26:76-84, 2006.
American Society of Plastic Surgeons. National Plastic Surgery Statistics. Available at
Baroudi R. Dermatolipectomy of the upper arm. Clin Plast Surg 2:485-494, 1975.
2851
Chapter 80 Brachioplasty
Bruschi S, Datta G, Bocchiotti MA, et al. Limb contouring after massive weight loss: func-
tional rather than aesthetic improvement. Obes Surg 19:407-411, 2009.
Cannistra C, Valero R, Benelli C, et al. Brachioplasty after massive weight loss: a simple al-
gorithm for surgical plane. Aesthetic Plast Surg 31:6-9; discussion 10-11, 2007.
Capella JF. Brachioplasty. Presented at the Baker-Gordon Symposium, Miami, Feb 2005.
Correa-Iturraspe M, Fernandez JC. Dermolipectomia braquial. Prensa Med Argent 34:2432-
2436, 1954.
Geerts WH, Heit JA, Clagett GP, et al. Prevention of venous thromboembolism. Chest
119:132S-175S, 2001.
Goddio AS. A new technique for brachioplasty. Plast Reconstr Surg 84:85-91, 1989.
Guerrero-Santos J. Brachioplasty. Aesthetic Plast Surg 3:1-8, 1979.
Hauben DJ, Benmier P, Charuzi I. One-stage body contouring. Ann Plast Surg 21:472-479,
1988.
Hurwitz DJ, Holland SW. The L brachioplasty: an innovative approach to correct excess tis-
sue of the upper arm, axilla, and lateral chest. Plast Reconstr Surg 117:403-411, 2006.
Juri J, Juri C, Elias JC. Arm dermolipectomy with a quadrangular flap and T closure. Plast
Reconstr Surg 64:521-525, 1979.
El Khatib HA. Classification of brachial ptosis: strategy for treatment. Plast Reconstr Surg
119:1337-1342, 2007.
Knoetgen J III, Moran SL. Long-term outcomes and complications associated with bra-
chioplasty: a retrospective review and cadaveric study. Plast Reconstr Surg 117:2219-
2223, 2006.
McCraw LH Jr. Surgical rehabilitation after massive weight. Case report. Plast Reconstr Surg
53:349-352, 1974.
Nemerofsky RB, Oliak DA, Capella JF. Body lift: an account of 200 consecutive cases in the
massive weight loss patient. Plast Reconstr Surg 117:414-430, 2006.
Pitanguy I. Correction of lipodystrophy of the lateral thoracic aspect and inner side of the
arm and elbow dermosenescence. Clin Plast Surg 2:477-483, 1975.
Posse RP. Cirugia Estetica. Buenos Aires, Argentina, 1946.
Richards MA. Minimal incision brachioplasty: a first choice option in arm reduction sur-
gery. Aesthet Surg J 21:301-310, 2001.
Strauch B, Greenspun D, Levine J, et al. A technique of brachioplasty. Plast Reconstr Surg
113:1044-1048; discussion 1049, 2004.
Taylor J, Shermak M. Body contouring following massive weight loss. Obes Surg 14:1080-
1085, 2004.
Temourian B, Malekzadeh S. Rejuvenation of the upper arm. Plast Reconstr Surg 102:545-
551; discussion 552-553, 1998.
Thorek M. Esthetic surgery of the pendulous breast, abdomen and arms in the female. Ill
Med J 58:48-57, 1930.
Vogt PA. Brachial suction-assisted lipoplasty and brachioplasty. Aesthet Surg J 21:164-167,
2001.
2852
Part XII Body Contouring
Back and Lateral Fold Contouring
DIRK F. RICHTER, ALEXANDER STOFF
CHAPTER 81
2854
Part XII Body Contouring
W
ith the steadily rising global rate of obesity—according to the World Health
Organization, 300 million people worldwide are obese—there has been a
substantial increase in the number of bariatric operations since the early 1960s. Be-
cause massive weight loss usually results in a significant and disfiguring excess of
skin and soft tissue, there has been an increasing demand among patients for body-
contouring procedures to complete the desired results. Many operative techniques
have been developed and refined to a high standard, increasing the popularity and
effectiveness of these procedures.
