BrachioplastyDr.Abdelhamid Abdelsalam

Introduction:

• First described in 1954 and since this description modifications have been proposed to vary the placement of scar, improve the contour of the upper trunk concomitantly, and minimize scarring.

• Major advances came in 1995 with Lockwood who postulated that loosening of the connections between superficial fascial system and the axillary fascia with age, weight changes, and gravitational pull yield a “loose hammock” effect resulting in ptosis of the posterior medial arm.

• Lockwood technique involves anchoring the arm flap to the axillary fascia.

• Despite the advances, brachioplasties were not routinely performed until the late 1990s when the takeoff of bariatric procedures produced and influx of patients.

• The majority of patient who present for brachioplasty have undergone massive weight loss.

• The arm and upper chest like all other parts of the body, demonstrates great variations after massive weight loss.

• Several attempts have been made to classify these deformities.

Classification:

There are several systems to classify deformities of the arm resulting from redundancy of skin and subcutaneous tissue:

1- Objective measurement (Co-efficient of Hoyer) , the ratio of the height of hanging skin.

2- Sacks described a technique of pinching the excess skin and measuring it’s length.

3- Straunch broke down the upper extremity in to four zones.

4- Appelt’s classification which takes into account the amount of residual fat as well as skin laxity to stratify the patient and determine which procedure is best in a given situation.

Appelt's classification:

• Type I : Patients have a relative excess of fatty deposits in the upper arm but good skin tone and minimal laxity. These patient are good candidates for liposuction alone.

• Type II : Patient have moderate skin laxity and with minimal excess fat.

• Type II is further divided in to IIA, IIB and IIC.

• Type IIA patients have only proximal upper arm redundancy and this group is further divided in to:

*Isolated horizontal laxity: treated with excision of vertical ellipse with the scar in the axilla.

* Horizontal and longitudinal excess: treated with an T-shaped excision along the proximal anterior aspect of the upper arm.

• type IIB: patients have redundancy of their entire arm and they are candidates for a traditional brachioplasty with a scar from the elbow to axilla.

• Type IIC: laxity of the entire arm and also along the chest wall and these are candidates for extended brachioplasty, ( arm skin and chest wall).

• Type III: patients have both excess fat and redundant skin, and best treated with staged liposuction and brachioplasty or a combined single-stage.

• The major drawback to brachioplasty is the long scar extending from the axilla to elbow.

• Ideal patient for mini brachioplasty-with a scar limited to the axilla- is the patients:

1) Who have moderate amount of skin and fat excess in the proximal third of the upper arm.2) Who have excellent Skin tone and skin quality. The excision is limited to the anterior and posterior limits of the axilla to

hide the scar when the arm is at rest, but this excision removes the skin in one dimension while most of the patients with redundant arm skin have two-dimensional excess and mini brachioplasty addresses skin excess in the longitudinal direction only.

• The scars for brachioplasty are notorious for being best in the hidden areas (the upper inner arm and axilla) and less acceptable in the more exposed areas (near the elbow)

• Some surgeons advocate a scar in the most posterior portion of the arm, whereas others prefer a scar medially in the bicipital groove.

• Candidates for a full brachioplasty have vertical and horizontal skin excess and willing to accept a high rate of unfavorable scarring along the medial arm in exchange for a contour improvement

• If the patient also has substantial fat excess throughout the arm they may require liposuction at first.

Marking for brachioplasy:

• Marking for a brachioplasty is best done in the standing position with the shoulder abducted to 90 degrees and the elbow flexed to 90 degrees.

• The first marking is the bicipital groove which represents the desired final position of the incision.

• The proximal extent of the incision is set high in the axilla.

• A second line estimates the amount of skin and fat to be resected is drawn but will be adjusted in the operating room.

• Aly proposed a marking technique described as two ellipse technique.

• An ellipse is marked after pinching the skin and fat of the arm.

• A second (inner) ellipse is marked which represents the proposed final excision.

• The second ellipse is marked after the pinched skin is measured

• Great care has to be taken while the markings are being done to adjust for the thickness of the tissue.

Brachioplasty procedure:

• Brachioplasty is usually performed with the arm extended on an arm board.

