COSMETIC

The L Brachioplasty: An Innovative Approach

to Correct Excess Tissue of the Upper Arm,
Axilla, and Lateral Chest
Dennis J. Hurwitz, M.D.
Sarah W. Holland, M.D.
Pittsburgh, Pa.; and New York, N.Y.
Background: Brachioplasty is aesthetic reshaping of the upper arm after re-
moval of excess medial skin and fat. Massive weight loss patients evolve a severe
arm deformity that extends through the axilla and onto the chest. Prevalent
operations are incomplete and leave conspicuous scars along the bicipital
groove that end as Ts or Zs in the axilla. The L brachioplasty starts with a long
ellipse centered over the lower half of the inner arm that sweeps up to the
deltopectoral groove. A shorter ellipse is connected at right angles through the
axilla onto the chest. The V flap formed between the ellipses is advanced across
the axilla to raise the posterior axillary fold. An improved arm, axilla, and chest
have an L-shaped zigzag crossing the axilla.
Methods: L brachioplasty, along with upper body lifting, was applied to 24
female weight loss patients over the last 2 years. Ultrasound-assisted lipoplasty
was also performed in five patients. All patients were interviewed. Follow-up
ranged from 6 to 28 months.
Results: All 22 patients were improved and pleased. One patient requested and
received a limited scar revision. Three patients had delayed healing at the tip
of the triangular flap. Four seromas near the elbow responded to multiple
aspirations. One hypertrophic scar was improved with intense pulsed light.
Conclusions: The L-shaped brachioplasty is an innovative, effective, reliable,
aesthetic, and safe technique. Integrating the brachioplasty into the upper body
lift improves the contours of the axilla, breast, and upper lateral chest, con-
tributing to improved harmonious body contour. (Plast. Reconstr. Surg. 117:
403, 2006.)

W
ith weight loss and aging, many women
disdain the increasingly hanging skin and
fat of their upper arms. Brachioplasty
treats this condition. Brachioplasty is the aesthetic
reshaping of the upper arm after the removal of
excess medial skin and fat. The new contour
should be attractive, the scars should be inconspic-
uous, and the complications should be minor.
After bariatric surgery and hundreds of
pounds of weight loss, patients evolve a bizarre
arm deformity that extends through the axilla
From the Department of Surgery (Plastic), University of Pitts-
burgh Medical Center, and the Department of Surgery, New
York-Presbyterian Hospital.
Received for publication December 19, 2004; revised April
20, 2005.
Presented at the Annual Meeting of the Ohio Valley Society
of Plastic Surgeons, in Cleveland, Ohio, June of 2004, and
at Plastic Surgery 2004, in Philadelphia, Pennsylvania,
October of 2004.
Copyright ©2006 by the American Society of Plastic Surgeons
DOI: 10.1097/01.prs.0000200800.81548.37
and onto the chest. We found prevalent
operations to be inadequate.1– 4 Furthermore,
the straight scars along the bicipital groove
are conspicuous, ending as Ts or Zs in the
axilla.
In the course of treating these challenging
cases, we developed a new technique of contin-
uous excision of excess skin from the arm
through the axilla and onto the chest, in the
form of the letter L.5 The sweeping scar across
the axilla resembles the letter L on its side. Dur-
ing the past 2 years, we have applied the L bra-
chioplasty successfully over the spectrum of arm
deformities. We present this technique and a
retrospective review of 24 consecutive cases
treated at Magee Women’s Hospital of Pitts-
burgh.
Treatment starts with analysis of the anatomy
(Figs. 1 and 2). There are five consistent defor-
mities in the brachioplasty candidate that are
exaggerated in the massive weight loss patient:
(1) the upper arm skin sags along the posterior

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 Plastic and Reconstructive Surgery • February 2006

Fig. 1. A 34-year-old woman, body mass index of 26, lost 250 pounds after gastric bypass and was
left with extreme hanging skin of the arms, axillae, breasts, and chest. The anterior axillary fold is
indistinct. The posterior axillary fold has descended. The axillae are oversized, with folds of skin. The
wrinkled skin of the lateral chest skin borders the pancake-like breasts.

Fig. 2. Side views of the patient shown in Figure 1.

