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Brachioplasty in the patient with massive weight loss
Operative Strategies
Brachioplasty in the Patient With Massive Weight Loss In performing brachioplasty, the authors have created a double-ellipse marking technique to avoid overresecting and leave adequate skin for closure. After resecting, they prevent the interference of soft-tissue swelling during wound closure by immediately closing each segment with temporary staples. Their technique is ideal for patients with massive weight loss. (Aesthetic Surg J 2006;26:76-84.)
T
he elimination of upper arm excess is often required in the treatment of the patient with massive weight loss. The inflation and deflation of skin caused by weight gain and subsequent weight loss can lead to varied arm deformities. Although the literature describes many brachioplasty techniques, the severe deformity frequently presented by the massive weight loss patient inspired us to develop a technique that specifically addresses the arm deformities in this population. We introduced this technique in 2002.1
Relevant Anatomy Careful examination of the intersection of the upper arm and lateral chest wall reveals that the anterior and posterior axillary folds create the boundaries of the hairbearing axilla. When a person gains significant weight and then loses it, the posterior axillary fold is the area of significant arm inflation and deflation. Because the posterior axillary fold originates from the lateral chest wall, by necessity, the upper arm excess crosses the axilla onto the lateral chest wall (Figure 1).
Patient Selection Some patients who gain significant weight in the upper arms retain most of their lipodystrophy after weight loss. For these patients, once weight loss has stabilized, we recommend a preliminary lipoplasty procedure to deflate the arms 6 months before undergoing our excisional procedure. If the skin-fat envelope surrounding the noncompressible musculoskeletal system in the upper arm is thick, the result of resection is significantly inferior to that achieved when the
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patient presents with a thin skin-fat envelope. The technique described in this article is ideal for the more commonly occurring arm presentation in the patient with massive weight loss— upper arms that are inflated by weight gain but significantly deflated by weight loss.
Surgical Conduct
Al Aly, MD, Coralville, IA, is a board-certified plastic surgeon and an ASAPS member. Co-authors: Daniele Pace, MD, Curitiba, Paraná, Brazil; Albert Cram, MD, Coralville, IA.
The “double-ellipse” marking technique
In any brachioplasty procedure, you must strike a balance between resecting enough tissue to achieve excellent contour but not resecting so much that you prevent closure. Because tissue is resected around a cylinder with a hard, noncompressible inner core of bone and muscle mass, the dangers of overly aggressive resection are compression of the neurovasculature and an inability to close the wound. To help determine the appropriate amount of resection, we developed a “double ellipse” marking technique. The initial marking is an outer ellipse based on anatomic reference points that follow the extent of the upperarm deformity across the axilla and distal to the elbow, if needed. The next marking is a second inner ellipse, based on the outer ellipse and adjusted to the thickness of subcutaneous fat to allow for closure around the cylindrical upper arm. This technique places the scar at the most inferior point of the upper arm when abducted, achieving a scar position that is as inconspicuous as possible when patients perform normal daily functions. Begin marking with the patient’s arms abducted to 90 degrees and the elbow flexed to 90 degrees. In this position, you can see that the excess tissue constitutes a redundant posterior axillary fold, which when resected will expose the normal underlying anatomy. At the axillary crease, pinch the excess just inferior to the musculoskele-
JANUARY/FEBRUARY
2006
Operative Strategies
Figure 1. Preoperative view of a 51-year-old woman who requested treatment after a 190-lb weight loss and a 33-point BMI drop. She has the type of upper arm deformity typically seen in the massive weight loss population. Note that the excess skin crosses the axilla onto the lateral chest wall as the posterior axillary fold.