• Preoperative discussion with the anesthesiologist regarding the blood pressure monitor and IV access is important.

• When the resection commences, the resection should progress from distal to proximal so that if the surgeon encounters too much tension, an adjustment can be made as such:

• The partially resected ellipse can be reintroduced in to the wound to reduce tension and subsequent line of resection can be adjusted.

• The more traditional brachioplasty techniques resect the excess skin and fat of the arm by incising along the proposed incision line and then undermining the skin and fat to be resected.

• The undermined flaps are overlapped over the proposed incision line and the excess removed.

• There is controversy about the need for a Z-plasty across the axilla, most of the brachioplasty patient are massive weight loss patient, with universal excess and laxity of the skin and hence a Z-plasty is not necessary.

• The initial tightness across the axilla will loosen with the recruitment of adjacent loose skin.

• Female patients are generally happy to have having the scar placed high in the axilla and having as much hair-bearing skin removed as possible, male patients tend to be the opposite.

• Manny patients presenting for brachioplasty also have excess of their lateral chest wall, this excess may not be appreciated unless the patient is examined wearing a bra.

• This excess of the lateral chest wall is quite annoying to the patients, for this reason many surgeons include contouring of the lateral chest when performing brachioplasty.

• For the patients who do not have arm excess, have already gone a brachioplasty or do not wish to have scars on their arms, the contouring of the lateral chest wall can be performed as a stand-alone procedure.

• It is important to avoid pulling the nipple in the lateral direction.

• Preoperative marking is critical because once the patient is supine on the operating table it is impossible to judge the amount to be removed without pulling the breast laterally.

• With the patient in the standing position, the loose or excess skin and fat of the upper chest is pulled anteriorly.

• A vertical line is drawn at this point from the axilla to the infra-mammary fold.

• This represents the line of final incision and resultant scar.

• The excess skin and fat is then pulled back and an ellipse is drawn to represent the line of excision.

• During this process the breast is observed to ensure that it is not deformed in the process.

• The skin and fat within the ellipse is then directly excised.

• If drains are used patient may find it more comfortable if the drains exit through the chest wall incision rather than the arm incision.

• Compressive garments may be used especially if liposuction has been added but many surgeons have abandoned it’s use due to bunching and pinching of the skin.

Complications:

• Complications with brachioplasty occur less frequently than with other body contouring, even in the massive weight loss population, it include:

• 1- seromas

• 2- paresthesia

• 3- wound infection

• 4- wound dehiscence

• 5- ugly scar

Nerve anatomy:

• The medial antebrachial cutaneous nerve becomes a superficial structure at about 14 cm proximal to the medial epicondyle and is therefor at risk during brachioplasty

• The medial brachial cutaneous nerve sends two or three branches to the skin 7 cm proximal to the medial epicondyle and another 3 or 4 branches pierce the fascia to innervate the skin 15 cm proximal to the medial epicondyle.

• Knowledge of the anatomy can help prevent damage to these nerves

• The scar is more common near the elbow.

• The scar tends to be narrow and less unattractive as the axilla approached.

• This should be discussed with the patient.

• For patients in whom the upper chest laxity is more extensive a transverse excision may be considered.

• These transverse excisions can be combined with brachioplasty or mastopexy to fully contour the upper body.

• Staged procedure may be necessary to avoid confluence of the scars

• Transverse excisions may be carried out as far as the excess occurs even to the extent of completely across the back.

• If the excision crosses the back it may be referred to as an upper body lift (UBL).

• The line of excision is dictated somewhat by the position of the skin and fat rolls but if possible the pattern of resection can be planned to place the scar under the brassiere line.

• Patients who have multiple skin rolls of the back and lateral chest are good candidates for (UBL)

• As with massive weight loss patients there is considerable variation in the presentation, size of rolls and positions of the rolls, so a surgical plan must be individualized.

• The main goal of a UBL is to correct the horizontal skin excess which exists on the posterior trunk and lateral chest wall.

• This procedure is reserved for patients with favorable BMI.

• UBLs are most commonly performed concurrently with other body contouring procedure during a second stage.

• Complications of direct excision and UBL surgeries have been reported as minor with seromas being the most common.

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