Brachioplasty

Anatomy and Physiology

The upper arm is the segment between the elbow and the glenohumeral joint, incorporating the axilla. The contour of the upper arm is afforded by the muscles, specifically the deltoid, biceps, and triceps. In youthful arms, the skin is taut, and there is little adiposity. The subcutaneous fat has a deep lamellar and superficial alveolar layer separated by the superficial fascial system, and it is lamellar that is prone to excess fat deposition.[10] The superficial fascial system of the arm is continuous with the clavipectoral and axillary fascia.[11]

The medial brachial and antebrachial nerves that provide sensory innervation to the inner arm and forearm, respectively, lie deep in this fascia within the deeper subcutaneous fat. The medial antebrachial cutaneous nerve branches (2-3) accompany the basilic vein from the medial epicondyle until they traverse the deep fascia of the arm approximately 8 cm proximal to the medial epicondyle. The medial brachial cutaneous nerve runs posterior and parallel to the basilic vein, and its branches terminate approximately 2 cm proximal to the medial epicondyle.[12][13] 

The deep fascia of the arm incorporates the major motor-sensory nerves (median, ulnar, radial), major vessels, including the brachial artery and its tributaries, and the muscles of the anterior and posterior compartments. The lymphatics of the upper limb accompany the venous tributaries and drain to the axillary lymph nodes. 

Appelt's classification stratifies the upper arm fat, skin excess, and lateral chest wall skin excess with corresponding recommendations.[9]

Appelt, et al., Classification[8]

Indications

Arm contouring procedures including liposuction [suction-assisted (SAL), power-assisted (PAL), ultrasound-assisted (UAL)], cryolipolysis, non-ablative radiofrequency, and focussed ultrasound are all suitable alternatives to brachioplasty in appropriately selected patients.[14][15] However, brachioplasty (either alone or in combination with liposuction) is most commonly employed for patients post MWL, although it may also be employed in the appropriate patient with significant skin laxity due to senile elastosis or following pregnancy. 

Patient selection and counseling are paramount in achieving acceptable results and a satisfied patient. MWL patients should be at least 1-year post-bariatric surgery and have a stable weight (defined as within 5kg of target weight) for at least 3 to 6 months, preferably 12 months.[16][17] 

Patients should have a current BMI<30, although many surgeons will selectively offer brachioplasty, among other body contouring procedures, to those with a BMI > 30.[18][19] Those patients with a high maximum BMI (pre-weight loss) and high delta BMI (difference between weight loss and body contouring surgery) have a greater likelihood of complications if undergoing multiple body contouring procedures in a single stage. Those with a high current BMI are at a greater risk of wound dehiscence and infection when undergoing a single procedure (e.g., brachioplasty alone).[20][18] 

Smoking cessation is critical, as smoking alone is associated with a significant risk of complications.[21] Many surgeons will recommend smoking cessation for at least four weeks, though improvements in other parameters after smoking cessation, such as nasal mucociliary clearance, can improve significantly as early as 15 days following smoking cessation.[22][23] 

Patients undergoing body contouring are unique in that they pose a greater risk of complications; thus, some surgeons recommend smoking abstinence for three months before considering body contouring surgery.[16]

The surgeon must also assess patient comorbidities and, where possible, optimize these through liaison with relevant specialties. Particular emphasis should be placed on optimizing diabetes and glycemic control, although many patients have a reversal of their diabetes following MWL. Furthermore, it is imperative to ascertain whether there is an increased likelihood of thrombosis (previous deep vein thrombosis/pulmonary embolism) and coagulopathies (either congenital or acquired through medications). The surgeon should specifically enquire about over-the-counter and herbal medications, as these are often unreported, and recommend that they be omitted at least two weeks preoperatively.[19][24]

Many MWL patients are prone to micronutrient deficiencies, including iron, folic acid, Vitamins B12, A, D, E, K, and minerals such as zinc and selenium.[25] The surgeon must assess these nutritional risks, and it is prudent to request a nutrition panel and address any deficiencies through liaison with the bariatric team, a dietician, and the patient's family doctor as appropriate to optimize their overall health before such an elective surgery.  