tal mass and mark the skin anteriorly and posteriorly. Repeat this process distally, including the total extent of the excess, even if it crosses the elbow (Figure 2). Use the same process proximally to delineate the lateral chest excess. Be guided by the amount of tissue necessary to eliminate horizontal thoracic excess. Then connect all the anterior and posterior marks to create the outer ellipse. If the outer ellipse were to be used as the actual excision line, the (created) defect could not be closed because the distance between the examiner’s fingers, while pinching, would not be taken into consideration. The second ellipse is created to accommodate for that distance (Figure 3). For example, if the distance between the pinched fingers at any particular point along the upper arm is 2 cm, move the marks 1 cm centrally on each side. Create a series of these marks along the entire upper arm up to the axillary crease. Proximal to the axillary crease, do not move the marks inward onto the lateral chest wall because closure along this area is not around a cylinder. Use these new marks to create the inner ellipse that serves as the actual resection line (Figure 4). Next, mark a central line through the midline of the ellipse that will help orient the excision, retract tissues
Brachioplasty in the Patient With Massive Weight Loss
AESTHETIC
during resection, and approximate the final scar position. Place cross-hatch marks at the axillary crease and at 8- to 10-cm intervals distal to facilitate alignment at closure. The cross-hatch marks will also be used as markers for the “segmental resection and closure” technique. Surgical details
Place the patient in the supine position, facilitating 360-degree access to the arms and lateral chest wall. Do not place intravenous lines in the upper extremity. Begin the resection of the inner ellipse distally in a segmental resection closure fashion. Incise the anterior and posterior ellipse marks up to the level of the first hatch mark. Perform the resection just superficial to the underlying muscle fascia. Once the first hatch mark is reached and all bleeding is cauterized, close the resected segment with temporary staples (Figure 5). Repeat the same process with the next hatch mark. Together, resect the remaining 2 segments that bracket the axillary crease, making sure that the resection is more superficial at the axilla to avoid injuring the rich lymphatics in this area (Figure 6). Place a closed-suction drain proximally, and thread it through the entire wound before placing the temporary
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Operative Strategies
Posterior marks
A
Illustrations by William M. Winn, Atlanta, GA
B
Figure 2. A, The upper arm excess is pinched just inferior to the musculoskeletal mass, and marks are made at multiple points anteriorly and posteriorly. The process is continued distally, past the elbow if needed, and proximally onto the lateral chest wall. B, The marks are connected to form the outer ellipse of the double ellipse.
Outer ellipse level Inner ellipse level
Figure 3. In this arm cross-section, the surgeon’s fingers demonstrate the pinch technique used to determine the amount of tissue that can be potentially excised. Markings based on the tips of the pinched fingers do not account for the distance between the fingers, the outer ellipse level. If the distance between the pinched fingers is 2 cm, then moving the marks in by 1 cm on each side, the inner ellipse level, will leave enough skin to surround the remaining arm mass.
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Operative Strategies
Axillary crease
Figure 4. Demonstrates completed markings for the double ellipse technique. The inner ellipse, created as an adjustment to the outer ellipse, allows for adequate remaining skin to safely close the arm. The cross-hatch marks, placed about every 10 cm, are used to help align the closure and also serve as guidelines for the segmental resection closure technique described here. The central line is used as a marker for retraction clamps and to approximate the final scar position.
Figure 5. The segmental resection closure technique begins distally and advances proximally. The illustration shows the marked inner ellipse resected to the level of the first hatch mark, and then closed immediately with temporary staples to prevent edema from developing in the operated tissue. It also shows the second segment, resected just before temporary closure.
Brachioplasty in the Patient With Massive Weight Loss
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Operative Strategies
Figure 6. Illustrates the segmental resection closure technique after the 2 distal segments are closed and the 2 proximal segments are resected together, bracketing the axillary crease level. A closed-suction drain is inserted through the lateral chest wall and threaded through to the distal arm. The total resected segment is shown next to the wound.
Figure 7. Depicts the arm after complete resection of excess tissue and temporary staple closure. A Z-plasty is marked at the axillary crease.
