Skin Laxity in Post-Weight Loss Upper Arm Body Contouring Procedures

| December 1, 2016

This column is written by medical students and is dedicated to reviewing the science behind obesity and bariatric surgery.

Column Editor: Daniel B. Jones, MD, MS, FASMBS
Professor of Surgery, Harvard Medical School, Vice Chair, Beth Israel Deaconess Medical Center, Boston, Massachusetts

This month: Skin Laxity in Post-Weight Loss Upper Arm Body Contouring Procedures

Featured student: by Kyle R. Burton, BS
Co-author: Samuel J. Lin, MD, FACS

Kyle R. Burton, BS, Medical Student, Harvard Medical School, Boston, Massachusetts. Samuel J. Lin, MD, MBA, FACS, Associate Program Director, Harvard Plastic Surgery Residency Training Program; Co-Director, Harvard Aesthetic and Reconstructive Fellowship at BIDMC; Associate Professor of Surgery; Divisions of Plastic Surgery and Otolaryngology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts

FUNDING: No funding was provided.
FINANCIAL DISCLOSURES: The authors reports no conflicts of interest relevant to the content of this article.

Bariatric Times. 2016;13(12):10–14.


ABSTRACT
Despite many advances in, not to mention increased demand for, several reconstructive surgery procedures, the ideal approach to fat removal and concomitant skin tightening remains elusive with more advanced upper arm adipose accumulation. Current interventions carry dangerous complication risks and do not always result in an appealing sight, which those desiring body contouring aspire towards. Energy-assisted liposuction provides an alternative option by improving skin retraction and the overall aesthetic appearance in non-excisional upper extremity contouring procedures. Radiofrequency-assisted liposuction represents a novel technique utilizing electromagnetic radiation to cause contraction of soft tissue matrix, obviating skin excision and consequent scarring, for lower rates of complication and morbidity. Here we explore the efficacy of energy-assisted liposuction, for upper extremity body contouring technique preference, through an investigation of skin laxity impact.

Background
Brachioplasty has experienced a 50-fold growth (17,099 in 2015) in the United States from year 2000 to 2015.[1] With obesity afflicting more than one-third (34.9%, 78.6 million) of the United States adult population,[2] and an increased reliance on modalities such as bariatric surgery for weight reduction efforts,[3] surgeons must continue optimizing techniques to reach heightened cosmetic expectations. Body contouring procedures attempt to eliminate excess skin that remains once the contents within them have been reduced and following the perioperative weakening of dermal collagen and elastic fibers. However, many individuals still express concern regarding large scars and/or more prominent skin folds following these body mass-reducing efforts.[6] Patients with massive weight loss, following bariatric surgeries make up a large portion of those driving the increased demand for upper extremity relaxed skin deformity treatment.[3–5] Energy-assisted liposuction has been shown to provide a body-contouring alternative to brachioplasty that avoids large scar production while even displaying evidence of skin tightening that better satisfies desires in appearance.[6] Here we explore the potential of energy-assisted liposuction to dethrone brachioplasty, for upper extremity body contouring technique preference, through an investigation of skin laxity impact. It is important to review options with your plastic surgeon prior to any procedure regarding risks and benefits and need for additional surgery in the future.

Anatomy
Skin in the arm is thin relative to the rest of the body. The arm subcutaneous fat, divided into superficial, Scarpa fascia, and deep layers, protects the major neurovascular structures of the arm, and envelops the muscles (Figure 1). Subcutaneous fat thickness and the fixed dimensions of the arm core need to be considered when marking the body contouring design since these factors will limit the amount of skin that can be safely excised. Reliably predicting the location of the sensory nerves has impacted incision choices in brachioplasty and limited depth of dissection.[3] Some authors recommend strategies to reduce the risk of injuring sensory nerves, including performing adjunctive liposuction to minimize dissection and limit undermining. Others claim that leaving at least 1 cm of fat on the upper arm deep brachial fascia may prevent nerve damage.[9] These recommendations for eliminating tissue near vulnerable neurovascular structures speak to the confidence in liposuction use above that of dissection techniques. Potential operative disruption of the lymph nodes also makes seromas or lymphoceles and wound healing problems more common in brachioplasty,[7] representing one of this procedure’s top complication risks.

