Journal of Plastic Surgery and Hand Surgery

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‘J’ brachioplasty technique in massive weight loss

patients

Maria A. Bocchiotti, Erind Ruka, Luca Spaziante, Umberto Morozzo,

Elisabetta A. Baglioni & Stefano Bruschi

To cite this article: Maria A. Bocchiotti, Erind Ruka, Luca Spaziante, Umberto Morozzo, Elisabetta
A. Baglioni & Stefano Bruschi (2018): ‘J’ brachioplasty technique in massive weight loss patients,
Journal of Plastic Surgery and Hand Surgery, DOI: 10.1080/2000656X.2018.1476363

To link to this article: https://doi.org/10.1080/2000656X.2018.1476363

Published online: 29 Jun 2018.

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JOURNAL OF PLASTIC SURGERY AND HAND SURGERY
https://doi.org/10.1080/2000656X.2018.1476363

ARTICLE

‘J’ brachioplasty technique in massive weight loss patients

Maria A. Bocchiotti, Erind Ruka, Luca Spaziante, Umberto Morozzo, Elisabetta A. Baglioni and Stefano Bruschi
Department of Reconstructive and Aesthetic Plastic Surgery, Citta della Salute e della Scienza Hospital University of Turin, Turin, Italy

ABSTRACT ARTICLE HISTORY

Upper extremity body reshaping is a very frequent surgical procedure in massive weight loss patients. Received 4 May 2017
Many surgeons have presented different patterns of brachioplasty skin excision and a variety of adjunct- Revised 28 April 2018
ive techniques, each of them claiming improvements in scar aesthetic, arm shape or overall safety of the Accepted 8 May 2018
procedure. In this pape,r we want to illustrate our personal brachioplasty technique for massive weight
KEYWORDS
loss patients. Our incision design named ‘J’ Brachioplasty is described. Between March 2013 and March Brachioplasty; massive
2016, a retrospective study of patients with massive weight loss and clinical diagnosis of brachial ptosis weight loss; body reshaping
undergoing surgical reconstruction with ‘J’ brachioplasty was performed. All patients were treated accord-
ing to a standard surgical procedure described in detail in the paper. The presence of axillary and thor-
acic skin excess was also recorded for every subject, as well as clinical and surgical postoperative
complications. A total number of 73 Caucasian underwent J-shaped brachioplasty. Our technique allowed
us to treat both arm and thoracic skin excess with a single skin incision. Among our casuistic we had
only two cases of postoperative bleeding and four cases of partial wound dehiscence due to tension.
Seroma was reported only in one (female) patient. Despite the recent introduction our technique has pro-
ven to reach good results in massive weight loss patients.

Introduction Patient selection

Upper extremity body reshaping in massive weight loss patients
was firstly described by Thorek in 1930 [1] although the first
description of aesthetic brachioplasty dates back to 1954 by
Correa Iturraspe and Fernandez [2]. Since then many surgeons
have presented different patterns of brachioplasty skin excision
and a variety of adjunctive techniques, each of them claiming
improvements in scar aesthetic, arm shape or overall safety of the
procedure (Table 1). An increasing scientific interest related to
body contouring was also accurately analysed by the American
Society for Aesthetic Plastic Surgery (ASAPS) in 2012: regarding
brachioplasties U.S. procedures grown from 338 in 2000 until
reaching 15.457 surgeries performed in 2012 [3], mostly amongst
patients who have sustained massive weight loss. Regardless such
scientific interest and surgical technique variations, the scar qual-
ity and the position remain still the main reason for patients
to complain.
In this paper, we want to illustrate our personal brachioplasty
technique for massive weight loss patients. The goal of this paper
is to give a valid surgical technique that can be successfully used
in this type of patients.
Materials and methods
The study was carried out in the Department of Plastic
Reconstructive and Aesthetic Surgery, Citta della Salute e della
Scienza Hospital Turin. Between March 2013 and March 2016, a
retrospective study of patients with massive weight loss and clin-
ical diagnosis of brachial ptosis was performed.
All patients needed to match precise inclusion criteria
listed below:

Previous documented BMI  40

Actual BMI  30 at time of surgery (body weight loss from
bariatric surgery or diet)

Recurrent local dermatitis (at least two episodes per year,
documented by dermatologist clinician)

