COSMETIC

Outcomes of Combined Liposuction/Laser

Skin Tightening versus Open Suction-Assisted
Brachioplasty in Moderate Arm Ptosis
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Mina Fayek, M.D.
Ibrahem N. Rizk, M.D.
Ahmed M. Hashem, M.D.
Omar A. El Sharkawy, M.D.
Cairo, Egypt
Background: Only a few studies have directly compared outcomes of different
arm contouring techniques across matched cohorts of patients. In this study,
the authors present preliminary data comparing outcomes of conventional
open suction-assisted brachioplasty (using the Pascal and Le Louarn proce-
dure) versus combined liposuction/laser skin tightening in (grade 2b arm pto-
sis per El Khatib classification).
Methods: Thirty patients (60 arms) (28 women, two men) with moderate bra-
chial ptosis (severe upper arm adiposity and a moderate degree of skin laxity)
(grade 2b arm ptosis per El Khatib classification) were included. Objective and
subjective measures were used in the assessment of results.
Results: There were no statistically significant differences in objective measure-
ments (arm circumference reduction ratio and percentage of ptosis elimination)
between the groups. Patient satisfaction scores were higher with liposuction/
laser skin tightening and found to be statistically significant (p < 0.05). Patients
in this latter cohort reported less pain and earlier return to work (mean less than
a week) (p < 0.05). Four patients complained of residual ptosis in each group.
Conclusions: Liposuction/laser skin tightening is a safe and effective alterna-
tive to open suction-assisted brachioplasty (using the Pascal and Le Louarn
technique) in patients with severe arm adiposity and moderate brachial ptosis
(grade 2b arm ptosis as described by El Khatib classification). Proper patient
selection remains critical for the success of this treatment strategy and requires
precise clinical analysis as described. (Plast. Reconstr. Surg. 149: 881e, 2022.)
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

C
onventional brachioplasty often results in
lengthy wounds that are prone to gapping,
prolonged healing, hypertrophic scarring,
and permanent disfigurement.1 Moreover, open
surgery can lead to nerve injury resulting in intrac-
table neuromas and paresthesias.2 These drawbacks
remain tolerable in massive weight loss patients as
they are the most likely to pursue arm lift second-
ary to significant skin excess and ptosis. Isolated
liposuction is effective in only a subset of arm con-
touring patients with no or limited skin surplus
but remains suboptimal with more advanced skin
redundancy. Between these two extremes exists
another cohort who display a variable combina-
tion of adiposity and skin excess. In these patients,
the decision-making process is less clear.
From the Department of Plastic Surgery, Cairo University.
Received for publication August 3, 2020; accepted August
12, 2021.
Copyright © 2022 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0000000000009058
Recently, laser skin tightening has emerged as
an adjunct to conventional liposuction with the
notion that it can maximize postoperative skin
retraction.3 Laser energy applied internally after
conclusion of liposuction causes immediate dis-
ruption and coagulation of dermal collagen. Skin
becomes tighter and over time a new, thicker,
more organized, and tighter reticular dermis
is generated.4 This premise of eliminating skin
redundancy without visible external scarring is
particularly appealing in those with mild to mod-
erate skin excess in whom scars of conventional
skin-reducing surgery seem less justified.
Disclosure: The authors have no financial inter-
ests or conflicts of interests to disclose. There was no
funding for this work.
Related digital media are available in the full-text
version of the article on www.PRSJournal.com.