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Volume 117, Number 2 • L Brachioplasty
margin from the axilla to the elbow; (2) the
posterior axillary fold descends along the poste-
rior axillary line; (3) the axilla is oversized and
distorted; (4) the anterior axillary fold is poorly
defined and does not relate to the breast; and
(5) the lateral chest skin is loose and leads into
the midtorso transverse roll.
Postoperative results of the L brachioplasty show
normal arm contour tapering to the elbow and
axilla (Figs. 3 and 4). A scarless posterior axillary
fold gracefully extends from the arm to the chest.
The smaller axilla has a smooth, deep dome bor-
dered by well-defined anterior and posterior axil-
lary folds. The upper lateral chest laxity is cor-
rected. The long curvilinear scar starts posterior to
the mid-medial arm to ascend to the height of the
axilla, and then plunges down to the chest. With
the patient’s arms at the side, the scars should not
be visible. With the arms raised, the scar unobtru-
sively crosses the axilla without contracture.
PATIENTS AND METHODS
Operative Technique
The anticipated excision of excess skin and fat
is drawn in the form of an inverted L, with the
closed angle at the dome of the axilla (Figs. 5 and
6). The two limbs are nearly perpendicular el-
lipses. The long ellipse is situated along the medial
aspect of the arm. The short ellipse is along the
outer half of the axilla and lateral chest. The mark-
ings are made with the patient sitting. The arm
and forearm are abducted 90 degrees with the
palm forward, as if the patient were taking an oath.
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 to-
ward the mid-axilla. The area between these inci-
sions incorporates the excess skin of the upper
arm, as determined by tissue gathering estimates.
When there is fatty excess, one has to consider the
volume reduction due to liposuction. The second
ellipse drops vertically from the deltopectoral
groove to include approximately the lateral half of
the axilla and continues vertically to include ex-
cess lateral chest wall skin. The chest portion of
this ellipse is coordinated with the transverse re-
moval of a back roll performed during an upper
body lift. An inferiorly based triangular flap is
formed as the inferior arm incision meets the lat-
eral incision of the vertically oriented axillary el-
lipse. The ability to advance this triangular flap to
the deltopectoral groove is checked by pinch ap-
proximation. This maneuver elevates the ptotic
posterior axillary fold and tapering of the arm
toward the axilla. The markings are re-evaluated
with the arm and forearm fully extended above the
head. The incision lines are then crosshatched for
proper alignment.
With the patient in the supine position, the
arms are placed on operating room table arm
boards. They are prepared with antiseptic from
midforearm to mid-lateral chest. The unprepared
forearm, with a forearm blood pressure cuff, is
wrapped in sterile drapes. The width of resection
is checked one more time. If there is any doubt,
then a slightly narrower ellipse is removed. We
infuse several hundred cubic centimeters of saline
with 1 mg of epinephrine and 40 cc of 1% Xylo-
caine per liter until the tissues are firm. After we
wait about 10 minutes for vasoconstriction to oc-
cur, we perform lipoplasty as needed in areas that
are not being resected.
With the medial skin rolled superiorly, the
inferior incision is made with a scalpel through
skin to the crural fascia enveloping the muscles.
About 1 cm of undermining is done. Hemostasis
is obtained by grasping vessels and electocautery.
The arching superior incision is then made from
the elbow to the deltopectoral groove; it is also
minimally undermined. Hemostasis is again ob-
tained. We similarly incise the outline of the ax-
illary chest ellipse, taking care to go just deep to
the dermis in the axilla. The triangle of skin and
fat at the elbow is grasped with a multitooth clamp
or rake. The instrument firmly distracts the ellipse
toward the chest as the tissue is cut away, leaving
a fine deep layer of subcutaneous fascia and fat
over the subcutaneous nerves. Dissection stops so
that larger bleeders can be electocoagulated. The
excision courses subdermally through the axilla
and then completes deeply over the muscular fas-
cia of the lateral chest. The clavipectoral fascia of
the axilla is seen but not entered. Major veins and
sensory nerves are not seen.
Using the previously marked guidelines, the
incisions are aligned with towel hooks. A contin-
uous, running, long-lasting but absorbable 2-0 su-
ture approximates the subcutaneous fascia. As a
towel clamp is approached, a second clamp leap-
frogs ahead before that clamp is released. A sec-
ond, smaller-caliber, continuous intradermal clo-
sure follows. Stern strips or dermal glue is used to
complete the operation. The patient’s arms are
wrapped in gauze and an Ace bandage.
As the skin tensions equilibrate, the scar
courses from the medial epicondyle to along the
inferior medial arm, inferior to the bicipital
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 Plastic and Reconstructive Surgery • February 2006

Fig. 3. Postoperative results for the patient shown in Figures 1 and 2, 14 months after bilateral
L brachioplasty with a total body lift using spiral flap breast augmentation. The patient has
normal-looking arms, axillae, chest, and breasts. Fading symmetrical L-shaped scars start at the
medial elbow and undulate posteriorly and then superiorly across the height of the axilla to
descend along the midlateral chest to reach transverse back scars. The faintly visible midlateral
axillary and chest extensions do not disrupt the axillary folds. A mildly concave, better-defined
anterior axillary fold flows into a gentle lateral breast convexity.