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Figure 8. Demonstrates the completed procedure, with the Z-plasty located at the axillary crease. Note that at the time of surgery, we were still using a distal placement of the closed-suction drain. We now place it proximally, along the lateral chest wall.
staples. Design a Z-plasty at the axillary crease (usually 2.5 cm in length) to prevent scar contracture across the axilla (Figure 7). After the Z-plasty is completed, remove the temporary staples individually and replace them with 2-0 PDS sutures to reapproximate the superficial fascial system and subdermis. Then close the skin with a running 2-0 or 3-0 Monocryl (Ethicon Inc., Somerville, NJ) subcuticular suture. At the area of the Z-plasty, we frequently reinforce the skin with interrupted 3-0 nylon or staples. Apply Dermabond (Ethicon) to the entire skin closure (Figure 8).
Discussion The reason for resecting and immediately closing a segment with temporary staples is to prevent swelling in the soft tissues of the arm prior to closure. If the defect created by the resection is left open (to control bleeding and make resection adjustments), the soft tissues of the upper arm invariably swell. Because the closure in a brachioplasty is performed around a cylinder with a hard, noncompressible core, it is possible, because of intraoperative edema, to find yourself unable to close a wellapproximated resection. Closing each segment as it is resected will prevent swelling and edema from developing before closure. In the immediate postoperative period, we do not use compression garments or wraps. Patients are required to elevate their arms above heart level, with a neutral bend at the elbow, for 2 to 3 weeks. However, they are allowed to temporarily lower their arms to perform necessary functions. Many patients will develop postopera-
Brachioplasty in the Patient With Massive Weight Loss
AESTHETIC
tive swelling in the distal arm and hands, which should resolve in 1 to 2 weeks. Most patients are able to return to relatively normal function in 3 to 6 weeks. Potential complications include unattractive scarring, wound separation, especially at Z-plasty level, hematoma, seroma, infection, sensory and motor nerve injury, inability to close the wound, vascular compromise, under or overresection, and permanent lymphedema.
Conclusion Treatment of the upper arm deformity in the patient with massive weight loss most frequently requires excisional surgery that must cross the axilla onto the lateral chest wall. To avoid overresection but still achieve the best possible result, we use a “double ellipse” marking technique. We perform the excision with a “segmental resection closure” technique that prevents the interference of soft-tissue swelling during wound closure. We place the scar along the inferior border of the arm (when in an abducted position), which we feel is superior to the more traditional bicipital groove placement. We have found this technique to be versatile and effective in producing the best possible upper arm contour in the patient with massive weight loss (Figures 9 and 10). ■ Reference 1. Aly AS. Body Contouring in the Post-Weight Reduction Patient. Presented at the Breast and Body Contouring Symposium of the Annual Meeting of the American Society of Plastic and Reconstructive Surgery; San Antonio, Texas, 2002.
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A
B
C
D Figure 9. A, C, Preoperative views of a 51-year-old woman who presented after a 193-lb weight loss and a 33-point BMI drop. B, D, Postoperative views 2 months after undergoing the brachioplasty technique described in this article. Note the position of the scar in the abducted arm position, the most likely position to view the inner arm during normal daily activity.
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A
C
B
D
E Figure 10. A, C, Preoperative views of a 43-year-old woman after a 110-lb weight loss and a 20-point BMI drop. B, D, E, Postoperative views 10 months after brachioplasty. The patient is able to completely abduct the arm because the Z-plasty prevented scar contracture across the axilla.
Brachioplasty in the Patient With Massive Weight Loss
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Bibliography 1. Aly AS, Cram AE. Brachioplasty. In Aly AS, editor. Body Contouring After Massive Weight Loss. St Louis: Quality Medical Publishing, 2006. pp 303-333. 2. Strauch B, Linetskaya D, Baum T, Greenspun D. Brachioplasty and axillary restoration. Aesthetic Surg J 2004;24:486-488. Reprint requests: Al Aly, MD, 501 12th Avenue, Suite 102, Coralville, IA 52241. Copyright © 2006 by The American Society for Aesthetic Plastic Surgery, Inc. 1090-820X/$32.00 doi:10.1016/j.asj.2005.11.004
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Volume 26, Number 1
Brachioplasty in the Patient With Massive Weight Loss In performing brachioplasty, the authors have created a double-ellipse marking technique to avoid overresecting and leave adequate skin for closure. After resecting, they prevent the interference of soft-tissue swelling during wound closure by immediately closing each segment with temporary staples. Their technique is ideal for patients with massive weight loss. (Aesthetic Surg J 2006;26:76-84.)