Finally, the psychosocial assessment of the patient should not be neglected, as it often governs whether the surgeon should proceed with the operation. Patients may have unrealistic expectations. They may have had no treatment or suboptimal treatment for any psychiatric disorders, with a reported prevalence of 40% in patients with MWL.[26]

About 15% of patients with MWL can also suffer from body dysmorphic disorder (BDD); thus, they may remain dissatisfied with the outcome of their brachioplasty, regardless of the aesthetic result and in the absence of complications.[19][27][19] Therefore, it is prudent to ask patients to complete a BDD screening questionnaire preoperatively and have a very low threshold to seek formal psychiatric consultation.

Contraindications

There are few absolute contraindications to brachioplasty. These include lymphoedema, peripheral arterial ischemia, and venous insufficiency, as well as those at high risk of lymphedema, such as a history of axillary dissection and radiotherapy.[28]

Relative contraindications take into account the aforementioned preoperative assessment. They include BMI>30, unstable weight, current smoking, comorbidities such as poorly controlled diabetes mellitus, nutritional deficiencies, BDD, and untreated or poorly managed psychiatric disorders.[19] 

More specifically, some patients may not be ideal candidates for brachioplasty. This may be due to little skin laxity (e.g., <5 cm ptosis) or residual excess adiposity unaddressed by MWL. Other patients may warrant a short-scar brachioplasty with limited resection, while others may be better suited to an extended brachioplasty that entails excision of excess tissue on the lateral chest wall. Decision-making on the most appropriate operation (if any) is contingent on a thorough preoperative examination and a plan tailored to each individual.

Equipment

Specialist equipment is not necessary. A general plastic surgical tray and equipment will often suffice when performing brachioplasty. When combined with liposuction, however, equipment for performing liposuction should be made available; this is often dependent on the surgeon's practice and location. Additionally, infiltration solution with local anesthesia (such as Klein's tumescent solution) will often be used when performing concurrent liposuction.[29]

Personnel

Working with a familiar multi-disciplinary theatre team that has operation awareness, appreciates the nuances of the procedure - the human factors - and knows the surgeon's preferences makes a tremendous difference.

Many, if not all, surgeons will elect to perform brachioplasty amongst other body contouring operations with staff known to them who are familiar with the operation. It enhances patient safety, reduces surgeon stress, and has better camaraderie in the workplace. At a minimum, there will be a surgeon, an anesthetic provider (whether the procedure is performed under general anesthesia or with conscious sedation), and an operative/circulator nurse. Additionally, there may be a scrub nurse or technician and a surgical assistant or co-surgeon.

Preparation

Perioperative safety enables safe surgery and mitigates adverse events. Patients following MWL often require multiple body contouring procedures, and it is recommended that such procedures are staged appropriately. This staging or separation of procedures into multiple operations, at least three months apart, reduces operative time, anesthesia time, blood loss, personnel fatigue, and complications.[19][30] 

The number of stages required will vary between patients and depends on several variables, including the number of surgeons operating, the number of theatre staff and availability of multiple teams, and the risk assessment of the patient. If brachioplasty is the only procedure intended, then this lessens the perioperative risk considerably but can be mitigated further if two teams are operating simultaneously, one on each arm. 

Intraoperatively, other than essential management of the patient under GA and optimizing their comorbid risk factors, specific attention must be paid to patient positioning, patient warming, and risk management of venous thromboembolism (VTE).[19]

In brachioplasty, patients are positioned supine, with the arms abducted on arm boards and elbows flexed 90 degrees. The forearm and hands should be covered in a sterile drape or equivalent circumferentially and secured; this offers flexibility in moving the arm as desired intraoperatively.[11]

Pressure points at bony prominences should be protected using gel pads to curtail the risk of nerve injury. Preventing hypothermia is imperative and may be achieved using several measures, including a heated gel pad, limiting exposure to the operative site, Bair huggers, warming blankets, and administering warmed intravenous fluids.