Classification
An understanding of local anatomic variations can help guide treatment utilization. Clinical classifications have been designed to correlate intervention recommendations with the degree of affliction, all while hoping that minimal complications will be necessary for arm rejuvenation. Several authors have developed classification systems facilitating discussion of anatomical upper extremity presentations with regard to the degree of fat and skin excess (Figure 2).[7,8] El Khatib[8] and Teimouran[9] assessed patients presenting for upper arm contouring and assigned specific stages with unique treatment algorithms according to skin laxity (Table 1).[11] Here, they recommend that the more advanced classes beyond Stages 1 and 2a, representing minimal fat (<250 mL) without ptosis and moderate fat with ptosis less than 5 cm respectively, should be treated with brachioplasty rather than liposuction alone. They did not feel that any clinical appearance combining a more dramatic image than moderate lipodystrophy, and greater than 5 cm of ptosis, could improve through liposuction management alone.

While the lengthened incision allows for more effective results,[5,8] it also has up to 40-percent postoperative complication rates and residual contour deformities with unattractive scarring (e.g., hypertrophic and widened scars or unfavorable scar locations).[11] Knoetgen and Moran reported significant Mayo Clinic brachioplasty complication (25–40%) and revision rates (3–25%), along with a five percent arm cutaneous nerve injury rate—major morbidities indirectly leading to the formation of pressure ulcers or painful neuromas over the anesthesia area.[3] Even worse, the very reason for which many desire the brachioplasty procedure may actually serve as a risk factor for complications with this body contouring technique. Nguyen identified post-brachioplasty patients from the CosmetAssure database and noted a BMI > 30kg/m2 (RR = 1.92) as an independent risk factor for the occurrence of infections (RR = 1.96, P = .04) and complications requiring emergency room visits, hospital admissions, or reoperation within 30 days of the procedure.[4] In an attempt to address the multiple deformities, and to limit the amount of exposure to general anesthesia, multiple body-contouring procedures are combined into one operation. Zomerlei et al found an improved aesthetic result of combining various surgical techniques with brachioplasty to address specific complications, including scar widening, scar tethering across the axilla, seromas, and hematomas.[5]

Liposuction
Modifications in brachioplasty skin excision patterns and various adjunctive techniques performed concomitantly with other, less invasive body contouring procedures leads to improvements in contour, scar, versatility, and safety.[5] The additional use of liposuction was originally popularized in a separate body contouring anatomical region with abdominoplasties. Liposuction has now been used in conjunction with brachioplasty to facilitate tissue undermining, minimize injury to nerves and lymphatics, and improve contour.[7] While once advocated that liposuction be performed in the first stage of a two-stage brachioplasty to allow satisfactory results in arms with significant adipose tissue, liposuction soon became increasingly performed in the arm during brachioplasty, adjacent to the excisional region, within the excisional region, or diffusely throughout the arm. Bossert reported level III evidence of a cohort in which 44.7 percent (64 patients) of the brachioplasty patients underwent concurrent liposuction. Their findings showed no significant complication rate, but there was an approximate 30-minute increased operative time in those with additional liposuction versus those without.[13] Gusenoff et al found the addition of arm liposuction with brachioplasties to increase arm-related complications in part due to longer operative times.[12] Some of these complications have encouraged surgeons to do away with the brachioplasty contouring technique altogether, especially if effectiveness can be achieved by an approach that does not produce such horrific scars and require additional time of operation.

