SOUTHEASTERN SOCIETY OF PLASTIC AND
An Outcome Analysis of Brachioplasty Techniques Following
Massive Weight Loss
John D. Symbas, MD, and Albert Losken, MD
Abstract: Body contouring following massive weight loss (MWL) has
gained in popularity. The demand for upper arm contouring procedures has
increased, and we elected to evaluate our results, complications, and patient
satisfaction with brachioplasty techniques in MWL patients.
A retrospective review was performed on all patients who underwent a
brachioplasty procedure. Patient demographics and risk factors were queried.
We evaluated surgical techniques and outcomes.
Thirty-one patients underwent a bilateral brachioplasty, with an average
follow-up of 16 months. The surgical technique included double ellipse n ⫽
16, and L-shaped n ⫽ 15. The average weight loss before the procedure was
146 pounds, and the average body mass index at the time of the surgery was
30. Risk factors were present in 68% of the patients. The complication rate
was 22%, including cellulitis, hematoma, infection, delayed healing, and
lymphocele. The revision rate was 16%, most being minor scar revisions for
contour improvement. Patient satisfaction scores included overall satisfac-
tion 4.3/5, contour improvement 4.3/5, symptomatic improvement 4.9/5, and
scar appearance 3.9/5. Most patients (94%) reported improved self-esteem,
94% being more comfortable wearing short sleeve shirts, and 94% would
undergo the procedure again.
Brachioplasty is a relatively safe and effective procedure for upper body
contouring in the MWL patient. Complications are minor, and small revi-
sions in contour are not uncommon. Patients report improvement in contour
and self-esteem, and a high level of satisfaction with this procedure, despite
the potential for an unfavorable scar.
Key Words: brachioplasty, massive weight loss, obesity surgery, bariatric
surgery, body contouring
(Ann Plast Surg 2010;64: 588 –591)
W eight loss procedures have increased in frequency and safety,
and offer the greatest degree of sustained weight loss to the
patient.1 The subsequent demand for body contouring has similarly
increased, being up 77% in the last 5 years, with 14,059 upper arm
lift surgeries in 2008 (a 4000% increase since 2000).2 Many of the
traditional body contouring procedures have been modified to pro-
vide better results in the massive weight loss (MWL) population.
Because the demand for these upper arm contouring procedures is
all relatively new, we are still learning about the best options for
treating these patients. Although the concept behind contouring the
upper arm is relatively simple and essentially involves skin resec-
tion, the procedures are more complex and are not without the
potential for complications and unfavorable results. Although there
have recently been some publications on brachioplasty technique,
Received October 18, 2009, and accepted for publication October 19, 2009.
From the Emory Division of Plastic and Reconstructive Surgery, Atlanta, GA.
The authors have no financial disclosures or conflict of interest to disclose.
Presented at the 52nd Annual Meeting of the Southeastern Society of Plastic and
Reconstructive Surgeons; Rio Mar, Puerto Rico; June 2009.
Reprints: Albert Losken, MD, Emory Division of Plastic and Reconstructive
Surgery, 550 Peachtree St, Suite 84300, Atlanta, GA 30308. E-mail:
alosken@emory.edu.
Copyright © 2010 by Lippincott Williams & Wilkins
ISSN: 0148-7043/10/6405-0588
DOI: 10.1097/SAP.0b013e3181c6cde8
588 | www.annalsplasticsurgery.com
RECONSTRUCTIVE SURGEONS
the actual data are limited and documentation of patient satisfac-
tion is sparse. The resulting scar can often be a major genesis of
dissatisfaction following body contouring procedures, and bra-
chioplasty is no exception. The arm scar can often be unfavor-
able, and appropriate preoperative counseling is critical. The
purpose of this review was to examine our experience with
brachioplasty techniques, and to evaluate complications, out-
comes, and patient satisfaction.
METHODS
All patients at Emory University who underwent a brachio-
plasty procedure after MWL by the senior author (A.L.) between
2003 and 2007 were reviewed. Thirty-one patients had sufficient
data and were included in the series. The demographics were
reviewed, and data points queried included age, weight loss prior to
the procedure, body mass index, and associated medical risk factors.
