Phẫu Thuật Tạo Hình Đường Nét Cơ Thể Và Hút Mỡ (Body Contouring and Liposuction)

Body Contouring
and Liposuction

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J. Peter Rubin, MD, FACS
UPMC Endowed Professor of Plastic Surgery
Chair, Department of Plastic Surgery
Director, Life After Weight Loss Body Contouring Program
University of Pittsburgh
Pittsburgh, PA, USA
Mark L. Jewell, MD
Assistant Clinical Professor of Plastic Surgery
Oregon Health Science University
Portland, OR;
Jewell Plastic Surgery Center
Eugene, OR, USA
Dirk F. Richter, MD, PhD
Associate Professor
University of Bonn
Chief, Department of Plastic and Reconstructive Surgery
Director of the Dreifaltigkeits
Krankenhaus
Wesseling, Germany
Carlos O. Uebel, MD, PhD
Associate Professor
Division of Plastic Surgery
PUCRS University
Porto Alegre, Brazil
Edinburgh  London  New York  Oxford  Philadelphia  St Louis  Sydney  Toronto
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Body Contouring
and Liposuction

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Notices
Knowledge and best practice in this field are constantly changing. As new research and experience
broaden our understanding, changes in research methods, professional practices, or medical
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Practitioners and researchers must always rely on their own experience and knowledge in
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Body contouring and liposuction is a wonderfully challeng­
ing and constantly evolving field at the intersection of surgi­
cal skill, artistry, and new technology. Through this highly
impactful practice, we reshape the bodies and the lives of
our patients.
This book was designed around a simple concept: to
provide a comprehensive reference for the full spectrum of
principles and techniques in body contouring and liposuc­
tion, as taught by the masters in the field across the globe.
The resulting compilation truly covers all aspects of the
specialty and puts into perspective applied anatomy, physi­
ology, patient selection, safety, technical aspects, problem-
solving, and management of complications.
The most up-to-date concepts are presented by leaders
in the field. Important principles, some rooted in the early
history of plastic surgery and others of more modern origin,
come together to form the foundation of current practice. It
is wonderful to see the evolution of this specialty, as well
as the breadth and scope of the creative solutions we can
use to sculpt the human form.
The international editorial team is greatly indebted to
the numerous contributors from around the world who have
so expertly composed the chapters in this book. The high
quality of this book is a result of the time and effort they
have spent distilling their techniques into such clear and
well written monographs. Additional thanks goes to the
talented members of the Elsevier staff who shepherded this
project from inception to final form.
J. Peter Rubin, MD
Mark L. Jewell, MD
Dirk F. Richter, MD, PhD
Carlos O. Uebel, MD, PhD
2013
Preface
vii

José H. Aboudib, MD
Professor of Plastic Surgery
President of Brazilian Society of Plastic Surgery
Rio de Janeiro, Brazil
Al S. Aly, MD, FACS
Professor
Director of Aesthetics
Aesthetic and Plastic Surgery Institute
The University of California
Irvine Orange, CA, USA
Noriyuki Aoi, MD
Graduate student
Department of Plastic Surgery
University of Tokyo Graduate School of
Medicine
Tokyo, Japan
Shannon D. Armstrong, MD
Chief Resident
Division of Plastic Surgery
GRMEP/Michigan State University
Grand Rapids, MI, USA
Ricardo A. Arnt, MD
Private Practitioner
Adjunct Secretary of Brazilian Society of
Plastic Surgery
Porto Alegre, Brazil
Juarez Avelar, MD
Voluntary Assistant Professor
Plastic Surgery Unit
Medical School of Marilia
Marilia, Brazil
Sergio Fernando Dantas de Azevedo, MD
Specialist member
Brazilian Society of Plastic Surgery
Sao Paulo, Brazil
List of Contributors
Ana Z.D. Badin, MD, MS
Technical Director
Department of Plastic Surgery
Athena Medical Center
Curitiba, Paraná, Brazil;
MS in Surgery Federal University of Paraná
(UFPR)
Curitiba, Brazil
Ricardo Baroudi, MD
Private Practitioner
Campinas
São Paulo, Brazil
Catherine Bergeret-Galley, MD, FACS
Plastic Surgeon
Private Practice
Paris, France
Reena A. Bhatt, MD
Assistant Clinical Professor
Department of Plastic Surgery
Miriam and Rhode Island Hospitals
The Warren Alpert Medical School
Brown University
Providence, RI, USA
Matheus Monseff Vieira Borela, MD
Resident
Department of Plastic Surgery
Santa Cecilia University
São Paulo, Brazil
Ronald P. Bossert, MD
Assistant Professor of Surgery;
Director
Life After Weight Loss Program
University of Rochester Medical Center
Rochester, NY, USA
Antonio R. Bozola, PhD
Head of Plastic Surgery Department
University of Medicine
São José do Rio Preto, Brazil
Joseph F. Capella, MD, FACS
Chief, Post-Bariatric Body Contouring
Division of Plastic Surgery
Hackensack University Medical Center
Hackensack, NJ, USA
Jennifer M. Capla, MD
Division of Plastic Surgery
North Shore – LIJ Lenox Hill Hospital;
Director
Body Contouring Surgical and Medical
Associates, PLLC
New York, NY, USA
Robert F. Centeno, MD, MBA, FACS
Medical Director
St Croix Plastic Surgery & MediSpa;
Chief Medical Quality Officer
Governor Juan F Luis Hospital & Medical
Center
Christiansted, VI, USA
Sydney R. Coleman, MD
Clinical Assistant Professor
Department of Plastic Surgery
New York University Medical Center
New York, NY;
Assistant Clinical Professor
Department of Plastic Surgery
University of Pittsburgh Medical Center
Pittsburgh, PA, USA
Pablo Silva Frizzera Delboni, MD
Member of the Brazilian Society of Plastic
Surgery
Vitória, Espirito Santo, Brazil
viii

ix
List of Contributors
Mauro F. Deos, MD
Private Practitioner
Porto Alegre
Rio Grande do Sul, Brazil
Barry E. DiBernardo, MD, FACS
Clinical Associate Professor
Department of Surgery
Division of Plastic Surgery
University of Medicine and Dentistry
of New Jersey
Newark, NJ;
Director
New Jersey Plastic Surgery
Montclair, NJ, USA
Kentaro Doi, MD
Graduate student
Department of Plastic Surgery
University of Tokyo Graduate School of
Medicine
Tokyo, Japan
Susan E. Downey, MD, FACS
Clinical Associate Professor of Plastic Surgery
Keck School of Medicine
University of Southern California
Los Angeles, CA, USA
Hitomi Eto, MD
Graduate student
Department of Plastic Surgery
University of Tokyo Graduate School of
Medicine
Tokyo, Japan
Antonio Luiz Rocha Gesualdi Fernandes
Neto, MD
Plastic Surgeon
Associate Member of Brazilian Society for
Plastic Surgery
Hospital Mater Dei, Belo Horizonte
Minas Gerais, Brazil
Madelyn H. Fernstrom, PhD, CNS
Professor of Psychiatry, Surgery, and
Epidemiology
Departments of Psychiatry and Surgery
University of Pittsburgh School of Medicine
Pittsburgh, PA, USA
Lydia M. Ferreira, MD, PhD, MBA
Head and Full Professor
Division of Plastic Surgery
Federal University of São Paulo
São Paulo, Brazil;
Coordinator Medicine III
CAPES/Researcher CNPq
Peter B. Fodor, MD, FACS
Private Practice
Los Angeles;
Associate Clinical Professor
Plastic Surgery
UCLA Medical Center
Los Angeles, CA, USA
James D. Frame, FRCS, FRCS(Plast)
Professor of Aesthetic Plastic Surgery
Anglia Ruskin University
Chelmsford, UK
Onelio Garcia Jr., MD, FACS
Voluntary Assistant Professor
Division of Plastic Surgery
University of Miami
Miller School of Medicine
Miami, FL, USA
Alberto di Giuseppe, MD
Associate Professor Lipoplasty
University of Austin
Austin, TX, USA;
Senior Surgeon
Plastic Surgery Department
University of Ancona
Ancona, Italy
Raul Gonzalez, MD
Associate Professor of UNAERP
Universidade De Ribeirao Preto
Ribeirão Preto, São Paulo, Brazil
Renato Nelson de Moura Guerra, MD
Plastic Surgeon
Associate Member of Brazilian Society for
Plastic Surgery
Hospital Mater Dei, Belo Horizonte,
Minas Gerais, Brazil
Rodrigo Nelson de Moura Guerra, MD
Plastic Surgeon
Associate Member of Brazilian Society for
Plastic Surgery
Hospital Mater Dei, Belo Horizonte
Minas Gerais, Brazil
Sebastião Nelson Edy Guerra, MD
Full member of SBCP – Sociedade Brasileira
de Cirurgia Plástica (Brazilian Society of
Plastic Surgery);
Past President, Brazilian Society of
Plastic Surgery
Chairman, Department of Plastic Surgery
Professor and Provost, Training Center in
Plastic Surgery
Hospital Mater Dei, Belo Horizonte,
Minas Gerais, Brazil
Hüseyin Güner, MD
Aesthetic and Reconstructive Surgeon
Chief and General Manager
Plastic, Aesthetic and Reconstructive Surgery
Superplast Aesthetic and Eye Surgery Hospital
Nisantasi, Istanbul, Turkey
Eduardo I. Gus, MD
Private Practitioner
Porto Alegre
Rio Grande do Sul, Brazil
Moustapha Hamdi, MD, PhD
Professor and Chairman of Plastic and
Reconstructive Surgery
Department of Plastic Surgery
Brussels University Hospital
Brussels, Belgium
Dennis C. Hammond, MD
Clinical Assistant Professor
Department of Surgery
Michigan State University College of Human
Medicine
East Lansing;
Associate Program Director
Plastic and Reconstructive Surgery
Grand Rapids Medical Education and Research
Center for Health Professions
Grand Rapids, MI, USA

x
List of Contributors
Charles K. Herman, MD, FACS
Chief Medical Executive
Chairman
Department of Surgery
Chief
Division of Plastic and Reconstructive Surgery
Pocono Health Systems
East Stroudsburg;
Clinical Professor of Surgery
The Commonwealth Medical College
Scranton, PA;
Clinical Assistant Professor of Surgery
Albert Einstein College of Medicine
New York, NY, USA
Erik A. Hoy, MD
Breast and Aesthetic Surgery Fellow
Maxwell Aesthetics
Nashville, TN, USA
Joseph P. Hunstad, MD, FACS
Associate Consulting Professor
Division of Plastic Surgery
The University Of North Carolina
Chapel Hill;
Section Head of Plastic Surgery
Department of Surgery
Carolinas Medical Center
University Hospital, Charlotte;
President
The Hunstad Kortesis Center for Cosmetic
Plastic Surgery
Huntersville, NC, USA
Dennis J. Hurwitz, MD, FACS
Clinical Professor of Plastic Surgery
University of Pittsburgh Medical Center
Pittsburgh, PA, USA
Harunosuke Kato, MD
Graduate student
Department of Plastic Surgery
University of Tokyo Graduate School of
Medicine
Tokyo, Japan
Kim Youn Hwan, MD, PhD
Assistant Professor
Department of Plastic and Reconstructive
Surgery
University of Hanyang
Seoul, South Korea
Jordan Jacobs, MD
Assistant Professor
Department of Surgery (Plastic)
New York Medical College
Valhalla, NY, USA
James L. Jewell
Medical Student
University of Wollongong
New South Wales, Australia
Mark L. Jewell, MD
Assistant Clinical Professor of Plastic Surgery
Oregon Health Science University
Portland, OR;
Jewell Plastic Surgery Center
Eugene, OR, USA
Hwang Weon Jung, MD, PhD
Plastic Surgeon
J-One Aesthetic Clinic
Seoul, South Korea
Kamran Khoobehi, MD, FACS
Clinical Professor of Surgery,
Director of Aesthetic Surgery Training
Louisiana State University
New Orleans, LA, USA
Christopher D. Knotts, MD
Aesthetic Surgery Fellow
The Hunstad-Kortesis Center for Cosmetic
Surgery
Charlotte, NC, USA
Bill G. Kortesis, MD
Partner
Hunstad-Kortesis Center for Cosmetic Surgery
Charlotte, NC, USA
Hermann Lampe, MD
Plastic Surgeon
Private Practice
Frankfurt, Germany
Angela S. Landfair, MD, MPH
Plastic Surgeon
Kaiser Permanente Medical Group
Walnut Creek, CA, USA
Peter Lin, MD
Chief Resident
University of California Irvine
Aesthetic & Plastic Surgery Institute
Orange, CA, USA
Michael Loffredo, MD
Plastic Surgeon
Cape and Islands Plastic Surgery
Hyannis, MA, USA
José Fernando López-Salguero, MD
Associate Professor
Institute of Plastic Surgery
Mexico City, Mexico
Alan Matarasso, MD, FACS
Department of Plastic Surgery
Manhattan Eye, Ear & Throat Hospital
Lenox Hill Hospital
North Shore-Long Island Jewish Health System
New York, NY, USA
Vinicius Aref M. Maykeh, MD
Resident
Division of Plastic Surgery
Federal University of São Paulo
São Paulo, Brazil
Constantino G. Mendieta, MD, FACS
Private Practice
Miami, FL, USA
Arnaldo L. Miró, MD
Director
Plastic and Reconstructive Clinic
Private Practice
Curitiba, Brazil
Luis Montellano, MD
Associate Professor
Gama Fillho University of Rio de Janeiro
Rio de Janeiro, Brazil

xi
List of Contributors
Lea M. Moraes, MD
Plastic Surgeon
Special and Titular Member of the Brazilian
Society of Plastic Surgery;
Graduate, Federal University of Paraná (UFPR)
Medical School;
Residency in General Surgery
Hospital of Our Lady of Grace Curitiba-PR;
Residency in Plastic Surgery
Hospital for Facial Defects
São Paulo, Brazil
Luis Humberto Uribe Morelli, MD
Resident
Plastic Surgery Department
UNISANTA
Plastic Surgery Service
Sao Paulo, Brazil
Donald S. Mowlds, MD, MBA
Resident Physician
The Aesthetic and Plastic Surgery Institute
University of California, Irvine
Orange, CA, USA
Sang Myun Cha, MD, PhD
Director;
Plastic Surgeon
Sein Aesthetic Plastic Clinic
Seoul, South Korea
Fabio X. Nahas, MD, PhD, MBA, FACS
Associate Professor
Division of Plastic Surgery
Federal University of São Paulo;
Associate Professor, Division of Plastic Surgery
State University of Rio de Janeiro
São Paulo, Brazil
Pierre Nicolau, MD
Consultant Plastic Surgeon
Department of Plastic Surgery and Burns Unit
Saint Louis University Hospital
Paris, France
Mário Farinazzo de Oliveira, MD
Preceptor of Rhinology
Division of Plastic Surgery
Federal University of São Paulo
São Paulo, Brazil
Luiz Haroldo Pereira, MD
Consultant Plastic Surgeon
Department of Plastic Surgery
LH Clinic
Rio de Janeiro, Brazil
Ewaldo Bolivar de Souza Pinto Sr., PhD, MD
Chairman of the Department of Plastic Surgery
Santa Cecilia University
São Paulo, Brazil
Ivo Pitanguy, ISAPS, FICS, FACS
Head-Professor
Plastic Surgery Department
Pontificial Catholic University
Carlos Chagas Institute of Post-Graduate
Medical Studies
Rio de Janeiro, Brazil
Harlan Pollock, MD
Private Practice
North Dallas Plastic Surgery;
Instructor
Department of Plastic Surgery
The University of Texas Southwestern
Medical School
Dallas, TX, USA
Todd Pollock, MD
Private Practice
North Dallas Plastic Surgery;
Instructor
Department of Plastic Surgery
The University of Texas Southwestern Medical
School
Dallas, TX, USA
Jason N. Pozner, MD, FACS
Affiliate Assistant Professor of Clinical
Biomedical Science
Charles E. Scmidt College of Medicine
Florida Atlantic University
Boca Raton;
Adjunct Clinical Faculty
Department of Plastic Surgery
Cleveland Clinic Florida
Weston, FL, USA
Oscar M. Ramirez, MD, FACS
Clinical Assistant Professor
The Johns Hopkins University School of
Medicine
Baltimore, MA;
Adjunct Clinical Faculty
Plastic Surgery Division
Cleveland Clinic Florida
Weston, FL, USA
Cassio Eduardo Raposo-Amaral, MD
Plastic Surgeon
Institute of Plastic and Craniofacial
Surgery-SOBRAPAR
Campinas
São Paulo, Brazil
Lawrence S. Reed, MD
Clinical Assistant Professor of Surgery (Plastic
Surgery)
Weill Cornell Medical College
New York, NY, USA
Dirk F. Richter, MD, PhD
Associate Professor
University of Bonn
Chief, Department of Plastic and Reconstructive
Surgery
Director of the Dreifaltigkeits
Krankenhaus
Wesseling, Germany
Alberto Romão
Resident
Division of Plastic Surgery
Federal University of São Paulo
São Paulo, Brazil
J. Peter Rubin, MD, FACS
UPMC Endowed Professor of Plastic Surgery
Chair, Department of Plastic Surgery
Director, Life After Weight Loss Body
Contouring Program
University of Pittsburgh
Pittsburgh, PA, USA
Neil S. Sadick, MD
Clinical Professor of Dermatology
Weill Cornell Medical College
New York, NY, USA