Venous thromboembolism is a serious and highly undesirable complication. Prudent measures to curtail its risk include using a sequential compression device (SCD) placed on calves intraoperatively, administering low molecular weight heparin or equivalent following thrombosis/bleeding risk assessment as per local policy, and most importantly, encouraging early mobilization after recovery from general anesthesia. Patients should be counseled preoperatively about the benefits and rationale for early mobilization in the postoperative period.[19]

Technique or Treatment

There are several techniques for performing a brachioplasty, specifically concerning scar placement and the extent of tissue resection. The patient is positioned supine, with the arms abducted and elbow flexed to 90 degrees. Pressure points are protected with gel pads, and SCDs are placed on calves to mitigate the risk of VTE.

Patient exposure is limited to the arms, axilla, and lateral chest, and the patient is warmed during the operation. A single dose of amoxicillin-clavulanate (or similar medication per local protocol) at least 30 minutes before skin incision is often routine antibiotic prophylaxis. No further antibiotic prophylaxis is employed unless the procedure is prolonged beyond 4 hours or there is >10% volume of blood loss.[31]

The preferred approach is to assess and offer excision site liposuction before proceeding with a brachioplasty. The scar can be placed medially in the bicipital groove with cross-hatch marks to guide accurate wound closure later; this is the conventional approach. Surgeons have employed different scar designs when performing brachioplasty, including straight, "W," "S," "L" shapes, and a Z-plasty in the axilla to mitigate skin contracture.[11] 

A short-scar brachioplasty, where the incision is limited to the axilla, has also been reported. For the limited scar, or minimally invasive brachioplasty (MIB), the patients selected should have skin ptosis of < 12 cm from the mid-humerus to the most dependent part of the hanging skin with arms abducted. Reed reported a 12% revision rate utilizing this technique in a series of 1,200 patients at one year, with scar revision being the most common revision procedure required.[32] 

Other authors prefer a posterior incision brachioplasty, such that the scar sits in the brachial sulcus; some authors prefer this because the scar is less perceptible anteriorly with arms abducted, although it can be seen posteriorly with arms adducted (at rest).[33][34]

Following the skin incision, the subcutaneous fat resection is limited to the superficial fat, leaving a layer of fat over the brachial fascia of the arm.[35][32] This also preserves the medial brachial cutaneous and medial antebrachial cutaneous nerves. The extent of skin resection is tailored by determining the laxity and pulling the wound edges together along the wound - tailor tacking with the use of towel clips placed along the wound allows the surgeon to determine the safe placement of the posterior incision for excision of excess skin. The anterior incision can be extended along with the axillary dome in a curvilinear fashion and onto the lateral chest wall as in an extended brachioplasty "L" shape.[11][36] 

The same approach using tailor tacking can be employed to determine the extent of skin resection. Following hemostasis, meticulous wound closure is performed in layers. The superficial fascial system layers along each wound edge are approximated by the inclusion of the floor of the brachial fascia in a 3-point closure technique.[35] This reduces dead space and tension on the skin closure. No drains are used. The wound is dressed with steristrips, and micropore tape and postoperative compression garments are applied, including the palm/forearm and arm. The procedure is then repeated on the contralateral arm.

Multimodal analgesia in the form of local anesthetic in the wound site during infiltration before liposuction and postoperative oral analgesia (paracetamol, codeine, or equivalent) is recommended. 

Postoperatively, patients are discouraged from any strenuous activity for a minimum of 2 weeks and refrain from driving for this period. The use of compression garments is recommended for four weeks. Nearly all patients are discharged on the same day and followed up in the clinic in 1 week, and patients are encouraged to wet the wounds as desired, provided there is no evidence of wound dehiscence or infection in the 1st outpatient clinic review.

