Brachioplasty Following Massive Weight Loss

| May 19, 2010

by Michele A. Shermak, MD, FACS

Dr. Shermak is Associate Professor at Johns Hopkins School of Medicine in Baltimore, Maryland.

Bariatric Times. 2010;7(5):16–18

Abstract
Individuals who sustain massive weight loss often develop skin redundancy and laxity, which globally affects them from head to toe. Brachioplasty is a powerful surgical tool to contour the arm. There is a spectrum of procedures available to address varying degrees of laxity, from the arm down to the chest wall. The doctor and patient need to discuss all of the possible options and weigh cosmetic outcomes with safety and risk of complications.

Introduction
After sustaining massive weight loss, individuals generally suffer from overall deflation and skin excess. The arm represents one of the body regions most susceptible to this phenomenon. Individuals present across a broad range of manifestations with regard to skin excess and laxity, as well as subcutaneous fat volume.

While in most cases, post-bariatric patients pursue brachioplasty for cosmetic reasons, there are functional complaints to be addressed as well, including rashes, skin breakdown, pain from skin pinching, and difficulty with finding sleeves to accommodate excessive arm girth.

The Ideal Patient
The ideal patient for surgery has achieved stable weight loss, preferably reaching a body mass index (BMI) less than 30kg/m[2]. The skin should be deflated with maximal reduction of subcutaneous fat. Alleviation of medical comorbidities with bariatric surgery, such as diabetes, sleep apnea, cardiac disease, and asthma, optimizes outcome, as well as tobacco cessation. Nutritional status should be assessed and be most favorable. Recruiting a nutritionist may be necessary. The potential patient also must be educated and accepting of reasonable outcomes and risks to assure the greatest level of satisfaction with the surgery.

Brachioplasty
In treating the arm, the region must be defined.To optimally improve the arm, it may be necessary to address adjacent body regions as well. Generally, the region of the arm is defined as the area spanning the axilla distally to the elbow (Figure 1). Some individuals have extension of the skin redundancy from the axilla down the lateral chestwall, with a “bat wing” deformity, that overlaps within the region of the breast, impacting surgical decision making. Some patients also have redundancy extending into the forearm.

Individuals who present for plastic surgery body contouring after weight loss often want multiple body regions to be addressed. In talking to potential patients, priorities need to be assessed, and these desires must be balanced by safety. Surgery on adjacent regions, such as the breasts, may impair results of surgery in the arm, so these procedures may need to be staged. Arm surgery is often not performed as a stand-alone procedure, and may be safely combined with multiple other procedures.

There is a range of brachioplasty procedures available to treat the varying degree of skin excess from minimal to extended. While the minimal scar technique is attractive for its barely perceptible scar, it is also accompanied by minimal results. Scar length correlates with the degree of skin removal. The various surgical options with their benefits and limitations need to be considered, and if the patient chooses the more limited scar, he or she should understand the result will be more limited. Currently, there are no effective scarless or minimally invasive techniques that can adequately reduce the skin laxity and excess associated with massive weight loss. Neither liposuction nor laser or light-based tightening therapies typically apply to the post-bariatric upper extremity.

Most patients qualify for a traditional brachioplasty with a “T” incision spanning the axilla to the elbow.[1,2] These patients have significant skin excess from the axilla to the elbow and variable degrees of lipodystrophy from deflated to fairly thick (Figure 2). Patients are marked in the preoperative area, sitting up and elevating his or her arm (Figure 3). In the operating room, symmetry and adequacy of the markings are assessed. Intravenous access needs to be routed away from the arm. If the breasts are ptotic, they may be taped together in the middle to improve access to the proximal arm (Figure 4). Skin is removed in a step-wise fashion after assuring the degree of excision is not too great, which may result in a wound that will not close or will be extremely tight. While working on the arms, they may be suspended on the half screen on the operating room table to gain better access to the axilla posteriorly to smooth out the excision and closure (Figure 5). A drain is placed in each arm and is typically removed after one week. Postoperatively, the patient should be followed for wounds and scar management.

For patients with skin redundancy extending down the chest wall, the “bat wing” deformity, a more extended incision is necessary.[3] This incision extends from the elbow to the axilla, continuing down along the chest wall. Surgery typically proceeds from distal to proximal to avoid over-resection. A “Z”-plasty may be designed in the axilla to confound potential scar contracture banding and accompanying limited range of motion (Figure 6 and Figure 7). A drain is placed and remains for a week or until drainage decreases appropriately.

There is a small subgroup of patients who have minimal redundancy or who demand minimal scar despite more conservative results.[4] They qualify for a minimal incision brachioplasty, including only an axillary excision and scar (Figure 8). The incision cannot be buried deep in the axilla and must be placed more distally to allow more power to be transferred to the upper arm for suspension. This procedure does not have as much utility as the traditional and extended brachioplasty techniques.