xii
List of Contributors
José Abel de la Peña Salcedo, MD, FACS
National Secretary
Ibero-American Federation of Plastic Surgery,
Aesthetic and Reconstructive (FILACP);
Director of the Institute of Plastic Surgery
Hospital Angeles de las Lomas
Col.Valle de las Palmas
Huixquilucan, Mexico
Cristianna Bonneto Saldanha, MD
Resident
General Surgery Service
Santa Casa of Santos Hospital
São Paulo, Brazil
Osvaldo R. Saldanha, MD
Chair of UNISANTA
Plastic Surgery Service
São Paulo, Brazil
Osvaldo R. Saldanha Filho, MD
Residant
UNISANTA
Plastic Surgery Service
São Paulo, Brazil
Renato Saltz, MD, FACS
Saltz Plastic Surgery and Spa Vitoria
Salt Lake City and Park City, UT, USA
Gerhard Sattler, MD
Director
Rosenparkklinik
Darmstadt, Germany
Thomas Scholz, MD
Resident Physician
Department of Aesthetic and Plastic Surgery
University of California, Irvine
Orange, CA, USA
Jeffrey L. Sebastian, MD
Assistant Clinical Professor of Surgery
David Geffen School of Medicine
UCLA, Los Angeles;
Private Practice
Santa Monica, CA, USA
Cemal Şenyuva, MD
Professor of Plastic, Reconstructive and
Aesthetic Surgery
Private Practice
Istanbul, Turkey
Fernando G. Serra, MD
Plastic Surgeon
Department of General Surgery
Rio de Janeiro State University (UERJ)
Rio de Janeiro, Brazil
Marion Shapiro, MD
Dermatologist
Private Practice
New York, NY, USA
Miguel A. Soto-Miranda, MD
Associate Professor
Institute for Plastic Surgery
Mexico City, Mexico
Aris Sterodimas, MD, MSc, PhD
Head
Department of Plastic Surgery
IASO General Hospital
Athens, Greece
Alexander Stoff, MD, PhD
Assistant Professor
Department of Plastic and Reconstructive
Surgery
University of Bonn
Dreifaltigkeits-Hospital Wesseling
Wesseling, Germany
Berish Strauch, MD
Chairman Emeritus
Department of Plastic and Reconstructive
Surgery;
Professor of Plastic Surgery
Albert Einstein College of Medicine
New York, NY, USA
Steven Teitelbaum, MD, FACS
Assistant Clinical Professor of Plastic Surgery
David Geffen School of Medicine
University of California
Los Angeles, CA, USA
Serhan Tuncer, MD
Associate Professor
Department of Plastic, Reconstructive, and
Aesthetic Surgery
Gazi University Faculty of Medicine
Ankara, Turkey
Carlos O. Uebel, MD, PhD
Associate Professor
Division of Plastic Surgery
PUCRS University
Porto Alegre, Brazil
Ismael Santiago Vásquez, MD
Plastic Surgeon
Associate Member of Brazilian Society for
Plastic Surgery
Hospital Mater Dei, Belo Horizonte
Minas Gerais, Brazil
Garrett A. Wirth, MD, MS, FACS
Associate Clinical Professor
Department of Plastic Surgery
Aesthetic & Plastic Surgery
University of California – Irvine Medical
Center
Orange, CA USA
Scott Woehrle, MS, PA-C
Physician Assistant
Capella Plastic Surgery
Ramsey, NJ, USA
Marianne Wolters, MD
Plastic Surgeon
Private Practice
Frankfurt, Germany
Kotaro Yoshimura, MD
Associate Professor
Department of Plastic Surgery
University of Tokyo
Tokyo, Japan
V. Leroy Young, MD
Director
Body Aesthetic Research Center
St Louis, MO, USA
Richard Zienowicz, MD
Associate Professor
Department of Plastic Surgery
Rhode Island Hospital
The Warren Alpert Medical School
Brown University
Providence, RI, USA

To my wife, Julie, whose love and support are
boundless, and our children, Eliana, Liviya, Zachary,
and Talya, who teach me about the important things
in life every day.
J. Peter Rubin, MD
To Mary, the love of my life; our children, Mark II,
James, and Hillary; Shelley, and Reed.
Mark L. Jewell, MD
Dedications
To my family with love; my wife Katja, my children
Moritz and Leonie and with respect and thanks to
my parents.
Dirk F. Richter, MD, PhD
To my dear wife Walderez, who is a constant source
of support and encouragement to me. To our children
Juliane and Hiddo; Paulo and Mariana; and to our
grandson Matheus who makes my life worthwhile.
Carlos O. Uebel, MD, PhD

1
© 2013 Elsevier Inc
Introduction
Body contouring surgery – a fifty year perspective
Ivo Pitanguy
Body contouring surgery is a collection of procedures with
the goal of volumetric manipulation of superficial tissue,
usually the adipose, with or without removal of excess skin
(dermolipectomies). Etiology of these deformities may be
primary (i.e., congenital or constitutional) or secondary
(i.e., weight gain or severe weight loss). In a broader sense,
this may include contouring of the face and breast. It is
therefore understandable that contouring surgery may
include most of the operations performed by the plastic
surgeon.
Concepts of beauty have been continuously evolving
throughout the history of mankind. The voluptuous figures
that were idealized by artists in the past have been substi­
tuted by slimmer forms. Until the second half of the 20th
century, contour deformities were mostly hidden under
heavy clothing and were reluctantly accepted. With fashion
promoting body-revealing attire and outdoor exposure,
and the emphasis on fitness and good health, people have
sought to reflect these trends by demonstrating youthful­
ness and vitality in their bodies. The subliminal as well as
overt message is that these are desirable requirements for
maintaining sensuality, social acceptance and professional
success.
On the other hand, sedentary lifestyle and dietary
excesses, associated with factors such as genetic determina­
tion, pregnancy and the aging process, contribute to corpo­
real alterations that result in the loss of the individual’s
body image. This creates a strong psychological motivation
for surgical correction. Localized fat deposits and skin flac­
cidity are sometimes resistant to the most sincere efforts in
weight loss and sport activities. Bariatric surgery by itself
has created a whole new field of medicine, where a multi­
disciplinary team will include the work of the plastic
surgeon.
Body contour deformities may involve one single ana­
tomical region or extend to multiple body regions. They
may be treated by a one-stage operation or may require
more complex combined procedures. In some cases,
multiple or severe deformities will be approached serially,
such as in patients who have undergone dramatic weight
loss. Planning and final results must be carefully discussed
with the patient, as well as location and extension of scars.
As the reader will appreciate in this book, the ever-
increasing request for contour surgery has been met by safe
and efficient surgical techniques, resulting in a high degree
of patient satisfaction. Personally, it has been fascinating to
follow the development of these procedures over the span
of some 50 years.
The concepts and principles that we have proposed for
body contouring are based on preservation of function,
acceptable location and extension of scars and an esthetic
correction of the deformity for a final, pleasing result. This
is exemplified by our approach to abdominoplasty. Many
different incisions had been forwarded to correct the
abdominal wall defect, with varying opinions regarding
muscle diastasis. Our methodology established an incision,
following a natural crease, which was adequately hidden
under beachwear. Emphasis was given to the functional
aspect, with plication of the rectus abdominis muscle
without opening of the aponeurosis. Likewise, other regions
were addressed aiming to achieve a satisfying, long-term
result with preservation of function.
Breast reduction up until the late 1950s was usually
performed with extensive dissections and undermining that
often resulted in large dead space with subsequent collec­
tion and skin necrosis. Resections that involved the upper
pole caused early flattening and sagging, with an upward
projection of the nipple.
I was also concerned with other anatomical regions that
comprise body contouring, including correction of other
deformities of the breast (hypertrophy, ptosis and hypomas­
tia; gynecomastia, and deformities of the nipple–areola
complex), the abdomen (lipodystrophy and atypical defor­
mities), the upper limbs, and the lower limbs (lipodystrophy
and flaccidity of the inner thighs and the trochanteric
region), and the “riding-breeches” (or “saddlebag”) defect.

2
Introduction
Of course, many of these techniques were placed in a
different perspective with the introduction of suction-
assisted lipectomy. Rapidly, plastic surgeons adopted
this procedure to safely and efficiently remove localized
adiposity through minimal incisions. Seemingly over­
night, gone were most of the indications for large inci­
sions and extensive procedures, with consequent faster
recovery and reduced problems of wound healing and
unesthetic scars.
Currently, it is interesting to notice that a cycle closes.
To address excess cutaneous tissues in post-obese patients,
plastic surgeons are bringing back principles that were
in vogue in the past. To cite two procedures that we
proposed, the thoracobrachial dermolipectomy and the
“riding breeches” deformity, fundamental concepts are
being reviewed: no dead space is created by unnecessary
dissection, scars are planned in natural creases, and the
positioning of nonundermined flaps is done by rotation,
instead of simply by pulling.
Finally, the precise methodology for combining proce­
dures was also a matter of interest, so as assure patient
safety while at the same time optimizing surgical timing
and post-operative down-time.
I am honored by this opportunity to introduce the book
Body Contouring and Liposuction. As Dr. Rubin and his
colleagues stated in their gracious invitation, I have been a
direct witness to the evolution of these myriad techniques,
and have seen paths that led to successful results and others
that failed. In the end, we must base our practice on basic
principles: careful surgical indication with an open discus­
sion with our patient; planning incisions and number of
proposed procedures, including surgical revisions; and
close postoperative care. As an almost encyclopedic text,
this book presents a culmination of years of development
of body contouring surgery, which is certain to remain the
solid reference on this subject. Congratulations to the
editors – Drs. Rubin, Jewell, Richter and Uebel – and their
collaborators on this magnificent achievement.
FURTHER READING
Pitanguy I. Breast hypertrophy. In: Transactions of the 2nd Congress of
the International Society of Plastic Surgeons. 1960. p. 509.
Pitanguy I. An eclectic approach to breast problems. Rev Bras Cir
1961;41:179–96.
Pitanguy I. Une nouvelle technique de plastique mammaire: Etudes de 245
cas consecutifs et presentation d’une technique personelle. Ann Chir
Plastique 1962;7:199–208.
Pitanguy I, Lima J. Treatment of some deformities of the lower extremity.
In: Young H, editor. The Year Book of Orthopedics, Traumatic and
Plastic Surgery. Chicago: Mosby Year Book; 1963. p. 538–90.
Pitanguy I, Torres E. Histopathological aspects of mammary gland tissue
in cases of plastic surgery of the breast. Br J Plast Surg 1964;
17(3):297–302.
Pitanguy I. Trochanteric lipodystrophy. Plast Reconstr Surg 1964;34:
280–6.
Pitanguy I. Transareolar incision for gynecomastia. Plast Reconstr Surg
1966;38(5):414–9.
Pitanguy I. Abdominal lipectomy: an approach to it through an
analysis of 300 consecutive cases. Plast Reconstr Surg 1967;40(4):
384–91.
Pitanguy I. Surgical treatment of breast hypertrophy. Br J Plast Surg
1967;20:78–85.
Pitanguy I. Thigh lift and abdominal lipectomy. In: Goldwyn RM, editor.
Unfavorable Results in Plastic Surgery. Boston: Little Brown; 1972.
p. 387.
Pitanguy I. Lipectomy abdominoplasty and lipodistrophy of the inner side
of the arm. In: Grabb W, Smith J, editors. Plastic Surgery: a Concise
Guide to Clinical Practice. 2nd ed. Boston: Little Brown; 1973.
p.1005–13.
Pitanguy I. Abdominal lipectomy. Clin Plast Surg 2:401–10, 1975.
Pitanguy I. Correction of lipodystrophy of the lateral thoracic aspect and
inner side of the arm and elbow dermosenescence. Clin Plast Surg
1975;2(3):477–83.
Pitanguy I. Personal preferences for reduction mammaplasty. In: Goldwyn
RM, editor. Plastic and Reconstructive Surgery of the Breast, vol.2.
Boston: Little Brown; 1976. p. 167–79.
Pitanguy I. Dermolipectomy of the abdominal wall, thighs, buttocks
and upper extremity. In: Converse JM, editor. Reconstructive
Plastic Surgery, vol.7. 2nd ed. Philadelphia: Saunders; 1977.
p. 3800–23.
Pitanguy I, Cavalcanti MA. Methodology in combined aesthetic surgeries.
Aesth Plast Surg 1978;2:331–40.
Pitanguy I. Transareolar incision for augmentation mammaplasty. Aesth
Plast Surg 1978;2(4):363–72.
Pitanguy I. The breast. In: Aesthetic Plastic Surgery of Head and Body.
Berlin: Springer-Verlag; 1981. p. 3–62.
Pitanguy I, Ceravolo M. Our experience with combined procedures in
aesthetic plastic surgery. Plast Reconstr Surg 1983;71(1):56–63.
Pitanguy I. Reduction mammaplasty by the personal technique. In: Chang,
WHJ, editor. The Breast: an Atlas of Reconstruction. Baltimore:
Williams & Wilkins; 1984. p. 75–160.
Pitanguy I. Aesthetic Surgery of Head and Body. Berlin: Springer Verlag;
1984.
Pitanguy I. Treatment of abdominal wall eventrations associated with
abdominoplasty techniques. Aesth Plast Surg 1984;8:173–9.
Pitanguy I. Upper extremity: dermolipectomy. In: Aesthetic Surgery of
Head and Body. Berlin: Springer Verlag; 1984. p. 153–8.
Pitanguy I. Body contour. Am J Cosm Surg 1987;4:283–93.
Pitanguy I. Thigh and buttock lift. In: Lewis JR, editor. The Art of Aes­
thetic Surgery, Vol 2. Boston: Little Brown; 1989. p. 1060–7.
Pitanguy I. Personal preferences for reduction mammaplasty. In: Geor­
giade ND, editor. Aesthetic Surgery of the Breast. Philadelphia: WB
Saunders; 1990. p. 167.
Pitanguy I. Reduction mammaplasty: a personal odyssey. In: Goldwyn
RM, editors. Reduction Mammaplasty. Boston: Little, Brown; 1990.
p. 95.
Pitanguy I. Abdominoplasty: Classification and surgical techniques. Rev
Bras Cir 1995;85:23–44.
Pitanguy I, Radwanski HN. Philosophy and principles in the correction of
breast hypertrophy. In: Mang WL, Bull HG, editors. Ästhetische
Chirurgie. Germany: Einhorn-Presse Verlag; 1996. p.216–32.

3
Introduction
Pitanguy I. Evaluation of body contouring surgery today: A 30-year per­
spective. Plast Reconstr Surg 105:1499, 2000.
Pitanguy I, Radwanski HN, Matarasso A. Approach to the face and neck
after weight loss. In: Rubin P, Matarasso A, editors. Aesthetic Surgery
after Massive Weight Loss. New York: Elsevier; 2007. p. 21–35.
Pitanguy I, Radwanski HN. Relative implant volume and sensibility altera­
tions after breast augmentation. Aesth Plast Surg 2007;238–43.
Pitanguy I, Radwanski HN. The Pitanguy breast reduction. In:
Aston S, editor. Aesthetic Plastic Surgery. China: Elsevier; 2009.
p. 609–20.

