Aesth. Plast. Surg.
31:6 9, 2007
DOI: 10.1007/s00266-006-0101-0
Brachioplasty After Massive Weight Loss: A Simple Algorithm for Surgical Plane
Claudio Cannistra, M.D., Ph.D.,1 Rodrigo Valero, M.D.,1 Charles Benelli,1 and Jean Pierre Marmuse, M.D.2
1
Plastic Surgery Unit, Bichat C.B. University Hospital, Paris, France
2
Obesity Surgery Center, Bichat C.B. Universitary Hospital, Paris, France
Abstract. After massive weight loss, patients experience a
severe skin laxity of the arms with or without associated fat
deposits. More than 20 years elapsed after the first aesthetic
brachioplasty in 1954 before this problem was addressed
with significant technical innovation. The current brac-
hioplasty techniques are somewhat unpredictable and
commonly associated with significant untoward results and
complications including misplaced, widened, or hypertro-
phic scars as well as contour deformities resulting from
overcorrection centrally and underresection. The authors
define preoperative marking that permits reduction of
overcorrection problems and makes the surgical technique
easy for young surgeons. They have performed this proce-
dure for 6 years with satisfactory results.
Key words: Brachioplasty—Lipo-aspiration—Massive weight
loss—Severe skin laxity
After massive weight loss, patients experience severe
skin laxity of the arms with or without associated fat
deposits. Aesthetic brachioplasty was first described
by Correa-Iturraspe and Fernandez [3] in 1954 in the
South American literature. More than 20 years
elapsed before the problem of skin laxity was ad-
dressed with significant technical innovation. Since
1975, different surgeons have proposed new technical
procedures to correct the arm deformity [1,2,5 9].
The introduction of liposuction procedures greatly
reduced the number of patients requiring excisional
surgery. However, the current brachioplasty tech-
niques are somewhat unpredictable and commonly
associated with significant untoward results. All sur-
geons have described frequent problems after brac-
Correspondence to Claudio Cannistra M.D., Ph.D., 71 rue
de Rome, 75008, Paris, France; email: c.cannistra@tiscali.
fr
hioplasty including misplaced, widened, or
hypertrophic scars; contour deformities resulting
from overcorrection centrally and underresection
proximally and distally; transverse cutaneous folds;
and delayed wound healing because of marginal skin
necrosis and suture dehiscence [4].
We define a preoperative marking procedure that
permits reduction of overcorrection problems and
makes the surgical technique easier for young sur-
geons. We have performed this procedure for 6 years
with satisfactory results.
Patients and Methods
During the past 6 years, we have performed
brachioplasty for 50 patients presenting with arm
dermolipodystrophy after weight loss of 25 to 100 kg.
These patients have ranged in age from 25 to 60 years.
We prefer to perform a liposuction with local
anesthesia 3 to 5 months before the brachioplasty to
reduce the excess of subcutaneous fat. The delayed
brachioplasty maintains the skinÕs retraction capa-
bilities, reduces the number of patients with primary
indications for surgery, and reduces surgical skin
dissection and resection.
For the first 10 patients, we placed the scar on the
bicipital sulcus [1], but the scar was constantly visible
to patients viewing themselves in a mirror and to
friends and family. For the next 40 patients, we
placed the scar well posterior to the medial bicipital
groove, along the line between the medial axillary line
and the olecranon.
Operative Technique
The procedure is performed with the patient under
general anesthesia. The patient is marked before
C. Cannistra et al.
Fig. 1. The anterior surface of the arm. Line AB from the
coracoid process (point A) to lateral epicondyle of the
humerus (point B) and points C, D, and E.
Fig. 2. The pinching test to assess skin surplus.
surgery in the standing position with the arm straight
abducted to 90°. The first line is traced along the axis
of the arm from the coracoid articulation (point A) to
the lateral epicondyle of the humerus (point B)
(Fig. 1). This line is 28 to 32 cm long.
After this marking, we make the anterior and
posterior arm face two incision lines after the pinch-
ing test to assess the skin excess (Fig. 2). Line AB
then is divided into three or four segments, creating
points C, D, and E (Fig. 3). The first line serves as a
reference about which two incision lines are planned
on either side of the excess skin fold. It is very
important to note the distance from points C, D, and
E to the anterior and posterior skin line incision and
the distance between the anterior and posterior arm
incision lines (Fig. 4).
