Most nerves in the arm such as the median, radial, ulnar, and musculocutaneous nerve lie deep to the deep fascia and are not at risk of injury during brachioplasty. However, the cutaneous nerves of the arm and forearm lie superficial to the deep fascia and are therefore at risk of damage. The median antebrachial cutaneous nerve (MABC; also known as the medial cutaneous nerve of the forearm) travels with the basilic vein and is most at risk of injury just proximal to the elbow, resulting in a painful neuroma, as in this scenario. The initial treatment of a neuroma is nonsurgical with massage, desensitization, physiotherapy, and analgesics. If the problem persists for more than 6 months as in this case, surgical intervention with resection of the neuroma and insertion of the ends into the triceps muscle may be beneficial.1 The anterior brachial and lateral antebrachial cutaneous nerves are both superficial but should remain outside of the zone of dissection during brachioplasty. The lateral antebrachial cutaneous nerve is the continuation of the musculocutaneous nerve that supplies sensation to the lateral (radial) aspect of the forearm. The other nerve that is at risk during brachioplasty when close to the axilla is the intercostobrachial nerve. Injury to this would result in altered sensation to the axilla and upper arm.
Subcutaneous fat in the arms tends to collect posteriorly and inferiorly with very little medially. It also tends to be found more proximally than distally. Therefore, when performing liposuction, the main target zone is the posterior arm with more subtle suctioning performed on the medial aspect, taking care not to overly thin the soft tissues such that 0.5 cm of subcutaneous fat is left in the skin and contour irregularities are avoided. The fat of the arm is supported by two fascial systems relevant to brachioplasty: the superficial system and the longitudinal system. The superficial system encases the fat circumferentially from the axilla to the elbow. The longitudinal fascial system begins at the clavicle and extends to the axillary fascia and superficial system. This is used in some techniques to support the arm tissues using permanent sutures to anchor the superficial system to the longitudinal fascia.1 The skin is also thinner medially than it is posteriorly or laterally; so, there is less dermal support for scars, particularly when closed under tension.1,2
Brachioplasty risks compromise to lymphatic flow from the upper limb and therefore should be avoided in patients who have chronic lymphedema, even if this is mild, as further interruption of lymphatic flow can be detrimental. Liposuction only in these patients may be beneficial as a treatment for their lymphedema, but compression garments will need to be worn long term. Other absolute contraindications to brachioplasty include reflex sympathetic dystrophy, smoking, and unrealistic patient expectations. Relative contraindications include symptomatic Raynaud’s disease, connective tissue disorders, advanced rheumatoid arthritis, residual obesity, and diabetes mellitus. Minimizing complication risk is paramount in brachioplasty and as always in aesthetic surgery, careful patient selection for the procedure must be performed.1,2
Brachioplasty is a good operation for recontouring the upper arms after weight loss in patients with excess skin with or without fat, but the main limitation is that the scarring is extensive and visible. Furthermore, the scars can become stretched, as there will be some tension across the wound during closure and the medial arm skin is relatively thin. For this reason, it is vital that patients have a clear understanding of the scars preoperatively. Markings should be made on the patient to show them the site, orientation, and extent of the scars during their preoperative consultation. This should be documented in the medical record. Postoperative photos of other patients can also be useful to illustrate the scar pattern.1 This procedure is not particularly painful for patients and the downtime is short. Early ambulation is advised postoperatively, and most cases are performed as day cases.1 The postoperative contour is usually good and patients tend to be satisfied with this. There is no functional loss following this surgery. In fact, it often helps function where larger skin volumes are resected.1,2
This patient requires liposuction only because there is fat excess in the absence of skin excess. As she is young and her skin quality is good, she should respond well to the liposuction with subsequent progressive natural skin tightening over time. In patients with mild to moderate skin laxity and small to medium adipose tissue excess, radiofrequency-assisted liposuction may be considered instead. This is thought to cause soft-tissue contraction and collagen formation secondary to thermal effects on the fibroseptal network in the subcutaneous space as well as a nonablative, inflammatory heating of the dermis. The combination of radiofrequency and liposuction can potentially result in a lower complication profile and greater skin tightening than liposuction alone.1,2 However, in this scenario, skin quality is good without excess, so liposuction alone would be sufficient. A mini brachioplasty is indicated where there is mild skin laxity and mild to moderate fat in the upper arm. It combines fat removal with liposuction and skin removal from the axilla with or without upper arm. Brachioplasty with liposuction is indicated in patients with moderate to severe skin and fat excess rather than fat only as in this scenario.
When deciding on a surgical plan for patients requesting brachioplasty, a stepwise approach is helpful. The first step is to decide whether there is any fat excess. If there is, then liposuction may be useful, otherwise further weight loss may be advised. The next step is to see whether there is any skin excess and to note the anatomic location of this. When considering treatment for skin excess, it should be remembered that the resection is performed in the “opposite” vector from the direction of excess (i.e., vertical excess is removed through a horizontal [longitudinal] excision and horizontal excess is removed through a vertical [axillary] excision). These descriptors, vertical and horizontal, assume the patient is standing for the assessment with the shoulder abducted and elbow flexed to 90 degrees. Therefore, if the skin excess is horizontal, then a vertical scar in the axilla is used. If there is a vertical excess, then a longitudinal scar is used. If there are both horizontal and vertical excesses, then a combination of horizontal and vertical scars is used. If the skin excess is restricted to the proximal arm only, then a short T-scar can be used. The patient in this scenario requires an extended brachioplasty as shown in Fig. 119.1, because they have a large volume of skin excess that extends beyond the arm and axilla to the lateral chest wall. As can be seen in the figure, the excision pattern passes the full length of the arm to the axilla and onto the chest wall. It has both horizontal and vertical components. If there was additional fat excess, then liposuction could also be incorporated into this procedure.1 Fig. 119.1 Laxity in this patient extends onto the lateral chest wall and requires extended brachioplasty technique.