4
© 2013 Elsevier Inc
Chapter 1 
Key Points
●
Complications of tobacco use are avoidable with a
concerted effort by both the patient and the surgeon.
Preoperative and postoperative urine cotinine testing
make detection of tobacco use straightforward and not
reliant on patient self-respect.
●
A thorough preoperative assessment should be
performed well in advance of the surgical date to
allow adequate time for necessary behavior
modification (i.e., tobacco cessation), medical
modification (improved glycemic control in a diabetic
patient), preoperative tests (i.e., sleep study for
undiagnosed sleep apnea), and preoperative
consultation with appropriate specialists (i.e.,
hematologist for family history of thrombophilia).
Rushing to the operating table can impede a
meticulous and safe preoperative investigation.
●
Hypothermia is a common preventable condition with
straightforward preoperative and intraoperative
measures such as warm irrigation and preoperative
warming blankets. These measures are essential in
long body contouring cases with wide exposure.
●
Surgical site infections should be prevented at every
step, with appropriate preoperative disinfection,
perioperative antibiotics, and close glycemic control.
●
Thromboembolic events are largely preventable with
comprehensive preoperative evaluation and
appropriate consultation, mechanical and chemical
prophylaxis, patient education, and high levels of
alertness and suspicion in the postoperative period.
Patient safety in body contouring
V. Leroy Young and Angela S. Landfair
INTRODUCTION
The current climate of plastic surgery engenders a culture
of safety that promotes careful patient selection, stream­
lined perioperative care, and structured systems of safety
measures in and out of the operating room. Ultimately,
vigorous training of medical professionals who can recog­
nize, prevent, and appropriately treat potential complica­
tions may play the most salient role in ensuring safe clinical
practices.
Body contouring surgery is fraught with potential for
complications due to the lengthy and complex nature of the
procedures and inherent patient demographics. Appropriate
patient selection and vigilant perioperative care is expected
and warranted. Body contouring is elective surgery in
which the tolerance for complications should be low.
In the end the science of human factors (HF) should be
foremost in our minds in designing a system of checks and
balances in a given clinical situation.1 A group of well-
trained surgeons and health care professionals can still miss
a step or two among the hundreds we take from the time
the patient enters the clinic for preoperative consultation to
the time the patient exits the clinic from the final postopera­
tive visit. In every scenario: the initial consultation, the
preoperative assessment, the preop holding area, the operat­
ing room, the postoperative care on the wards and in the
office, a detail missed can lead to grave consequences.
While this chapter is in no way comprehensive, it should
aid a surgeon in developing his or her own standardized
model for safe clinical practice.
PREOPERATIVE ASSESSMENT
AND PATIENT SELECTION
The value of comprehensive history taking at the initial
consultation cannot be overstated. Overlooking a critical
detail in the patient’s medical history can lead to mishap
and preventable disasters. Our specialist colleagues should
be brought into consultation whenever the patient has sig­
nificant comorbidities or when we suspect an undiagnosed
condition that can negatively impact surgical outcome.
Medical Assessment
Cardiac clearance is often a nebulous concept that may get
glossed over. Cardiac tests are doled out according to
patient age and prior history, and too often, according to
institutional guideline. Often a “normal” electrocardiogram
tells us very little about the patient. The patient’s functional
status should be assessed using exercise tolerance, stress
tests, and if deemed appropriate, a cardiology consultation
Part 1  Patient evaluation and safety

5
Chapter | 1  Patient safety in body contouring
Connective tissue diseases are frequently under good
medical control when a patient is cleared for surgery.
However, connective tissue disorders are independent pre­
dictors of thromboembolic events and patients should be
informed of this risk factor. Steroids and other immunosup­
pressants are frequently used in medical management of
connective tissue disorders and can place a patient at risk
for wound healing complications.5
Pulmonary disease, especially when undiagnosed and
undertreated, can have grave consequences in the postop­
erative period. In patients with pre-existing pulmonary con­
ditions such as chronic obstructive pulmonary disease
(COPD) or asthma, their medical management should be
optimized well before the patient is placed on the surgical
schedule. Perioperatively, these patients require a more
aggressive pulmonary toilet and often pharmacotherapy,
regardless of whether they took any at home.
Obstructive sleep apnea (OSA) is a frequently underdi­
agnosed condition that affects 24% of men and 9% of
women. OSA diagnosis can pose a challenge in the
with further noninvasive and invasive studies. All too often,
patients are deemed “cleared for surgery” by a physician
who is both unfamiliar with the surgical procedure, as well
as the duration of recovery and rehabilitation afterwards.
Family history is crucially important when a seemingly
healthy patient presents to us, since a patient with no appar­
ent cardiac history in the family is a different beast from
the patient with three close relatives suffering an early
cardiac event. Hypertensive patients should be carefully
monitored in the perioperative period because their antihy­
pertensive regimen may have to be changed during periods
of fluid shifts, body weight change, and postoperative
anemia.2
Patients with significant cardiovascular history deserve
special attention. Elective surgery should be delayed until
adequate preoperative clearance and tests are attained. If a
patient has undergone cardiac intervention, the timing of
elective surgery is crucial. Perioperative stent thrombosis
is associated with high mortality and morbidity and should
not be taken lightly. Patients undergoing noncardiac surgery
within 1–2 weeks after placement of a bare-metal stent are
at high risk of stent thrombosis and death even if periopera­
tive antiplatelet therapy is continued. Perioperative throm­
bosis of drug-eluting stents has been reported as late as 21
months after stent implantation. A cardiologist should be
consulted to determine both the appropriate surgery date
and the appropriate stop date for antiplatelet agents. If
elective surgery is pursued too quickly, patients are at
risk for stent thrombosis because of increased thrombotic
state parlayed by surgery and by the therapeutic absence
of antiplatelet agents. In general, elective surgery should
be delayed until 6 weeks after balloon angioplasty or
bare metal stents, and a year after drug-eluting stents.
Patients should be continued on their preoperative beta
blockers throughout and post surgery, barring unexpected
hypotension.3
Close attention must be paid to the patient’s personal
and family history of coagulopathy4 (Tables 1.1 and 1.2).
Hereditary thrombophilia is surprisingly common – with
approximately 5% of patients displaying factor V Leiden
mutation and 2–4% of the population testing positive for
antiphospholipid syndrome. Recent data suggest that the
family history of a thrombotic event even in the absence
of hereditary thrombophilia significantly increases the like­
lihood that the patient will have a postoperative thrombo­
embolism. In women who smoke, hormone therapies
(including oral contraceptives) should ring warning bells,
as should a history of multiple miscarriages. Bleeding dis­
orders are rarely life-threatening, but a 2% incidence of
Von Willebrand’s in the general population is no small
figure. The risk of bleeding should be carefully considered,
especially if the patient is about to undergo multiple proce­
dures over large anatomic areas.
TABLE 1.1  Prevalence of Molecular Abnormalities
Healthy Subjects
First VTE Episode
Antithrombin
deficiency
0.02
1
Protein C
deficiency
0.3
3
Protein S deficiency
?
1–2
Factor V Leiden
5
20–40
Prothrombin gene
mutation
1–2
6
Fasting
homocysteine
>95th %
5
23
Anti-phospholipid
antibodies
3
16
TABLE 1.2  Indications for a Laboratory Workup
for Thrombophilia
Venous thrombosis before 40–50 years of age
Unprovoked thrombosis at any age
Recurrent thrombosis at any age
Unusual sites such as cerebral, mesenteric, portal, or hepatic
veins
Positive family history for thrombosis
Thrombosis during pregnancy, oral contraceptives, or hormone
replacement therapy (HRT)
Unexplained abnormal laboratory test such as prolonged PTT

6
PART | 1  Patient evaluation and safety
possible even in weight stable patients, and routine screen­
ing of protein malnutrition is reasonable. Due to physio­
logic changes and changes in their GI tract and their dietary
patterns, anemia can result from deficiencies in iron and
vitamin B12. All massive weight loss patients need a pre­
operative complete blood count prior to undergoing surgery.
Psychiatric and Behavioral
Tobacco use is an independent risk factor for wound com­
plications and cessation should be the rule in body contour­
ing surgery. According to CDC data as of November 2007,
20.8% of adults in the United States smoke cigarettes. The
health risks of habitual tobacco use are profound, but in the
plastic surgery population, the risk immediately impacts
postsurgical outcome.
First and foremost, smokers are prone to pulmonary
complications due to chronic airway inflammation and
decreased pulmonary function. Smokers are more prone to
postoperative atelectasis and hypoxia, even in the absence
of a diagnosis of COPD.
Second, tobacco impacts wound healing in numerous
pathways. Tobacco use reduces cutaneous blood flow in a
significant and meaningful way even in light smokers by
impairing microvascular vasodilation. Wound healing, im­
mune, and inflammatory responses are blunted in smokers,
and collagen deposition and remodeling are decreased.
Smoking has been associated with increased wound com­
plications in both aesthetic and reconstructive patients.
There is no consensus as to when patients should quit smok­
ing prior to surgery, as benefits of quitting have been found
whether a patient quit for 3 weeks, 4–8 weeks, or greater
than 2 months. There is no definitive consensus that quitting
for a longer period necessarily improves outcome, but the
current CDC recommendation is to halt tobacco for 30 days
prior to surgery. Self-report of smoking cessation is notori­
ously unreliable, especially when a patient is incentivized
to lie in order to attain the go-ahead for plastic surgery.
Objective tests of smoking cessation, such as urine cotinine,
may be warranted in order to ensure patient safety.8–14
While tobacco use is a behavior that can be monitored
objectively, the plastic surgeon is often faced with a patient
who is medically stable, but displays poor judgment, imma­
turity, unrealistic expectations, or psychiatric illness. Body
dysmorphic disorder (BDD) is a DSM diagnosis marked by
obsession over a perceived defect that results in compulsive
behavior and illogical methods to hide or transform the
perceived defect. This is most commonly seen in rhino­
plasty patients, but is seen with greater frequency than in
the general population among cosmetic patients. BDD is a
clear psychiatric contraindication for plastic surgery and
patients who are suspected of this condition should receive
a psychiatric evaluation, not surgery.15
preoperative interview because, very frequently, the patients
are unaware of the symptoms. Physiologically, the parapha­
ryngeal fat pads narrow the airway, causing restrictive ven­
tilation defects, and resulting in measurable decreases of
functional residual capacity and total lung capacity. Of
note, over 80% of patients with OSA are undiagnosed, and
up to 80% of elderly patients may be affected. Periodic
apnea/hypopnea can result in hypertension, arrhythmias,
increased intrathoracic negative pressure, and decreased
restorative sleep.6
During the consultation, it is often more useful to ask a
patient’s significant other about the sleep habits, as patients
themselves may be unaware. Male, obese, hypertensive
patients are at an elevated risk. When sleep apnea is sus­
pected, the symptom checklist should include choking, rest­
less sleep, impaired sleep maintenance, daytime sleepiness,
frequent awakening, hypersomnia, depressed mood or
mood swings, fatigue, gasping, gastroesophageal reflux
disease, and snort arousals. Sixty to 90% of people with
OSA are obese and frequently have a neck circumference
measuring >40 cm. While weight loss improves OSA
symptoms, many patients may have incomplete symptom
relief and still require continuous positive airways pressure
(CPAP) postoperatively. There is no effective pharmaco­
logic therapy for sleep apnea.
Close preoperative monitoring is especially important
in patients with diabetes.7 While the presence of diabetes
itself should not preclude surgery, poorly controlled diabe­
tes should halt surgery until better medical management is
achieved. HgbA1C is a useful screening tool to check for
patient compliance and an index of overall glycemic
control, and should be included in the preoperative workup.
Even patients who are no longer on insulin will frequently
require perioperative insulin to compensate for the stress of
surgery as well as diet fluctuations in the postoperative
period.
Clinical obesity is common in the body contouring
population even after massive weight loss. Many clinicians
employ a BMI “cutoff” in their practice, but in reality many
patients will end up on the operating room table while still
obese. Obesity increases every type of surgical complica­
tion especially pulmonary, thromboembolic, and wound
complications. Undiagnosed obstructive sleep apnea is fre­
quent in obese patients and should be carefully assessed.
Medication doses should sometimes be adjusted as well to
compensate for obesity. There is some indication that obese
patients should be treated with a higher dose of Lovenox
when used as a chemoprophylactic agent.
Nutritional Assessment
In the bariatric population, preoperative screening should
include nutritional screening. Protein malnutrition is

7
Chapter | 1  Patient safety in body contouring
Psychiatric history should be a routine part of the history
and physical examination. Body contouring patients are at
an increased risk for depression and anxiety disorders com­
pared to the general population. These patients are often
labeled as having BDD, when in fact their concern is real­
istic based on the extreme deformity after massive weight
loss. These patients are often former over-eaters who have
a psychological barrier against self-discipline and equilib­
rium. Occasionally, massive weight loss patients have dif­
ficulty forming a marriage of their former self image and
the new image in the mirror before them. The plastic
surgeon should learn basic psychiatric assessment and
ascertain that any prior psychiatric illness is stabilized prior
to embarking on surgical treatment.
One specific concern for body contouring patients can
be the high incidence of maladaptive eating patterns, espe­
cially binge eating disorder. In concert with nutritional dif­
ficulties presented by the physiology of weight loss, this
can lead to poor perioperative nutritional status or weight
fluctuations. Psychiatric history should include eating and
dieting patterns. Patients with a history of binge eating
disorder, in particular, should be carefully assessed to make
sure that they have not recently engaged in pathologic
eating behaviors.16
Patients who have undergone massive weight loss
are also at an increased likelihood of having personality
disorders compared to the general population. These are
difficult to diagnose and can prevent optimizing the post­
operative course. Personality disorders are often insidious
and, unlike AXIS I disorders, are pharmacologically
untreatable. When faced with a particularly difficult
patient, surgeons should beware that a patient with person­
ality disorder may be particularly threatening to his/her
reputation and office morale, and that these patients’ disor­
ders are at best slightly ameliorated by preoperative psy­
chiatric intervention.
INTRAOPERATIVE MANAGEMENT
Hypothermia has been shown to increase postoperative
complications in body contouring patients by inhibiting
tissue oxygen delivery, impairing wound healing, and
leading to a three-fold increase in wound infections.17
Due to length of surgeries and large areas of physical
exposure, body contouring patients are at particular risk of
hypothermia. Studies have shown that unwarmed patients
almost always become hypothermic. Maintaining normo­
thermia is an active process that should begin in the preop­
erative holding area and be carefully checked throughout
the perioperative period. Preoperative warming with forced
air for 60 minutes is the most effective way of warming the
patient so that core temperature remains normal. Prewarmed
patients cool at about half the rate of patients who are not
prewarmed, and core temperature can be maintained even
through a multi-procedure, lengthy operation. Other mea­
sures should be engaged to maintain core temperature,
including covering areas not being worked on, continuous
forced air heating, maintaining ambient room temperature
at 23°C (73°F), and warming the irrigation fluids.
Malignant hyperthermia is a rare but serious complica­
tion that has a 70% mortality rate without proper treatment
(Box 1.1). The surgeon should be aware of the signs. A
thorough preoperative history should ask about family
history of sudden death during or after anesthesia. The most
consistent sign should be a rapid rise in end tidal CO2, along
with high fever, rigidity, acidosis, and tachycardia. The
surgery center should always be fully stocked with dan­
trolene, with the understanding that obese patients require
much more dantrolene for symptom reversal than their non­
obese counterparts.
Prevention of surgical site infections is of utmost impor­
tance. Preoperative antibiotics should be chosen based on
type of organisms encountered, and the patient’s unique
infectious disease history. Too frequently, antibiotics are
administered as an afterthought after the operation has
already begun. Surgical patients should receive antibiotics
30 minutes to 1 hour prior to incision, and before any tour­
niquet is applied, although this is less relevant in body
contouring surgery. Vancomycin and fluoroquinolones take
longer to infuse and should be started in the preoperative
area, about 2 hours prior to incision time. A study of over
3000 surgical patients found an increased rate of surgical
site infections if the antibiotics were administered more
than 1 hour prior to incision, at the time of incision, or after
the incision was already made. Antibiotics should be
re-dosed during lengthy procedures and more frequently if
there is significant blood loss (>1.5 L). There is no evidence
that shows continuing prophylactic antibiotics beyond 24
hours postoperatively is beneficial. In fact, routine use of
postoperative antibiotics increases the likelihood of drug
resistance and places the patient at risk for clostridium dif­
ficile infections.18,19
Shaving increases (Table 1.3) the likelihood of surgical
site infection (SSI) fourfold. Clipping is less likely to
increase surgical site infections, although the risk is not
zero. Locally, trauma to the epithelial barrier caused by
both shaving and clipping is likely to place the patient at
risk for contamination and even infection. Patients should
be instructed not to shave the operative site the week prior
to surgery.
Artificial nails are another potential source of SSI.
The glue used to adhere the artificial nail to the nail plate
rapidly becomes colonized with bacteria and patients
often run their fingers over their incisions and can inocu­
late their wounds with the colonized bacteria which
are often Gram negative. Artificial nails should be