www.PRSJournal.com 881e
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Several classifications were proposed for arm
deformities.5–9 For the purpose of clinical analy-
sis, we stratify patients according to the classifica-
tion published by El Khatib6 in 2007 as it employs
clear metrics and reliable anatomical landmarks.
It permits the surgeon to accurately define the
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degree of brachial ptosis and group similar
patients in a consistent and reproducible manner
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(Table 1). The treatment protocol for stages 2b, 3,
and 4 in this classification involves some form of
brachioplasty.6
At our institution, open brachioplasty is most
performed using the Pascal and Le Louarn10
procedure. This technique was previously shown
to be associated with a low rate of nonaesthetic
complications, easily correctable adverse aesthetic
sequelae, and favorable scar placement.11
Only few studies have directly compared out-
comes of different arm contouring techniques
across matched cohorts of patients. In this study,
the authors present preliminary data comparing
outcomes of conventional open suction-assisted
brachioplasty (using the Pascal and Le Louarn
procedure) versus combined liposuction/laser
skin tightening in two matching cohorts of
patients with moderate brachial ptosis (grade 2b
arm ptosis per El Khatib classification)6 (severe
upper arm adiposity and moderate degree of
skin laxity). This is a prospective nonrandomized
controlled study. Efficacy, safety, and patient sat-
isfaction were compared between the two groups.
PATIENTS AND METHODS
Following institutional review board approval,
30 patients (60 arms in 28 women and two men)
with moderate brachial ptosis (severe upper arm
adiposity and moderate degree of skin laxity; grade
2b arm ptosis per El Khatib classification) were
recruited. Massive weight loss patients (defined as
50 percent or greater loss of the excess weight or
equal to 100 pounds/45.45 kg), candidates with
poor skin tone, those younger than 20 years of age
Table 1. El Khatib’s Classification and Recommended Treatment for Each Group
Classification
Stage 1: Minimal adipose tissue deposit (300 ml lipoaspirate)
with no ptosis
Stage 2a: Moderate adipose tissue deposit with grade 1 ptosis* (5 cm)
Stage 2b: Severe adipose tissue deposit with grade 2 ptosis* (5–10 cm)
Stage 3: Severe adipose tissue deposit (500 ml lipoaspirate)
with grade 3 ptosis* (10 cm)
Stage 4: Minimal or no adipose tissue deposit with grade 3 ptosis
*The grade of ptosis is determined by measuring the distance from the brachial sulcus to the lowermost border of the pendulous skin
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Plastic and Reconstructive Surgery • May 2022
and older than 60 years of age, and patients with
other degrees of arm contour deformities were
excluded.
Group A (15 patients) underwent combined
liposuction/laser skin tightening. Group B (15
patients) received open suction-assisted brachio-
plasty (using the Pascal and Le Louarn tech-
nique). Patients were allocated to each subgroup
according to individual preference after thorough
explanation of the pros and cons of each treat-
ment approach. Candidates preferring the lipo-
suction/laser skin tightening were those more
willing to accept residual ptosis or undergo a sec-
ondary contouring procedure later if necessary, in
addition to shouldering extra fees for laser skin
tightening.
All patients were preoperatively assessed with
both arms abducted 90 degrees and elbows flexed
90 degrees. Skin elasticity (i.e., excellent, fair,
poor) was recorded using skin pinch and noting
the presence of stretch marks (signifying poor skin
quality). The maximum circumference of each
arm was measured in centimeters (Fig. 1). The
maximum degree of arm ptosis was determined
by measuring the distance from the brachial sul-
cus to the lowermost border of the pendulous arm
in centimeters6 (Fig. 2).
Patient Counseling and Photography
The details of the operation and the expected
results were discussed with the patients with
specific focus on scar positioning, scar visibil-
ity, asymmetry, and the likelihood of a second
stage or revision surgery in case of residual pto-
sis. Photographs were taken preoperative and
postoperative in the following views: (1) anterior
with arms abducted 90 degrees and both elbows
flexed to 90 degrees then with arms abducted and
elbows fully extended and (2) posterior with arms
abducted 90 degrees and both elbows flexed to
90 degrees then arms abducted and elbows fully
extended.
Treatment
Circumferential liposuction
Staged circumferential liposuction
Liposuction of the lower posterior and medial arm
assisted short longitudinal scar brachioplasty
Liposuction of the lower posterior and medial arm
assisted short longitudinal scar brachioplasty
Traditional brachioplasty as described by the author
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Fig. 1. Arm circumference measurement in centimeters.
Operative Procedure
Marking started with the patient’s arms
abducted to 90 degrees and the elbows flexed to
90 degrees. Areas for liposuction were marked.
General anesthesia with endotracheal intubation
was used in all patients. Tumescent solution was
infiltrated using the following formula12: 10 ml of
1% lidocaine, 12.5 ml of 8.4% sodium bicarbon-
ate solution, and 1ml of 1:1000 epinephrine per
liter of normal saline. Infiltration ranged from
750 to 1500 ml per arm.