In the past, operations such as abdominoplasties and medial thigh and gluteal lifts
were performed as multistage procedures for patients after massive weight loss. These
have given way to modern, holistic concepts of treatment, such as circumferential
lifting and full lower body lifts, the current benchmark procedures for postbariatric
patients.
However, to date, treatment of the lateral and dorsal thoracic regions has not been as
satisfactory, as indicated by surgical experience and the absence of reports of good re-
sults in the literature. The thick skin, fibrous soft tissue with lobulated fat, and poor
retraction capability of this region have limited the success of treatment. Further-
more, scarring in the lateral and dorsal thoracic regions cannot be adequately hid-
den by underwear, especially in male patients; because of the thickness and quality
of the skin, the scars in this region are usually significant and remain visible. In ad-
dition, scars are difficult to place in the natural, relaxed skin-tension lines. Because of
these difficulties, minimally invasive, scar-reducing techniques such as liposuction
are usually preferred, although the problem of poor skin retraction has remained in-
surmountable. Thus the results of liposuction-only treatments are disappointing, es-
pecially in patients after massive weight loss, primarily because of insufficient skin
retraction.
To address these problems, we have developed a new method for treatment of the
back, particularly the lateral and dorsal thorax, in massive-weight-loss patients. This
technique combines surgical excision of skin redundancy with preliminary liposuc-
tion. The upper lateral thoracic lift (ULTL) is an alternative approach for eliminating
skin excess in this region. It can be performed alone or as an integral part of a com-
bined technique with upper body lift procedures.
Indications and Contraindications
The choice of technique must be individualized, based on the patient’s preoperative
characteristics. The importance of the individual’s psychological attitude cannot be
overstated, particularly in regard to his or her acceptance of the visible scars associ-
2855
Chapter 81 Back and Lateral Fold Contouring
ated with this procedure. Fortunately, massive-weight-loss patients usually have a
high tolerance for scar length and visibility.
In general, if there is skin and soft tissue excess in the form of local folds in the dor-
sal and lateral thorax, an excisional procedure will be necessary to correct the re-
dundancy. Local liposuction can be worthwhile in cases of local soft tissue excess if
there are no skin folds. The surgeon must assess the entire back preoperatively to de-
termine the amount of skin elasticity present so that the areas of skin with the worst
retraction potential can be distributed across a larger body surface, which will pro-
mote more effective skin retraction.
Patient Profiles
The ideal candidate for an excisional lifting operation is a psychologically prepared
individual with significant skin and soft tissue excess with ptotic skin rolls and fold
development. A BMI of 32 is the generally accepted upper limit for lifting operations
to achieve good results with an acceptable complication rate. If patients are still too
obese, their results will be poor and scarring unacceptable. Patients who tend to de-
velop hypertrophic scars should not be considered for this operation, because the
back is prone to noticeable scars and development of keloids.
Suitable candidates for liposuction have skin that is neither too thin nor too thick,
with an obvious excess of subcutaneous fat. Using a technique that combines super -
ficial and deep liposuction of the area, the surgeon can achieve good skin retraction;
however, there is a risk of skin dimpling. If dimples occur, ultrasound-assisted lipo-
suction may be used to ameliorate this problem (Jewell).
2856
Part XII Body Contouring
Pertinent Anatomy
The entire back and lateral thoracic areas have a central conjoined zone over the ver-
tebral column. When a person gains weight, this zone remains nearly unchanged;
there are few fat cells there that can hypertrophy because of the connections between
skin and fascia. More laterally, the tissue is thicker and heavier, and it gradually col-
lapses back on itself, like a roman shade. Thus multiple rolls are formed, as previ-
ously described by Strauch and colleagues.
A classification for these back rolls includes an upper breast roll, followed by a lower
scapular roll and a deeper lower chest/thoracic roll. An analogous classification is
made for the iliac area hip rolls. The wrinkles can be seen individually as well as col-
lectively.
In our patient population we have found strongly asymmetrical patterns, such as one
roll on one side and four rolls on the other side. For this reason the surgeon has to
evaluate each patient carefully for the presence of scoliosis, hip problems, or leg dif-
ferences. It is thought that ligamentous structures of different strengths are responsible
for the development of these asymmetrical rolls. A pathohistologic study that correlates
the different types of collagen to the clinical outcome is currently under analysis.