8
PART | 1  Patient evaluation and safety
Routine Preoperative Questioning
All patients about to undergo general anesthesia should be
asked these specific questions as part of a medical history:
●
Is there a family history of MH?
●
Have there been unexpected deaths or complications
arising from anesthesia (including the dental office) with
any family members?
●
Is there a personal history of a muscle disorder (e.g.,
muscle weakness)?
●
Is there a personal history of dark or cola-colored urine
following anesthesia?
●
Is there a personal history of unexplained high fever
following surgery?
Intraoperative Preparedness
The following precautions should be taken in order to
detect MH in its early stages, when it is usually amenable
to treatment without sequelae:
Planning Ahead
●
A written treatment plan should be posted in a
conspicuous place. A plan is available from the Malig­
nant Hyperthermia Association of the United States
(MHAUS);
●
A kit or cart containing drugs necessary for the treatment
of MH should be immediately available to all operating
rooms. Each kit should contain 36 vials of dantrolene,
bacteriostatic water for injection, and bicarbonate.
MHAUS offers a brochure listing the recommended
supplies.
●
A refrigerator unit near the operating room should be
stocked with iced saline. Ready access to an ice
machine is important.
●
All operating and recovery room personnel should be
trained in the recognition and treatment of MH. Peri­
odic dry-runs of an MH emergency are recommended.
In-service materials can be provided by MHAUS.
During Surgery
●
Evaluate any unexpected hypercarbia, tachycardia,
tachypnea or arrhythmia (e.g., arterial and venous blood
gases). Avoid suppressing tachycardia with beta block­
ers until MH has been ruled out.
●
Core temperature should be monitored in all patients
given general anesthesia for 30 minutes or more.
Acceptable core temperature sites include: distal esoph­
agus, nasopharynx, axilla, rectum, bladder and pulmo­
nary artery. Skin temperature may not adequately reflect
core temperature during MH episodes. Consider MH in
the differential diagnosis of any temperature rise.
●
Stop inhalation anesthetic and succinylcholine if mas­
seter rigidity occurs. If surgery must continue, immedi­
ately switch to nontriggering anesthetics.
●
Do not give triggering agents to patients with Duchenne
dystrophy, central core disease, myotonia and other
forms of muscular dystrophy.
●
Sudden cardiac arrest in a young male with normal
oxygenation should be considered as secondary to
hyperkalemia and so treated.
Treating the Known or Suspected
MH-Susceptible Patient
Preoperative Preparations:
●
Anesthesia machine:
●
Remove vaporizers, if possible. Otherwise, drain
and disconnect or tape in the off position.
●
Flow 10 l/m O2 through circuit for at least 20
minutes. If fresh gas hose is replaced, 10 minutes is
adequate. During this time a breathing bag should
be attached to the Y-piece of the circle system and
the ventilator set to inflate the bag.
●
Use new or disposable breathing circuit.
●
Take a preoperative creatine kinase (CK) and CBC.
●
Place a cooling blanket on the table.
Dantrolene Prophylaxis
Dantrolene prophylaxis should be considered on an indi­
vidual patient basis but is not recommended for most MH
susceptibles. When used, dosage is 2.5 mg/kg IV starting 30
minutes prior to anesthesia. For consultation, contact
MHAUS.
NOTE: Dantrolene can worsen muscle weakness in
patients with muscle disease and should be used with
caution. For procedures with local anesthesia only, dan­
trolene prophylaxis may be omitted.
Intraoperative Considerations
●
Techniques of choice
●
Spinal, epidural, regional or local, if possible.
●
Safe drugs
●
Local: No local anesthetics trigger MH; thus any
type of regional anesthesia is safe for MH
susceptibles.
●
General: Benzodiazepines, opioids, barbiturates,
propofol, ketamine, nitrous oxide, etomidate. Pan­
curonium, atracurium, vecuronium, pipecuronium,
mivacurium, doxacurium, or curare may be used
for relaxation. Neostigmine and atropine are used
for reversal by some; others disagree on their
safety.
●
Unsafe drugs/MH triggers
●
Halothane,
enflurane,
isoflurane,
desflurane,
methoxyflurane, ether, cyclopropane, sevoflurane,
ether.
●
Succinylcholine.
●
Monitoring
●
Essential: blood pressure, central temperature,
ECG,
pulse
oximeter,
and
capnograph
or
capnometer.
●
Strongly suggest respirometer.
●
Use arterial line, CVP or other invasive monitors as
appropriate for the surgery.
BOX 1.1  Questions to Ask About Malignant Hyperthermia

9
Chapter | 1  Patient safety in body contouring
with the length of operation and these risks should not be
taken lightly.
POSTOPERATIVE MANAGEMENT
Postoperative Antibiotics
SSI is a common adverse event in the plastic surgery
patient, and is particularly devastating when the surgery
was elective and cosmetic in nature. Plastic surgeons are
apt to place patients on antibiotic regimens based upon
anecdotal evidence. Large studies have shown no decrease
in SSI with postoperative antibiotics. So far, practices such
as placing patients on oral antibiotics due to a new implant
or while drains are in place have no scientific evidence to
support them.21
DVT Prophylaxis
Assessment of thromboembolic risk is the most crucial part
of reducing events. However, simple maneuvers should be
undertaken (making sure sequential compression devices
(SCDs) are in fact on the patient and functioning preopera­
tively) to continue to reduce risk. Daily rounds should
include ensuring the patient has adequate assistance to get
out of bed and ambulate in the hallway, and that ambulation
is happening as often as can be tolerated. Chemoprophy­
laxis is frequently indicated, especially in instances where
patients are relatively immobile due to postsurgical pain.
At this time, there is no evidence that chemoprophylaxis
increases the risk of postoperative return to the operating
room for a bleeding event. The details of assessing throm­
boembolic risk and perioperative management will be
covered in greater detail in Chapter 4.
removed at least 1 week before surgery and surgical staff
should never wear artificial nails or jewelry in the
operating room.
STAGING
There is great debate as to (1) how long is too long and (2)
how many procedures are too many. Unfortunately, there is
no simple answer. On the plus side, combining procedures
is simply more convenient and more cost effective-, for
both the patient and the surgeon.20 In a healthy patient who
presents a low risk overall, combining procedures is
unlikely to lead to serious detriment. However, surgical site
infections and thrombotic risk are shown to increase along
TABLE 1.3  Hair Removal
SSI Rate1
SSI Rate2
SSI Risk4
Razor shave
5.6%
2.3%
5.7%
Depilatory
0.6%
–
–
Clipped
–
1.7%
2.9%
No shave
0.6%
0.9%
–
3Shaving increases the risk of infection 2.4 fold.
1. Seropian R, Reynolds BM. Wound infections after preoperative
depilatory versus razor preparation. Am J Surg 1971;121;251–4.
2. Cruse PJ, Foord R. A five-year prospective study of 23,649 surgical
wounds. Arch Surg 1973;107;206–10.
3. Kalmeijer MD, van Nieuwland-Bollen E, Bogaers-Hofman D, et al.
Nasal carriage of Staphylococcus aureus is a major risk factor for
surgical-site infections in orthopedic surgery ICHE 2000;21:319.
4. Alexander JW, Fischer JE, Boyajian M, et al. The influence of
hair-removal methods on wound infections. Arch Surg
1983;118:347–52.
●
Use potassium-containing solutions with caution.
●
Monitor potassium and CK levels q 6 hours at least.
●
Monitor urine output.
●
Register patient with North American MH Registry.
Forms are available by contacting North American
MH Registry, Pennsylvania State University, College
of Medicine, Dept of Anesthesia, PO Box 850,
Hershey, PA 17033–0850, (717) 531–6936.
●
Alert family to the dangers of MH in other family
members.
●
Refer for testing at nearest center (list available from
MHAUS).
BOX 1.1­  Continued
Postoperative Procedure
●
If the anesthetic course has been uneventful:
●
Continue to monitor temperature and ECG for 1 to
2 hours. No further dantrolene is necessary.
●
If MH has occurred:
●
Recover patient in an ICU for 24–48 hours.
●
Continue IV dantrolene for 48–72 hours, titrated to
alleviation of muscle rigidity, tachycardia, acidosis,
and CK levels. Suggested dantrolene dosage is at
least 1 mg/kg q 6 hours IV. After that, 1 mg/kg may
be given q 6 hours orally × 24 hours.
●
Monitor the patient’s coagulation status, watching
for DIC.
●
Look for myoglobinuria and renal failure, and treat
as needed.
This protocol may not apply to every patient and must of necessity be altered according to specific patient needs.
From the MHAUS website

10
PART | 1  Patient evaluation and safety
best method of PONV prevention appears to be employ­
ment of multiple agents. The triple cocktail of Benadryl,
dexamethasone, and Zofran appears to be 98% effective in
preventing PONV. Emend, an oral agent taken preopera­
tively, appears to be as effective as IV Zofran and has an
effect lasting for 48 hours.23
Respiratory Management
In patients with a diagnosis of obstructive sleep apnea,
CPAP should be made immediately available at the preop­
erative settings. The patient should be carefully monitored
in PACU for their respiratory status. Supine position is
suboptimal and should be avoided even during sleep. Sup­
plemental oxygen should be expected. Patients with
obstructive sleep patterns have a respiratory status that is
more sensitive to pain medications and sedatives. Addi­
tional monitoring may be necessary in a patient who has
undergone a lengthy and painful procedure and requires
narcotics in the postoperative period.
PATIENT SAFETY IN YOUR PRACTICE
A well choreographed preoperative, intraoperative and
postoperative clinical regimen should optimize risk reduc­
tion. During the first visit, a thorough history should be
taken so that any “warnings” in the history can generate a
proper workup (Fig. 1.1). While it’s tempting to have the
patient obtain medical clearance from his or her internist,
additional specialists should weigh in prior to a complex
surgery with a long recovery. Age-based preoperative labs
and testing may not apply to the massive weight loss popu­
lation with multiple comorbidities.
Complete smoking cessation is ideal and patients should
be educated fully on the wound healing complications of
nicotine use. Getting in the habit of checking patients for
tobacco use with cotinine urine tests the month prior to
surgery can eliminate guesswork.
Antiplatelet and Beta-blockers
While it is universally agreed that patients should stop
certain medications and herbal supplementation that can
increase bleeding risk, there is less certainty about medi­
cally necessary medications. Antiplatelet agents should not
be stopped perioperatively for 1 year after stents, and
should be restarted quickly after surgery. If the planned
surgery does not require a great deal of undermining, con­
tinuing one antiplatelet agent (i.e., hold Plavix but continue
aspirin) may be a safe and viable option.3
Beta-blockers should be continued throughout the peri­
operative period with hold parameters for hypotension.22
Numerous studies and large meta-analyses have shown that
beta-blockers are cardioprotective when used in the periop­
erative period in patients with cardiac risk factors. Beta-
blocker therapy appears effective when started several
weeks prior to surgery, and long-acting agents appear more
successful than short-acting agents. Currently there is no
reason to start a beta-blocker for a healthy patient without
significant cardiac risk factors.
Glycemic Control
Patients with diabetes are at an increased risk for wound
infection due to impaired immunity, microvascular changes
and delayed healing mechanisms. Hyperglycemia before
and after surgery increases the likelihood of surgical sight
infection by three to fourfold. According to Olsen et al, a
serum glucose level of greater than 125 before or after
surgery parlayed into a more than fourfold increase in surgi­
cal site infections.19 In addition, diabetics are also at risk of
noninfectious complications including seromas and isch­
emic necrosis. HgbA1C should have been included in the
preoperative workup. The standard diabetic sliding scales
would accept glucose levels of 125. Therefore, tight glyce­
mic control (glucose <110) should be the goal of medical
protocol postoperatively. If a standard sliding scale is
deemed inadequate or the patient has a history of difficult
glycemic control, IV insulin and endocrinology consulta­
tion should be utilized in the immediate postoperative
period.
POSTOPERATIVE NAUSEA
AND EMESIS (PONV)
PONV, while not life-threatening, can delay patient clinical
course and discharge from hospital care, and can negatively
impact patient satisfaction. Risk factors for PONV include
female gender, history of motion sickness, history of PONV,
preoperative opioids, and nonsmoking (Table 1.4).
The plastic surgery population usually has several risk
factors for PONV, and the outcome of PONV can be tem­
porary hypertension and increased risk of bleeding. The
TABLE 1.4  Important Risk Factors for VTE
Prior history of DVT/PE
Malignancy (active or in patient history)
Thrombophilia disorders (inherited or acquired)
Obesity (risk may be highest for those younger than 40)
General anesthesia (risk rises with each hour in surgery,
regardless of procedure)
Age ≥40 years (risk rises as age rises)
Use of estrogen-containing drugs
Varicose veins
Abdominal surgery
Smoking
Recent surgery of any kind
Prolonged travel by air, train or car

11
Chapter | 1  Patient safety in body contouring
or pressure injury should be used, and all pressure points
should be rechecked when patient position is changed
during surgery. If the patient is prone, the face should be
checked periodically to make sure there is (1) no pressure
over the globe and (2) no pressure from the endotracheal
tube or tubing against skin surface.
Two hours before the end of surgery, Zofran should be
administered for patients at high risk of PONV (Table 1.6).
Continuing 80% FiO2 for 2 hours with a nonrebreather face
mask can reduce the risk of pulmonary complications. The
pneumatic compression devices should be on and continu­
ing to function in the postoperative period.
In the postoperative period, the focus should be on
adequate pain control, maintenance of fluid balance, and
early ambulation. If PONV develops, alternate agents to the
Skin folds of massive weight loss patients can harbor
high bacterial colony counts and yeast infections that
can predispose to surgical site infections. Topical creams
and powders should be religiously applied to get rid of
yeast infection before surgery. Patients should be provided
with Hibiclens with which to shower prior to surgery, and
instructed not to shave in or near surgical zones the week
prior to surgery.
In the preoperative area, forced-air prewarming for at
least 45 minutes prior to the operation can deter hypother­
mia. Intermittent pneumatic compression devices (IPCs)
should be on and functioning on the patient at least 30
minutes prior to surgery to allow for optimal fibrinolysis.
Appropriate parenteral antibiotics should be adminis­
tered within 60 minutes before incision. The drug protocol
to prevent PONV should be initiated.
Once the patient reaches the operating room, the battle
against hypothermia begins. The room temperature should
be set at 23°C (73°F). Continuing active warming with
forced air throughout surgery will help, as well as keeping
parts of the body that do not need to be visualized during
a portion of the operation covered. Using warmed (41°C)
irrigation and/or IV fluids can help, particularly if incisions
are large and the patient’s core is exposed for a significant
period of time.
Weight loss patients who have recovered from diabetes
may need insulin during and briefly after surgery. Glucose
should be checked periodically and IV insulin utilized to
keep the patient normoglycemic (Fig. 1.2 and Table 1.5).
A Foley catheter should be utilized in longer body contour­
ing cases, particularly when large volume liposuction is
planned and guidelines for catheter removal followed.
Proper padding and gel heel protectors to prevent traction
FIG. 1.1  Two-group comparison of prewarming.
No warming
Prewarming
38
37
36
TM (°C)
35
34
-60
0
Time (min)
60
FIG. 1.2  Impact of postoperative glucose control on SSI rates
after beginning tight insulin protocol. From Furnary AP, Zerr KJ,
Grunkheimer GL, et al. Continuous intravenous insulin infusion reduces
the incidence of deep sternal wound infection in diabetic patients after
cardiac surgical procedures. Ann Thorac Surg 1999;67:352–62.
DM Pts.
Non-DM
DM Pts.
DM Pts
3.0
1.0
4.0
2.0
0.0
89
90
96
97
88
87
92
93
94
95
91
Year
DSWI (%)
TABLE 1.5  Tight Glucose Control and SSI
HbA1c Level (%)
Plasma Glucose Level (mg/dL)
6
135
7
170
8
205
9
240
10
275
11
310
12
345
Maintaining a HbA1c level < 7 is associated with decrease in infectious
complications across a variety of surgical procedures.
Odds ratio of 2.13.
95% CI.
P value of 0.007.
From Dronge AS, Perkal MF, Kancir S et al. Long-term glycemic
control and postoperative infectious complications. Arch Surg. 2006;
141:375–80.

