Monday, June 25, 2007

Tailoring

There is a “tailor” in every plastic surgeon, especially when it comes to the surgeries needed for massive weight loss patients (MWL). The brachioplasty procedure is used to reduce the excess arm skin (sleeve, if you will) so that it fits the underlying subcutaneous tissue/muscle/bone frame. When adjusting a pattern for a large upper arm, slashes are made in two directions to add fabric for the sleeve. When doing the brachioplasty, think about reversing the adjustments made for the sleeve. Now transfer these adjustments to the underside of the arm so that the resulting scar will be least visible. The bi-directional adjustments are made (1) along the length of the upper inside of the arm and (2) by Z-plasty into the axilla. With fabric/patterns you must remember to keep the adjusts parallel to the grainline. In surgery, we have to remember the anatomical structures that we don't want to injure (nerves, blood vessels, lymphatics), scar placement, and not to resect too much skin and thereby forming a constriction band. (Photo credit)


The ideal candidate for a brachioplasty (arm lift) has what we call highly deflated arms. In other words, lots of loose skin and not much underlying fat tissue. Those with significant residual fat around the arms may benefit from liposuction of the arms done at an earlier stage than the skin excision. If much liposuction needs to be done at the time of skin excision, this can greatly increase the post-surgery edema (swelling) that will occur. Swelling can be a significant problem postsurgery. It is important to limit elbow flexion (static, okay when arm is being used) and to keep the arms elevated when not being used for the first 2-3 weeks. When resting, it is helpful to gently open and closed the hands/fists--squeeze on an anti-stress ball.

Scar placement is important for more reasons than just to be “not as visible”. It is important that the Z-plasty part of the scar is well placed in the axilla so that no axillary contracture is formed. This can limit shoulder/arm motion. Good scar (incision) placement decreases the risk of injury to the cutaneous skin nerves, so there will be less chance of postoperative skin numbness.

Scar placement is usually either in the bicipital groove or more posterior at the most inferior point of the upper arm while it is raised and abducted (positioned away from the body). The second choice is less visible in everyday activity. Either way, the scar is there. The scar can be quite apparent, so this procedure should never be undertaken if the patient is not willing to make this trade-off (less skin, but a significant scar). Pre and Post-operative photos here.

References:

  1. The L Brachioplasty: An Innovative Approach to Correct Excess Tissue of the Upper Arm, Axilla, and Lateral Chest; Hurwitz, Dennis J. MD, Holland, Sarah W. MD; Journal of Plastic & Reconstructive Surgery;Vol 117(2):403-411, February 2006.

  2. A Technique of Brachioplasty; Strauch, Berish MD, Greenspun, David MD, Levine, Joshua MD, Baum, Thomas PAC; Journal of Plastic & Reconstructive Surgery;Vol 113(3):1044-1048, March 2004.

  3. Textbook: Body Contouring After Massive Weight Loss by Al S Aly, MD

  4. Shaping Futures Web Site (you must register for access to the procedures)

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