2857
Chapter 81 Back and Lateral Fold Contouring
Breast fold
Scapular fold
Lower thoracic fold
Hip fold
The back is perfused primarily by the perforating vessels of the latissimus dorsi. The
area around the sacrum is supplied by numerous small arteries with no single main
vessel, making the area a danger zone for development of decubitus ulcers and cir-
culatory disturbance after a lifting procedure. New data must be evaluated with re-
gard to lymphatic clearance, since surgical interventions in these areas (such as a
latissimus dorsi flap, belt lipectomy, or extensive liposuction) present a high risk for
seroma formation.
Preoperative Assessment
A detailed medical history is taken and the patient’s BMI is determined during the
initial consultation and physical examination. All local physical conditions must be
assessed. It is important to ensure that the patient is psychologically prepared to ac-
cept the significant scars associated with these procedures. This is particularly criti-
2858
Part XII Body Contouring
TDA
DCIA
SCIA
LCFA
TDA
LA
SCIA
LCFA
MCFA
IPA
SGA
LSA
SGA
LPIA
LPIA
DPIA
CSA
CSA
TCT
TCT
IGA
IGA
LA
Superior
gluteal
artery
Circumflex
scapular
artery
Inferior
gluteal
artery
Lumbar
arteries
Lateral
sacral
artery
Thoracodorsal
artery
Left: Cutaneous vascular territories are shown in different colors in this cadaver angiogram to facilitate
identification: CSA, Circumflex scapular artery; DCIA, deep circumflex iliac artery; DPIA, dorsal branches
of posterior intercostal arteries; IGA, inferior gluteal artery; IPA, internal pudental artery; LA, lumbar
arteries; LCFA, lateral circumflex femoral artery; LPIA, lateral branches of posterior intercostal arteries;
LSA, lateral sacral arteries; MCFA, medial circumflex femoral artery; SCIA, superficial circumflex iliac
artery; SGA, superior gluteal artery; TCT, thyrocervical trunk; TDA, thoracodorsal artery.
The patient is evaluated with his or her arms maximally elevated and lowered. We
recommend that a standard photographic series be obtained showing the full range
of motion of the arms from 0 to 180 degrees to clarify and document the mobility
of the skin folds and the overlying tissue.
The individual breast, scapular, and lower thoracic rolls should be measured with
skin calipers. If liposuction-only treatment is indicated for a patient with one roll or
even a certain degree of generalized obesity of the back or hip, it is essential to eval-
uate the thickness of the fat layer for preoperative planning. If liposuction is to be
done, high-resolution ultrasonography may be helpful to define the thickness of the
skin and fat layers to enhance planning.
We generally advise patients to refrain from taking any nonessential medications for
14 days before the operation, particularly those that could interfere with coagula-
tion or lead to increased bleeding.
2859
Chapter 81 Back and Lateral Fold Contouring
cal for treatment of the upper folds of the back, because these often leave visible scars
that are not easy to hide. Careful planning and explicit discussion with the patient
are essential.
The quality and thickness of the skin folds are of particular interest and should be
measured. The degree of mobility and the elasticity of the tethered areas provide
helpful information for planning an effective operation.
Preoperative Planning
Primarily we attempt to combine an upper arm lift with a breast lift and an inte-
grated ULTL. This technique treats the upper part of the body as one unit. As a guide,
we say that the two upper folds often can be treated by various surgical options or the
lower body lift (LBL) alone (because this lift exerts such an influence on the entire
back), whereas the two lower folds can only be effectively treated by using an LBL
or a belt lipectomy.
When planning an LBL, it is important to remember the principle that force equals
counterforce, so approximately one quarter of the soft tissue should be excised from
the cranial side, with approximately three quarters removed from the caudal side.
However, we agree with the majority of surgeons that direct undermining of the
back, especially in the sacral area, should be avoided. Aly excises the lower thoracic
fold using a slightly higher incision line with the belt lipectomy. Thus approximately
half of the lower thoracic fold can be resected, whereas the other half can be tightened
by pulling downward.
Classification
The Pittsburgh Rating Scale has proved helpful for selecting the best operative ap-
proach. Overall, we agree with the general recommendations for treatment in this
classification system; however, we have found a greater indication for the combined
technique of liposuction and excisional procedures of the back.
