We divide patients undergoing brachioplasty into 3 groups, according to their characteristics. Group 1 comprises patients with moderate to firm skin and voluminous upper-arm fat deposits. We perform lipoplasty with specific limitations on how much fat is removed based on the patient’s skin turgor. These principles are the same as those advocated by Vogt.

Group 2 comprises patients with flabby skin and fat deposits. Treatment includes lipoplasty and skin resection in the same stage. Surgery begins with lipoplasty. We perform skin undermining superficially, preserving the subcutaneous tissue to avoid severing of lymphatic vessels and superficial nerves.

Group 3 comprises patients with flaccid skin and no fat deposits. Resection of excess skin is the only indication for this group. In almost all of these patients, we resect an elliptical or triangular shaped piece of skin flap, saving the internal brachial sulcus as reference. We place the suture and final scar 1 to 3 cm above or below this sulcus (Figure 1). The amount of axillary skin resected is based simply on redundancy. It is imperative, however, that the scar is placed at the inner aspect of the upper arm; otherwise it will be exposed.

Schematic representation of the triangular and elliptical incisions for resection of excess skin. XX’ represents the internal brachial sulcus. It is important to place the final scar 1 to 3 cm above or below this sulcus so that the scar is hidden when the arm is adducted.

The general preoperative evaluation for any patient undergoing arm contouring includes the “pinch test” to determine the amount of skin to be resected. When performing this test, have the patient stand with his or her arms abducted.

Surgery is performed under sedation and local anesthesia; the patient is prone, with arms abducted at about 80 degrees. The specific technique — lipoplasty, surgical excision, or both — is carried out in accordance with the plan made before surgery.

Even though we have been performing lipoplasty since 1981, it did not become part of our standard approach to brachioplasty until after 1988. Since then, we have routinely used lipoplasty in selected patients undergoing brachioplasty. In the past 6 years, we have also used 2 other techniques to improve results. First, we perform conservative skin undermining only on the area to be resected to avoid dead space. Second, patients with redundant skin in the elbow region are treated with elbowplasty, which we perform in a manner similar to the procedure described by Lewis. Elbowplasty may be combined with brachioplasty in the same surgical stage.

Conservative skin undermining

When skin dissection is to be performed, the skin flap is stretched above the superior limit of the incision to estimate the amount of skin to be resected. Three-zero isolated intradermal absorbable stitches are placed all along the upper nondissected skin edge, and the dissected lower limit, to avoid dead space and irregular tension on the suture. Then resect the excess skin (Figure 2).

A, Transoperative aspect of the upper arm, showing the skin excess undermined up to its resection limits. Estimate the dissection step by step to avoid unnecessary undermining. B, Isolated absorbable 3-0 sutures are applied all along the upper incision edge to the limits of the undermined skin. C, Excess skin is resected. D, Routine 4- 0 absorbable running intracuticular skin suture.

Finish suturing with a running intracuticular 4-0 absorbable material. Straight and zigzag suture lines have demonstrated similar scar quality. In long-term follow-up, we have found that suture tension results in broadening of scars. Scar widening is more evident in patients with thin dermis.

Excess elbow skin is common in older patients and in slim patients with lax skin. In contrast to Lewis’ procedure, which looks like an elliptical resection, we perform a “horseshoe-type” resection for excess skin This has resulted in generally acceptable scars. The scar may resemble one of the remaining elbow-skin folds; a broader and somewhat less desirable scar may result, depending on individual healing characteristics. In all patients, the scar remains reddish for months.

A, Preoperative posterior view of a 46-year-old woman. B. Postoperative posterior view, demonstrating the skin excess resection. C, Preoperative anterior view. D, Postoperative anterior view after 10 months. Upper-arm contour was improved; the scar has been placed along the brachial internal sulcus. E, Preoperative view demonstrates cutis laxa of the elbow. Patient is marked for a horseshoe-like skin incision similar to that described in Lewis’ procedure. F, The pinch test is performed. G, Demonstrates the dissection and the excess skin to be resected. H, The patient has been sutured. I, Postoperative view, 10 months after elbowplasty. The scar remains reddish and broad, possibly because of the histologic skin structure (cutis laxa). J, Postoperative view after 8 months demonstrates the final elbow scar. Posterior view of the arm shows no evidence of a scar.