Group A (15 Patients): Liposuction/Laser Skin
Tightening
Traditional liposuction (standard liposuction/
suction-assisted liposuction) was performed on all
marked areas (Fig. 3), with extensive feathering at
Fig. 2. Degree of arm ptosis measurement in centimeters.
Copyright © 2022 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
the borders to achieve gradual transitioning with
the rest of the arm and maximize the surface area
available for laser skin tightening. After comple-
tion of liposuction, the laser probe was introduced
through the same skin stabs. Neodymium-doped
yttrium aluminum garnet laser energy (ProLipo
PLUS; Sciton, Inc., Palo Alto, Calif.) was then
applied to the skin undersurface using a 2-mm
cannula with the following parameters: 30 per-
cent wavelength, 1064 nm; 70 percent wavelength,
1319 nm at 20 watts.
Total energy was applied by a crossed-fanning
movement from various points in the medium,
deep, and superficial planes tangential to skin.
Care was taken to avoid perpendicular hit of
the tip of the cannula to the skin to avoid burns.
Patients received from 12,000 to 18,000 joules per
arm. A temperature sensor (TempAssure; Sciton,
Inc.) was used to avoid skin overheating and
burns. The alarm was set to trigger once tempera-
ture exceeds 50°C. [See Video (online), which
demonstrates the technique of liposuction/laser
skin tightening.]
All patients were seen on the next day to
exclude any skin problems and ensure adequate
compression garment application. Patients were
advised to maintain these garments for 2 months.
Group B (15 Patients): Open Suction-Assisted
Brachioplasty Using Pascal and Le Louarn
Technique
Fifteen patients were subjected to surgical
resection using the Pascal and Le Louarn tech-
nique. This involves liposuction of the area to be
excised followed by superficial skin-only excision
to preserve lymphatics and cutaneous nerves.
Markings and operative technique were per-
formed identical to the original description.10
Adhesive tapes were initially applied to relieve
tension on the skin sutures followed by bulky
gauze pads. A compressive garment was pre-
scribed for 2 months. Drains were removed after
3 to 5 days. Patients were advised to avoid physical
exertion for 2 to 3 weeks to permit undisturbed
wound healing. All patients were advised to use
Silicon-based ointments after suture removal for a
period of 3 months.
Assessment
Objective Assessment
The following parameters were measured
every 6 months up to 1 year postoperatively in
both groups. The position was consistent at arm
abduction 90 degrees from trunk and elbow
flexed 90 degrees:
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Fig. 3. Preoperative marking for the liposuction/laser skin tightening group, (left) anterior and (right) posterior views.
• Arm circumference reduction ratio was
measured according to the following
equation:
Arm circumference reduction ratio =
arm circumference preoperative – arm circumference postoperative
*100
arm circumference preoperative
• Percentage of ptosis elimination ratio
was measured according to the following
equation:
Arm ptosis reduction ratio =
arm ptosis preoperative – arm ptosis postoperative
* 100
arm ptosis preoperative
• Complications were recorded with special
attention to burns, wound dehiscence, con-
tour irregularities, hypertrophic scars, and
neurologic alterations (e.g., paresthesia).
Subjective Assessment
A questionnaire was administered using a
modification of the BODY-Q questionnaire spe-
cifically tailored to the arms (Table 2). 4,13
Patient satisfaction was evaluated regarding
arm shape, skin tightening, and postoperative
pain period of recovery (return to normal daily
activities). Each question was given a score 0 to 3,
with the total score of 10 questions ranging from
0 (least) to 30 (maximum). The questionnaire
was conducted at 1 year postoperatively by paper
forms filled out during follow-up visits.
Statistical Methods
Descriptive statistics were presented as median
and interquartile range for numeric variables;
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Plastic and Reconstructive Surgery • May 2022
frequencies and ratios were used for categorical
variables. For comparisons of numerical variables,
Wilcoxon rank sum test was used, while for cat-
egorical variables, the chi-square test was applied.
Any p values less than 0.05 were considered statis-
tically significant. Data were coded and entered
using Stata 14.2 (StataCorp, LLC, College Station,
Texas).
RESULTS
Demographic Data
Thirty patients met inclusion criteria. Fifteen
women were in group A (liposuction/laser skin
tightening), and 13 women and two men were
in group B (open suction-assisted brachioplasty).
The age, sex, and body mass index characteristics
are listed in (Table 3). Two patients presented
with marked arm asymmetry; both were in the
liposuction/laser skin tightening group.
Follow-Up
Follow-up ranged from 6 to 12 months (mean,
10 months) in group A (liposuction/laser skin
tightening) (Figs. 4 and 5) and 6 to 14 months
(mean, 9 months) in group B (open suction-
assisted brachioplasty) (Fig. 6). Arm circumfer-
ence and arm circumference reduction ratio are
shown in Table 4 and Figures 7 and 8.
Arm Ptosis
Preoperative arm ptosis in group A (lipo-
suction/laser skin tightening) ranged from 6 to
9.5 cm (median, 7 cm; interquartile range, 6 to
8 cm), whereas in group B (open suction-assisted
brachioplasty), it measured from 6 to 10 cm
 Volume 149, Number 5 • Liposuction versus Brachioplasty

