Brachioplasty: A Personal Approach: Sepehr Egrari, MD, FACS
Brachioplasty: A Personal Approach: Sepehr Egrari, MD, FACS
Accepted for publication June 29, 2015; online publish-ahead-of-print September 29, 2015.
Brachioplasty is one of the most rapidly growing operations in and its relevance to the lateral chest wall and upper body.
body contouring. In 2014, the American Society for Aesthetic Operative techniques are described along with markings,
Plastic Surgery’s annual procedural statistics reported 22 829 scar positioning, and various intraoperative maneuvers.
arm lifts. In comparison to its frequency in 1997, brachio- Postoperative care, especially attempts at scar control, is
plasty had risen 807.4%.1 A beautiful arm has always exuded discussed, as well as a report of a series of consecutive pa-
a sense of fitness and anatomic prowess. From the early tients with a description of outcome, complications, and
works of the Renaissance to our new popular culture, a fit limitations.
arm has been an important part of the quest for beauty and
health. In the literature of plastic surgery, the first description
of brachioplasty was by Correa-Iturraspe in the Argentinian PATIENT SELECTION
Medical Press in 1954.2 Today, our literature is laced with de-
scriptions of various techniques, the categorization of The main indication for brachioplasty was either lipodystro-
anatomy, and the outcomes of brachioplasty.3-5 phy or excess skin in the upper arms. The extent of the lipo-
Recently, a tremendous body of knowledge has arisen dystrophy or excess skin then determined the types of
on the heels of the well-established revolution of massive brachioplasty that these patients needed. The dramatic differ-
weight loss body contouring in plastic surgery. The ravages ences in body habit and weight loss translate to myriad pre-
of weight loss are responsible for the production of myriad sentations in arm recontouring (Figure 1). The extension of
diverse and complex anatomic and structural changes to excess arm skin and lipodystrophy also carried toward the
the skin and integrity of the arm. From a simple excess of lateral chest wall and upper body (Figure 2). Some of these
skin to complex multifaceted lipodystrophy, the presenta- patients had a combination of brachioplasty and thoraco-
tion of arm laxity has become an integral part of the prac- plasty. Some also had upper body lifts as a part of the constel-
tice of the body-contouring specialist. Along with the radial lation of strategies aimed at their upper truncal recontouring.
excess of arm skin, the upper body and lateral chest wall
also present a relevant and connected comorbidity that can Dr Egrari is a plastic surgeon in private practice in Bellevue, WA.
be addressed for a complete upper-body contouring.
Corresponding Author:
In this featured operative technique article, the author Dr Sepehr Egrari, 2950 Northup Way, Suite 100, Bellevue, WA 98004,
describes a personal experience with brachioplasty. This in- USA.
cludes patient selection, classification of excess arm skin, E-mail: segrari@egrari.com
194 Aesthetic Surgery Journal 36(2)
Figure 2. (A) The extent of lipodystrophy and excess of skin not only involves the arms, but also can extend to the lateral chest
wall. (B) The posterior upper body can further be a part of the constellation of the presenting defect.
From this diverse group, four types of brachioplasty were Table 1. Classification and Treatment of Various Presentations
determined and classified. Type I patients had very little
Classification Skin and Anatomic Type of Brachioplasty
excess skin, most of it occurring in the upper arms. These Involvement
individuals were candidates for the less commonly used
Type I Minimal Excess Skin Minimal Incision Brachioplasty
minimal incision brachioplasty. These patients had minimal
lipodystrophy. Type II patients had moderate excess skin in Type II Excess Skin Standard Brachioplasty
the upper arms and underwent a standard brachioplasty.
Type III Excess Skin and Fat Extensive Brachioplasty ± SAL
This was a common group that presented with the arm as • ±Lateral Chest Wall
their central complaint. Many of the non-weight loss patients Involvement
fell into this category. Type III patients had both excess
skin and lipodystrophy, and majority of this group had a Type IV Excess Skin and Fat Extensive Brachioplasty ± SAL
combination of brachioplasty and suction-assisted lipectomy • Lateral Chest Wall Excess • Thoracoplasty
• Upper Body Excess and • Upper Body Lift
(SAL). Most of these patients also had involvement to some Ptosis
extent of the lateral chest wall. Many of the patients that did
not have optimal weight resolution were in this category. SAL, suction assisted lipectomy.