T
he elimination of upper arm excess is often required in the treatment of the patient with massive weight loss. The inflation and deflation of skin caused by weight gain and subsequent weight loss can lead to varied arm deformities. Although the literature describes many brachioplasty techniques, the severe deformity frequently presented by the massive weight loss patient inspired us to develop a technique that specifically addresses the arm deformities in this population. We introduced this technique in 2002.1
Relevant Anatomy Careful examination of the intersection of the upper arm and lateral chest wall reveals that the anterior and posterior axillary folds create the boundaries of the hairbearing axilla. When a person gains significant weight and then loses it, the posterior axillary fold is the area of significant arm inflation and deflation. Because the posterior axillary fold originates from the lateral chest wall, by necessity, the upper arm excess crosses the axilla onto the lateral chest wall (Figure 1).
Patient Selection Some patients who gain significant weight in the upper arms retain most of their lipodystrophy after weight loss. For these patients, once weight loss has stabilized, we recommend a preliminary lipoplasty procedure to deflate the arms 6 months before undergoing our excisional procedure. If the skin-fat envelope surrounding the noncompressible musculoskeletal system in the upper arm is thick, the result of resection is significantly inferior to that achieved when the
76
AESTHETIC
SURGERY
JOURNAL
~
patient presents with a thin skin-fat envelope. The technique described in this article is ideal for the more commonly occurring arm presentation in the patient with massive weight loss— upper arms that are inflated by weight gain but significantly deflated by weight loss.
Surgical Conduct
Al Aly, MD, Coralville, IA, is a board-certified plastic surgeon and an ASAPS member. Co-authors: Daniele Pace, MD, Curitiba, Paraná, Brazil; Albert Cram, MD, Coralville, IA.
The “double-ellipse” marking technique
In any brachioplasty procedure, you must strike a balance between resecting enough tissue to achieve excellent contour but not resecting so much that you prevent closure. Because tissue is resected around a cylinder with a hard, noncompressible inner core of bone and muscle mass, the dangers of overly aggressive resection are compression of the neurovasculature and an inability to close the wound. To help determine the appropriate amount of resection, we developed a “double ellipse” marking technique. The initial marking is an outer ellipse based on anatomic reference points that follow the extent of the upperarm deformity across the axilla and distal to the elbow, if needed. The next marking is a second inner ellipse, based on the outer ellipse and adjusted to the thickness of subcutaneous fat to allow for closure around the cylindrical upper arm. This technique places the scar at the most inferior point of the upper arm when abducted, achieving a scar position that is as inconspicuous as possible when patients perform normal daily functions. Begin marking with the patient’s arms abducted to 90 degrees and the elbow flexed to 90 degrees. In this position, you can see that the excess tissue constitutes a redundant posterior axillary fold, which when resected will expose the normal underlying anatomy. At the axillary crease, pinch the excess just inferior to the musculoskele-
JANUARY/FEBRUARY
2006
Operative Strategies
Figure 1. Preoperative view of a 51-year-old woman who requested treatment after a 190-lb weight loss and a 33-point BMI drop. She has the type of upper arm deformity typically seen in the massive weight loss population. Note that the excess skin crosses the axilla onto the lateral chest wall as the posterior axillary fold.