Complications

Patient counseling, preoperative discussion, and informed consent are paramount. It mitigates dissatisfied patients, provides realistic expectations, and prepares patients for potential complications and revision surgery. Patients following MWL often undergo several procedures to address excess skin and lipodystrophy in many areas not limited to the arms, chest, back, abdomen, and thighs. As a result, these patients are at a greater risk of complications, especially when such procedures are combined in 1 operation.[37] Massive weight loss achieved through bariatric surgery confers even higher risk to these patients.[20]

In a meta-analysis of 29 studies including nearly 1600 patients, the most common complications included unfavorable scarring (9.9%), recurrence of skin ptosis (7.8%), and wound dehiscence (6.9%).[28] 

The incidence of seroma (collection of fluid in the upper arm) and infection was 5.9% and 3.6%, respectively. Less common complications were nerve-related (2.5%), lymphoedema or lymphocele (2.5%), skin necrosis or delayed healing (2.3%), and hematoma (2%). Revision surgery was required in 7.5% of patients to improve the aesthetic outcome, whilst re-operation for non-aesthetic reasons was uncommon (1.6%). Furthermore, combining liposuction with brachioplasty reduced the incidence of complications (p<0.05).[28] 

In a prospective study of nearly 2,300 patients undergoing brachioplasty, the authors intended to capture major complications; they reported that hematoma (1.7%) and infection (1.1%) were the most common major complications.[38]

Further insight from their study revealed that male gender and having combined procedures were associated with increased risk of hematoma, whilst a BMI = or > 30 was independently associated with increased infection risk. Therefore, judicious patient selection and informing patients about the increased morbidity as appropriate facilitates thorough preoperative counseling and tailors expectations.

Clinical Significance

Most patients are pleased with the aesthetic and functional outcome of their brachioplasty. Yet, as mentioned earlier, the most common reason for revision operation is to enhance the aesthetic outcome.[28] Nevertheless, it is important to warn patients about unfavorable scarring, and that scar maturation and fading are prolonged following brachioplasty; it may only mature adequately after one year, unlike other anatomical sites.[35]

Enhancing Healthcare Team Outcomes

Brachioplasty is a body contouring procedure that can be performed in various approaches, guided by surgeon preference. As a result, there is limited robust evidence to recommend specific techniques or approaches to brachioplasty for all patients; as with many plastic surgery procedures, the tailoring of a surgical plan to each individual patient offers the best chance of a successful outcome.

The most recent meta-analysis of complications of brachioplasty identified the most common complications are unfavorable scarring, recurrence of skin ptosis, and wound dehiscence.[28] Other complications are less common. Patient selection and optimization are crucial to maximize safety and mitigate the risk of both procedure-specific and general complications.

Preoperatively, patients should have an adequate review of their weight stability, BMI, and nutrition profile assessed in consultation with a bariatric dietician or nutritionist. Their comorbidities should be identified and optimized by liaising with relevant specialist colleagues, for example, endocrinologists, cardiologists, and pulmonologists, as appropriate.

Patients with poorly managed or untreated psychiatric disorders should have a consultation with a psychiatrist to optimize their mental health, and similarly, those with BDD or with unrealistic expectations should be reviewed by a clinical psychologist and may not be candidates for brachioplasty or other body contouring procedures. A preoperative assessment for anesthesia with the anesthesiologist is essential to minimize the risk of GA and optimize patients for surgery. Coordinated activity and sharing of information between all interprofessional healthcare team members will facilitate successful outcomes in brachioplasty procedures.

Nursing, Allied Health, and Interprofessional Team Monitoring

Brachioplasty can often be performed as a day-case operation, although high-risk patients (BMI>30, other comorbidities) may warrant overnight admission and monitoring. Pain management can be guided in consultation with the anesthesiologist, and a multi-modal approach is preferable to reduce opiate dependency. The use of closed suction drains is surgeon-dependent, but current evidence does not indicate that the use of drains reduces seroma incidence.[39] 

Many surgeons will recommend postoperative compression garments to reduce swelling and provide comfort, but there is no robust evidence that they reduce the incidence of any complications.[11]