Traditional liposuction is a minimally invasive procedure intended primarily for healthy, younger, relatively fit patients with firm elastic skin who are within 30 percent of their ideal weight.[14] Arm reduction and aesthetic contouring, without excising skin, presents a difficult challenge due to the dependent nature of the redundant skin and its relative non-adherence to the underlying structures following suction-assisted lipectomy [SAL]. Although some degree of skin tightening is observed following SAL, this tightening mechanism is based on a nonthermal inflammatory process resulting from subdermal stimulation and elastic contraction of skin after removing the internal turgor created by excessive adhesive tissue. Unfortunately, residual skin laxity and superficial contour irregularities can often occur when liposuction is performed in patients with moderate to severe skin laxity and poor skin quality.6 Energy-assisted liposuction, via laser-assisted liposuction (LAL), power-assisted liposuction (PAL), and ultrasound-assisted liposuction (UAL), may improve skin retraction and the overall aesthetic result in nonexcisional upper extremity contouring procedures.[14]

Energy-Assistance
Heat denatures collagen, which leads to shrinking of redundant or lax connective tissue. Fibroblast cells in the dermis produce these collagen molecules, which consist of three polypeptide chains wrapping around one another in a final triple helix structure. Collagen thermal shrinkage begins with denaturation of the triple helix, in which the heat-labile intramolecular cross-links are broken and the collagen undergoes a transition from a highly organized crystalline structure to a random, gel-like state. Here, there is a cumulative effect of “unwinding” the triple helix, due to the destruction of the heat-labile intermolecular cross-links, and a residual tension of the heat-stabile intermolecular cross-links.[20] Heated fibroblasts are also associated with new collagen synthesis and therefore, tissue remodeling.[21] Through collagen remodeling, an increase in temperature as small as 5°C can trigger heat-shock protein (HSP) release from the endoplasmic reticulum, and an increased level of HSPs triggers a healing cascade with tissue fibroblast production of 3D collagen type I molecules. Increasing the dermal temperature, from 52°C to 55°C, triggers the fibroblasts to destruct old dysfunctional collagen, building new collagen fibers.[21] Altogether, energy-assistance effects in liposuction are based on mild heating of the collagen and elastin fibers, which can lead to collagen shrinkage and dermal thickening, thus improving the firmness and elasticity of the skin.[20] Several studies corroborate the need to reach a clinically effective temperature range in the skin for esthetic-related effects, and Hiragami et al demonstrated that treating skin for 10 min at 43°C enhanced proliferation of normal human fibroblasts, which consequently led to greater expression of new collagen.[20]

Kenkel et al theorized that most of the skin contraction seen with heat-mediated devices is due to contraction of the underlying septal network.[16] In this sense, degree of skin contraction is directly dependent on the thermal temperature achieved and the duration of that thermal stimulus, which in turn is reflected in the amount of energy used at the site during treatment. Volumetric dermal tissue heating, for noninvasive and nonablative aesthetic skin tightening, is being increasingly studied and clinically applied. Well-documented results indicate a high safety margin with moderate efficacy, which is dependent on correct patient selection and realistic patient expectations.[19]

Radiofrequency-assisted liposuction
Despite additions of these recent advances to the plastic surgery armamentarium, the ideal treatment for fat removal and concomitant skin tightening remains elusive,[6,14] especially with more advanced upper arm adipose accumulation. Leclere et al found minimal operative pain, high overall mean opinion of treatment, and skin caliper measure reduction confirmation among 45 patients with Teimorian grades I to IIb after having a single session of LAL in upper arm remodeling.[18] However, a separate study cited ecchymoses and prolonged edema complaints, on satisfaction questionnaires, as the reason that only 41 percent of 22 patients with excessive upper arm fat (Teimourian grade III and IV) would recommend others for their LAL treatment.[17]