Table 2. Questionnaire Used to Assess Patient Satisfaction in This Study*

With your upper arms in mind, how dissatisfied or
satisfied have you been with: 0 1 2 3
1. Did you feel discomfort after the procedure? Severe Moderate Mild No
2. Has the procedure prevented you from Severe Moderate Mild No
working or interfered with your work?
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3. The size of your upper arms? Very dissatisfied Somewhat dissatisfied Somewhat satisfied Very satisfied
4. How smooth your upper arms look? Very dissatisfied Somewhat dissatisfied Somewhat satisfied Very satisfied
5. The shape of your upper arms? Very dissatisfied Somewhat dissatisfied Somewhat satisfied Very satisfied
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6. How the skin on your upper arms looks? Very dissatisfied Somewhat dissatisfied Somewhat satisfied Very satisfied
7. How toned your upper arms look? Very dissatisfied Somewhat dissatisfied Somewhat satisfied Very satisfied
8. How your upper arms look when you lift Very dissatisfied Somewhat dissatisfied Somewhat satisfied Very satisfied
them up?
9. Had the treatment fulfilled your expectations? 0–25 % 25–50% 50–75% 75–100%
10. W
 ould you recommend this treatment to No Yes
thers?
*Adapted from Leclère FM, Alcolea JM, Vogt P, et al. Laser-assisted lipolysis for arm contouring in Teimourian grades I and II: A prospective
study of 45 patients. Lasers Med Sci. 2015;30:1053–1059; and Klassen AF, Cano SJ, Alderman A, et al. The BODY-Q: A patient-reported outcome
instrument for weight loss and body contouring treatments. Plast Reconstr Surg Glob Open 2016;4:e679.

(median, 8 cm; interquartile range, 7 to 9 cm)
(Table 5).
Postoperative arm ptosis in group A (liposuc-
tion/laser skin tightening) ranged from 0 to 4 cm
(median, 0.5 cm; interquartile range, 0 to 1 cm),
whereas in group B (open suction-assisted bra-
chioplasty), it measured from 0 to 5 cm (median,
0 cm; interquartile range, 0 to 4 cm). Distribution
of percentage of arm ptosis reduction in both
groups is demonstrated in Figure 9.
There were no statistically significant differ-
ences in objective measurements (arm circum-
ference reduction ratio and percentage of ptosis
elimination) between the two groups (p = 0.54,
0.66 respectively).
Patient Satisfaction
Patient satisfaction in group A (liposuc-
tion/laser skin tightening) ranged from 15 to
29 (median, 26; interquartile range, 22 to 28),
whereas in group B (open suction-assisted brachio-
plasty), it measured from 13 to 27 of 30 (median,
20; interquartile range, 16 to 23) (Table 6).
Patient satisfaction scores were higher in
group A (liposuction/laser skin tightening)
(Fig. 10) and found to be statistically significant
(p < 0.0001). Patients reported less pain and
Table 3. Patient Demographics
Group A Group B
(L/LST) (OSAB) p ment. By reducing wound length or changing
Sex 15 women 13 women — incision placement, greater patient tolerance is
and 2 men
Median age, years (IQR) 33 (28–42) 32 (26–53) 0.91
Median BMI, kg/m2 (IQR) 32 (27–34) 32 (28–35) 0.74
BMI, body mass index; IQR, interquartile range; L/LST, liposuction/
laser skin tightening; OSAB, open suction-assisted brachioplasty.
earlier return to work (mean, less than a week) in
group A (p < 0.05).
Complications
Group A: Liposuction/Laser Skin Tightening
Four patients complained of residual pto-
sis (up to 4 cm) at 12 months postoperatively
(Table 6). None of them requested further sur-
gery. No burns were encountered in any of the
cases. Two seromas were aspirated in the office
followed by compression with eventual success-
ful resolution. No neurologic complications were
encountered.
Group B: Open Suction-Assisted Brachioplasty
Four patients complained of residual pto-
sis (up to 5 cm) at 12 months postoperatively
(Table 6). One of them requested a repeat bra-
chioplasty, which was performed elsewhere. Three
patients required secondary sutures after wound
gapping. Two patients underwent scar revision
(after 12 months) for widened pigmented scars.
No neurologic complications were encountered.
DISCUSSION
Postoperative scarring remains a major con-
cern in brachioplasty.2 Wounds are prone to
gapping, prolonged healing, and may result in
widened, dyschromic, and hypertrophic scars.14
Indeed, dissatisfaction with brachioplasty scars has
led to legal proceeding.15 Many proposed techni-
cal refinements contemplate better scar conceal-
hoped for.16 Nevertheless, the optimum length
and location from patient and surgeon perspec-
tive remains ill-defined and is still not clear.15 In
our community, patient sensitivity to scars is high