Type IV patients had not only excess arm skin and lipodys-
trophy, but also significant involvement of the lateral chest
wall and upper body. This group had a combination of bra- All patients underwent a rigorous preoperative evaluation
chioplasty along with thoracoplasty and/or an upper body that included consultations, medical evaluation, examina-
lift (Table 1, Figure 3). tion of appropriate laboratory and diagnostic parameters,
Egrari 195
OPERATIVE TECHNIQUE
Preoperative Markings
Accurate preoperative marking is a stepping-stone for an or-
ganized and efficient operative approach for brachioplasty.
However, given the tremendous diversity that the patients
present with, significant operative improvisation is also im-
perative. This not only addresses the tremendous variety
of presentations, but also prevents over-resection, which is Figure 4. The strategy for the marking is based on using a
posterior-medial position (red) for the eventual scar and not
a fear in complex presentations. In body contouring, stan-
the higher bicepetal groove or the lower posterior positions.
dardized approaches and preoperative markings must be
looked at with caution. A complete video of the author’s
described technique can be viewed at www.aestheticsurgery
journal.com. inspection and an overall approximation of the extent of re-
In this article, the author describes two adaptable tech- section. The two initial reference points are the medial epi-
niques of brachioplasty. All patients are marked in a standing condyle and the apex of the axillary fossa. Marks are placed
position. A thorough evaluation of preoperative photos of in both of these points. The expected position of the scar, in
arms in both adducted and abducted positions is a prelude the posterior-medial position, is forecasted and drawn in a
to an accurate marking session. As the author’s experience red line. The line will carry on to the surface of the upper
has evolved, the final scar is more commonly planned to lie chest wall, making a sharp turn at the axilla. This maneuver
in a posterior-medial position and not in the higher position, often alleviates an unsightly and challenging excess of skin
bicipital grove, or the lower line, posterior (Figure 4). This that is gathered near the axillary fossa. The author also feels
becomes an important guide and point of reference for the that a sharp turn of this excision at the axillary fossa, and
initiation of the marking. All marking begins by a manual its continuation towards the chest wall can indeed replace a
196 Aesthetic Surgery Journal 36(2)
z-plasty (Figure 5A). Z-plasties can disrupt the natural chest wall. When all the markings are done (Figure 6A), it
contour of the dome of the axilla, and hence make this linear is helpful to ask the patient to raise their arms up high. This
technique more attractive. The extension into the chest is de- allows the determining of the geometric and linear propor-
pendent on the excess of lateral chest wall skin. The commit- tion of the upper and lower scar. It is at this junction that
ted upper incision is then placed slightly—1 cm—above the adjustments are made to the distal aspect of the scar to
predicted incision line. This marking follows the general di- avoid dog-ears and unequal scar approximation (Figure 6B).
rection of the scar line and carries to the lateral chest wall as
needed. The approximate predicted lower incision line is
Positioning
also placed, with the condition that operative “tailor tacking”
might change its extent (Figure 5B). This line is often deter- All cases are done under general anesthesia. Patients are
mined by pinching the skin and approximating the extent placed in a well-padded supine position. Sequential com-
of the excision. As this line approaches the axilla, it is im- pression garments are placed over the calves. The arms are
Figure 5. (A) The medial epicondyle and the apex of the axillary fossa are marked. The position of the predicted scar (in red) is
also marked in a posterior-medial position. (B) A committed line is chosen above the scar and an approximate predicted line is
chosen inferiorly.
Figure 6. (A) Demonstration of the completed marking in a 52-year-old woman. (B) Symmetry, balance and linear relationship of
the designed marking is inspected with the patient’s arms in fully raised position.
Egrari 197
(Figures 8F and 10F). As scar widening and thickening is a epicondyle. Other branches innervate the skin at about 15
significant sequella of brachioplasty, meticulous low-tension cm proximal to the medial epicondyle.7 The injury to these
closure is paramount to and a prerequisite of a good nerves can cause sensory disturbances of the mid arm to
outcome. The strength of SFS closure and the use of forearm and significant paresthesia and dysesthesia for the
long-absorbing sutures are important variables in the quest patient. It is important to understand the anatomy of this
for adequate results. region and hence avoid injury to these nerves. Leaving a
healthy and robust brachial fascia is imperative for avoiding
these cutaneous nerves. Given its more anterior course, it is
Anatomy and Cutaneous Nerves
also prudent to avoid placing the scar anteriorly and using
Avoiding the medial brachial cutaneous nerve (MBCN) and the already described posterior-medial position.
the medial antebrachial cutaneous nerve (MABCN) has
been the subject of anatomic studies and a point of atten-
POSTOPERATIVE CARE
tion for brachioplasty performance.7 MBCN derives from
T1-2, and MABCN takes its origin from C8-T1 (Figure 12). The immediate postoperative care includes placing Steri-
The course the nerve leads is superficial, as two to three Strips on the skin and compressing with a bolero garment.