Arm/forearm circumference rate (at their maximal width) of
1.8 (±0.1).
The above criteria are fundamental and are formulated by the
direction of our hospital. Patients lacking these criteria cannot
perform any type of body reshaping surgery.
All patients were treated according to a standard surgical pro-
cedure described below and informed consent was obtained from
every subject.
The presence of axillary and thoracic skin excess was also
recorded for every subject, as well as clinical and surgical postop-
erative complications.
Planning and marking
The patient is first evaluated in standing position, arms abducted
to 90 , forearms extended. Skin excess, laxity and quality are
assessed with a ‘pinch test’ and the forecast of possible results is
obtained with gently overlapping of the redundant skin flap, thus
assisting in planning skin markings. The markings are then con-
trolled again in supine position with the elbows flexed to 90 .
We first trace a line along the axis of the arm, from the lateral
epicondyle of the humerus (point A) to the coracoids articulation
projection (point B), in order to place the final scar position in an

CONTACT Erind Ruka erind549@hotmail.com Department of Reconstructive and Aesthetic Plastic Surgery, Citta della Salute e della Scienza Hospital
University of Turin, Via Cherasco, 23, Turin 10126, Italy
ß 2018 Acta Chirurgica Scandinavica Society
2 M. A. BOCCHIOTTI ET AL.

Table 1. History of techniques

Year Authors Technique
1954 Correa-Iturraspe Fusiform excision of the medial surface of the arm
1975 Baroudi Elliptical excision with scar in the brachial sulcus
1975 Pitanguy S-shaped incision
1979 Juri Quadrangular flap with axillary T-scar
1982 Borges W-plasty incision
1989 Goddio Deepithelialization of the posterior skin flap
1995 Lockwood T-incision with axillary anchoring of the arm’s superfi-
cial fascial system
1997 Gilliland Circumferential para-axillary superficial tumescent
(CAST) liposuction
1998 Teimourian T-incision with purse-string suture
2000 De Souza Pinto Double-S-shape incision Figure 1. Pre-operative ‘J’ brachioplasty marking and planning. Approximation of
2001 Richards Minimal-incision brachiplasty þ liposuction point D with D0 and B with B0 gives the ‘J’-shaped remaining scar.
2004 Strauch Posterior sinusoidal excision
2004 Abramson Minibrachioplasty
2005 Pascal Posterior longitudinal incision with axillary Z-plasty
2006 Chandawakar Fish-incision
2006 Hurwitz L-brachioplasty
2006 Aly Double-ellipse pattern incision with axillary Z-plasty
2007 Cannistra Posterior longitudinal incision with axillary Z-plasty
and axillary anchoring
2007 Reed Oval excision within axillary hollow (minimal incision
brachioplasty)
2008 Trusslertrussler Limited medial incision
2010 Nguyen Liposuction-assisted posterior brachioplasty
2012 Duncan Radiofrequency-assisted liposuction of the arm
2013 Aboul Wafa S-shaped incision
2013 Bracaglia V-flap with axillary ellipse removal (‘Kris
knife’) þ liposuction
2014 Knotts Avulsion brachioplasty
2014 Fantozzi Balance triple-vector (BTV) technique with dual oppos-
ing flaps
2015 Ferraro Modified fish-incision technique in brachioplasty: a
surgical approach to correct excess skin and fat of
the upper arm (restoring the armpit contour).
Figure 2. Superior incision is made as soon as the liposuction is finished.