Radiofrequency-assisted liposuction (RFAL), followed by SAL, has recently gained popularity for treating subcutaneous adipose regions while inducing tissue contraction with a combination of soft tissue and skin heating.[6] Radiofrequency (RF) energy is a type of electromagnetic wave, which is exponentially attenuated during transition into the target tissue. At lower electromagnetic wave frequencies in the spectrum of RF, energy penetration is deeper (“bulk tissue heating”) because the wavelength is greater and therefore the heating cannot be localized to limited areas.[19] RF energy penetration depth (mm) is inversely proportional to the square root of the frequency (Hz). The transfer of energy from the electric field (Figure 3) to charged particles in the target tissue can be achieved by three mechanisms of interaction between the electromagnetic field and the charges.[19] With (i) orientation of electric dipoles that already exist in the atoms and molecules in the tissue and (ii) polarization of atoms and molecules to produce dipole moments, heat is generated by the energy use involved in the electric field-influenced movement of the particles. Heat is generated by collisions between the transmission charges and immobile particles through the (iii) displacement of conduction electrons and ions in the tissue. Electrical conductivity influences the depth to which RF energy penetrates. Body contouring takes advantage of the bipolar RF configuration, which carries energy via two cathodes and an anode with a fixed distance while both electrodes are in contact to the skin, limiting the RF’s electrical current propagation to the area between the electrodes.[19] Unlike monopolar configurations (popular for electrosurgery due to high power surface density), the bipolar configuration provides an RF current inside the tissue that has a controlled distribution limited by the volume between each electrode. Focused localization requires less energy to achieve the same heating effect. The controlled distribution also makes the bipolar system more suitable for homeostasis and controlled vessel contraction. Of all tissue heating techniques, RF is the most established and clinically proven.[19] The success of RFAL as an alternative, non-excisional procedure for patients with mild to moderate skin laxity[15] indicates its premiere potential in replacing brachioplasty for advanced skin laxity treatment of overweight and massive weight loss patients.[22] Studies show that RF systems produce electrothermally mediated rejuvenation-related cutaneous and subcutaneous effects,[20] supporting RF energy use feasibility for selective heating of relatively large subcutaneous adipose tissue volumes. The heating effect leads to increased microcirculation, thus increasing blood flow to adipose tissue, which in turn increases metabolism of the tissue, homogenizing subdermal fat and increasing skin elasticity to improve skin texture. Studies also show that RFAL skin tightening and soft tissue contraction results from its effect on the fibroseptal network (FSN).[16] Yoshimura identified more than 80 percent of cells to reside in this FSN region, and Blugerman et al found RF thermal stimulation of FSN to cause skin surface contraction of up to 45 percent.[22,23]

Several studies have been conducted to explore skin laxity as a component of RFAL efficacy in body contouring procedures. Duncan et al found that adding RFAL heating to the liposuction treatment region induced significant, long-lasting skin surface area contraction. At 6 weeks post-treatment, an additional 15.2 percent skin surface contraction was noted beyond the SAL “baseline” in lower abdominal treatment regions.[6] Vectra measurements taken at one year showed a much larger difference – 28.1 percent more skin contraction found in the RFAL-plus-SAL regions than in SAL-only areas.[6] While the SAL-treated regions lost some skin contraction with time, the areas treated with RFAL-plus-SAL continued to show further tightening with little to no residual skin laxity at one year.[6] One year prior, Duncan attempted to determine whether, after long-term follow-up, the classification of upper arm deformities and their corresponding treatment protocols could be refined to offer patients with prominent skin laxity an alternative to traditional brachioplasty. This comparison of preoperative and one-year postoperative caliper and skin tattoo measurements, for 12 RFAL upper arm treated patients, showed a 50-percent average reduction in vertical height of pendulous skin laxity and 33.5-percent average skin surface area contraction – all without complications (or revision-requiring skin contour irregularity). Results led the authors to provide a revised classification and treatment algorithm for upper arm deformities, which now reflects a recommendation for fewer brachioplasties when contouring in this region, as Categories 2b and 4 can successfully be treated without the need for additional excisional procedures.10 Several additional studies also found evidence of successful RFAL treatment and patient satisfaction, with improvements in contour and degree of volar skin laxity for Category 2b and 4 patients, while only one Stage 3 patient (having extreme lipodystrophy plus extreme ptosis) required a limited short-scar upper brachioplasty.[12] Recent randomized, blinded papers have shown 35 percent soft tissue contraction after a year of RFAL, compared with 8.1 percent soft tissue contraction observed after a year of nonthermal, traditional SAL.[6,10]