12
PART | 1  Patient evaluation and safety
in all systems. The science is used to create systems that
optimize performance and minimize error. Simple steps
such as always arranging pneumatic compression and a
warming blanket to arrive to the preoperative area with the
patient, making standardized order forms always available
for DVT prophylaxis and antibiotics, and having automatic
urine cotinine test administered routinely, can contribute to
minimizing patient risk.
CONCLUSION
This chapter should serve as a rough guideline toward
developing one’s own clinical protocol to optimize safety
and minimize risk. While surgery itself is an imperfect art,
it is amenable to continued improvement. The art of mini­
mizing risk and optimizing perioperative management
should advance along with the techniques to achieve
optimal surgical outcomes.
REFERENCES
1. Reason J. Understanding adverse events: human factors. Qual Health
Care 1995;4:80–9.
2. Kim A. Eagle, Chair. Task Force Members: Raymond J. Gibbons,
Elliott M. Antman, Peter B. Berger et al. ACC/AHA Guideline
Update for Perioperative Cardiovascular Evaluation for Noncardiac
Surgery – Executive Summary. Anesthes Analges 2002;94(5):
1052–64.
3. Grines CL, Bonow RO, Casey DE, et al. Prevention of premature
discontinuation of dual antiplatelet therapy in patients with coronary
artery stents. A science advisory from the American Heart Associa­
tion, American College of Cardiology, Society for Cardiovascular
Angiography and Interventions, American College of Surgeons, and
American Dental Association, with representation from the Ameri­
can College of Physicians. Circulation 2007;115:813–8.
4. Friedman T, Coon DO, Michaels JV, et al. Hereditary coagulopa­
thies: practical diagnosis and management for the plastic surgeon.
Plasts Reconstr Surg 2010;125:1544–51.
5. Harris EN, Boey ML, Mackworth-Young CG, et al. Anticardiolipin
antibodies: detection by radioimmunoassay and association with
thrombosis in systemic lupus erythematosus. The Lancet 1983;
322(8361):1211–4.
6. Jain SS, Dhand R. Perioperative treatment of patients with obstruc­
tive sleep apnea. Curr Opin Pulm Med 2004;10(6):482–8.
7. Jacobers SJ, Sowers JR. An update on perioperative management of
diabetes. Arch Int Med 1999;159:2405–511.
8. Centers for Disease Control and Prevention (CDC). Smoking and
tobacco use: fact sheet. Online. Avaialbe lfrom
tobacco/data_statistics/fact_sheets/index.htm (accessed 20 March
2012).
9. Monfrecola G, Riccio G, Savarese C, et al. The acute effect of
smoking on cutaneous microcirculation blood flow in habitual
smokers and non-smokers. Dermatology 1998;197:115–8.
10. Manassa EH, Hertl CH, Olbrisch RR. Wound healing and problems
in smokers and non-smokers after 132 abdominoplasties. Plast
Reconstr Surg 2003;111:2082–2087.
ones that have already been used should be employed.
Continued supplemental oxygen throughout hospitalization
to maintain SpO2 > 90% is ideal. In OSA patients, a CPAP
device should already be in the hospital room if the patient
utilizes one at home.
Incentive spirometry and pneumatic compression
devices should not only be ordered, but the surgeon should
check to make sure these devices are being utilized prop­
erly. Beginning chemoprophylaxis at 12 hours postop is
ideal, barring any bleeding complications.
The Foley catheter should be discontinued as soon as
it is reasonable, to prevent catheter-related urinary tract
infections. Antibiotics should not be given for more than
24 hours after a routine clean elective body contouring
operation.
COMPLICATIONS AND THEIR
MANAGEMENT
Nowhere is a cliché truer than this: the best way to manage
complications is to prevent them from happening in the first
place. Risk prevention, not risk management, is the primary
objective. Problems occur when the surgeon is too hasty in
his or her decision to operate and misses a vital piece of
information, or over-relies on others to carry out the risk-
prevention protocols. Even despite our best efforts, compli­
cations can occur in the practice of the most careful
clinician. The key is to make the steps of the risk-prevention
easily administered, orderly, clearly laid out, and unvaried
from patient to patient.
The study of HF is a division of psychological studies
that exclusively deals with the inevitability of human error
TABLE 1.6  PONV
Risk Factors
Female gender
History of PONV or motion sickness
Non-smoker
Perioperative opioid treatment
PONV Risk Stratification
# of Risk Factors
Risk of PONV
0
10%
1
20%
2
40%
3
60%
4
80%
Many of our patients have at least 3 risk factors: female gender,
nonsmoking, and perioperative opioids.

13
Chapter | 1  Patient safety in body contouring
17. Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to
reduce the incidence of surgical-wound infection and shorten hospi­
talization. Study of Wound Infection and Temperature Group. New
Engl J Med 1996;334:1209–16.
18. Classen D, Menlove RL, Burke JP, et al. Surgical site infections.
N Engl J Med 1992;325:281–6.
19. Olsen MA, Nepple JJ, Riew KD, et al. Risk factors for surgical site
infection following orthopaedic spinal operations. J Bone Joint Surg
Am 2008;90:62–9.
20. Cárdenas-Camarena LMD, González LEMD. Large-volume liposuc­
tion and extensive abdominoplasty: a feasible alternative for improv­
ing body shape. Plast Reconstruct Surg 1998;102(5):1698–707.
21. Perrotti JA, Castor SA, Perez PC, et al. Antibiotic use in aesthetic
surgery: a national survey and literature review. Plast Reconstruct
Surg 2002;109(5):1685–93.
22. Auerbach AD, Goldman L. Beta blockers and reduction of cardiac
events in noncardiac surgery. JAMA 2002;287:1435–44.
23. Peach MJ, Rucklidge MWM, Lain J, et al. Ondansetron and dexa­
methasone dose combinations for prophylaxis against postoperative
nausea and vomiting. Anesth Analg 2007;104(4):808–14.
11. Theadom A, Cropley M. Effects of preoperative smoking cessation
on the incidence and risk of intraoperative and postoperative com­
plications in adult smokers: a systematic review. Tob Control 2006;
15:352–8.
12. Spear SL, Ducic I, Cuoco F, et al. The effect of smoking on flap and
donor-site complications in pedicled TRAM breast reconstruction.
Plast Reconstr Surg 2005;116:1873–80.
13. Bluman LG, Mosca L, Newan N, et al. Preoperative smoking habits
and postoperative pulmonary complications. Chest 1992;113:883–9.
14. Warner MA, Offord KP, Warner ME, et al. Role of preoperative
cessation of smoking and other factors in postoperative pulmonary
complications: a blinded prospective study of coronary artery bypass
patients. Mayo Clin Proc 1989;64:609–16.
15. Sarwer DB. Awareness and identification of body dysmorphic disor­
der by aesthetic surgeons: Results of a Survey of American Society
for Aesthetic Plastic Surgery Members. Aesthet Surg J 2002;22(6):
531–5.
16. Kinzl JF, Trefalt E, Fiala M, et al. Psychotherapeutic treatment of
morbidly obese patients after gastric banding. Obes Surg 2002;12(2):
292–4.

14
© 2013 Elsevier Inc
Chapter 2 
Key Points
●
Patient selection is crucial and the skin quality of the
target region should be assessed.
●
Deformities should be classified, and simultaneous or
late excisional surgery should be discussed with the
patient.
●
Conventional technique can be used or energy
delivering technology can be used to get better skin
retraction.
●
Gentle surgical technique should be used and
soft tissue thickness should be even and esthetic
contours should be achieved at the end of the
procedure.
●
To get a smooth result the surgery should be extended
to the entire esthetic unit of the arm.
Liposuction of the upper extremities
Cemal Şenyuva and Hüseyin Güner
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 Teimourian1 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.
Chamosa’s cadaver study4 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 com­
bined 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 stand­
ing. 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, bra­
chioradialis 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
Part 2  Upper extremity contouring

15
Chapter | 2  Liposuction of the upper extremities
VAL (VASER)
Third-generation solid probe ultrasound liposuction systems
that were introduced in 2001 for use in other body parts
may also be used for the correction of arm fat deposits. In
this procedure, fat fragmentation and emulsification is
obtained by ultrasound energy in the first step. For this
purpose, 2.9 or 3.7 mm diameter probes may be used. The
2.9 mm probes include three rings, which enable penetra­
tion and delicate shaping. The 3.7 mm probes may include
one, two, or three rings. Probes with one ring have more
penetration ability and the ultrasound energy is denser at
the tip of the probe. The energy is higher at the sides in the
probes with three rings. The same arm positions and stab
incisions are used as for the SAL technique. Skin protectors
should be used and should be sutured with 3/0 silk materials
to prevent the incision edges from heat trauma. Klein solu­
tion is infiltrated. At least 100 ml wetting solution infiltra­
tion is recommended for each 1 minute of ultrasound
application.
Probe choice is determined according to the fibrous
content of the fat tissue and also the resistance to the probe.
Energy amplitude (ranged 0–100) and mode of energy
transfer (continuous or intermittent) is set. VASER applica­
tion for the posterior arm usually lasts between 3
and 4.5 min. VASER is carried out with depletion of the
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 begin­
ning of the treatment.
The techniques currently being used are the conven­
tional suction-assisted lipectomy (SAL), the third genera­
tion 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 infiltra­
tion 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.
FIG. 2.1  The basic position with the arm held in vertical position
and forearm held in flexion to ease the operation.
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

16
PART | 2  Upper extremity contouring
contraction. In the SlimLipo system, these two wavelengths
are transferred to subcutaneous fat tissue by a 1.5 mm fiber­
optic cable. The power may be set to 0–20 W for 924 and
975 nm, which is 40 W in total. We can accomplish a safe
lipolysis and dermal subdermal retraction by using those
two laser wave lengths separately or simultaneously with
this laser liposuction system.
Surgical Technique for LAL on the Upper Arm
LAL resembles classic liposuction. It is important that the
operation be done under slight sedation for the patient to
maintain position. A good result in liposuction surgeries
very much depends on good patient positioning. For the
posterior upper arm, the best position is while the patient
is lying down lateral supine, the shoulder is on 90° abduc­
tion and flexion, the elbow is flexed 90°, and the patient is
holding the other forearm with the operative side hand. The
entire operation can be done in this position. While the fat
tissue on the deltoid or brachioradialis area is treated, the
arm is simply adducted and the forearm is extended so that
the operation can continue smoothly.
At the start of the operation, 1/500 000 epinephrine
(adrenaline) and 0.8 g/l lidocaine Ringer’s lactate solution
is infiltrated in such a manner that the lidocaine dosage is
not over 55 mg/kg. Following the infiltration, laser is
started by inserting a 1.5 mm fiber into the subcutaneous
fatty tissue.
For arms with thick fat and sufficient turgor, 3040 W
blend mode of 924 and 975 nm laser is used together in
equal amounts or in different ratios. In total, 15–20 kJ is
applied equally to the overall area. Following this, a suffi­
cient amount of liposuction must be done by inserting a
2 mm suction cannula. As sufficient tissue heating and
retraction may not always be achieved with the 924 nm
wavelength alone, the 975 nm wavelength is also available
to be combined or used independently. The 975 nm wave­
length is highly absorbed by water, and as there is sufficient
water content in the tissue adjacent to the adipocytes, this
high absorption coefficient allows for some rapid heating.
It is important to remember that this water-absorption based
heating is rather hard to contain as there is high water
content in much of the adjacent tissue. The 975 nm wave­
length should not be used in high wattage in the superficial
levels of tissue nearest the dermal tissue. External cooling
can help with overheating.
Older patients or those with a medium amount of fat
and diminished skin tone and who do not want an incision
are generally difficult cases. Conventional liposuction will
not produce a satisfactory outcome. For these patients no
suction-only laser liposuction application or laser liposuc­
tion application with less suction will result in better out­
comes. While the fat tissue is discharged in months, the skin
resistance in fatty tissue and the second phase is initiated.
Aspiration is made with 3, 3.7, and 4.6 mm blunt-windowed
VentX® liposuction cannulas in the second stage.
Lipoaspiration is terminated when desirable esthetic
contours are achieved and the pinch test thickness is equal­
ized with adjacent esthetic units. 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.
Laser-Assisted Liposuction (LAL) and Laser
Tissue Interaction
The laser method has two main aims:
1. To selectively break down fat cells and separate fat
lobules into small pieces.
2. To stretch and remodel the dermal collagen and the
dense nondermal collagen, which is found in the con­
nective tissue between muscle and dermis.
The distinctive features of laser treatments are their
selectivity. Laser therapies are selective, unlike other tech­
niques. There are two target chromophores in our area of
liposuction: triglyceride and water. Fat cells and lobules are
composed of 90% triglyceride and all other tissues are 60%
water. With the wet technique, triglyceride concentration in
fat cells decreases to 80% and water concentration in other
tissues increases significantly to 80–90%. For the wet tech­
nique, there are two chromophores with the same concen­
trations subcutaneously.
According to the laser laboratory studies, it has been
seen that although the 924 nm laser beam is absorbed very
well by triglyceride, it is absorbed less well by water – the
other chromophore in the operative area. This type of pho­
tothermal selectivity allows for the absorption of the light
into the targeted adipose tissue, while leaving the adjacent
tissue relatively undamaged. This type of selectivity is par­
ticularly useful when in the superficial layer of the tissue,
near the dermal junction. As the dermal tissue contains a
large amount of water, any water-only absorption-based
system (YAG laser based) can present problems with burns
or necrosis as a result of overheating.
The goal is to minimize thermal damage on the periph­
eral tissues while melting fat with 924 nm laser. This way,
selective laser lipolysis can be done. By heating the water
with 975 nm laser, the deep dermis and dense collagen
tissue in the connective tissue are stimulated. Both acute
and augmented dermal and subcutaneous retraction is tar­
geted. There is an additional effect of the diffusion of the
heat created in the adipocytes from the 924 nm laser by
selective absorption into the triglyceride. As the connective
tissue is 90% embedded in the fat cells, this type of diffu­
sion allows for a more controlled method of collagen

17
Chapter | 2  Liposuction of the upper extremities
While the patient is lying down supine, the forearm is
placed on the surgical table and the wrist is flexed slightly.
Following local solution infiltration with 1/500 000 epi­
nephrine (adrenaline), laser liposuction is applied with
924 nm wavelength at about 10–20 W alone or with
blending of the 975 nm wavelength, not exceeding 4–8 W.
Following the application, suction from the forearm
and/or dorsum of the hand is done with a 1.5 mm blunt-
faced cannula. Incisions are closed with 6/0 Prolene and a
hand wrist bandage with mild compression is applied to the
dorsum.
OPTIMIZING OUTCOMES
Patient selection is important. Also, the patient should have
realistic expectations. The surgery should be performed
smoothly and a gentle surgical technique should be used.
To get skin retraction and a smooth surface without wavi­
ness the surgery should be performed on the whole esthetic
arm unit extensively and soft tissue thickness should be
even at the end of the operation (Figs 2.2–2.4).
POSTOPERATIVE CARE
A special arm corset should be applied to the arm postop­
eratively. If the patient has an intravenous line in the upper
will be retracted slowly. This application must be done very
carefully. The 924 nm wavelength must be used at about
10–20 W and no tissue other than fat tissue must be harmed.
If the fat amount in the arms is large, and for faster heating,
975 nm wavelength can be added in small doses. In careful
and delicate applications there will be controlled fat necro­
sis and fat cell apoptosis. Since vascular and lymphatic
tissues and connective tissue in the same compartment will
stay intact, fat necrosis will be absorbed in weeks. It may
take several months to produce the final outcome. These
patients must be well documented photographically and
must understand that results come over time.
The incisions are immediately sutured with 6/0 Prolene
or Monocryl following the surgery and the patient dressed
with an upper arm corset.
FOREARM
A forearm application is rarely done. Most of these patients
are over 60 years old. Their complaints are mostly not being
able to wear a watch or jewelry.
FIG. 2.2  Arm liposuction: preoperative and postoperative view of
the patient.
A
B
FIG. 2.3  Axillary lipodeposits before and after LAL.
A
B

