Brachioplasty and Upper Trunk Contouring Flashcards
Brachioplasty The most common technique leaves a visible scar along the inner aspect
of the arm
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Upper body contouring includes removal ofan axillary roll
and back skin to tighten the entire upper torso. This is commonly known as a bra-line lift and may be combined with
breast and arm contouring
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The maximum body mass index
(BMI) prior to weight loss should be recorded along with the current BMI. Higher BMI at both time points has been associated with
higher complication rates after surgery
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Timing ofbody contouring
procedures should allow at least 12 months after bariatric surgery
and 6 months at a stable weight for patients to achieve metabolic and
nutritional homeostasis.
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No amount of physical exercise will correct
an excess of loose skin
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Classification schemes are not widely used in clinical practice;
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Teimourian and Malekzadeh in 1998, divided upper
arm findings into four categories
■ Group 1: Patients with minimal to moderate subcutaneous fat and
minimal skin laxity
■ Group 2: Patients with generalized accumulation ofsubcutaneous
fat and moderate skin laxity. The authors suggested management
of these patients with liposuction, with the possible addition of a
small axillary skin excision
■ Group 3: Patients with excess fat and extensive skin laxity requiring combined liposuction and direct soft-tissue excision
■ Group 4: Patients with minimal excess adiposity but significant skin laxity, requiring brachioplasty without adjunctive
liposuction
Appelt et al. in 2006 added the variable of location of
skin excess
■ Type I: Patients with relative excess ofadipose tissue but good skin
quality and tone, for whom liposuction alone was recommended
■ Type II: Patients with minimal to moderate adipose tissue and
moderate skin laxity. Excisional brachioplasty techniques were
endorsed for this patient population, with a further subdivision
into type IIA, IIB, and IIC based on the location ofskin excess and
the related skin excision pattern
■ Type III: Patients with both significant lipodystrophy and redundant skin laxity fall into three categories:
o Continued weight loss prior to surgery
o Staged treatment with initial liposuction followed by excisional brachioplasty
o Combined liposuction-excisional brachioplasty
The superficial fascia! system is found between the superficial and deep layers ofsubcutaneous fat
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some authors advocate plication of The superficial fascia! system during
the closing portion of the procedure
Loosening of this layer with
age or significant weight fluctuations can contribute to upper arm
ptosis
The deep fascia! system envelops the musculature, and all major neurovascular structures of the
arm lie deep to this layer. Care should be taken to avoid violation of
this layer during all aspects of the procedure
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Two sensory nerves travel superficial to the deep fascia! layer and
are thus at risk during brachioplasty procedures
the medial brachia!
cutaneous nerve and the medial antebrachial cutaneous (MABC)
nerve
Both nerves arise from the medial cord of the brachia! plexus
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Wich of these nerve more frequently involved
Medial antebrachial cutaneous nerve
MABC is more frequently involved of the two,
pierces the deep fascia an average of 14 cm proximal to the medial
epicondyle
T. MABC is more frequently involved of the two,
pierces the deep fascia an average of 14 cm proximal to the medial
epicondyle and travels with the basilic vein in the superficial plane of
the distal half to third of the upper arm
hoe we can prevent damage to this nerve
To prevent damage to these
sensory nerves, at least 1 cm offat should be left on the deep brachia!
fascia ofthe upper arm if possible
Adjunctive liposuction can also be
employed to facilitate atraumatic dissection and lymphatic preservation of lymphatics to decrease seroma formation
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full
motor and sensory examinations of the bilateral upper extremities,
in addition to assessment of skin quality and tone
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For patients with minimal skin laxity and a mild to moderate amount
of adipose deposits in the upper extremity, liposuction can be performed as a stand-alone technique for upper extremity recontouring
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leaving a layer of fat above the deep brachia! fascia
to preserve lymphatics and avoid significant contour irregularities
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Liposuction to the bicipital groove is avoided, WHY ?
to minimize contour irregularity in this region, which is known anatomically to be relatively devoid of fat
For patients with good skin quality but a moderate excess of skin and
adipose tissue limited to the proximal one-half to one-third of the
upper arm what type of intervention you will employ
Minibrachioplasty (Limited Medial Incision
Brachioplasty)
the minibrachioplasty is a reasonable option to consider.
This procedure has little to no benefit for the MWL patient
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the witch of flap in minibrachioplasty which is generally
limited to 3 to 5 cm at its widest point
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The axillary elliptical incisions are made using a
scalpel, and then electrocautery is used to raise the tissue in a subcutaneous plane.
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No need to undermine the medial and lateral flap for closure in minbrachioplasty
T The medial and lateral skin flaps may be undermined
to facilitate closure, but this is typically not necessary
Most MWL patients require extended brachioplasty
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a vertical dart (dashed
lines) for dog-ear removal or to excise more redundant upper arm skin.
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An
extension to the chest wall is often added and is known as an
L-brachioplasty along the postrerior axillary line
F with the superior L-point in or near the deltopectoral groove along the anterior axillary line
The amount of tumescent fluid should be minimized,
so as to avoid large-volume swelling that may ultimately inhibit the
degree of resection
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Liposuction can be don
beyond the borders of the planned resection
F Liposuction
beyond the borders of the planned resection is intentionally limited, as aggressive liposuction of these areas may compromise the
remaining soft tissue and lead to postprocedure skin loosening when
swelling resolves
Reapproximation of the superficial fascia! system importantly helps maintain contour and prevents scar
puckering
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Liposuction facilitates the dissection plane and leaves fat down on the deep fascia, thus helping to preserve
nerves and lymphatics
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Recent studies have demonstrated intact sensory and lymphatic
function following brachioplasty employing liposuction for atraumatic dissection of tissue planes
T This technique helps preserve
the layer of fat above the deep brachia! fascia harboring the sensory
nerves and lymphatics.
Risk factors
that may increase the chance of overall complications, hematoma,
or infection include»»>
male gender, BMI >30, and combined procedures.