tal mass and mark the skin anteriorly and posteriorly. Repeat this process distally, including the total extent of the excess, even if it crosses the elbow (Figure 2). Use the same process proximally to delineate the lateral chest excess. Be guided by the amount of tissue necessary to eliminate horizontal thoracic excess. Then connect all the anterior and posterior marks to create the outer ellipse. If the outer ellipse were to be used as the actual excision line, the (created) defect could not be closed because the distance between the examiner’s fingers, while pinching, would not be taken into consideration. The second ellipse is created to accommodate for that distance (Figure 3). For example, if the distance between the pinched fingers at any particular point along the upper arm is 2 cm, move the marks 1 cm centrally on each side. Create a series of these marks along the entire upper arm up to the axillary crease. Proximal to the axillary crease, do not move the marks inward onto the lateral chest wall because closure along this area is not around a cylinder. Use these new marks to create the inner ellipse that serves as the actual resection line (Figure 4). Next, mark a central line through the midline of the ellipse that will help orient the excision, retract tissues
Brachioplasty in the Patient With Massive Weight Loss
AESTHETIC
during resection, and approximate the final scar position. Place cross-hatch marks at the axillary crease and at 8- to 10-cm intervals distal to facilitate alignment at closure. The cross-hatch marks will also be used as markers for the “segmental resection and closure” technique. Surgical details
Place the patient in the supine position, facilitating 360-degree access to the arms and lateral chest wall. Do not place intravenous lines in the upper extremity. Begin the resection of the inner ellipse distally in a segmental resection closure fashion. Incise the anterior and posterior ellipse marks up to the level of the first hatch mark. Perform the resection just superficial to the underlying muscle fascia. Once the first hatch mark is reached and all bleeding is cauterized, close the resected segment with temporary staples (Figure 5). Repeat the same process with the next hatch mark. Together, resect the remaining 2 segments that bracket the axillary crease, making sure that the resection is more superficial at the axilla to avoid injuring the rich lymphatics in this area (Figure 6). Place a closed-suction drain proximally, and thread it through the entire wound before placing the temporary
SURGERY
JOURNAL
~
January/February
2006
77
Operative Strategies
Posterior marks
A
Illustrations by William M. Winn, Atlanta, GA
B
Figure 2. A, The upper arm excess is pinched just inferior to the musculoskeletal mass, and marks are made at multiple points anteriorly and posteriorly. The process is continued distally, past the elbow if needed, and proximally onto the lateral chest wall. B, The marks are connected to form the outer ellipse of the double ellipse.
Outer ellipse level Inner ellipse level
Figure 3. In this arm cross-section, the surgeon’s fingers demonstrate the pinch technique used to determine the amount of tissue that can be potentially excised. Markings based on the tips of the pinched fingers do not account for the distance between the fingers, the outer ellipse level. If the distance between the pinched fingers is 2 cm, then moving the marks in by 1 cm on each side, the inner ellipse level, will leave enough skin to surround the remaining arm mass.
78
Aesthetic
Surgery
Journal
~
January/February
2006
Volume 26, Number 1
Operative Strategies
Axillary crease
Figure 4. Demonstrates completed markings for the double ellipse technique. The inner ellipse, created as an adjustment to the outer ellipse, allows for adequate remaining skin to safely close the arm. The cross-hatch marks, placed about every 10 cm, are used to help align the closure and also serve as guidelines for the segmental resection closure technique described here. The central line is used as a marker for retraction clamps and to approximate the final scar position.
Figure 5. The segmental resection closure technique begins distally and advances proximally. The illustration shows the marked inner ellipse resected to the level of the first hatch mark, and then closed immediately with temporary staples to prevent edema from developing in the operated tissue. It also shows the second segment, resected just before temporary closure.
Brachioplasty in the Patient With Massive Weight Loss
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JOURNAL
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January/February
2006
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Operative Strategies
Figure 6. Illustrates the segmental resection closure technique after the 2 distal segments are closed and the 2 proximal segments are resected together, bracketing the axillary crease level. A closed-suction drain is inserted through the lateral chest wall and threaded through to the distal arm. The total resected segment is shown next to the wound.
Figure 7. Depicts the arm after complete resection of excess tissue and temporary staple closure. A Z-plasty is marked at the axillary crease.
