In America culture, the slender “super model” figure has been held in high regard in our society, thus placing a premium on body shaping and skin tightening procedures. Brachioplasty is a broad based term that is used in relation to various surgical procedures that address the cosmetic appearance of the upper arm. Such procedures focus on the problem of varying degrees of excess fat and excess skin in the upper arm between the elbow and the axilla, or armpit. Historically this area has been addressed primarily with liposuction in 30-60 year old women with mild-to-moderate excess body weight.
Bariatric surgery has become an extremely effective therapy for morbid obesity producing weight loss with significant functional improvement. Patients who have undergone massive weight loss typically need skin tightening procedures of their abdomen, breasts, face, legs and arms. In this section we will address brachioplasty, which addresses the arm area alone.
Analyses of the arms using radiographs have shown that at the age of 10, the soft tissue mass in the upper half of the arm is equal to that of the lower half. However, over time gravity causes tissue to descend so that by age 70 most of the mass of the arm is hanging by the elbow. This has been attributed to loss of fatty tissue in addition to stretching of the fibrous connections between the skin and the muscle below it. These fibers extend through the fat to reach the muscle layer. Massive weight gain stretches these “fibrous septae”. When much of the weight is lost, the fibrous bands do not shrink accordingly and the tissue descends.
Patients are candidates for various forms of brachioplasty and posterior arm contouring improvement if they have a contour of the arm that is unacceptable. Subtle deformities should never be addressed if the risks of the procedures do not outweigh the benefits.
The goals of the procedure are to achieve a cosmetically pleasing contour of the upper arm through the removal of excess skin excess or skin laxity without causing significant contour deformities. In cases of extreme skin excess, a noticeable scar is unavoidable and is not considered a complication. This trade-off is the most difficult consideration for many patients to accept. In severe cases most patients feel that the resulting scar outweighs the unsightly appearance of the arm. The scar considerations cannot be emphasized enough and all patients must be well aware of the pros and cons of the procedure.
A listing and description of the various procedures that can be used for brachioplasty will be presented, followed by an explanation in general terms of when each one of these procedures should be utilized.
Limited Medial (Inner arm) Brachioplasty
Skin that is stretched has poor elasticity and will never drape and respond like youthful skin. Therefore, even after improved contour in the first few weeks after brachioplasty, there is some relaxation of this newly tighter skin over time. Most of this relaxation occurs in the first year after surgery. Typically there is still significant improvement over the preoperative contour. However, in some patients a secondary skin tightening procedure is advantageous for those patients who want the very best contour possible and are willing to go through a secondary procedure. Again, this staged procedure for excess skin in massive weight loss patients should be discussed clearly before surgery.
For traditional liposuction of the upper arm, the recovery is fairly straightforward with some mild soreness for 3 days and minimal soreness for another week. A compression garment is usually utilized depending on the patient’s age. For example, the patient wears a compression garment one week for every decade of life, with a minimum of 3 weeks and a maximum of 6 weeks. Bruising is to be expected with all liposuction procedures and surgical procedures. If bruising occurs, it usually takes 2 to 3 weeks to resolve.
The main side effects for liposuction include contour deformities, rippling and dimpling of the skin. They are more often seen with aggressive liposuction. They can occur in any patient, even when performed by the most experienced surgeon.
An important consideration of any type of brachioplasty is scarring. Scarring is very unpredictable along the inside of the upper arm, and the closer one gets to mobile areas (the elbow joint and the armpit) there is potential for more scarring. Suboptimal scarring must be accepted as a possibility by every patient. It is an inherent risk of the procedure.
Other potential though uncommon complications include persistent swelling in the forearm and hand because of interruption of the lymphatic drainage in the upper arm and numbness in the arm below the incision.
Alternatives to this procedure would include non-invasive fat removal procedures. Techniques such as cryolipolysis, which currently is performed by the “Coolsculpting” technique by Zeltiq, is an option for fat reduction. This is a slower type of fat reduction that occurs over several months. The volume of fat that can be removed is less than that of liposuction.
Other treatment alternatives would include any technology that would tighten the skin non-surgically. The two leading technologies currently on the market are Thermage and high- frequency focused ultrasound, specifically the Ulthera device. The Ulthera device is currently the only non-invasive device FDA approved for brow lifting and tightening of the skin. It is not FDA approved for tightening skin off the area of the face (e.g. arms); however, it can be used “off label” in such areas. This is, however, infrequently done. Thermage is another technique used for body tightening. The problem with any non-invasive technique is the unpredictability and variability of the result that is highly dependent on the patient’s collagen response to the treatment. Some patients receive very satisfactory results, and some patients see negligible to no results.
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