Additionally significant in considering the viability of RFAL, one study found a majority of patients to have either minimal or no pain in the tumescent phase (80%), the application of heat phase (80%), or fat aspiration phase (87%) of the operation. This study also found no difference in the technique of energy application or fat removal for a series of local anesthesia patients and patients who had RFAL under traditional anesthesia.[15]

Not without fault, the overall incidence of RFAL technique complications (specifically using the BodyTiteTM device [Invasix Ltd., Irvine, California]) still reaches 6.25 percent – only reduced from 8.6 percent of the best nonenergy-based traditional liposuction technique (superficial liposuction).[24] Potential liposuction complications of numbness or hypesthesia, seroma, chronic swelling, pain, hyperpigmentation, hematoma, infection, irregular skin surfaces, and skin slough now accompany possible burns at access points.[24] These “end hits” can occur if the cannula is passed too close to the skin at the furthest excursion of the stroke, causing a dermal burn or depression which could result in palpable nodules of fat necrosis. Depressions may even occur with over-reductions in volume.[22] However, the development of a suction device within the cannula, that aspirates heated fat, attempts to reduce the risk of seroma or local tissue burn.[10] Other complication evasions include constant RFAL cannula movement, to deposit modest levels of thermal energy and avoid exceeding FSN contraction temperatures of 69°C.[6] Further interventions exist to circumvent thermal injuries and over resections. The development of a Teflon sheath, over the probe and the tip of the catheter, decreases the risk of burn.[15] Temperature monitoring, visual recognition, and other equipment modifications help mitigate risks. Sterile ice can cool areas of erythema on the skin (”hot spots”) that can result in blistering and full-thickness burns, while burns and seromas have been successfully treated with local care.[15]

Conclusion
No matter the body contouring technique consideration following dramatic weight loss, physicians must ensure proper management of patient expectations. Patients must receive details regarding the respective risks of brachioplasty and liposuction techniques since elicited patient desires ultimately determine preference in surgical approach. Stage-specific treatment algorithms have assisted in allowing surgeons to recognize outcomes related to anatomical variations. Outcomes must, however, correlate with new innovations and improving surgical capabilities. Currently, the benefits of liposuction are questionable for patients with massive brachial ptosis and poor skin tone, especially if skin retraction is likely to be insufficient.[11] However, the horizon holds potential for nonsurgical skin tightening technologies.[7] RFAL represents a novel technique utilizing electromagnetic radiation to cause contraction of soft tissue matrix, obviating skin excision and consequent scarring in order to lower rates of complication and morbidity.