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Chapter 81 Back and Lateral Fold Contouring
The Pittsburgh Rating Scale*
Area
Scale
Preferred Procedure
Arms
0 Normal
None
1 Adiposity with good skin tone
UAL and/or SAL
2 Loose, hanging skin without severe adioposity
Brachioplasty
3 Loose, hanging skin with severe adiposity
Brachioplasty UAL and/or SAL
Breasts
0 Normal
None
1 Ptosis grade I/II or severe macromastia
Traditional mastopexy, reduction, or augmentation
techniques
2 Ptosis grade III or moderate volume loss or
Traditional mastopexy augmentation
constricted breast
3 Severe lateral roll and/or severe volume loss
Parenchymal reshaping techniques with dermal
with loose skin
suspension, consider autoaugmentation
Back
0 Normal
None
1 Single fat roll or adiposity
UAL and/or SAL
2 Multiple skin and fat rolls
Excisional lifting procedures
3 Ptosis of rolls
Excisional lifitng procedures
Abdomen
0 Normal
None
1 Redundant skin with rhytids or moderate
Miniabdominoplasty, UAL and/or SAL
adiposity without overhang
2 Overhanging pannus
Full abdominoplasty
3 Multiple rolls or epigastric fullness
Modified abdominoplasty techniques, including fleur-
de-lis and/or upper body lift
Flank
0 Normal
None
1 Adiposity
UAL and/or SAL
2 Rolls
UAL and/or SAL
3 Ptosis of rolls
Excisional lifting procedures
Buttocks
0 Normal
None
1 Mild to moderate adiposity and/or mild to
UAL and/or SAL
moderate cellulite
2 Severe adiposity and/or severe cellulite
UAL and/or SAL excisional lifting procedure
3 Skin folds
Excisional lifting procedure
Mons
0 Normal
None
1 Excessive adiposity
UAL and/or SAL
2 Ptosis
Monsplasty
3 Significant overhang below symphysis
Monsplasty
Hips/lateral
0 Normal
None
thighs
1 Mild to moderate adiposity and/or mild to
UAL and/or SAL
moderate cellulite
2 Severe adiposity and/or severe cellulite
UAL and/or SAL excisional lifting procedure
3 Skin folds
Excisional lifting procedure
Medial
0 Normal
None
thighs
1 Excessive adiposity
UAL and/or SAL excisional lifting procedure
2 Severe adiposity and/or severe cellulite
UAL and/or SAL excisional lifting procedure
3 Skin folds
Excisional lifting procedure
Lower
0 Normal
None
thighs/
1 Adiposity
UAL and/or SAL excisional lifting procedure
knees
2 Severe adiposity
UAL and/or SAL excisional lifting procedure
3 Skin folds
Excisional lifting procedure
*Ten regions are assessed on a scale of 0 to 3. The presence of specific deformities determines the score. For each rating, the indicated surgical proce-
dures are outlined. The procedures may be performed alone or in combination.
SAL, Suction-assisted lipectomy; UAL, ultrasound-assisted lipectomy.
It is important to start the planning with the LBL operation as the core part of the
plan, because this operation exerts such a significant influence on the entire back.
Sometimes no additional steps are needed after an LBL or a belt lipectomy has been
performed.
For precise preoperative planning of any body-contouring operation, we suggest us-
ing the anatomic description by Strauch and colleagues (seen on p. 2856).
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Part XII Body Contouring
0 (Normal)
1
2
3
PITTSBURGH RATING SCALE
Treatment of the Upper Two Folds
We rarely see an isolated upper breast fold; therefore our method of choice is the
ULTL, which we usually combine with a breast lift and an upper arm lift. The ULTL
is also our method of choice when two folds are present, such as an upper breast
fold and a lower scapular fold. If the old folds are more distinct or the fat excess is
greater, we generally start with liposuction in a single operation.
For a patient with Pittsburgh grade 3 folds that are heavy and reach the spine, direct
excision either in an oblique direction (referring to the relaxed tension lines) or in a
horizontal direction may be indicated. Horizontal excisions, crossing these relaxed
tension lines, usually result in unfavorable scars, although hiding them under the bra
straps is easier than for vertical incisions.