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Fig. 4. A 42-year-old female patient of the liposuction/laser skin tightening group. (Left) Preoperative and (right) 12-month post-
operative anterior and posterior views.
and is key in decision-making. Discouraged by the
final scar appearance, many elect to endure the
arm deformity instead of undergoing surgery.
Liposuction can offer optimum correction in
young patients with no or minimal skin laxity but
remains inadequate in older individuals and those
with more advanced tissue redundancy.6 Massive
weight loss patients represent a distinct group that
lies at the other extreme end of the spectrum. In
this cohort, which is the patient population most
likely to pursue arm lift for significant skin excess
and ptosis, severe laxity mandates open surgery,
which remains the gold standard and the only
route of achieving a meaningful correction. None
of our patients belonged to the latter category.
Patients displaying arm adiposity with moderate
redundancy, however, evoke the least clear deci-
sion-making process and warrant a more careful
evaluation. In this group, isolated liposuction will
result in improved fatty contour, but postopera-
tive skin retraction remains largely unpredictable.
In fact, skin laxity may worsen and require sec-
ondary interventions. On the other hand, con-
ventional brachioplasty in this cohort can result
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Plastic and Reconstructive Surgery • May 2022
in significant scarring that may prove worse than
the original deformity. Different minimal-incision
brachioplasty techniques17–19 were suggested to
address the needs of this population, but lack of
proof for consistency and reproducibility has hin-
dered their wide-spread implementation.
Our study focused on this latter group of
patients. It confirmed the safety and efficacy of
liposuction/laser skin tightening in treating this
cohort (moderate arm ptosis to grade 2b arm pto-
sis as described by El Khatib classification6). More
importantly, it suggests the approach to be equiva-
lent to open surgery in this subset of patients. We
used clear preoperative and postoperative objec-
tive measurements to evaluate the outcomes of
our interventions (i.e., circumference arm reduc-
tion, ptosis elimination). These showed compa-
rable results between both treatment groups. In
addition, we employed a questionnaire to gauge
patient’s perceptions. Liposuction/laser skin
tightening was associated with greater patient sat-
isfaction, less pain, and earlier return to work.10
Although we encountered two seromas in the lipo-
suction/laser skin tightening group, these were
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Fig. 5. A 31-year-old female patient of the liposuction/laser skin tightening group. (Left) Preoperative and (right) 12-month post-
operative anterior and posterior views.
readily resolved with office aspirations and com-
pression. Nevertheless, secondary procedures (i.e.,
secondary sutures, scar revision) were more often
required in the open surgery cohort. In fact, none
of the patients in the liposuction/laser skin tight-
ening arm underwent an additional procedure.
Earlier studies established the effectiveness of
laser-assisted liposuction in contouring the arms of
patients with limited skin laxity but reported sub-
optimal outcomes in those with more advanced
redundancy.4
A study comparing laser lipolysis to conven-
tional liposuction was also previously reported.3
It showed laser lipolysis to be equally effective in
treating patients with mild to moderate arm laxity.
Those who received the laser energy in addition
showed greater improvement in arm circumfer-
ence reduction. The results are thought to be sec-
ondary to improved skin retraction.3
In contrast to previous reports using laser
energy in arm contouring, our protocol employed
the laser energy after completion of liposuction.
Thus, no laser energy is wasted for lipolysis har-
nessing the whole power toward skin tightening.
Presumably, this modification maximizes subse-
quent skin retraction. When applied for lipolysis,
laser is believed to facilitate suction and decrease
Copyright © 2022 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
operator fatigue; this is negligible in the arm
where volumes of lipoaspirate rarely exceed 1.5
liters. A temperature sensor and maintaining the
cannula parallel to the skin are essential to avoid
laser-induced burns with this approach, though.
To our knowledge, this is the first study com-
paring liposuction/laser skin tightening with
open suction-assisted brachioplasty. At the outset
of the study, we anticipated a higher incidence
of residual ptosis in the liposuction/laser skin
tightening group. Thus, all patients were con-
sented to the potential need for secondary con-
touring surgery at 1 year. Nevertheless, we found
the prevalence of residual ptosis to be similar in
both groups. Moreover, the only patient request-
ing secondary brachioplasty belonged to the open
surgery cohort.
Our protocol did not include a financial anal-
ysis of each treatment approach. We anticipate a
higher overall cost incurred by liposuction/laser
skin tightening. Nevertheless, the potential to
negate problematic scarring with equal clinical
results to open surgery remains an immeasurable
benefit for this subset of patients.
Our study involved a limited number of partic-
ipants. A larger cohort would undeniably validate
our results with greater certitude. Nevertheless, it
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Fig. 6. A 30-year-old female patient of the open suction-assisted brachioplasty group. (Left) Preoperative and (right) 12-month
postoperative anterior and posteriors views.