anterior position and straight shape. At the level of the coracoids

articulation the line is extended caudally in a medial convex
shape, following the natural axillary anterior pillar. This line is
drawn as a smooth Italic S shape and may be prolonged caudally
depending on axillary skin excess (point C). Patients with thoraci-
cal skin excess may require great extension of this line along lat-
eral aspect of thorax proportional to the amount of tissue to be
removed. A second line is then marked starting from the elbow
(point A) and running inferiorly to the previous one, based on the
prior pinch test and the subcutaneous tissue thickness evaluation.
This line ends when crossing an imaginary line connecting cora-
coids articulation (point B, the most superior point of anterior axil-
lary pillar) to the most inferior point of posterior axillary pillar
(point D). Points D and C are then joined in a slightly posterior
convex shape until final marking is completed. Point B results to
be at the maximum convexity point of ABC line, while point B’ is
located in the maximum concavity of the AD line. Segment CD’
and CD are approximately equal in length as well as segment BD’
and B’D. Point B’ and D’ are placed depending on the degree and
main direction of the desired lifting (Figure 1).
Line AB is then divided in multiple segments and for each one
circumference width is measured and compared with contralateral
arm for symmetry. Incision lines are crosshatched for proper align-
ment. Approximation of point D with D’ and B with B’ will give
the ‘J’-shaped remaining scar (Figure 1).
Local tumescent infiltration of brachial flap and of elbow
region for proper liposuction is achieved with approximately
1000 ml saline and 1 ml adrenaline. Liposuction of all areas is then
performed after a period of 15 min with 3 mm blunt canulas in a
superficial plane. Additional liposuction may be executed at the
end of procedure in case proper shape is not considered satisfac-
tory by the surgeon.
Superior incision is made as soon as the liposuction is finished
(Figure 2) and the flap dissection is carried out with extreme care
not to interrupt muscle fascial layer. During flap elevation we
always leave a thin layer of subcutaneous tissue in order to pro-
tect muscular fascia and lymphatic vessel, as well as MCB (medial
cutaneous brachialis) nerve (Figures 3 and 4).
Flap excision and definitive inferior line incision are completed
after intraoperative evaluation of the exact quantity of tissue to
be removed. We do not accomplish any type of fascial suspension
or flap undermining (Figure 5). Temporary stitches are placed to
prevent tissue swelling (Figure 6).
Approximation of point D with D’ and B with B’ is achieved
and then residual skin redraping and suturing is completed. The
‘J’-shaped final scar is achieved. Skin closure is obtained with 2/0
Vycril deep layer and 3/0 Monosyn superficial layer. Subcuticular
3/0 running Monocryl suture and positioning of suction drainage
complete our surgical procedure (Figure 7).

Surgical technique Postoperative

The surgical procedure is performed under general anaesthesia. All patients were discharged 24 h postoperatively. We use to
The patient is laid supine with arms abducted at 90 , with fore- insert a drain, which is usually removed after 24 h. A standard
arms totally extended. compressive dressing is applied immediately after surgery and

Figure 3. Flap dissection after liposuction.
Figure 4. Cutaneous view of the flap after liposuction.
Figure 5. Flap excision and definitive inferior line incision completed.
Approximation of point D with D0 and B with B0 .
kept in place for one month 24 h per day. Medications follow at
day 4, 10, 15 and 20 post-operative. Follow up was performed at
1 month, 3 months, 6 months, and 1 year. The mean follow-up was
1 year. Asymmetries, recurrence of cutaneous ptosis, quality and
extension of the scars were evaluated. Satisfaction among
JOURNAL OF PLASTIC SURGERY AND HAND SURGERY 3
Figure 6. Temporary stitches placed to prevent tissue swelling.
Figure 7. Residual skin redraping and suturing completed.
patients was investigated by personal interview. Patient’s opinion
regarding the aesthetic outcome was asked. A numeric scale from
0-10 was used.
Results
A total number of 73 Caucasian underwent ‘J’ brachioplasty. 13
males and 60 females. All of the patients were post obese who
had lost weight due to bariatric surgery (45 patients; 36 sleeve
gastrectomy, 9 bypass) or diet (28 patients). Average age was
38.9; the youngest 28 and the oldest 62. Diabetes (three patients)
and hypertension (four patients) were the most common co-mor-
bidities. The surgical procedure time was 110 min.
Two cases of postoperative bleeding with haematoma forma-
tion occurred. A revision surgical procedure was necessary to
resolve this issue. We had no cases with nerve injury. There were
4 cases of partial wound dehiscence due to tension; however, sec-
ondary healing and minimal revision surgery resolved this.
Seroma was reported only in one (female) patient. It was resolved
within 10 days of medications and pharmacological treatment.
Three patients presented hypertrophic scars during the follow-
up. Silicone sheets were applied with good improvement of the
scar quality. In all the patients we obtained a good improvement
in their upper arm contour with satisfaction of both surgeon and
patients. (Figures 5–19).
4 M. A. BOCCHIOTTI ET AL.
Figure 8. Case 1. 30 years old female. Weight loss of 47 kg with residual brachial
ptosis. Frontal view. Pre and post-operative figures (12 months after surgery).
Figure 9. Right and left arm. Pre and post-operative figures (12 months
after surgery).
Figure 10. Case 2. 48 years old female. Weight loss of 57 kg with residual bra-
chial ptosis. Frontal view. Pre and post-operative figures (12 months
after surgery).
Regarding the aesthetic outcome we had an average score of
7.83 with a 95% confidence interval 7.57 to 8.1.
Discussion
The first description of arm reshaping dates back to 1930 by
Thorek [1] and since then many authors described technical varia-
tions regarding incision or fascial plication or both these
aspects [4–8].
Figure 11. Right and left arm. Pre and post-operative figures (12 months
after surgery).
Table 1 summarizes the historical evolution of the techniques
performed through years (Table 1) [1–38].
Important innovations were introduced in 1995 following
Lockwood’s studies on brachial fascial system and more contem-
porary mini-brachioplasty that combined the skin contractility
from liposuction with skin excision to address both longitudinal
and transverse skin excess [9,10]. This technique cannot be used
in our department because our National Public Health System lim-
ited us to offer brachioplasty only to post obesity patients.
So obviously minimal scar incision or liposuction alone were not
considered as a possible treatment.
Regardless such scientific interest and surgical technique varia-
tions, the scar quality and the position remain still the main
reason for patients to complain. Even though, unfortunately the
specific cutaneous regions involved, often lead to a dystrophic
scar [10].
In fact scar positioning is a real challenge even for the experi-
enced surgeon. The debate about whether it should be posi-
tioned medially or posteriorly is actually open and lasts since
50 years [11,12].
Those claiming posterior approach superiority believe it theor-
etically reduces the chances of nerve damage with good scar hid-
ing but many authors also describe this scar location shows a
greater tendency to hypertrophy due to higher tensive lines.
Furthermore, it is partially visible, even with arms at rest.
The anterior approach, consisting in placing the final scar dir-
ectly in the bicipital groove, is ideally the most natural incision
because well hidden while the arm is in adduction, although
there is a higher risk of medial antebrachial cutaneous nerve and
elbow lymphatic vessels injury [4].
Recently an excellent work by Samra et al. [13] seems to dem-
onstrate patients and surgeon’s general preference of the medial
scar positioning compared to posterior approach, and the super-
iority of a linear incision type rather than ellipsoidal shape.
We find very interesting the recently proposed technique by
Fantozzi [14]. Although in our opinion its supposed aesthetic scar
improvement does not worth such an important scar lengthening
and risk of visibility.
Our personal incision technique is mainly derived from
Chandawarkar fish-incision [15] and Hurwitz L-brachioplasty [16]
and allows the surgeon to treat both arm and thoracic skin excess
with a single skin incision. Such incision allows both brachial der-
molipectomy and lifting. Axillary dermolipectomy and lifting is
performed at the same time. In this way, we can get a lifting
effect in the axillar direction and a diameter modulation of the
arm. Attention should be focused on the angle at C point, defined