18
PART | 2  Upper extremity contouring
continuously. Progressive soft tissue indurations and altera­
tions in sensation regress after the third postoperative week.
In the third postoperative month, a visit should be arranged
for photographing, and arm circumference and tissue thick­
ness measuring.
COMPLICATIONS AND
THEIR MANAGEMENT
Careful patient selection and accurate surgical planning is
essential for a good esthetic result in arm liposuction.
Complications such as bleeding, infection, prolonged soft
tissue indurations, burns, or seroma may occur. However,
in our clinical experience, seroma is the only complication
that is observed in other parts of the body and none of
those complications have been observed in our clinical
experience on the arm. None of our patients who had
arm liposuction necessitated or demanded additional
brachioplasty.
CONCLUSION
In conclusion, liposuction in the arm region is a simple
surgical procedure and anatomic structures are avoided as
long as the procedure is applied to the suprafascial plane.
SAL, VAL, or laser liposuction may be used alone for
patients without soft tissue laxity and ptosis. Patients with
minimal ptosis and loose skin may benefit from VAL or
laser liposuction, which provide better skin retraction. In
patients with ptosis, liposuction is used only to facilitate
brachioplasty.
REFERENCES
1. Teimourian B, Malekzadeh S. Rejuvenation of the upper arm. Plast
Reconstr Surg 1998;102:545–51.
2. El Khatib HA. Classification of brachial ptosis: Strategy for treatment.
Plast Reconstr Surg 2007;119:1337–42.
3. Appelt EA, Janis JE, Rohrich AJ. An algorithmic approach to upper
arm conturing. Plast Reconstr Surg 2006;118:237–46.
4. Chamosa M, Murillo J, Vazquez T. Lipectomy of arms and lipograft
of shoulders balance the upper body contour. Aesth Plast Surg
2005;29:567–70.
extremity, a corset on that side should be deferred until
the removal of the intravenous line. In this case, the upper
arm is wrapped with cotton and bandaged loosely. Except
for showering, the arm corset should be used for 2 weeks
FIG. 2.4  Patient with lipodeposits on her forearms: preoperative
and postoperative view after LAL.
A
B

19
© 2013 Elsevier Inc
Chapter 3 
Key Points
●
The patient must be willing to accept the possibility of
visible and even poor scarring.
●
Improvement in contour must be significant to justify
the visible scarring.
●
The arm must be adequately deflated before
brachioplasty.
●
If there is laxity on the lateral chest wall consideration
should be given to extending the excision to the
inframammary fold.
●
In massive weight loss patients, a Z plasty is not
usually necessary in the axilla.
Brachioplasty with bicipital groove scar
Susan E. Downey
INTRODUCTION
The increase in obesity in the United States of America and
the concurrent meteoric rise in bariatric surgery has led to
an increasing interest and popularity of the brachioplasty
procedure. Statistics from the American Society of Plastic
Surgeons have borne this out, with an increase in the
number of brachioplasties from 2516 in 1997 to 16 102 in
2009.1 Massive weight loss patients make up the bulk of
brachioplasty patients. As is true in all parts of the body
after massive weight loss, the deformities can be highly
varied. Some patients do not have much loss of fat from
their arms and require debulking before a formal brachio­
plasty. Other patients have truly deflated arms and describe
“pinching” of the loose skin as it is folded into their
clothing.
Esthetic
brachioplasty
was
first
described
by
Correa-Inturraspe and Frenandez2 in 1954. Lockwood
(1995)3 described the superficial fascial repair of the arm,
but as was the case with his work on lower body lifts, most
of his patients were complaining of aging and not massive
weight loss. However, until the avalanche of massive
weight loss patients entered the plastic surgeon’s office
there was little interest in the procedure. That said, many
plastic surgeons were still reluctant to perform the proce­
dure due to concerns about scars and axillary contractures.
The massive weight loss patients have helped change the
plastic surgeons’ minds, focusing the improvement of
contour with fewer concerns about scars. Plastic surgeons
of course, however, continue to try and improve the scars
and argue about scar placement. Some plastic surgeons
advocate a scar along the most inferior point of the upper
arm4 and others have recommended a sinusoidal type of
scar placement.5 At polls taken during plastic surgery meet­
ings the most common scar placement has been reported to
be within the bicipital groove (Downey S, personal com­
munication). A survey taken of the general public, plastic
surgeons and patients confirmed that the most acceptable
position of a scar is along the bicipital groove.6 Many
plastic surgeons are now continuing the excision proxi­
mally into the axillary area7 and in some massive weight
loss patients this excision may be extended down the trunk
to the inframammary fold.8,9
PREOPERATIVE PREPARATION
The evaluation of patients presenting for brachioplasty
involves consideration of how much residual fat is present
and the looseness of the skin. One of the first considerations
will be whether there is enough laxity to justify a scar from
elbow to axilla or longer (Figs 3.1 and 3.2). Patients with
minimal looseness may benefit from looking at pictures of
patients who have undergone brachioplasty in order to
understand the length of the scars and the typical “rope-
like” appearance of the scar near the elbow. Some clinicians
have advocated drawing the proposed scar on the patient so
they can live with the proposed scar for a while and see if
it is something that they can accept.
The second type of patient is the opposite – the patient
who has had minimal deflation of their arms. These patients
will not have a satisfactory result from a brachioplasty
without deflation. Attempts to perform a brachioplasty will
lead to an arm still very full, but now with the addition of
a long scar. There are two schools of thought: liposuction
at the time of brachioplasty, and liposuction or deflation
followed at a later interval (usually several months) by the
formal excision. In many cases the arms are not the patient’s
Part 2  Upper extremity contouring

20
PART | 2  Upper extremity contouring
extension down the chest wall as many male shirts now are
more body revealing and a smooth contour in this area is
desirable. Even in these patients who will have a significant
improvement in contour it is advisable to show them pic­
tures of brachioplasty patients so that they are aware of the
length of the scars, the scar position, and the length of time
that it will take the scars to mature.
Preoperative consultation not only should include dis­
cussions as to the improvement to be seen in the arms but
also the limits. Many patients are concerned about the lower
arm. Often the lower arm exhibits laxity but not enough
looseness to justify extending the incision below the elbow.
Many patients who have experienced extreme weight loss
will always have more laxity to their skin and no surgical
procedure to date will improve this. The scar of a brachio­
plasty needs to be discussed in detail with patients. In
general, the scar closest to the axilla will do the best while
the scar closest to the elbow will do the worst (Figs 3.4 and
3.5). This is, of course, opposite to what the patient (and
surgeon) wishes. Although the scar close to the elbow will
eventually settle down and become flatter, it is often a long
process and may require not only a lot time but topical
therapy such as taping or even steroid injections. In some
cases the scars are thick and wide (Fig. 3.6).
FIG.
3.1  Preoperative massive weight loss patient before
brachioplasty.
FIG. 3.2  Six weeks following bicipital groove brachioplasty.
FIG. 3.3  Massive weight loss patient before (A) and after (B) defla­
tion (liposuction) of arms.
A
B
first priority and the deflation can be combined with the first
excisional procedure the patient is undergoing (for example,
an abdominoplasty) and then the formal brachioplasty
could occur at a later time. Often this is a very acceptable
plan for the patient as the deflation will allow the patient to
wear more normal clothes or clothes that better fit their
torso even though the arms are still loose (Fig. 3.3).
The third type of patient has adequate deflation and
enough looseness that they will have enough improvement
in contour to justify the scar. Evaluation of these patients
needs to include the skin of the forearm as well as the
excess and laxity of the lateral chest wall. Rotation of the
skin/fat flap in an upwards and inwards manner will some­
what improve the loose skin of the forearm, but not signifi­
cantly. This upward/inward rotation will leave an excess or
dog-ear in the axilla. To excise this dog-ear and to give
patients an even better outcome the excess can be excised
down to the inframammary fold. Patients often consider
this a real benefit as they object to the “bra roll” fat.9 This
fat or roll may not be visible to the plastic surgeon unless
the patient has on or puts on their bra during the consulta­
tion. Even male weight loss patients may benefit from this

21
Chapter | 3  Brachioplasty with bicipital groove scar
FIG.
3.4  Preoperative massive weight loss patient before
brachioplasty.
FIG. 3.5  Postoperative scars 3 months following bicipital groove
brachioplasty. Note scar is better in axillary area and worsens as the
scar approaches the elbow.
FIG. 3.6  Extensive scarring after brachioplasty.
FIG. 3.7  Preoperative markings for bicipital groove brachioplasty.
SURGICAL TECHNIQUE
The markings for a brachioplasty should be done with the
patient in the standing position (Fig. 3.7). Patients should
hold their arms at 90° to their body with the elbow flexed.
A horizontal line should be drawn from the axilla to the
elbow marking the desired position of the final incision line
along the bicipital groove. The high point of the axilla
should be marked. This will represent the high point
position of the flap to be excised from the upper arm as it
is rotated up and in. A horizontal line should be marked,
which corresponds to the inframammary fold, to mark the
end of the lateral chest excision. The excess tissue of the
back should be pulled forward and then a vertical line
drawn, which now represents the desired position of the
final incision line along the lateral chest. The excess skin
and fat of the chest wall should then be pinched, utilizing
the marked posterior line as the final extent of the excision.
Care should be taken to observe the breast to make sure
that the breast tissue is not pulled posterior and the lateral
aspect of the breast is not violated. The excess tissue to be
excised is then marked. This excision of the lateral chest
wall tissue allows the skin and fat of the upper arm to be
rotated up and in and the resultant dog-ear to be excised
along the lateral chest wall.
For female patients, the excision within the axilla will
include all or most of the hair-bearing skin. For male
patients this needs to be modified as the normal male has
hair in his axilla (Fig. 3.8). The incision can be moved
FIG. 3.8  Positioning of scar in axilla of male patient to maintain
normal hair-bearing pattern.

22
PART | 2  Upper extremity contouring
posterior to leave behind hair-bearing skin, which also
helps camouflage the scar.
For massive weight loss patients a Z plasty has not been
found to be necessary in the axilla. The incision and even­
tual scar in the axilla will recruit some of the residual laxity
from the surrounding upper thorax area, which adds to the
eventual cosmetic outcome of the procedure (Figs 3.9 and
3.10).
The procedure is done with the patient in the supine
position with both arms extended. The arms should be
prepped circumferentially to allow for movement and the
lateral chest prepped and draped as well. The incision is
made along the markings and dissection is carried down to
the fascia of the arm musculature. At this juncture the loose
inferior skin and fat is elevated off the arm musculature
dissecting towards the inferior aspect of the arm. The skin
and fat is then rotated up and in, in order to improve loose­
ness around the elbow as well as remove the excess of the
lower upper arm. This maneuver creates a dog-ear in the
axilla, which is then taken out with the upper lateral chest
excision. Once the excess skin and fat is elevated, the assis­
tant should hold the upper skin and fat in place so that the
FIG. 3.9  Male massive weight loss patient after brachioplasty with
extension down thorax to inframammary fold.
A
B
FIG. 3.10  Full extension of arm after brachioplasty without Z plasty
in axilla.
incision lies in the desired position along the biciptial
groove. The excess skin and fat can then be marked for
excision without any fear of inability to close the wound.
The excess of the upper lateral chest is excised directly
using the preoperative marking. Once the excess skin and
fat is excised then the wound is closed over a closed suction
drain which is exited through the inferior portion of the
lateral chest excision. Closure can be done in a single layer.
Use of barbed sutures can make the closure quicker (Fig.
3.11). If cyanoacrylate is used to seal the wound then no
dressings are needed. Many surgeons have found that
patients do well without compression garments. Compres­
sion garments may pinch the arm skin, especially around
the axilla and can in some cases cause areas of uneven
swelling. A drain may be placed and, if it is used, the drain
should exit along the chest wall for the patient’s comfort.
OPTIMIZING OUTCOMES
1. Manage expectations with detailed preoperative coun­
seling on scar length, position, and quality.

23
Chapter | 3  Brachioplasty with bicipital groove scar
COMPLICATIONS AND
THEIR MANAGEMENT
Wound dehiscence can be seen primarily in the axillary area
where the wound is under tension; the area can be moist
and the movement of the arm can lead to disruption. In most
cases these areas are small and can be handled with local
wound care only.
Hematomas can occur and should be dealt with if pos­
sible as soon as identified. If the hematoma is not fully
evacuated there can be scar contracture, which is a more
difficult problem in the long term. Seromas are sometimes
seen as well. Seromas are usually small and most often are
seen near the elbow although they can occur anywhere
along the incision. Serial aspiration of the small seromas
usually is adequate.
Despite not using a Z plasty in the axilla, scar contrac­
ture is rarely seen in the axilla in the massive weight loss
patient. Some patients report feeling tight across the axilla
in the first few weeks following the operation. In these
patients stretching exercises can help the natural relaxation
of the scar. Massive weight loss patients typically have a
lot of looseness to their upper torso and the body recruits
this surrounding loose tissue to relax the scar. The side
benefit to this process is an improvement in the contour of
the upper torso.
REFERENCES
1. American Society for Aesthetic Plastic Surgery. Online. Avail­
able from
(accessed 8 March 2012).
2. Correa-Inturraspe M, Fernandez JC. Dermatolipectomia braquial.
Prensa Med Argent 1954;34:24–32.
3. Lockwood T. Brachioplasty with superficial fascial system suspen­
sion. Plast Reconstr Surg 1995;96:912–20.
4. Lockwood T. Brachioplasty with superficial fascial system suspen­
sion. Plast Reconstr Surg 1995;96:912–20.
5. Aly A, Cram A. Brachioplasty. In: Aly A, editor. Body Contouring
after Massive Weight Loss. St. Louis: QMP; 2006.
6. Strauch B, Greenspun D. Approach to the arm after weight loss. In:
Rubin JP, Matarasso A, editors. Aesthetic Surgery after Massive
Weight Loss. Oxford: Elsevier; 2007.
7. Samra S, Sawh-Martinez RM, Kiu Y, et al. Plast Reconstr Surg
2010;126:77.
8. Rubin JP, Michaels J. Correction of arm ptosis with a medial bicipital
scar. In: Strauch B, Herman C, editors. Encyclopedia of Body Sculpt­
ing after Massive Weight Loss. New York: Thieme; 2010.
9. Downey S, Gross J. Lateral thoracic excisions in the post massive
weight loss patient. Clin Plast Surg 2008;35(1):115–20.
2. Modify the excision for male patients to leave some
axillary hair-bearing skin.
3. On-table marking of excision prevents over-resection
and inability to close.
POSTOPERATIVE CARE
Early on in the experience with brachioplasty many sur­
geons advocated compression garments or wrapping the
arms. In some patients this led to pinching of the skin
especially when ace wraps were used. From the experience
of patients who could not tolerate the wrapping, the tech­
nique has evolved to not using compression garments. With
the use of cyanoacrylate as a wound sealant, dressings are
also unnecessary and the avoidance of dressings means less
chance of pinching and asymmetric swelling.
If a drain is used then it can be removed when the
surgeon feels that the drainage has decreased sufficiently.
Most patients are able to undergo this procedure, when
done alone, as an outpatient. The most common complaint
is tightness under the axilla, which generally resolves in a
few weeks to months.
As mentioned earlier, the scars from a brachioplasty can
take a long time to settle down. The scars nearer the axilla
improve earlier than the scars near the elbow. This is frus­
trating to both the surgeon and the patient as the scars near
the axilla are less visible. The patient will need to be reas­
sured that the scars near the elbow will eventually settle
down as well, although this process may take up to a year
or even longer. Steroid injections, taping of the scars and/
or silicone sheeting, massage and other usual scar manage­
ment modalities can help the process along.
FIG. 3.11  Intraoperative view.