Treatment of the Lower Two Folds
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Chapter 81 Back and Lateral Fold Contouring
Good results can be obtained with an LBL and a belt lipectomy for treating the lower
two folds. Even without direct treatment of the annoying lower thoracic rolls in pa-
tients with moderate folds, the folds can be reduced by the mechanism of draw and
counterdraw (stretching one side to reduce the other side). Additional mobilization
with liposuction is often necessary in patients with distinct hip rolls; this results in
a supplementary lifting effect of this region.
OPERATIVE APPROACH: UPPER TWO FOLDS
Liposuction Alone
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Part XII Body Contouring
We do not usually use liposuction-only for contouring the back folds but for treat-
ing back rolls of massive-weight-loss patients, because of the poor shrinkage capa-
bilities of the thick skin of the back and because of the subjacent fibrous tissue, as
seen in these two patients.
Markings
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Chapter 81 Back and Lateral Fold Contouring
Back rolls should be carefully marked before the operation with the patient both
standing and then lying down, because once the patient is positioned prone on the
operation table, the rolls essentially disappear, thus making it nearly impossible to
determine the areas of soft tissue excess.
Technique
We always use tumescent infiltration and superwet technique. Infiltration of the en-
tire back is essential to achieve a consistent result. Then we massage the area to dis-
tribute the fluid among the fatty tissue. For liposuction we use 3 to 4 mm cannulas
and a low suction pressure (0.3 bar). We start at the top and use a crisscross tech-
nique to avoid dimples and to achieve better skin retraction. The surgeon should not
suction in the rolls alone but should cross their folds. Careful pinching provides es-
sential information about the thickness of the tissue. Liposuction is stopped at the
hip rolls, where we perform some superficial refinements with a 2 mm cannula. The
procedure is complete when the tissue thickness is consistent all over. The patient
wears a compression garment for 2 to 4 weeks.
Indirect Excisional Procedures
If there is an indication (after the LBL) for indirectly treating the two upper folds (the
upper breast and lower scapular folds), we use an approach from the lateral thoracic
region with a local excision for indirect lateral and dorsal thoracic rejuvenation.
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Part XII Body Contouring
Upper Lateral Thoracic Lift
Assessment and Markings
Our preferred method for moderate upper folds with more than 2 to 3 cm of over-
lapping skin is the ULTL (for Pittsburgh 3). To better assess whether this technique
is appropriate for meeting the patient’s expectations, it is helpful to grab the tissue
in the lower axillary region and give it a good pull to see how much of the upper
back folds will disappear or remain. In most cases, this lateral pull test will provide
the surgeon and patient with a clear idea of what can be achieved.
6
81-1 Upper lateral
thoracic lift
The ULTL is usually carried out in combination with a breast lift and upper arm lift.
Typically a moderate extension of the incision that sweeps toward the back becomes
necessary if an additional scapular fold exists. This means it is possible to achieve
transposition and rotation of the soft tissue upward and outward so that the scar
will be located in a medial or posterior axillary line.
For such an indirect excisional procedure without concomitant liposuction of the
back, we position the patient supine with the upper arms at a 90-degree angle. This
affords good access to the posterior resection line; however, in special cases we may
place the patient in a lateral position, which results in considerable additional op-
erating time.
With the ULTL, the breast fold is directly excised, and the laterocaudal tissue is re-
moved through the lower incision. Balancing of the scapular fold can be achieved at
the same time.
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Chapter 81 Back and Lateral Fold Contouring
The ULTL can be carried out as a single maneuver just to address the back rolls, or,
as is done in many of our cases, it can be used after an upper arm lift and breast lift
to connect the lateral scar from the mastopexy procedure with the axillary end of
the arm lift scar.
After carefully pinching and watching how much lateralization of the breast occurs
with the patient supine, we begin the incision at the curved ventral line. Because there
is no clear definition of Scarpa’s fascia at this level, we do not go too deep and leave
a small amount of fat on top of the deep fascia. This helps to protect underlying
nerves, such as the lateral thoracic nerve and lower intercostobrachial branches.
Once the incision has been made and preparation has been completed to the dorsal
resection line, we carefully pull the ventral wound edges dorsally, estimating whether
the breast shows a tendency to move laterally. If there is too much lateralization, we
suture the deep layer of the ventral wound edges down to the deep muscle fascia to
provide a good anchor, usually with 2-0 Monocryl.
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Part XII Body Contouring