by the initial markings. This is directly related to the degree and
the vector of the desired brachial lifting. This angle represents a
fundamental step in our operative planning. The ‘J’ final scar also
avoids creation of a single right suture angle that carries all the
main suture tension forces and prevents wound dehiscence in the
axillary region improving the L final scar. In fact this is often a
delicate surgical site regarding wound dehiscence. We believe
that it is possible to reach a good axillary dome definition with
the use of proper scar positioning and a curve angle rather than
with Z-plasty.
We also believe that Samra [13] analysis is to be considered
fundamental at the moment, and a medial non-sinusoidal scar
position must be the gold standard.
We tried different solutions through the years and in our
hands fascial suspension as proposed by Lockwood [17] did not
show significant aesthetic improvement and possible surgical
complications (damaging of intercostal nerves, lymphatic vessels
and medial brachial cutaneous nerve) can occur [4,7,17–19].
A stable BMI < 30 for more than 6 months is mandatory in our
opinion to avoid the risk for postoperative body shape modifica-
tions not related to the surgical procedure. In addition patients
must be encouraged to reach ideal BMI of 25 in order to get as
more ptosis and laxity as possible thus enabling surgeon to better
manage skin flaps and achieve more stable contour results.
Literature is replete with plastic surgeons applying liposuction
in order to decrease dog-ears and contour irregularities, mainly
located at the elbow region [7,20,21], and we do believe that this
is very useful in quite all surgical cases. Beside this, the complete
liposuction of the flap area permits an easier flap dissection low-
ering the risk of nerve and lymphatic damage with only minimum
elongation of surgical time [7,22]. We suggest performing liposuc-
tion just only beneath the flap that has to be removed.
Conclusions
Despite the recent introduction the ‘J’ Brachioplasty technique
has proven to reach good results in massive weight loss patients.
The post-operatory clinical evaluations, carried out until now,
show a good improvement in their upper arm contour with satis-
faction of both surgeon and patients.
Disclosure statement
No potential conflict of interest was reported by the authors.
Patient consent
Patients provided written consent prior to their inclusion in
the study.
The study was approved by the ethics committee of our
institution and was performed in accordance with the ethical
standards laid down in the 1964 Declaration of Helsinki and its
later amendments.
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