Second Thoughts

Arm Contouring

The authors have updated their brachioplasty technique, adding conservative skin undermining in the
treatment area only and, in some instances, elbowplasty.
Patients are divided into 3 distinct groups for treatment
planning on the basis of skin quality and fat deposits.
(Aesthetic Surg J 2003;23:290-292.)

e 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 specic limitations on how much
fat is removed based on the patients skin turgor. These
principles are the same as those advocated by Vogt.1
Group 2 comprises patients with abby 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 supercial nerves.
Group 3 comprises patients with accid 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 ap,
saving the internal brachial sulcus as reference. We place
the suture and nal 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.25
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 specic technique lipoplasty, surgical
excision, or both is carried out in accordance with the
plan made before surgery.

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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
Ricardo Baroudi, MD, So
patients undergoing braPaulo, Brazil, is a member of
chioplasty. In the past 6
the Brazilian Society of Plastic
Surgery.
years, we have also used 2
Co-author Carlos Alberto A.
other techniques to improve
Ferreira, MD, So Paulo.
Brazil, is a member of the
results. First, we perform
Brazilian Society of Plastic
conservative skin underminSurgery.
ing 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.6
Elbowplasty may be combined with brachioplasty in the
same surgical stage.
Conservative Skin Undermining

When skin dissection is to be performed, the skin ap

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).
Finish suturing with a running intracuticular 4-0
absorbable material. Straight and zigzag suture lines have
demonstrated similar scar quality. In long-term followup, 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 (Figure 3).
This has resulted in generally acceptable scars. The scar

2003

Second Thoughts

Figure 1. 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 nal scar 1 to 3 cm above or below this sulcus so that the scar is hidden when the arm is adducted.

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.

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.

3. Baroudi R. Dermolipectomy of the upper arm. In: Gonzalez-Ulloa M,

Meyer R, Smith JW, Zaoli G, eds. Aesthetic Plastic Surgery, vol 5.
Padua, Italy: Piccin; 1988: 219.
4. Guerrerosantos J. Arm lift. In: Courtiss E, ed. Trouble in Aesthetic
Surgery. St. Louis, MO: Mosby; 1978:232.

References
1. Vogt PA. Surgery of the upper arm. Lipoplasty Newsletter 1994;11:24.

Arm Contouring

2. Baroudi R. Dermatolipectomy of the upper arm. Clin Plast Surg

1975;2:485.

5. Guerrerosantos J. Brachioplasty. Aesth Plast Surg 1979;3:1.

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Figure 3. 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.6 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 nal elbow scar. Posterior view of the arm shows no evidence of a scar.

6. Lewis JR Jr. Atlas of Aesthetic Surgery. Boston, MA: Little, Brown;

1973:271.
Reprint requests: Ricardo Baroudi, MD, Rua Itabaquara, 48,
01234-020, So Paulo SP, Brazil.
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Copyright 2003 by The American Society for Aesthetic Plastic Surgery, Inc.
1090-820X/2003/$30.00 + 0
doi:10.1067/maj.2003.63

2003

Volume 23, Number 4