Finally, there are the patients who have arms that are very heavy with a thick subcutaneous fat layer that has not been decompressed adequately with massive weight loss. These patients do not qualify for brachioplasty. They may be candidates for an initial liposuction procedure for decompression followed by brachioplasty. This is one of the only applications for liposuction in management of the arm in post-bariatric body contouring. These patients generally have a BMI greater than 35 and are at greater risk for complications.

Brachioplasty may be performed as an outpatient, stand-alone procedure. When performed in conjunction with other body lifting procedures, admission for overnight observation may be considered, particularly if a lower body lift is completed. Postoperative care requires limited use of the arm for approximately a month, moisturizing of the scar with petrolatum, and drain care for one to two weeks. Compression is controversial after surgery because of its risk of mimicking a tourniquet, resulting in neuropathy and ischemia of the skin. Postoperative visits occur weekly until drain removal, and then at progressively longer intervals as long as all is healing well.

Risks
The arm is prone to having more issues with wound healing due to the extreme need for mobility, leading to stress and shear forces.  This, combined with possible disruption or scarring of the axillary or forearm lymphatics, may excacerbate swelling, seromas, lymphoceles, and infections. The arm skin is relatively thin, and therefore more prone to dehiscence. The density of sensory nerves in the arm and possible disruption or pressure on them with the surgery may result in numbness, pain, or exacerbation of compression neuropathies like carpal tunnel syndrome, which may be temporary or permanent. Scarring tends to be more prominent in the arm, and scars may become hypertrophic and visible. This is an issue that must be understood by the patients; there will be an exchange of contour for scar. Scars require at least one year to mature. Being vigilant about following these patients and modifying scars with topical creams, such as cocoa butter, shea butter and vitamin E; aggressive massage; silicone gel sheeting; or laser therapy, will optimize outcome. Other complications associated with brachioplasty tend to occur local to the arm and not systemically, including discomfort, bleeding, perceptible and/or symptomatic scar, asymmetry, lymphedema, and postoperative relaxation of the skin leading to recurrent laxity. Venous thromboembolism, including deep venous thrombosis, is an unlikely but possible risk.[5–7]

Patients who have undergone brachioplasty surgery may return to the operating room for revisions after the scars have matured, typically waiting at least six months and preferably one year. Some patients develop a constricting band across the axilla, which symptomatically impacts range of motion, requiring Z-plasty lengthening. Some patients require revision of hypertrophic scars, which may be itching or painful, and the scars modified are more frequently those resulting from secondary healing from a wound dehiscence or patients who are prone to developing thick scar. Some patients return to the operating room for further liposuction or tightening to further improve contour. The majority of patients, however, are very satisfied with the initial surgical results. If they are well educated prior to surgery, they understand and are satisfied with the likely outcome, including possible complicating issues.

Due to the risks of brachioplasty surgery and the overall complexity of the arm, it is critical to have the surgery performed by a board-certified plastic surgeon who is familiar with the anatomy, surgical procedure, and postoperative management. The risks of a poor outcome may range from a result that is “underdone” or “overdone,” in addition to all the risks discussed previously. Some complications, such as numbness or recurrent laxity, cannot be avoided and it is best to have these followed by a surgeon who is well-trained in this area.

Conclusion
Despite the risk of postoperative complication, brachioplasty is a powerful procedure for the individual suffering from significant skin redundancy and laxity in the arm after substantial weight loss. Patients who fare best have optimal health and BMI. Patients must understand that scarring and complications are possible, but in the end, brachioplasty will dramatically improve arm contour.

References
1.    Lockwood T. Brachioplasty with superficial fascial system suspension. Plast Reconstr Surg. 1995;96:912–920.
2.    Aly A, Soliman S, Cram A. Brachioplasty in the massive weight loss patient. Clin Plast Surg. 2008;35:141–147.
3.    Strauch B, Greenspun D, Levine J, Baum T. A technique of brachioplasty. Plast Reconstr Surg. 2004;113:1044–1048.
4.    Trussler AP, Rohrich RJ. Limited incision medial brachioplasty: technical refinements in upper arm contouring. Plast Reconstr Surg. 2008;121:305–307.
5.    Chowdhry S, Elston JB, Lefkowitz T, Wilhelmi BJ. Avoiding the medial brachial cutaneous nerve in brachioplasty: an anatomical study. Eplasty. 2010;10:e16.
6.    Gusenoff JA, Coon D, Rubin JP. Brachioplasty and concomitant procedures after massive weight loss: a statistical analysis from a prospective registry. Plast Reconstr Surg. 2008;122:595–603.
7.    Knoetgen J 3rd, Moran SL. Long-term outcomes and complications associated with brachioplasty: a retrospective review and cadaveric study. Plast Reconstr Surg. 2006;117:2219–2223.

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