allowed us to establish sufficient proof of concept
to offer liposuction/laser skin tightening instead
of conventional brachioplasty to future similar
candidates.
We used only one technique of brachioplasty
for comparison. Alternative methods may yield dif-
ferent outcomes. Nonetheless, our preference was
to employ the technique most performed at our
institution. Previous reports established its low rate
of nonaesthetic complications and favorable scar
placement.11 Moreover, resultant adverse aesthetic
sequelae are easily correctable in our experience.
The questionnaire we administered lacked
proper anonymity. Furthermore, the patients
chose which technique they preferred at the out-
set. This has the potential to create bias when
assessing patient satisfaction with the outcome and
risks being skewed toward favorable responses.
Nevertheless, it was conducted to both groups in
a similar fashion, and we believe the differences
identified are truthful representation of patients’
perceptions.
Our study was limited to 1 year of follow-up.
We hypothesize that skin retraction would con-
tinue to improve over time. Future longitudinal
studies over extended durations might establish
the precise temporal timeline and endpoint of
laser-induced dermal tightening.
In this new era, innovative technologies are
increasingly utilized to enhance surgical outcomes.
We investigated the effect of laser skin tightening
in arm contouring with favorable results.
Ultrasound-assisted liposuction is another
excellent energy-based modality with great poten-
tial. Nevertheless, in our hands, it appears to result
in less skin retraction when compared to laser skin
tightening. Thus, we reserve ultrasound-assisted
liposuction to challenging areas with considerable
fibrous/glandular component (e.g., gynecomas-
tia and redo cases). Collins and Moyer previously
reviewed studies comparing ultrasound-assisted
liposuction and laser-assisted liposuction with suc-
tion-assisted liposuction. Their review suggests a
superiority of ultrasound-assisted liposuction over

Table 4. Arm Circumference Preoperatively and 1 Year Postoperatively with Percentage of Reduction
Group A (L/LST) Group B (OSAB) p
Preoperative arm circumference, median (IQR) 42.25 (38–45) 40.5 (37–46) 0.45
Postoperative arm circumference, median (IQR) 35 (32–36) 33 (20–36) 0.67
Arm circumference reduction ratio, median (IQR) 21 (15–24) 22.5 (19–27) 0.54
IQR, interquartile range; L/LST, liposuction/laser skin tightening; OSAB, open suction-assisted brachioplasty.