24
© 2013 Elsevier Inc
Chapter 4 
Key Points
●
Upper arm excess in massive weight loss patients most
often crosses the axilla onto the lateral chest wall.
●
Since upper arm excess most often crosses the axilla
onto the chest wall, the resection needs to cross the
axilla.
●
The arm is a cylindrical structure with a hard inner
core that is noncompressible.
●
It is important to account for the distance between the
pinched fingers in the marking process to prevent
over-resection during the operative procedure.
●
A complete tailor tacking of the arms prior to making
the incisions during brachioplasty will prevent
over-resection and banding.
●
It is dangerous to leave the arm wound open for any
considerable time during a brachioplasty procedure.
●
The advantages of a posterior scar in brachioplasty
include less visibility in normal life animation and less
risk to important anatomic structures.
Brachioplasty – the double
ellipse technique
Al S. Aly and Peter Lin
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 embarrass­
ment, 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 defor­
mity 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.
Another important concept that the senior author intro­
duced 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 danger­
ous 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 brachio­
plasty 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
Part 2  Upper extremity contouring

25
Chapter | 4  Brachioplasty – the double ellipse technique
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 tech­
nique”. 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.
Preoperative Markings: Double
Ellipse Technique
1. Patient seated with arms abducted to 90° and elbows
flexed at 90°.
2. At the axillary crease, located at the junction of the arm
with the chest wall, excess skin and subcutaneous
tissues are pinched just below the musculoskeletal
complex. The anterior and posterior margins of this
pinch are marked.
3. This process of pinching just below the musculoskeletal
system is repeated at multiple points along the entire
upper arm. In some patients the excess will have to be
followed past the elbow.
4. The pinching of excess tissue is continued onto the
lateral chest wall.
5. The marks are then all connected, both anteriorly and
posteriorly, to create the first ellipse. This ellipse does
not account for the distance between the pinching
fingers and if used to resect tissues will not allow enough
skin to be left behind to close the arm.
6. A second ellipse is created, based on the first ellipse,
which accounts for the distance between the pinching
fingers. Thus at multiple points along the upper arm, this
pinch is repeated and the distance between the pinched
fingers is noted. Marks that move in from the original
ellipse edges by half the distance of the pinch are then
made.
7. This process is repeated along the extent of the arm but
not the lateral chest wall, since the resection is not
around a cylinder at this point.
8. The second set of marks is then connected to create the
inner ellipse.
9. Horizontal hatch marks are made at varying distances
along the length of the ellipse to assist with final closure
(see Fig. 4.2).
Surgical Sequence
1. If a brachioplasty alone is to be performed the patient
is placed in the supine position, with arm tables on
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.
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 transi­
tion 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 com­
posed of bone and muscle mass, surrounded by soft tissue

26
PART | 2  Upper extremity contouring
5. The inner ellipse is then tailor tacked with staples in its
entirety, simulating a complete resection and closure.
With the tailor tack in place, the entire arm is observed
for the tightness and evenness of the proposed resec­
tion. The markings are adjusted to avoid areas of under-
resection and over-resection. It is especially important
to avoid areas of “spot tightness” which will lead to
tight bands if not appropriately adjusted for with the
markings. After the markings are adjusted, the staples
are removed. This tailor tacking step virtually elimi­
nates the chance of over-resection.
6. The resection starts distally by incising both sides of
the ellipse up to the first hatch mark. The skin and
underlying fat are elevated off the underlying muscle
fascia, starting at the distal end of the ellipse and up to
the hash mark. There should be no vital neurovascular
structures in this layer.
7. After obtaining excellent hemostasis, the skin edges of
the ellipse are re-approximated using temporary skin
staples.
8. This same process of resecting and temporarily closing
the wound with staples is repeated from hash mark to
hash mark in what the authors call the “segmental
resection-closure technique”. While the arm is open,
swelling can and will occur, thus it behoves the surgeon
to work efficiently till the temporary staples are in
place. The temporary closure prevents any further
swelling from taking place.
9. In the region of the axilla, the resection should be more
superficial than the muscle fascia to preserve as many
lymphatics as possible.
10. After the entire resection is complete and the temporary
staples are in place, they are replaced with sutures. The
authors prefer to use 2-0 long lasting nonpermanent
monofilament interrupted/inverted sutures that re-
approximate all of the deep soft tissues in one layer,
interspersed with subcuticular nonpermanent staples.
Sometimes a more superficial 3-0 monofilament short-
lasting suture is placed in a continuous subcuticular
fashion. The skin is then covered with glue.
11. Drains are not utilized.
POSTOPERATIVE CARE
At the conclusion of the procedure the arms are elevated
on multiple pillows with a slight bend at the elbow. No
compression sleeves or wrappings are used. The arms are
kept elevated above the heart for 2 to 3 weeks but patients
are allowed to lower them for brief periods of time to
perform necessary activities. Swelling in the arms and
hands is not uncommon and typically resolves in 1 to 2
weeks. Patients can usually return to normal vigorous activ­
ity 3 to 6 weeks after surgery.
either side, so that the arms can be manipulated in a
variety of positions during the surgery. In the case of
combining brachioplasty with an upper body lift, the
patient is placed in the lateral decubitus position and
turned to the other side when the other side is
approached.
2. Intravenous lines should be avoided in the upper
extremities. If a line in the arm is required for induction
of general anesthesia, this should be moved to the foot
or other location prior to prepping.
3. Assistants during surgery are required to stand above
the head of the patient so the patient’s head is either
turned 180° away from anesthesia or the operating
room table is moved away from the anesthesia machine
to allow the assistants enough room.
4. The inner ellipse is injected with a small amount of
epinephrine-containing anesthetic to reduce bleeding at
incision and the patient is prepped and draped.
FIG. 4.2  The double ellipse markings. The outer ellipse is based on
the pinch of the soft tissues just below the musculoskeletal anatomy of the
arm. The inner ellipse is created as an adjustment of the outer ellipse,
based on the need to leave enough skin behind to account for the distance
between the pinched fingers. Note that once the resection moves onto the
lateral chest wall, the outer ellipse is reverted to.

27
Chapter | 4  Brachioplasty – the double ellipse technique
COMPLICATIONS AND
THEIR MANAGEMENT
General risks of surgery should always be discussed with
the patient, including infection and bleeding. Specific to
brachioplasty, superficial nonhealing areas tend to be the
most common complication. They often occur in the region
of the axilla and can mostly be allowed to heal by secondary
intention. Deeper dehiscences are less frequent in the expe­
rience of the authors and may or may not require formal
closures.
Patients should also be made aware of the risks of
potential seromas, which tend to occur right above the
elbow, but can be located anywhere. They are treated ini­
tially by repeated aspirations, progressing to the use of
sclerosing agents, and finally they are exteriorized by
opening the scar over the area of the seroma and leaving a
wick in place to allow for drainage and closure from deep
to superficial. Infections are uncommon but tend to occur
in association with seromas. Initial treatment is decompres­
sion and antibiotic treatment and then exteriorization.
Historically, poor scarring has always been a problem
with brachioplasty. Even with the use of deep sutures to
support the superficial fascial system, scars often appear
raised and cordlike. It is presumed that the etiology of
poor scaring is tension on closure but it is not clear that
this is more of a problem with the arms than other areas
of the body. Thus it may also be related to the intrinsic
nature of arm skin. Despite the poor quality of many arm
scars, especially within the first year, it is the impression
of the authors that they eventually mature, similar to
other scars, but take considerably longer, up to 2 years,
to mature.
A distal dog-ear can result distally if there is consider­
able forearm excess. In those instances, the authors do
not hesitate to cross the elbow. This can be performed
during the original brachioplasty operation or revised in a
subsequent procedure. If the excess extends all the way to
It is not unusual for patients to experience small areas
of wound separation, especially in the axilla. The authors
prefer to leave a few external skin staples around the axilla,
to help reduce that risk.
OPTIMIZING OUTCOMES
Because of the nature of closing around a cylinder the
resultant healing scar often has a scalloped appearance
that tends to resolve over a 6 to 12 month period. Patients
are often concerned about scalloping unless they are coun­
seled about its likely presence for a period of time after
surgery. It is also the authors’ experience that scar quality
takes longer to reach maturity than most scars in the body.
The technique described in this chapter leads to a more
posteriorly positioned scar when compared to the previ­
ously more popular bicipital groove scar. The position of
the scar in brachioplasty is a matter of surgeon preference,
with no right or wrong position. The authors’ preference
for a posterior scar is based on a number of issues. First,
the most visible aspect of the arm during normal anima­
tion of an individual facing an observer is the bicipital
groove. The posterior scar is essentially invisible in that
situation. Second, resections that are centered on the
bicipital groove may injure the medial antebrachial cuta­
neous nerve, as well as a relatively lymph-rich area of the
arm. The potential negative aspect of a posterior scar is
that an observer standing behind a patient may see part of
the scar.
The technique described in this chapter is quite effective
in reducing upper arm access, reducing axillary laxity, and
because of the lateral chest wall component of the excision,
can also be utilized to decrease horizontal thoracic excess.
In the authors’ experience the technique is far more effec­
tive than the previously popular “T” type brachioplasty
technique, especially when the excess is of a severe nature.3,4
A typical early postoperative result of the technique dis­
cussed in this chapter is shown in Fig. 4.3.
FIG. 4.3  A patient is shown preoperatively (A) and early in the postoperative period (B) after brachioplasty performed utilizing the technique discussed
in this chapter.
A
B

28
PART | 2  Upper extremity contouring
particularly the ulnar nerve. This can create a scenario
similar to compartment syndrome. Treatment of this
requires release of the tension and close follow up to evalu­
ate the extent of injury as well as to monitor return of
function.
CONCLUSION
Massive weight loss patients often present with a “bat
wing” deformity that extends to the lateral chest wall. This
type of deformity requires that the resection cross the axilla
from the upper arm onto the lateral chest wall to allow for
maximal improvement. Multiple checks during the marking
process and the surgical procedure allow for accurately
approximating the amount to be resected and prevention of
problems with under- or over-resection. Efficient surgical
technique will also prevent intraoperative swelling leading
to an inability to close the arm. Finally, although scar posi­
tion in brachioplasty is a matter of surgeon preference,
placing the scar in a posterior aspect of the arm effectively
hides the scar during normal daily activities and avoids
potential medial antebrachial cutaneous nerve injury and
may lead to less injury of the lymphatics of the upper arms.
REFERENCES
1. Aly AS, Cram AE. Brachioplasty. In: Aly AS, editor. Body Contouring
after Massive Weight Loss. St Louis: Quality Medical Publishing;
2006. p. 303–33.
2. Aly A, Pace D, Cram A. Brachioplasty in the patient with massive
weight loss. Aesth Surg J 2006;26:76–84.
3. Lockwood T. Brachioplasty with superficial fascial system suspen­
sion. Plast Reconstruct Surg 1995;96(4):912–20.
4. Baroudi R. Body sculpturing. Clin Plast Surg 1984;11(3):419–43.
the wrist, the resection is limited to 8 to 10 cm below the
elbow in the preliminary procedure. Subsequently, after
the lymphatic drainage of the arm is re-established, a sec­
ondary final excision can be undertaken in a secondary
procedure.
While the brachioplasty resection is performed superfi­
cial to the muscle fascia, thus sparing the deep vital struc­
tures, some skin sensory nerves are necessarily resected.
This will cause some degree of sensory loss in the upper
arm that is difficult to avoid.
The lymphatic drainage of the arm is often temporarily
compromised after brachioplasty, which can lead to early
postoperative edema. This usually resolves in 1 to 2 weeks.
However, if extensive lymphatic interruption occurs, which
is more likely to be associated with bicipital scar position,
there is potential for permanent lymphedema. To help
reduce the risk, leaving behind some intact lymphatics in
the axilla is advantageous.
Inability to close a brachioplasty incision is a difficult
problem. It may manifest as a very tight closure that
compromises skin vascularity or loss of distal pulses. Once
encountered, the area of greatest constriction has to be
identified and the sutures in that segment released. An
option at this juncture is to utilize some of the resected skin
as a full thickness skin graft to bridge the gap. Another
option, especially if the problem is felt to be secondary to
intraoperative swelling rather than over-resection, is to
lightly wrap the arm for a few days to allow the swelling
to resolve, then attempt closing the arm without tension. Of
course, it is best to avoid this problem in the first place by
following some of the recommendations mentioned in this
chapter.
Another problem with a brachioplasty closure that is
overly tight is compression of the deeper motor nerves,

29
© 2013 Elsevier Inc
Chapter 5 
Key Points
●
Include the deformity of the axilla and upper chest in
the arm reduction plan.
●
Close the excision along the posterior half of the
medial arm and zigzag across the axilla.
●
Fully remove excision site fat and reduce excess fat
elsewhere through liposuction.
●
Anchor the proximal posterior flap to deltopectoral
fascia.
●
Close in two layers using barbed sutures.
Brachioplasty with
liposuction resection
Dennis J. Hurwitz
INTRODUCTION
The female arm has a smoothly full but adherent skin cover­
ing 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 cla­
vipectoral 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 defor­
mity.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 inclu­
sive 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 swell­
ing due to lymphatic and/or venous incompetence are
contraindications.
Meticulous surgical markings permit expeditious con­
servative excision of the excess skin and fat, leaving sym­
metrical 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 lipo­
suction (see video demonstration). At the time of closure,
if the resection proves to be inadequate then another centi­
meter 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 termina­
tion 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
Part 2  Upper extremity contouring

30
PART | 2  Upper extremity contouring
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 inci­
sion 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).
SURGICAL TECHNIQUE (Fig. 5.3)
If brachioplasty is an isolated procedure, the arms, axillas
and upper chest are prepped while the patient is sitting and
then dressed in a paper surgeon’s gown. Lay the patient
supine, and abduct the arms about 80° on arm boards.
FIG. 5.1  These are color-coded preoperative markings for the
L-brachioplasty. The ink dots 1–6 are placed sequentially freehand as
described in the text. The dots are connected to create upper arm hemi-
elliptical and lateral chest elliptical excisions. After the lines are drawn
the linear distances are measured and adjusted so that 1–3 equals the
distance from 3–5, and the distance 5–6 equals the distance from 1–6.
Inset shows that the outstretched arm better demonstrates these relation­
ships. If the arm deformities are symmetrical then these measured dis­
tances, as well as the width from point 2 to point 4, will be the same or
otherwise adjusted.
A
B
Points 1-3 equals:
Points 3-5
Points 5-6 equals:
points 1-6
1
3
4
6
2
A
B
5
2
3
5
6
4
1
Hatch marks
FIG. 5.2  (A) The advancement point 5 is being dotted with a surgical marker, as it is found along the posterior incision line by pinch approxi­
mation to the deltopectoral groove. (B) Connecting the dots point 4 to point 5 completes the descending limb of the hemi-ellipse.

31
Chapter | 5  Brachioplasty with liposuction resection
then is undercut about 1 cm. The posterior incision is then
continued across the axilla and along the lateral chest to the
tapered end at point 6. The anterior straight line arm inci­
sion is similarly made, undermined, and continued across
the axilla and descends as the anterior incision of the lateral
chest to a depth of the serratus fascia. If breast augmenta­
tion or a spiral flap breast reshaping is to be performed, the
anterior limb of the chest ellipse is not incised until the
mastopexy/ augmentation is completed, because the recruit­
ment of skin flaps in a breast augmentation reduces the need
for lateral chest skin resection.7
The skin resection begins with thick full thickness skin
and subcutaneous tissue resection from the chest and con­
tinues through the thin axillary tissues over the clavipec­
toral fascia. Stay immediately subdermal to avoid entering
the axilla and damaging neurovasculature. Distal traction
of the arm skin produces avulsion removal, assisted by
scalpel along the exposed dermis. Little bleeding is
Under deep sedation of general anesthesia, sterile draping
is completed. We avoid arm intravenous infusion. The
width of resection is rechecked. About 150 ml of saline
with 1 mg of epinephrine (adrenaline) and 30 ml of 1%
Xylocaine per liter are infused through a thin multiholed,
blunt tipped needle. If only excision site liposuction (ESL)
is being done, limit the infusion to within the borders of the
planned excision so the closure is not compromised. The
subcutaneous fat within the arm excision site is suctioned
as completely as possible, and the author favors preliminary
application of ultrasonic energy. The remainder of the arm
can have fat suctioned as needed, with care taken to mini­
mize trauma to the closure margins (see video).
The final adjustment for the adequacy of the width of
resection is aided by temporary staple or towel clip closure.
Then the posterior arm incision is made through the skin
and superficial fascia with traction anteriorly on the arm
skin. Once through the fascia the incision pops open and
FIG. 5.3  Operative sequence for L-brachioplasty. (A) The right arm has been marked and then circumferentially prepped. The patient was dressed
in a paper surgeon’s gown, which was cut open after being positioned supine and the arm was placed on an arm board angled 80 ° from the operating
room table. (B) Complete liposuction of the excision site is being completed as the 4 mm multiple holed suction cannula is pulled up against the dermis,
revealing the thinned tissues. (C) The perimeter incision has been completed through the skin and subcutaneous tissue and with about a centimeter of
undermining of the wound edges. (D) The full thickness skin and fat excision of the right lateral chest has been done. (E) The skin excision is completed
with a scalpel assisted avulsion from proximal to distal. A lattice work of connective tissue with preserved neurovasculature lies in the wound bed.
(F) The subcutaneous layer has been closed using a single Quill #1 PDO 30 cm long suture. A second layer of 3-0 Monoderm follows.
A
B
C
D
E
F