References
1.     American Society of Plastic Surgeons. 2015 Cosmetic plastic surgery statistics [Internet] Arlington Heights, IL: American Society of Plastic Surgeons; c2015. http://www.plasticsurgery.org/Documents/news-resources/statistics/2015-statistics/2015-plastic-surgery-statistics-report.pdf. Accessed May 25, 2016
2.    Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of childhood and adult obesity in the United States, 2011-2012. JAMA. 2014;311(8):806–814.
3.    Knoetgen J, III, Moran SL. Long-term outcomes and complications associated with brachioplasty: a retrospective review and cadaveric study. Plast Reconstr Surg. 2006;117:2219–2223.
4.    Nguyen L et al. Incidence and risk factors of major complications in brachioplasty: analysis of 2,294 patients. Aesthet Surg J. 2016 May 23. pii: sjv267. [Epub ahead of print].
5.    Zomerlei TA, Neaman KC, Armstrong SD et al. Brachioplasty outcomes: a review of a multipractice cohort. Plast Reconstr Surg. 2013;131:883–889.
6.    Duncan DI. Nonexcisional tissue tightening: creating skin surface area reduction during abdominal liposuction by adding radiofrequency heating. Aesthet Surg J. 2013;33:1154–1166.
7.    Paul M, Blugerman G, Kreindel M, et al. Three-dimensional radiofrequency tissue tightening: a proposed mechanism and applications for body contouring. Aesth Plast Surg. 2011;35:87–95.
8.    El Khatib H. Classification of brachial ptosis: strategy for treatment. Plast Reconstr Surg. 2007;119:1337–1342.
9.    Teimourian B, Malekzadeh S. Rejuvenation of the upper arm. Plast Reconstr Surg. 1998;102:545–551.
10.    Duncan DI. Improving outcomes in upper arm liposuction: adding radiofrequency-assisted liposuction to induce skin contraction. Aesthetic Surgery Journal 2012; 32(1):84–95.
11.    Abboud et al. Brachioplasty by power-assisted liposuction and fat transfer: a novel approach that obviates skin excision. Aesthetic Surgery Journal. 2016, 1–10.
12.    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.
13.    Bossert RP, Dreifuss S, Coon D, et al. Liposuction of the arm concurrent with brachioplasty in the massive weight loss patient: Is it safe? Plast Reconstr Surg. 2013;131: 357–365.
14.    Theodorou SJ, Paresi RJ, Chia CT. Radiofrequency-assisted liposuction Device for body contouring: 97 patients under local anesthesia. Aesth Plast Surg. 2012);36:767–779.
15.    Theodorou SJ, Chia CT. Radiofrequency-assisted liposuction for arm contouring: technique under local anesthesia. Plast Reconstr Surg Glob Open. 2013;1:e37.
16.    Kenkel J. Response to evaluation of skin tightening after laser-assisted liposuction. Aesthet Surg J. 2009;29(5): 407–408.
17.    Leclère FM, Alcolea JM, Vogt PM, Moreno-Moraga J, Casoli V, Mordon S, Trelles MA. Laser-assisted lipolysis for arm contouring in Teimourian grades III and IV: A prospective study involving 22 patients. Plast Surg (Oakv). 2016;24(1):35–40.
18.    Leclère FM1, Alcolea JM, Vogt P, Moreno-Moraga J, Mordon S, Casoli V, Trelles MA. Laser-assisted lipolysis for arm contouring in Teimourian grades I and II: a prospective study of 45 patients. Lasers Med Sci. 2015 Apr;30(3):1053-9. Epub 2015 Jan 18.
19.    Belenky I, Margulis A, Elman M, Bar-Yosef U, Paun SD. Exploring channeling optimized radiofrequency energy: a review of radiofrequency history and applications in esthetic fields. Adv Ther. 2012;29(3):249–266.
20.    Hiragami F, Motoda H, Takezawa T, et al. Heat shock-induced three-dimensional-like proliferation of normal human fibroblasts mediated by pressed silk. Int J Mol Sci. 2009;10:4963–76.
21.    Dierickx C. The role of deep heating for non-invasive skin rejuvenation. Lasers Surg Med. 2006; 38: 799–807.
22.    Hurwitz DJ, Smith D. Treatment of overweight patients by radiofrequency-assisted liposuction (RFAL) for aesthetic reshaping and skin tightening. Aesth Plast Surg 2012;36:62–71.
23.    Blugerman G, Schavelzon D, Paul M. A safety and feasibility study of a novel radiofrequency-assisted liposuction technique. Plast Reconstr Surg. 2010;125:998–1006.
24.    Teimourian B, Rogers WB. A national survey of complications associated with suction lipectomy: a comparative study. Plast Reconstr Surg. 1989;84:628–631.

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