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Fig. 7. Range of preoperative and postoperative arm circumference and ptosis. OSAB, open
suction-assisted brachioplasty; L/LST, liposuction/laser skin tightening.

suction-assisted liposuction in gynecomastia, better In our study, we utilized liposuction cou-

skin retraction with ultrasound-assisted liposuction
and laser-assisted liposuction over suction-assisted
liposuction, and finally less bloody aspirates with
ultrasound-assisted liposuction and laser-assisted
liposuction when compared to suction-assisted
liposuction in mega-volume treatments.20
pled with laser skin tightening rather than
laser-assisted liposuction as described above.
Directly comparing ultrasound-assisted lipo-
suction, laser-assisted liposuction, and liposuc-
tion/laser skin tightening in terms of efficacy,
skin retraction, cost, complications, and clinical

Fig. 8. Distribution of arm circumference reduction. OSAB, open suction-assisted brachio-

plasty; L/LST, liposuction/laser skin tightening.

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 Plastic and Reconstructive Surgery • May 2022

Table 5. Ptosis Preoperatively and 1 Year Postoperatively with Percentage of Reduction

Group A (L/LST) Group B (OSAB) p
Preoperative ptosis, median (IQR) 7 (6–8) 8 (7–9) 0.16
Postoperative ptosis, median (IQR) 0.5 (0–1) 0 (0–4) 0.74
Ptosis reduction ratio, median (IQR) 94.5 (83–100) 100 (60–100) 0.66
IQR, interquartile range; L/LST, liposuction/laser skin tightening; OSAB, open suction-assisted brachioplasty.
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Fig. 9. Distribution of arm ptosis reduction. OSAB, open suction-assisted brachioplasty; L/

LST, liposuction/laser skin tightening.

outcome is necessary to establish the relative
merits of each.
Radiofrequency is another energy-based
strategy that has been utilized to maximize skin
retraction following arm liposuction. Previous
reports suggest a favorable tightening effect.21,22
Also, J-plasma (Apyx Medical, Clearwater, Fla.) is
increasingly marketed on the internet as a means
of minimally invasive skin tightening, but clinical
studies to validate its effectiveness and safety pro-
file are still lacking.
Future studies to establish the basic biology
underlying the skin response to different energy
modalities and compare their effectiveness, com-
plications, and therapeutic profile in variable clin-
ical settings will improve understanding of this
fascinating and critical aspect of plastic surgery.
Finally, emerging nonsurgical modalities (e.g.,
cryolipolysis, external laser fat treatments, focused-
ultrasound, injection lipolysis) are increasingly mar-
keted as office-based body contouring strategies.
Their precise therapeutic role in the arm contouring

Table 6. Satisfaction Score, Complications, and Revision Surgery

Group A (L/LST) Group B (OSAB) p
Satisfaction score, median (IQR) 26 (22–28) 20 (16–23) <0.0001
Complications
 Residual ptosis 4 patients 4 patients 0.76
 Wound gapping — 3 patients —
 Poor scar necessitating revision — 2 patients —
 Seromas 2 patients — —
Revision surgery — 6 patients (secondary sutures: 3 patients; scar revision: —
2 patients; secondary brachioplasty: 1 patient)
IQR, interquartile range; L/LST, liposuction/laser skin tightening; OSAB, open suction-assisted brachioplasty.

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Fig. 10. Distribution of patient satisfaction scores. OSAB, open suction-assisted brachio-
plasty; L/LST, liposuction/laser skin tightening.
patient is still ill-defined and requires well-designed
studies to establish their clinical indications, limita-
tions, and long-term results. Nevertheless, detailed
review and description of these treatments rest
beyond the scope of this report.
CONCLUSIONS
Liposuction/laser skin tightening is a safe and
effective alternative to open suction-assisted brachio-
plasty (using the Pascal and Le Louarn technique)
in patients with severe arm adiposity and moderate
brachial ptosis (grade 2b arm ptosis as described by
El Khatib classification). Proper patient selection
remains critical for success of this treatment strategy
and requires precise clinical analysis as described.
Mina Fayek, M.D.
Department of Plastic Surgery
Cairo University
Al Kasr Al Ainy
Cairo, Egypt 11562
minafayekdanial@gmail.com
Facebook: boshkashdanial
Instagram: @mina.fayek
Twitter: @minafayekdanial
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