The type of brachioplasty technique was either an L-shaped
technique (the first 16 patients) or the double ellipse technique (n ⫽
15). Outcomes were assessed by evaluating the associated proce-
dures performed along with the brachioplasty, complications, and
any need for revisional surgery. Complication rates were reported
only for the brachioplasty procedure.
Patient satisfaction was then analyzed by asking the patients
a series of standardized questions regarding their motivations for
undergoing the procedures, self-esteem, and overall satisfaction with
the procedure. Patients were asked to rate their satisfaction to each
specific query on a scale from 0 to 5 (0 being the worst and 5 being
the best). Specific questions were related to their overall satisfaction
with the procedure, the improvement in their skin contour, the
improvement in the way their arms feel without the hanging skin, the
scars, the pain of the procedure, and the recovery.
Surgical Technique
Essentially 2 approaches were used to correct excess tissue of
the upper arm, axilla, and lateral chest.
The first was an inverted L-shaped resection of the excess
tissue as described by Hurwitz and Neavin3 (Fig. 1). The superior
incision of the arm ellipse rises from the medial elbow along the
bicipital groove to the deltopectoral groove. The inferior incision
of the arm ellipse runs from the medial elbow along the posterior
margin of the arm to rise toward the midaxilla. The area between
these incisions incorporates the excess skin of the upper arm, as
determined by tissue gathering estimates. The second ellipse
drops vertically from the deltopectoral groove to include approx-
imately the lateral half of the axilla and continues vertically to
include excess lateral chest wall skin. An inferiorly based trian-
gular flap is formed as the inferior arm incision meets the lateral
incision of the vertically oriented axillary ellipse. The ability to
advance this triangular flap to the deltopectoral groove is checked
by pinch approximation. It is also checked after elevation of the
flap and before skin resection. This maneuver elevates the ptotic
posterior axillary fold and creates a natural tapering of the arm
toward the axilla, leaving the scar anterior in the grove and in the
axilla.
Annals of Plastic Surgery • Volume 64, Number 5, May 2010
Annals of Plastic Surgery • Volume 64, Number 5, May 2010
FIGURE 1. A, L-shaped brachioplasty technique illustrating
the preoperative markings. B, This 63-year-old woman pre-
sented after having lost 95 pounds following gastric bypass
surgery. She underwent an L-shaped brachioplasty and is
shown 2 years postoperatively with improvement in her con-
tour.
The second technique is known as the double-ellipse tech-
nique as described by Aly et al4 (Fig. 2). Markings are made
preoperatively by pinching the excess tissue at the axillary crease
just inferior to the musculoskeletal mass of the upper arm. The
excess skin and subcutaneous tissue are marked anteriorly and
posteriorly, and this process is repeated distally to include the
total extent of the excess even if it crosses the elbow. The same
process is used to delineate the lateral chest excess guided by the
amount of tissue necessary to eliminate the horizontal thoracic
excess. Then all the anterior and posterior marks are connected to
create the outer ellipse. The principal behind the double ellipse
technique lies in the fact that if the outer ellipse were used as the
actual incision line, the defect could not be closed because the
distance between the examiner’s fingers, while pinching, would
not be taken into consideration. The second ellipse is created to
accommodate for that distance. For example, if the distance
between the pinched fingers at any particular point along the
upper arm is 2 cm, the marks would be moved 1 cm centrally on
each side to create the inner ellipse. Proximal to the axillary
crease, the marks need not be moved centrally because closure
along this area is not around a cylinder. The skin resection is then
performed with no undermining, starting at the elbow, and
closing temporarily as the skin is removed. Closure is then
performed in layers with the incision being more posterior along
the arm. Extension in the axilla is possible if addition lateral
chest skin removal is desired. A Z-plasty is typically required in
the axilla to prevent scar contracture. Drains are typically not
required.
© 2010 Lippincott Williams & Wilkins
Brachioplasty Techniques Following Weight Loss
FIGURE 2. A, Double ellipse technique illustrating the preop-
erative markings. B, This 52-year-old woman underwent a
double ellipse type brachioplasty following weight loss. She
is shown 4 months postoperatively with scars still reddened
and raised.