Fig. 4. Side views of the patient shown in Figure 3.

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Fig. 5. The preoperative markings for an L brachioplasty in a 59-year-old woman (no weight loss) are made with the
patient’s arm extended 90 degrees and the forearm flexed 90 degrees. (Above, left) A line joins three points from the
medial epicondyle, the midarm bicipital groove, and the deltopectoral groove. (Center, left) At the widest sagging of the
mid-arm, the skin is gathered and pinched closed and an inferior mark is made. (Below, left) The inferior line is drawn from
the epicondyle to the inferior resection mark. (Above, right) The elevation of the posterior axillary fold is estimated and
marked by gathering lower skin to the delopectoral mark and straightening the inferior line. (Center, right) The inferior
incision line continues to that mark. (Below, right) A vertical line roughly bisects the axilla to the mid-lateral chest.

groove. It gently rises to the axillary dome and
then drops vertically to the chest, forming an in-
verted L. The inferior contour of the arm drops
slightly at the midhumerus and then distinctly
rises to a superiorly positioned posterior axillary
fold. The suspended posterior axillary fold skin
conforms well to the axillary hollow (Figs. 7 and
8).
This L-shaped brachioplasty technique, along
with the upper body lift, was applied to 24 female
massive weight loss patients over the last 2 years.
Ultrasound-assisted lipoplasty was also performed
in five of the patients because of excess adiposity
(Figs. 9 and 10).
RESULTS
Twenty-two 22 of the 24 patients were inter-
viewed and all office charts were reviewed. The
operative time was approximately 90 minutes for
the two sides, but frequently the time was halved
by team surgery. Follow-up ranged from 6 to 28
months. All 22 patients were pleased with their
results. The senior author felt that all patients
were greatly improved, but that the arms were
still a bit large in some of the severe cases, even
though the wound closures were very tight. Most
patients wear sleeveless tops in the summer, be-
cause their scars are not visible unless their arms
are outstretched.
One patient requested and received a limited
scar revision. There were few complications.
Three patients had delayed healing at the tip of
the triangular flap due in part to pressure from
elastic sleeves. Four seromas near the elbow re-
sponded to multiple aspirations. The portion of
the scar close to the elbow stayed red and thick the

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 Plastic and Reconstructive Surgery • February 2006
Fig. 6. While the posterior axillary fold triangular flap is pulled
toward the deltopectoral groove, the axillary and chest excision
lines are completed, avoiding dog-ears.
longest. One hypertrophic scar was improved with
intense pulsed light.
DISCUSSION
Although designed for the massive weight loss
patient, the L brachioplasty is suitable for a range
of arm and axillary deformities. Positioning the
excision in a curving L shape obscures the ap-
pearance of the scar and retards contracture. The
operation is simply designed and rapidly exe-
cuted. Confidence in planning and experience
permit expeditious removal of the excess skin in
the proper plane just over the deep subcutaneous
fascia. If the resection width is difficult to assess, we
are conservative in the resection and may resect
more later in the operation. Alternatively, the pro-
cedure can be performed with repeated cutting
and checking, but we believe the decision of the
right amount to remove is best made at the onset,
before fluid infusions and operative swelling. The
assistant’s traction and the surgeon’s countertrac-
tion easily keep one in the right plane along the
deepest subcutaneous fascia, away from larger sen-
sory nerves and veins.
Closure is performed with two-layer running ab-
sorbable sutures placed into the weakly developed
subcutaneous fascia and then intradermally. There
is no need to anchor the triangular flap into the
axillary fascia.3 We do not enter the axilla, to avoid
injury to neurovascular structures. We are impressed
with how nicely the elevated posterior axillary fold
skin smoothly conforms to the hemidome of the
408
axilla without deep sutures or drains. Lockwood’s T
plasty excision leaves two right-angle arm flaps that
lead into the axilla.3 Tip necrosis, with widened scars
and contracture, does occur. The top of the T fre-
quently drifts toward the inner arm.
The medial arm scar slowly rises from the distal
posterior arm to the apex of the axilla, thwarting the
tendency of contracture when it lies totally within the
bicipital groove. Some advocate placing the scar
along the posterior margin of the arm.6 We and
others2 find those scars tend to become hypertro-
phic and contract. We also find the axillary Z-plasty6
to be ill-fitting and geometric. The ill fit relates to the
static Z-shaped scar in a dynamically reshaping axilla
and the subtle coning at each closed angle of the
Z-plasty. The Z shape of the scar is subtle only if the
scar fails to become hypertrophic.
The L brachioplasty is similar to Pitanguy’s
extended brachioplasty through the axilla and
onto the chest and under the breast.7 He made
little note of improvement of the axilla. In fact,
plastic surgeons have virtually ignored the beauty
of the axilla and upper lateral chest.
The cutaneous axilla (armpit) is a dome-
shaped structure formed by the tight adherence of
thin axillary skin to the suspending clavipectoral
fascia. The axilla is bordered by the inner arm,
lateral chest, and axillary folds. The anterior ax-
illary fold is created by firm skin adherence to the
lateral edge of the pectoralis major muscle. The
gentle concave of the anterior axillary fold turns
abruptly convex around the lateral boarder of the
breast. The posterior border is the posterior ax-
illary fold, created by firm skin adherence along
the lateral edge of the latissimus dorsi muscle.
Atrophy or resection of these muscles disrupts
these folds. Unseen with the arms at the side, the
armpit crevasse is seductively deepest when the
arm is extended 90 degrees and gently undulates
when the arm is fully raised.
The L brachioplasty restores these anatomical
subtleties in both weight loss and aging patients
without an obtrusive scar. The success is due to the
rather large resection of skin and the direct tri-
angular flap advancement of the axillary fold.
There are no geometric scars or dog-ears caused
by rotation flaps.
CONCLUSIONS
The L-shaped brachioplasty is an innovative, ef-
fective, reliable, aesthetic, and safe technique after
massive weight loss. The excess upper arm skin is
reduced, leaving a tapered junction to a raised pos-
terior axillary fold. Arm mobility is unrestricted, with
an inconspicuous scar across the axilla. Integrating
Volume 117, Number 2 • L Brachioplasty