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Operative Strategies
Figure 8. Demonstrates the completed procedure, with the Z-plasty located at the axillary crease. Note that at the time of surgery, we were still using a distal placement of the closed-suction drain. We now place it proximally, along the lateral chest wall.
staples. Design a Z-plasty at the axillary crease (usually 2.5 cm in length) to prevent scar contracture across the axilla (Figure 7). After the Z-plasty is completed, remove the temporary staples individually and replace them with 2-0 PDS sutures to reapproximate the superficial fascial system and subdermis. Then close the skin with a running 2-0 or 3-0 Monocryl (Ethicon Inc., Somerville, NJ) subcuticular suture. At the area of the Z-plasty, we frequently reinforce the skin with interrupted 3-0 nylon or staples. Apply Dermabond (Ethicon) to the entire skin closure (Figure 8).
Discussion The reason for resecting and immediately closing a segment with temporary staples is to prevent swelling in the soft tissues of the arm prior to closure. If the defect created by the resection is left open (to control bleeding and make resection adjustments), the soft tissues of the upper arm invariably swell. Because the closure in a brachioplasty is performed around a cylinder with a hard, noncompressible core, it is possible, because of intraoperative edema, to find yourself unable to close a wellapproximated resection. Closing each segment as it is resected will prevent swelling and edema from developing before closure. In the immediate postoperative period, we do not use compression garments or wraps. Patients are required to elevate their arms above heart level, with a neutral bend at the elbow, for 2 to 3 weeks. However, they are allowed to temporarily lower their arms to perform necessary functions. Many patients will develop postopera-
Brachioplasty in the Patient With Massive Weight Loss
AESTHETIC
tive swelling in the distal arm and hands, which should resolve in 1 to 2 weeks. Most patients are able to return to relatively normal function in 3 to 6 weeks. Potential complications include unattractive scarring, wound separation, especially at Z-plasty level, hematoma, seroma, infection, sensory and motor nerve injury, inability to close the wound, vascular compromise, under or overresection, and permanent lymphedema.
Conclusion Treatment of the upper arm deformity in the patient with massive weight loss most frequently requires excisional surgery that must cross the axilla onto the lateral chest wall. To avoid overresection but still achieve the best possible result, we use a “double ellipse” marking technique. We perform the excision with a “segmental resection closure” technique that prevents the interference of soft-tissue swelling during wound closure. We place the scar along the inferior border of the arm (when in an abducted position), which we feel is superior to the more traditional bicipital groove placement. We have found this technique to be versatile and effective in producing the best possible upper arm contour in the patient with massive weight loss (Figures 9 and 10). ■ Reference 1. Aly AS. Body Contouring in the Post-Weight Reduction Patient. Presented at the Breast and Body Contouring Symposium of the Annual Meeting of the American Society of Plastic and Reconstructive Surgery; San Antonio, Texas, 2002.
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2006
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Operative Strategies
A
B
C
D Figure 9. A, C, Preoperative views of a 51-year-old woman who presented after a 193-lb weight loss and a 33-point BMI drop. B, D, Postoperative views 2 months after undergoing the brachioplasty technique described in this article. Note the position of the scar in the abducted arm position, the most likely position to view the inner arm during normal daily activity.
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Surgery
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2006
Volume 26, Number 1
Operative Strategies
A
C
B
D
E Figure 10. A, C, Preoperative views of a 43-year-old woman after a 110-lb weight loss and a 20-point BMI drop. B, D, E, Postoperative views 10 months after brachioplasty. The patient is able to completely abduct the arm because the Z-plasty prevented scar contracture across the axilla.
Brachioplasty in the Patient With Massive Weight Loss
AESTHETIC
SURGERY
JOURNAL
~
January/February
2006
83
Operative Strategies
Bibliography 1. Aly AS, Cram AE. Brachioplasty. In Aly AS, editor. Body Contouring After Massive Weight Loss. St Louis: Quality Medical Publishing, 2006. pp 303-333. 2. Strauch B, Linetskaya D, Baum T, Greenspun D. Brachioplasty and axillary restoration. Aesthetic Surg J 2004;24:486-488. Reprint requests: Al Aly, MD, 501 12th Avenue, Suite 102, Coralville, IA 52241. Copyright © 2006 by The American Society for Aesthetic Plastic Surgery, Inc. 1090-820X/$32.00 doi:10.1016/j.asj.2005.11.004
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Volume 26, Number 1