RESULTS
Demographics
Thirty-one patients underwent a brachioplasty for upper arm
contouring after MWL with an average follow-up of 16 months
(range: 2– 42 months). All patients were female, and the average age
at the time of the procedure was 45 years (range: 27– 62 years). The
average weight loss before the procedure was 146 pounds (range:
75–500 pounds) with the average body mass index at the time of
surgery being 30 (range: 22.4 –52.3). The majority of patients had
risk factors, with all of them having obesity either as a current issue
or a history of obesity. Nonobesity related risk factors were present
in 21 of 31 patients (68%), many with multiple risks including
hypertension, sleep apnea, and diabetes.
Only 2 patients had the bilateral brachioplasty procedure by
itself. Twenty-nine patients (94%) had additional body contouring
procedures, including panniculectomy (n ⫽ 2), mastopexy (n ⫽ 13),
abdominoplasty (n ⫽ 8), breast augmentation (n ⫽ 4), posterior
lipectomy (n ⫽ 1), medial thigh lift (n ⫽ 7), belt lipectomy (n ⫽ 2),
blepharoplasty (n ⫽ 1), and liposuction (n ⫽ 5), reverse abdomino-
plasty (n ⫽ 1), and breast reduction (n ⫽ 1). Sixteen patients (52%)
had 2 or more body contouring procedures in addition to the
brachioplasty.
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Symbas and Losken
TABLE 1. Patient Satisfaction and Rating Scores
Satisfaction Score From
Query 0 (Worst) to 5 (Best)
Overall satisfaction 4.3 (range: 1–5)
Improvement in the contour of their skin 4.3 (range: 0–5)
Satisfied with the way their arms felt without 4.9 (range: 4–5)
the hanging skin
Appearance of the scars 3.9 (range: 0–5)
Rate the pain associated with the procedure 4.3 (range: 2–5)
Rate the recovery 4.3 (range: 2–5)
Complications
The complication rate for the brachioplasty procedure was
22% (n ⫽ 7/31). The majority were relatively minor, including
cellulitis (n ⫽ 1), hematoma (n ⫽ 2), lymphocele (n ⫽ 2), infection
(n ⫽ 1), and delayed healing (n ⫽ 1). One patient had an acute
complication requiring return to the operating room for a hematoma,
the rest were managed conservatively. The revision rate was 16% (n ⫽
5/31), and included revisional surgery for dog ears (n ⫽ 2), scar band
contracture (n ⫽ 1), scarring (n ⫽ 1), and re-excision (n ⫽ 1).
Patient Satisfaction
Eighteen patients (58%, n ⫽ 18/31) responded to our survey
with an average follow-up of 11 months. Most of the respondents
had the double ellipse procedure (61%, n ⫽ 11/18). All respondents
said their main reason for undergoing the procedure was to correct
the appearance and pain associated with the hanging skin. Overall,
patients were satisfied with their outcome following the procedure.
A total of 94% of the patients said their goals were met with the
procedure, 94% stated that the procedure improved their self esteem,
and 94% reported that they were more comfortable wearing clothes
that revealed their upper arms and axillary region. Satisfaction
scores are presented in Table 1.
Eighty-nine percent of the patients said that they were pleased
with the overall result, and 94% of the patients stated that they
would undergo the procedure again knowing what they know now.
DISCUSSION
Contouring of the upper arms has become a necessary addi-
tion to complete body contouring following MWL. It has recently
become more popular and many surgeons are now asked to perform
brachioplasties having had limited exposure during training. Al-
though the actual technique essentially involves removal of skin
and/or fat from the arms, certain nuances do exist, which could
maximize outcomes. The brachioplasty was first introduced in 1954
by Correa-Iturraspe and Fernandez. Since then, the procedure has
undergone a series of modifications to improve the appearance of the
scar and the resulting contour of the arm. These include techniques
such as Z-plasties, W-plasties, curving S-incisions, quadrangular
flaps and T-closure, de-epithelialized rolled-up flaps, and fascial
system suspensions. More recently Aly and Hurwitz have published
their data on the double ellipse and inverted L-shaped brachioplasty
techniques, which likely represent the majority of techniques used
today.3,4 We have demonstrated in this series that despite moderate
complications, revision rates, and potentially unfavorable scarring
with the brachioplasty techniques, patients generally are satisfied
with their results.
