"Depending on the patient's clinical presentation and desired outcome, brachioplasty may involve liposuction and/or skin excision, and with the latter, there are a number of different options for incision placement and length. Therefore, it is important to examine the patient carefully and discuss the surgical options, especially with respect to the appearance and quality of the various resultant scars," Dr. Sacks says.
"While it is difficult to anticipate exact scar appearance because of individual variations in healing, it can be said that most patients are surprised at the prominence of excisional brachioplasty scars," he adds.EXAMINATION TIPS The examination involves both feeling the skin to assess the amount of laxity and pinching the tissue to determine the amount of excess fat. However, patients must also be asked to describe specifically what they like and don't like about the appearance of their upper arms, as well as how they feel about having a visible scar. In discussing the scar, the arm should be marked to demonstrate the location of various scars, and then patients should be asked to look in the mirror as they raise their arms up and down.
"Maybe the patient does not mind some of the excess skin, but doesn't like the thickness of her arm, and if she objects at all to a visible scar, she may be happy with liposuction alone," Dr. Sacks says.
EXCISION OPTIONS When skin excision is being performed, the scar may be horizontal, either in the bicipital groove or along the posterior border of the upper arm, and/or vertical in the axilla. The choice among these options depends in part on the area(s) of greatest laxity and whether the patient is content to wear short sleeves or is hoping to have an improved appearance in sleeveless clothing.
An extended horizontal scar allows tightening over a greater length of the upper arm, but it may need to be extended into the axilla if the skin is very loose. This is because the horizontal scar must be narrowed near the axilla, limiting the width of skin removal possible at the proximal region. A vertical axilla scar alone or combined with a short horizontal scar may suffice if the laxity is greatest proximally.
Dr. Sacks notes that when a horizontal excisional procedure is performed, most of his patients choose scar placement in the bicipital groove. In this procedure, most of the skin is removed from the inner surface of the arm, whereas with a horizontal scar along the posterior border of the upper arm, the procedure extends around the lateral surface of the upper arm.
A vertical axilla pattern offers the extra benefit of simultaneously removing hair-bearing underarm skin and sweat glands, which makes it particularly appealing to women. This technique has not been associated with increased sweating in other areas, Dr. Sacks says. He cautions, however, that the vertical incision must be carefully designed, taking into account the potential for bowing across the scaphoid shape of the axilla.
"It may be best to design a Z-plasty into the scar. That can be done after the surgery, if needed, but if the patient has a very deep axilla, the Z-plasty is best done at the time of the primary procedure," Dr. Sacks says.
PREOP PLANNING In planning the procedure, Dr. Sacks says he places pen marks at equidistant sites along the area to be excised. After starting the excision and performing the undermining from the posterior border first, he pulls the skin edges together with clips to assess whether the markings are correct or whether further excision is needed.
"However, when one begins to do these operations, it is best to be conservative and remove a narrower ellipse of skin first to avoid too tight a closure," he cautions.
When brachioplasty combines liposuction with skin excision, the fat removal procedure is best performed first, as this will enable a tighter and smoother skin closure. However, it is important to avoid being too aggressive with the liposuction, as well.
"Be careful to leave some fat on the undersurface of the skin, because that will provide a smoother result. If you are excising fat, don't go too deep, as there is a risk of damaging the medial antebrachial cutaneous nerve and thereby causing localized numbness. However, it is better to do the fat removal with a small suction cannula and avoid sharp excision," Dr. Sacks says.