32
PART | 2  Upper extremity contouring
FIG. 5.4  Before and 7 months after L-brachioplasty frontal views
with a 7 kg (15 pound) weight gain for the 51-year-old patient (BMI
28) seen in the operative sequence in Fig. 5.4. The preoperative draw­
ings are seen. The hanging posterior skin is gone. The incompletely
faded scar curves from the axilla down to the mid arm and then
slightly ascends to the elbow.
A
B
FIG. 5.5  Before and 7 months after L-brachioplasty posterior views
for the patient seen in the operative sequence in Fig. 5.4. Despite her
7 kg (15 pound) weight gain, her arms are smaller and better shaped.
A
B
encountered as the arm skin is removed like a full thickness
skin graft. Superficial veins, lymphatics, and sensory nerves
are preserved on the arm, within a latticework bed of con­
nective tissue nearly empty of adipose tissue.
A nonundermined proximal posterior triangular flap is
advanced to the deltoid fascia at the groove with the pec­
toralis using several 2-0 braided absorbable sutures. Under­
mining of this flap threatens the vitality of this precarious
skin blood supply. Upon closure across the axilla there will
be fullness that over time will recontour to a natural axillary
hollow. Using the preoperative hatch marks as a guide, the
incisions are then aligned with towel clamps. Excess skin
can be resected along the wound edge if needed.
While any continuous horizontal running 2-0 absorb­
able suture could approximate the subcutaneous fascia, the
author prefers the even and reliable long-term retention of
the knotless, 0 or #1 PDO double armed barbed Quill
(Angiotech Pharmaceuticals, Vancouver, British Columbia,
Canada). The 24 cm long #1 barbed PDO comes on a
38 mm tapered needle that is passed through as a running
horizontal mattress suture, starting from the center of the
wound and advancing distally (elbow) and proximally (del­
topectoral groove). To start the closure, two horizontal bites
are taken away from the center with each needle and the
Quill suture is pulled taut. After two passes of the suture
on either side of the wound, the barbed suture is cinched
and secured under the appropriate tension. As the suturing
proceeds, the barbs keep the closure from slipping. Thus
there is no segmental slippage as may occur with other
running sutures. At the end of the wound, the barbed suture
is returned back for several throws, forming a J, and the
end is then cut. The series of dermal dimpling caused by
the horizontal suture pull of the subcutaneous fascia to the
dermis will disappear over several months. A second con­
tinuous barbed intradermal suture closure follows, using
3-0 Monodern Quill SRS. Dermal glue or taping completes
the closure.
Only late lymphoceles, rather than early seromas, can
be a problem. As such, suction drains are unnecessary and
we believe are contraindicated as negative pressure encour­
ages flow from damaged lymphatics. The operative time for
each arm is approximately 40 minutes. The incisions are
covered with foam dressing and then wrapped in ace ban­
dages with the hands elevated. Before and after photo­
graphs are seen in Figs 5.4–5.6. The result of an L-
brachioplasty with circumferential liposuction is seen in
Figs 5.7–5.9. Please see the accompanying video for this
chapter for this surgical technique.
OPTIMIZING OUTCOMES
1. The positioning and precise geometry of the surgi­
cal markings are standardized, thereby increasing
symmetry, expediting the operation, and leaving the
least conspicuous scar.
2. The posterior V-shaped advancement flap is firmly
secured to the deltopectoral fascia, assisting vertical lift
and minimizing distal scar drift.
3. Thorough excision site liposuction (ESL) of the antici­
pated hemi-elliptical arm excision allows for excision
of skin only, preserving the neurovasculature; thereby
eliminating chronic edema and lymphoceles.
4. A two-layered absorbable horizontal running barbed
suture closure reduces operative time, improves wound
retention and the incidence of delayed healing.

33
Chapter | 5  Brachioplasty with liposuction resection
hand. Skin edge necrosis and delayed wound healing may
lead to widened and hypertrophic scars, and contractures
across the axilla. Chronic swelling, lymphoceles, sensory
loss and muscular paralysis due to radial nerve and muscu­
locutaneous nerve injury and pain are recognized but
uncommon complications.
Since using the modifications described here, complica­
tions have been reduced and satisfaction improved. The
markings are more precise, leading to expeditious surgery.
The anchoring to deltopectoral fascia is more secure with
less distal drifting of the axillary scar. Over the past 4 years,
there were 13 women and 2 males treated. There have been
no seromas or lymphoceles. Appreciable swelling has
FIG. 5.6  Before and 7 months after L-brachioplasty left oblique
views for the patient seen in the operative sequence in Fig. 5.4. The
full course of the brachioplasty scar is seen as it crosses the axilla and
descends on the chest. The arm, axilla and lateral chest are well
shaped and reduced.
A
B
FIG. 5.7  Before and 1 year after frontal views of a L-brachioplasty
with circumferential liposuction in a 48-year-old MWL patient with a
BMI of 35.5. The upper arm sagging skin has been improved.
A
B
FIG. 5.8  Before and 1 year after left oblique views of a L-
brachioplasty with circumferential liposuction in the same 48-year-
old MWL patient with a BMI of 35.5. The axillary and chest wall
improvement is seen.
A
B
FIG. 5.9  Before and 1 year after posterior views of a L-brachioplasty
with circumferential liposuction in the same 48-year-old MWL patient
with a BMI of 35.5. The overall arm and arm to chest attachment
improvement is seen.
A
B
POSTOPERATIVE MANAGEMENT
The arms are elevated on pillows for 3 days. The sponge
and ace bandages are removed and replaced with securely
fitting elastic sleeves at 3 days. Complete maturation of the
scars with massage and a variety of topical agents takes
over 2 years.
COMPLICATIONS AND
THEIR MANAGEMENT
While under-resection results in inadequate treatment,
partial recurrence can result even with adequate resection,
from inherent tissue laxity, which is common after MWL.
Over-resection of skin is difficult to close and can lead to
incision line dehiscence or vascular compromise to the

34
PART | 2  Upper extremity contouring
REFERENCES
1. El Khatib HA. Classification of brachial ptosis; strategy for treatment.
Plast Reconstr Surg 2007;119:1337–42.
2. Aly A, Soliman S, Cram A, et al. Brachioplasty in the massive weight
loss patient, Clin Plast Surg 2008;35:141–7.
3. Lockwood T. Brachioplasty with superficial fascial system suspen­
sion. Plast Reconstr Surg 1995;96:912–20.
4. Pitanguy I. Correction of lipodystrophy of the lateral thoracic aspect
and inner side of the arm and elbow. Clin Plast Surg 1975;
2:477–83.
5. Hurwitz DJ, Holland SW. The L Brachioplasty: An innovative
approach to correct excess tissue of the upper arm, axilla and lateral
chest. Plast Reconstr Surg 2006;117:403–11.
6. Hurwitz DJ, Jerrod K. L-Brachioplasty: an adaptable technique for
moderate to severe excess skin and fat of the arms for featured opera­
tive techniques. Aesth Plast Surg. J 2010;July–August:620–9.
7. Hurwitz DJ, Agha-Mohammadi S. Post bariatric surgery breast
reshaping: the spiral flap. Ann Plast Surg 2006;569(5):481–6.
8. Symbas L, Losken A. An outcome analysis of brachioplasty tech­
niques following massive weight loss. Ann Plast Surg 2010;64(5):
588–91.
resolved in all cases within a month, with no cases of pro­
longed edema.
Incision dehiscence was limited to less than 1 cm in five
patients. Tip necrosis of the V advancement flap occurred
in three arms, leaving small wounds in the axilla to heal
secondarily. Secondary skin reduction was not needed.
There were no contractures across the axilla in this group
of patients.
CONCLUSION
The originally designed L-brachioplasty is commonly used
for the MWL arm deformity.5 With our better understanding
of the esthetics and the four modifications described herein,
we have improved our results and lowered complications.6
We have gone beyond the concept of arm reduction surgery
to sculpturing a region to esthetic beauty.7 It is better to
leave a little extra tissue than compromise shape or hazard
serious complications. Already a commonly accepted pro­
cedure,8 with the improvements in shape, scar placement,
and reduced complications, L-brachioplasty can take its
place as the optimal cosmetic operation for moderate to
severe skin and fat redundancy of the upper arm.

35
© 2013 Elsevier Inc
Chapter 6 
Key Points
●
Good for many, but not all, cases of brachial
dermatolipodystrophy in non-massive weight loss
patients. The vertical height from the mid-humerus
to the most dependent portion of the mid-upper
arm (with the arm at 90° to the body) should
be no greater than 10 cm. For excessive upper
dermatolipodystrophy, the traditional method should
be used.
●
The tailor tack method should always be used
intraoperatively to confirm the accuracy of the
preoperative markings. This should be done after any
liposuction, if necessary, is performed. Corrections or
modifications can be made at this time. The tailor tack
closure should always be checked with the patient in
the upright position and the arm at a 90° angle to the
lateral chest.
●
A superficial plane should be used for the resection
of the involved area, taking only a thin layer of fat
with the resected specimen.
●
The elbows should not be raised above the level of the
shoulders until 3 weeks postoperatively.
●
During the preoperative marking, the transverse axis
width of the incision (in the axillary fold) should stop
at 1.5–2 cm medial to the visible portion of the
axillary crease on the anterior and posterior shoulder.
This helps in preventing the final scar from extending
into visible areas.
●
Undesirable anterior axillary and post-axillary fullness
can also be corrected during this procedure.
●
12% of patients need some form of revisional surgery
performed at 1 year or later. The most common reason
is for scar correction.
Limited scar brachioplasty
Lawrence S. Reed
INTRODUCTION
There is an ever increasing demand, mainly in women, for
correction of brachial dermatolipodystrophy. Most patients,
however, are not willing to accept the traditional brachio­
plasty scar that extends, in various configurations, from the
axilla, running along the inner arm to the elbow. Following
the seminal paper by Pollock,1 which described his
technique for the treatment of hidradenitis suppurativa by
excision of the involved axillary area followed by direct
closure, I began to adapt this approach for esthetic bra­
chioplasty. I now have 25 years of experience with this
approach. There have been numerous refinements over the
years.1–8 The minimal incision brachioplasty (MIB) tech­
nique is the preferred approach for most patients that I see,
save for those with excessively dependent dermatolipodys­
trophy of the upper arms (as commonly seen in massive
weight loss patients). In all other cases, it provides predict­
ably good results that are equal to those achieved in com­
parable patients with the traditional approach. I am most
frequently asked how simply tightening the skin of the
axilla, in the minimal incision approach, can replicate the
result achieved when the customary extended incision
method is employed. This is best demonstrated by referring
to the mechanics of the classic bamboo finger trap (Fig.
6.1), which when pulled on just one end circumferentially
tightens the entire length of the tube.
PREOPERATIVE PREPARATION
Patients are instructed not to shave their axillary hair for 48
hours before surgery. Standard preoperative laboratory
testing is performed, as indicated by age and medical
history.
SURGICAL TECHNIQUE
Markings
1. Marking is performed in the preoperative holding area
with the patient in the upright position. With arms
against sides, mark the anterior and posterior shoulders
at the junction of the axilla with the shoulder. The final
scar should not be visible beyond these markings
(Fig. 6.2A).
2. Mark longitudinal axis from central inner arm, through
center of axilla, to the midlateral chest area (Fig. 6.2B).
3. Mark the transverse axis from anterior shoulder to pos­
terior shoulder in the axillary crease or fold. This line
Part 2  Upper extremity contouring

36
PART | 2  Upper extremity contouring
necessary adjustments have been made, remark the
planned surgical site (Fig. 6.3A).
7. Remove the tailor tack sutures or Adairs, and with
the patient in the recumbent position, excise the
involved area with just a thin layer of fat attached
(Fig. 6.3B).
8. Clean area with 5% Betadine and mark out the area of
the axillary crease (Fig. 6.3C).
9. Wound closure:
a. First layer 1 Vicryl which incorporates the base of
the wound in the area of the axillary fold (Fig. 6.4)
b. Two layered closure with 2-0 14×14 PDS Quill
suture
c. Final layer running 3-0 plain gut vertical mattress
suture.
10. Concealing the scar: In many cases the closure of the
surgical site can cause the final scar to extend into the
visible portions of the anterior or posterior shoulder,
or both. This should be addressed at the time of closure
using the purse string technique:
a. Undermine the involved area and defat if necessary
(Fig. 6.5)
b. Use a 2-0 7×7 Quill suture anchored in the axillary
fold to bring the visible portion of the scar back into
the axillary fold. This will leave some bunching and
a dog-ear. These largely disappear in 3–6 months
(Figs 6.6 and 6.7)
c. After the purse string correction, complete the
closure in the standard fashion (Fig. 6.8).
11. Selective use of bolster dressing. In those cases where
it is felt that the axillary fold may be difficult to recre­
ate or there is obvious tension, use a bolster dressing
made from a rolled up ABD pad.
Prior to beginning closure of the wound, place four
#1 retention sutures, placed 3 cm from the wound
edges. These sutures should pass carefully through the
base of the wound. After the final closure, these sutures
will be used to snug the bolster dressing in place. The
bolster is normally left in place from 2 to 4 days. No
drains are used. Bacitracin and gauze are placed on the
surgical sites. No arm wraps or surgical arm garments
are used (Fig. 6.9).
should stop 1.5–2 cm medial to the anterior and poste­
rior axillary crease–shoulder junction. This helps avoid
a scar that will extend into a visible area of the shoulder
(Fig. 6.2B).
4. Determine the longitudinal length of excision using the
pinch technique. First, move the skin of the triceps
towards the transverse axis line until the arm has a
pleasing contour. Then move the lateral chest skin
towards the transverse axillary line. It is important to
advance the lateral chest skin towards the transverse
axillary crease to fix and stabilize the upper arm correc­
tion (Fig. 6.2C, D).
5. Mark areas that require liposuction. These should
include, if indicated, the area of lipodystrophy of the
upper outer breast/anterior axillary area as well as the
posterior shoulder/axillary area. Both of these areas of
lipodystrophy – which patients frequently point out as
being of concern – can be easily corrected during the
MIB procedure by liposuction and the subsequent axil­
lary skin tightening.
The Procedure
1. Place patient on operating room table with arms
outstretched.
2. Circumferentially prep arms and chest and apply
appropriate draping.
3. Infiltrate tumescent solution into the areas to be lipo­
suctioned (approximately 1 : 1).
4. Infiltrate dilute local anesthesia (1% Xylocaine plain
50 ml and 0.25% Marcaine 50 ml, 1 ml 1 : 1000 epi­
nephrine (adrenaline) plus 150 ml normal saline) into
areas of planned surgical resection.
5. Carry out liposuction on both upper arms.
6. Use the tailor tack method to check the accuracy of
the preoperative markings. It is important to check the
tailor tack closure with the patient in the upright posi­
tion and the arm at 90° to the lateral chest. Make any
revisions necessary in the initial preoperative mark­
ings. At this time also check for any abnormal folds
or rotations in the skin of the arm. Adjust the tailor
tack suture placements to correct these as well. After
FIG. 6.1  The bamboo finger trap aptly demonstrates the principle of the transaxillary brachioplasty in which traction in the axilla narrows
the circumference of the upper arm. (A) Finger trap with no traction on it. (B) Traction on one end of finger trap narrows its entire circumference.
A
B

37
Chapter | 6  Limited scar brachioplasty
1.5 cm
1.5 cm
Meridian
Axillary crease
B
Axillary crease
C
FIG. 6.2  (A) With the patient standing with arms at the side (adducted),
the visible portions of the anterior and posterior axillary folds are marked
with a triangle. This mark is used to determine the transverse diameter of
the planned exposure, which extends 1 to 1.5 cm medial to the point of
each triangle. (B) The arm is sufficiently abducted to mark the axillary
hollow or crease apex. This line is then shortened so that it stops about
1.5 cm before hitting the axillary fold marks. The line is bisected and
carried up the arm and down the chest wall to mark the meridian of the
axilla. (C) The arm is abducted 90°, and the excess skin of the triceps
area is forcefully advanced toward the axillary crease and marked as point
A. (D) Next, the skin of the chest wall is next similarly advanced toward
the axillary crease with force adequate to balance the tension (point B).
The points are connected to make an oval area of proposed resection.
Continued
A

38
PART | 2  Upper extremity contouring
OPTIMIZING OUTCOMES
1. Patient selection. Ideal candidates have skin laxity that
can be well corrected by axillary skin excision alone.
Patients with excessive skin laxity should be counseled
about a standard brachioplasty.
2. Careful preoperative markings.
3. Always employ the tailor tack method prior to surgical
excision and check it in the upright position with
the arm at 90° to the lateral chest. Any abnormal
folds of the upper arm skin can also be addressed at
this time.
4. Do not be timid in executing the correction. Remember
you will check the accuracy of your preoperative mark­
ings with the tailor tack method.
5. If the axillary fold is not well defined or in more fatty
arms, a bolster dressing should be considered. It may be
necessary to defat the area of the axillary fold for better
definition using direct excision or liposuction.
POSTOPERATIVE CARE
1. No surgical dressings or garments.
2. Encourage patients to limit arm motion as much as
possible.
FIG. 6.3  (A) Final determination of the amount of tissue to be removed
is made during surgery, using the tailor tack method. (B) Intraoperative
view of axillary area of resection measuring 17 × 9 cm. (C) This intraop­
erative view demonstrates the amount of tissue removed as well as the
remarking of the axillary crease with methylene blue. Note the presence
of subcutaneous fat remaining on the axillary fascia.
A
B
C
Area to be
resected.
Predetermined
to remain in
the axilla
A
B
D
FIG. 6.2  Continued