Patients will often present with varying degrees of upper arm
skin excess and lipodystrophy, and the type of technique varies
based on patient concern and presentation. Four stages of arm ptosis
have been described by Hamdy in 2007, with stage 1 only requiring
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Annals of Plastic Surgery • Volume 64, Number 5, May 2010
liposculpturing, stages 2b, 3, and 4 requiring some sort of skin
excision as opposed to liposuction alone.5 Traditional brachioplasty
was used in stage 4 cases. Their complication rate in those patients
who required skin excision was 13%. The author reports that the
patients were able to wear short sleeve shirts and bathing suits
without embarrassment. Teimourian and Malekzadeh has similarly
described the degree of excess subcutaneous tissue and skin laxity as
a determinant of surgical technique.6 Although it is often preferable
to hide the scar within the axilla and perform a limited incision
medial brachioplasty, this is only reasonable when there is localized
ptosis very proximal in the upper arm.7,8 Invariably skin resection is
required all the way down to the elbow to adequately correct the
deformity. The L-shaped brachioplasty became a popular technique
for its ease of markings and predictability.3,9 This technique allows
for the “cut as you go” technique once the flap has been elevated to
reduce the possibility of removing too much skin. The revision rate
in Hurwitzs’ series of 50 patients was approximately 16%. Other
series have demonstrated similar revision and complication rates.
Knoetgen and Moran described their experience over a 16-year
period, with a revision rate of 12.5% and complication rate of 25%
in 40 patients.10 Their specific brachioplasty technique was not
elaborated upon; however, their most distressing complication was
injury to the medial antebrachial cutaneous nerve in 2 cases. The risk
of nerve injury following brachioplasty procedures is a real phe-
nomenon, and attention to detail and anatomy is critical, especially
when the technique involves skin removal anteriorly. The average
distance at which this nerve penetrated the deep fascia was variable
but averaged 14 cm proximal to the medial epicondyle (range, 8 –21
cm). At this point, it was considered a superficial structure and thus
at risk during brachioplasty procedures, especially when the superior
skin incision is placed near the intermuscular septum. Neurolysis of
the ulnar nerve secondary to postoperative edema has also been
reported.11 The more posterior skin resection in the double ellipse
technique2 places the scar more posteriorly, which is preferred by
some, but it also minimizes risk of injury to the medial antebrachial
FIGURE 3. This 39-year-old woman lost 148 pounds and
underwent a double ellipse brachioplasty, along with a mas-
topexy and abdominoplasty. The arms are often part of the
complex chest deformity, and are treated along with the
breast for optimal results. She is shown 3 years postopera-
tively with scars favorably located and healed.
© 2010 Lippincott Williams & Wilkins
Annals of Plastic Surgery • Volume 64, Number 5, May 2010
nerve. This technique also has predictable markings and results;
however, it is critical not to over-resect. Since no undermining is
performed, drains are often not required. The purpose of our series
was not to compare one technique versus the other given the limited
sample size; however, it is our preference now to perform the double
ellipse technique (Fig. 3). It is often reasonable to stop the resection
at the level of the axilla; however, this can also be taken down onto
the lateral chest wall, if necessary, with the addition of a Z-plasty
within the axilla to prevent scar contracture. Since the arms are often
part of a complex deformity, they are often done together with
mastopexy for better harmony.
Different brachioplasty techniques exist depending on the
degree of the deformity and surgeon preference, and none of them
are without complications and the need for revisional surgeries as
discussed earlier. Scarring in the arm is often unfavorable and can be
visible when wearing short sleeved shirts. It is important that we
appropriately counsel our patients preoperatively on the potential for
scarring, and that this procedure is often a tradeoff for scars. We
recognize the limitations of this retrospective review of different
brachioplasty techniques and the limited sample size; however, it is
the first series documenting patient satisfaction. Despite the almost
universal complaint of scars, patients are generally satisfied with the
procedure, and would undergo it again. It seems to adequately
address their complaints of excess tissue and hanging skin. More
comprehensive body image questionnaires would be interesting,
especially when given preoperatively and postoperatively. This
would more accurately allow us to determine the psychological
benefits of this body contouring procedure.
The demand for body contouring will likely continue to grow,
and brachioplasty procedures are an important part of the upper
© 2010 Lippincott Williams & Wilkins
Brachioplasty Techniques Following Weight Loss
body contouring process. As we continue to learn more about the
MWL deformity and evaluate our results, we will continue to refine
our surgical techniques to minimize potential morbidity and maxi-
mize esthetic results and patient satisfaction.
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