On the controlateral arm, we trace first line AB
with the C, D, and E points. We report the same
distance between these points and the incision line.
Then we mark the anterior and posterior incision
lines. Normally, the lengths between the anterior and
posterior lines at the C, D, and E points are identical.
This value corresponds to the new circumference of
the arms. This marking makes identical arms possible
(Fig. 5).
7
Fig. 3. Complete operating design on the anterior surface
of the arm. The large numbers (F) are the measurements of
the new arm circumference. The small numbers (G) are the
distances from AB to the incision lines.
Fig. 4. Complete operating design on the back.
After the skin incisions, dissection is performed on
the superficial fascial system suspension because the
subcutaneous resection was performed previously by
liposuction. This procedure reduces the risk of
vascular and nerve injury [6].
The superficial fascial system is plicated at the level
of the inferior arm margin. The scar is located on the
inferior margin of the arm where the gravitational
tension is absent. The laxity of the remaining skin
should permit easy closure. At the level of the axillary
fold, we prefer a Z-plasty closure to preserve the
axillary fold (Fig. 6). A redon drainage is positioned
for 48 h, and an elastic bandage is proposed for 15
days to reduce tissue edema and scar traction.
Results
Follow-up assessment at 1 year has shown a good
result (Figs. 7 9). Large scars are observed on 20%
of our patients. We have not observed skin under- or
overresection with unnatural postoperative contours
8 Brachioplasty After Massive Weight Loss
Fig. 5. Patient at the end of the drawing. Symmetric design
on the arms.
Fig. 6. View of the arm after resection of the skin. The
anterior and posterior lines are connected to obtained a
symmetric reconstruction of the arm.
Fig. 7. Patient after weight loss of 90 kg. Massive arm skin
ptosis.
or lymphedema. No seromas were observed in our
series.
Discussion
The literature analysis showed that the technical
procedure about brachioplasty is carefully explained.
However, skin resection errors, with tissue over- and
Fig. 8. Results 10 months after the procedure.The scars are
not visible on the front.
Fig. 9. Back of same patient as in Fig. 8. The scars are
visible.
underresection as well as anesthetic unnatural con-
tours, can occur. Also, the possibility of nerve and
vascular damage during this procedure and associ-
ated medicolegal problems have stimulated the search
for an easy surgical procedure that can be performed
with the patient under local assisted anesthesia.
Our experience with patients after massive weight
loss has shown that it is very important to prepare
the subcutaneous layers preventively before molding
the superficial skin layers. It also is very important
that the patientÕs weight be allowed to stabilize near
C. Cannistra et al.
ideal body weight before any surgical procedure.
The more skin flaccidity and ptosis there is, the
better the result.
We have not performed preventive lipo-aspiration
for 20% of our patients because in these patients, we
have observed skin ptosis in zone II of the upper
extremity, according to Strauch et al. [9]. In these
cases, there was no subcutaneous fat excess.
We do not prefer the transverse axillary minimal
incision [8] because we believe that the transverse arm
scar can easily damage the axillary lymphatic vessels,
causing lymphatic arm edema. We believe the tech-
nical procedure described by Lockwood [6] is very
dangerous for young surgeons because of the axillary
vein and brachial cutaneous nerve exposure in the
axillary fold to obtain a suspension of the axillary
fold. We propose an algorithm for marking a surgical
plane to avoid postoperative arm asymmetry and to
reduce surgical complications. The plicature of the
superficial fascial system permits a circumferential
arm reduction at the zone II level. A Z-plasty at the
level of the aponeurosis and axillary skin corrects any
zone III axillary deformity.
Positioning of the scar parallel to the axillary
lymphatic vessels reduces the possibility of lymphatic
arm edema. We have not had any cases of hyper-
trophic scar [1]. The scar between the medial humeral
epicondyle and the medial axillary line is positioned
without gravitational tension. The quality of the scar
is good, and the location is more acceptable to
patients because it is not visible when the patient
looks in the mirror.
9
Conclusion
The algorithm for marking the surgical plane during
brachioplasty is carefully explained and planned.
This technique simplifies the method for younger
surgeons and helps to prevent postoperative arm
asymmetries. Scar revision is necessary 1 year post-
operatively for 10% of patients.
References
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