his BMI to be 34, with moderate fat excess and vertical skin excess along the length of the upper arm. Which one This patient requires a standard brachioplasty with a horizontal incision placed in the brachial groove as shown in Fig. 119.2. As can be seen in the figure, the excision pattern passes the full length of the arm to the axilla, but without extension onto the chest wall or a vertical component into the axillary crease. This is to accommodate the vertical skin excess he has when the arm is positioned flexed at the elbow to 90 degrees and abducted at the shoulder to 90 degrees. He will also benefit from liposuction given the excess fat present, and this will allow slightly more skin to be resected. Scar placement would traditionally be on the medial aspect of the arm as shown in Fig. 119.2, but it can be more aesthetically placed by moving it slightly more posteriorly; so, ideally it is barely visible with the arm placed relaxed by the side and the scar is located in thicker dermis, less likely to stretch.1 The avulsion brachioplasty is a technique that relies on liposuction as part of the process and cannot be performed in isolation without it. It is an alternative to standard brachioplasty, and can be used for patients such as this man with moderate-to-severe excess skin with excess fat. The procedure begins by planning the resection margin then aggressively liposuctioning this area until all the subcutaneous fat is removed. After completion of liposuction, there should be a very distinct, “dished-out” deformity. Incisions are then made through the skin and superficial fascial system to allow complete release around the area of planned resection. The tissue is grasped proximally with a Kocher clamp, and avulsed proximally to distally. The procedure is completed with hemostasis and two-layer wound closure.2 Fig. 119.2 This patient has isolated vertical skin redundancy that is treated with a horizontal excision along the brachial/bicipital groove.
The main difference between a mini brachioplasty and a standard brachioplasty is the site and size of the skin excision and subsequent scars. In a mini brachioplasty, the incision is hidden in the axilla (Fig. 119.3). It still includes liposuction in the posteromedial upper arm where necessary. In some cases, a short dart extension onto the medial arm (not posterior) may be required, creating a T-shaped scar. Lockwood described a technique for anchoring the superficial fascia to the longitudinal fascial system (dense axillary and clavipectoral fascia) in order to correct the laxity of the upper arm. However, this is not always performed and is not exclusive to a mini brachioplasty approach. The mini brachioplasty is indicated in select patients only. They should have mild skin excess and mild to moderate fat excess. The most important step in successful mini brachioplasty is patient selection, and in the right patient it can be highly effective. However, patients who have more significant excess skin will benefit from a standard or full brachioplasty approach.1,2
During marking for a brachioplasty, the patient should face you with their arms abducted 90 degrees at the shoulder and elbows flexed to 90 degrees as if flexing the biceps. A dotted line should be placed in the bicipital groove to help mark the planned scar. The upper incision should then be marked 1 cm above this, and the lower incision can then be estimated by pinching the skin (Fig. 119.4). Fig. 119.3 Placement of the axillary incision for a mini brachioplasty. Fig. 119.4 Preoperative markings for a standard brachioplasty. Upper incision Bicipital groove (proposed scar location) Lower incision Placement of the scar posteriorly may provide a more favorable quality of scar but one that is more visible from behind. A compromise between the two may be chosen, as this can help make the scar placement more discrete and located in better quality skin than in the medial arm. This is worth considering with experience of the procedure, although should be done with caution to avoid skin over resection and the incision falling too far posteriorly. Vertical crosshatch markings are made to divide the incision into fifths and facilitate correct wound edge approximation, once the skin resection has been performed.1,2
liposuction is required and have jointly marked the patient preoperatively with a 3 cm × 20 cm ellipse. Which one When undertaking a brachioplasty, the order of excision and closure must be modified from standard excisional and closure techniques. It is easy to over-resect skin during this procedure; so, a single upper incision is made first and a posteriorly based skin flap is carefully elevated. Closure is tested before committing to the lower incision. The excision and closure are staged to close each part of the wound segmentally to minimize arm swelling that might otherwise prevent closure. A three-layer closure should be used without undermining. The superficial fascial system is closed with a long-lasting absorbable suture, and the skin closed in two layers (deep dermal and subcuticular) with shorter-acting ones. Infiltration is useful to limit bleeding, regardless of whether liposuction is to be performed.1,2
The main problem with transection of a sensory nerve, such as the MABC during brachioplasty, is the risk of subsequent neuroma formation, leaving the patient with chronic pain in the upper limb. The loss of sensation tends to be much better tolerated than the neuroma symptoms. For this reason, when a sensory nerve is divided, it should either be repaired or managed such that a neuroma is unlikely to occur. By cauterizing the nerve and burying it in muscle, the risk of neuroma formation will be reduced. Smaller nerve branches can just be cauterized. Use of a graft is not indicated, as the harvest will create a similar defect elsewhere anyway.1–3