This document discusses brachioplasty procedures to address excess skin and fat in the arm region following significant weight loss. It covers the basic science behind arm deformities after weight loss, patient presentation and goals, candidate selection criteria, preoperative evaluation and clearance, surgical technique, and postoperative care. The best candidates are those who are otherwise healthy and have maintained a stable weight for several months after losing a substantial amount of weight, such as 50 pounds or more. The procedure involves liposuction and excision of skin and fat from the arm, axilla and lateral chest to improve contour.

1. BRACHIOPLASTY
MOEEZ FATIMA
R4

2. Introduction
 Increase in demand for surgical procedures to address the contour
deformities of the arm.
 4059% increase in the number of brachioplasty procedures performed in
the US
 Special challenge for plastic surgeons.

3. Basic science
 The arm deformity associated with weight loss is often dramatic.
 multiple factors:
1)body mass index (BMI)
2) highest BMI ever obtained
3) change in BMI
4) age
5) sex (Figs 29.1–29.5).

4.  In the morbidly obese individual, fat deposits are usually most prominent
along the axilla, anterior, posterior and medial arm.

5.  Patients presenting at a lower BMI and particularly those who had reached a very
high BMI prior to weight loss are likely to have more soft excess

6.  Patients an individual who has had smaller change in weight will have less
excess soft tissue.

7.  Patients in their fifth decade and beyond, often present with large
amounts of excess tissue despite relatively small changes in BMI.

8.  Men tend to have the majority of their deformity limited to the proximal
arm and axilla

9. Patient presentation
Primary concern or one of the many concerns.
Specific to the upper limb:
1) A “bat-winged“ appearance
2) Arm stretch marks
3) large size of the arm relative to the forearm
4) excess skin and fat at axilla and lateral thoracic region.
5) loose skin along the proximal forearm.

10.  The average age in our postbariatric population is 39.
 The patient’s goals should be carefully considered in formulating a plan.
 Tolerance for scars and of the degree of contour improvement they are
expecting.
 A postbariatric patient anticipating an optimum result from a limited
procedure in the proximal arm is likely to be disappointed.

11. Patient selection:
 Thorough history and physical examination.
 Weight history.

12. HISTORY:
 Patient’s height.
 current weight.
 Maximum weight.
 The time interval between their maximum and current weight?
 Length of time at the current weight should be documented.
 How weight loss was achieved?
 Follow up by a bariatric surgeon?
 Supplemental medication?
 Frequent vomiting, abdominal pain, weakness, light-headedness,
and frequent bowel movements.
 Lost weight through lifestyle changes

13. Examination
Thorough, with particular attention directed toward the upper body.
1) The degree of soft-tissue excess present along the forearm, arm, and axilla.
2) Breasts.
3) Lateral thoracic region.
4) Back.

14.  Inrtriginous dermatitis is present, potentially along the axilla.
 Lymphedema.
 Arterial or venous insufficiency.
 Existing scars.
 Transverse arm bands.
 Striae along the upper extremity should be noted.

17. Best Candidate:
 Healthy individual.
 Stable weight .
 BMI <28
 Lost Substantial Weight: 50lb (23kg)

18.  Individuals with a BMI greater than 28 can obtain dramatic results;
however the final aesthetic result is less likely to be ideal.
Relative contraindications:
 High patient BMI and small BMI change from highest weight,
 Significant patient reservations regarding arm scars,
 History of hypertrophic or hyperpigmented scars
 Unrealistic patient expectations, particularly with

19.  Absolute contraindication:
History of lymphedema
Arterial or venous insufficiency.
High risk of developing one of these conditions :axillary lymph
node dissection or axillary radiation.

20. Plan formulation
 Patients expressing concerns only about their arms, the plan is clear.
 It is important to clarify the importance of addressing the axilla in
rejuvenating the arm.
 Pptions available are multiple.
 Perform a body lift first, as a single procedure.
 After 3 months a combination mastopexy/lateral
thoracoplasty/brachioplasty.
 A medial thigh lift, if necessary, would take place at least 3 months later.

21. Criteria:
 The patient should be at a stable weight for at least several months.
 Problems related to bariatric surgery should be evaluated by their
surgeon.
 History of major mental illnes.
 Maintain the supplemental regime.
 Tobbacco consumption are urged to stop.
 Stop Weight loss medications.
 Medical clearance.

22. Laboratory:
 Complete blood count.
 Complete metabolic panel.
 Malnourished with a total protein <6 g/dL and/or albumin < 3 mg/dL may
be referred back to their bariatric surgeon for re-evaluation.
 Severely anemic patients with hemoglobin <10 g/dL are referred to their
primary physician and/or hematologist.
 Hb above 10 g/dL are advised to continue on iron, folate, and B12
supplementation and to have their blood cell count repeated in a week.
 Preference is for patients to have hemoglobin above 12 g/dL before
surgery.

23. Preoperative visit
 2 weeks prior to surgery.
 surgical procedure
 potential complications
 highlight existing asymmetries
 presence of bands
 the degree to which the planned procedure or procedures will address
their deformities.
 process of scar maturation
 potential risks for hypertrophic and hyperpigmented scars.
 Medications: aspirin and nonsteroidal anti-inflammatory agents and those
that increase the risk for deep-vein thrombosis (oral contraceptives or
hormone replacement therapy).

24. Thromboembolic disease prophylaxis
 Sequential compression devices in place prior to surgery,
 Encouraged to ambulate shortly after the conclusion of the procedure.
 Patients with a BMI of greater than 32 are given 5000 units of heparin
subcutaneously prior to surgery.

25. Anatomy

29. Marking:

30. Operative Technique:
 supine position
 sequential compression device
 intravenous catheter is placed in the dorsal aspect of the hand or wrist.
 Intravenous antibiotics are given, typically a first-generation cephalosporin
 pulse oximeter device is placed on the ear
 General anesthesia, often with a laryngeal mask.
 the forearm, arm, axilla, flank, and chest are prepped with Betadine
 The previously made markings along the axilla, points A to B and back to A
through C are scored with a knife blade.
 the line from E through H and on to the lateral limb of the axillary ellipse is
scored.

31.  Beginning with the right arm and using a no. 15 blade, four stab wounds
are made.
(1) along the proximal medial forearm.
(2) just proximal to the medial epicondyle.
(3) in the proximal and mid posterior arm
(4) in the distal lateral arm.
Tumescent fluid:
1 liter of saline, 1 cc of 1/1000 epinephrine, 50 cc of 1% lidocaine.
Liposuction is then performed with a 3–4-mm cannula

32.  Ellipse at the axilla is excised.
 The subcutaneous tissues are divided to reach the “honeycomb”-
appearing plane produced by the liposuction.

33. Postoperative car
 Ambulation is encouraged
 Dressings are removed 2 days postoperatively.
 Showering is permitted.
 keep axillae dry.
 Avoid perspiring
 Avoid excessively lifting their arms (not forearms) above shoulder level for
2 weeks following

37. COMPLICATIONS