branches are sent to the skin 7 cm proximal to the medial Patients are instructed not to bend at the elbow for the first
200 Aesthetic Surgery Journal 36(2)
24 hours and are highly encouraged not to engage in any Table 2. Complications (n = 123)
strenuous activity for the first 2 weeks after the operation. Complication Number
They are all cautioned that edema is certain and are in-
structed to avoid wearing rings or any compressive orna- Wound Dehiscence 4 (3.3%)
ments for the first 2 weeks after the operation. Seroma 1 (0.8%)
Regular postoperative visits start a regimented program
Total 5 (4.1%)
of scar care. For the first 2 weeks, the scar is covered with
Steri-Strips. This is then replaced with Micropore brown
tape for another week. At this point, a rest period from any
coverage will determine the integrity of the scar and lack of complication was wound separation (Table 2). Reoperative
any wound separation or eschar formation. Once this is de- rate was 5.7%. Four of these reoperations were scar revisions
termined, silicon strips are placed on the incision and com- and 3 patients were operated on for recurrent laxity.
pressed. It is recommended that the patient continue with Standard brachioplasty was the most common variant of the
the silicone regimen for at least 4 months after the proce- four classified procedures (Figures 13-15). Eighty-six pa-
dure. Patients who are not compliant with the silicone com- tients (70%) underwent resection and closure technique,
pression are given a commercially available silicone spray and 37 patients (30%) underwent intraoperative staple ap-
that has shown some promise in the group of patients proximation technique. The mean follow-up time was 4.5
treated. months (range, 4 weeks-5 years).
Stretching the arm into a full arm raise and manual
massage are also important instructions that are given to DISCUSSION
patients postoperatively.
The extraordinary rise of brachioplasty continues to be an im-
portant part of addressing the total solution for massive
RESULTS
weight loss patients. This also has trickled into non–weight
During a 12-year period (2002-2014), the author performed loss patients who desire a more toned arm. The complexity
123 brachioplasties. All patients were females. The average of the position of arms and their proximity to the lateral chest
age of the patient was 47.9 years (range, 23-73 years). wall, upper back, and even breast makes this an operation
Average BMI was 28.2 kg/m2 (range, 18.9-46.9 kg/m2). that requires proper patient selection, a thoughtful marking
The complication rate was 4.1%. The most common approach, and a safe and effective operative strategy.
Egrari 201
Figure 13. (A) This is a 58-year-old woman with a history of 150-pound weight loss. (B) She is shown 6 months after a standard
brachioplasty with some extension into the axilla.
Figure 15. (A) This is a 36-year-old woman with a history of 250-pound weight loss. (B) She is shown 6 months after an extensive
brachioplasty, involving the lateral chest wall.
Figure 16. (A) This is a 47-year-old woman presented with massive weight loss. (B) Scar shown 3 months after an extensive brachio-
plasty. (C) Scar shown at 7 months. (D) She is now shown 3 years after the procedure with significant maturity and fading of the scar.
202 Aesthetic Surgery Journal 36(2)
There have been myriad of different techniques described to this operation, there are limitations that are worthy of
on the management of arm excess skin. From classical de- discussion. The scar of the brachioplasty is one that is
scriptions8,9 to some of the modern evolving methods, the prone to widening and hypertrophic transformation. The
goal has been to emphasize an appropriate contour, well- exposed area of the inner arm cannot be easily hidden and
positioned scars, and management of the excess associated can be a source of significant dissatisfaction for the patient
not only to the arm but also the chest wall. Hurwitz10 de- and the practitioner. It is imperative to warn the patient of
scribed the L brachioplasty that preserves the contour of the the reality of an unsightly scar. It is also important to
axilla by creating an exaggerated anteriorly projecting point realize that time is an essential ally in the fight with the
to the turn into the chest wall. He also describes the impor- scar. The brachioplasty scar does not follow some of the
tance of extension into the upper chest wall. This anteriorly usual patterns of scars in the face and body that start to
oriented apex can however be more easily exposed than mature and fade at 3 to 4 months. Patients are advised that
the turn that is described in this report. Gusenoff11 described this scar has a timeline that in the authors experience can
Figure 17. (A) This is a 40-year-old woman with history of 125-pound weight loss. (B) She is shown here at 4 months after the op-
eration with adequate results and appropriate skin tightening. (C) At 3 years, the patient has a significant recurrence of her arm
excess skin.
Egrari 203