Fig. 7. (Above) Preoperative frontal view of the patient shown in Figures 5 and 6. (Below) The
7-month result shows the symmetrical improvement of the arms, axillae, and chest. The poste-
rior axillary fold skin has molded into the axillae. The arm scar slowly rises from the posterior
elbow to the axillary dome. The axillary scar bisects the anterior and posterior axillary folds. The
scars are symmetrical and fading, and there is no suggestion of arm or posterior axillary con-
tracture. This demonstrative case is not included in the data for this series of weight loss patients.

Fig. 8. (Above) Preoperative oblique view of the patient shown in Figures 5 and 6. (Below) The
7-month result shows the symmetrical improvement of the arms, axillae, and chest.

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Fig. 9. Preoperative and 1-year postoperative frontal views after L brachioplasty with ultra-
sound-assisted lipoplasty. The patient lost 90 pounds and has a body mass index of 36. She had
a two-stage total body lift. The arms, axillae, chest, and breasts are improved. The scars are
symmetrical and fading, and there is no suggestion of arm or posterior axillary contracture.

Fig. 10. Preoperative and 1-year postoperative oblique views of the patient shown in Figure 9.

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the brachioplasty into the upper body lift improves 2. Vogt, P. A., and Baroudi, R. Brachioplasty and brachial suc-
the contours of the axillae, breast, and upper lateral tion-assisted lipectomy. In M. Cohen (Ed.), Mastery of Plastic
and Reconstructive Surgery. Boston: Little, Brown, 1994. Pp.
chest and contributes to an improved and harmo- 2219-2236.
nious body contour. The L brachioplasty shows 3. Lockwood, T. Brachioplasty with superficial fascial system sus-
promise for selected aging cases. pension. Plast. Reconstr. Surg. 96: 912, 1995.
4. Teimourian, B., and Malekzadeh, S. Rejuvenation of the up-
Dennis J. Hurwitz, M.D. per arm. Plast. Reconstr. Surg. 102: 545, 1998.
3109 Forbes Avenue, Suite 500 5. Hurwitz, D. J. Single-staged total body lift after massive weight
Pittsburgh, Pa. loss. Ann. Plast. Surg. 52: 435, 2004.
drhurwitz@hurwitzcenter.com 6. Strauch, B. A technique of brachioplasty. Plast. Reconstr. Surg
113: 1044, 2004.
REFERENCES 7. Pitanguy, I. Correction of lipodystrophy of the lateral thoracic
1. Regnault, P. Brachioplast, axilloplast, and pre-axilloplasty. Aes- aspect and inner side of the arm and elbow. Clin. Plast. Surg.
thetic Plast. Surg. 7: 31, 1983. 2: 477, 1975.

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