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

We divide patients undergoing brachioplasty into3 groups, according to their characteristics.Group 1 comprises patients with moderate tofirm skin and voluminous upper-arm fat deposits. Weperform lipoplasty with specic limitations on how muchfat is removed based on the patients skin turgor. Theseprinciples are the same as those advocated by Vogt.1

Group 2 comprises patients with abby skin and fatdeposits. Treatment includes lipoplasty and skin resec-tion in the same stage. Surgery begins with lipoplasty.We perform skin undermining superficially, preservingthe subcutaneous tissue to avoid severing of lymphaticvessels and supercial nerves.

Group 3 comprises patients with accid skin and nofat deposits. Resection of excess skin is the only indica-tion for this group. In almost all of these patients, weresect an elliptical or triangular shaped piece of skin ap,saving the internal brachial sulcus as reference. We placethe suture and nal scar 1 to 3 cm above or below thissulcus (Figure 1). The amount of axillary skin resected isbased simply on redundancy. It is imperative, however,that the scar is placed at the inner aspect of the upperarm; otherwise it will be exposed.25

The general preoperative evaluation for any patientundergoing arm contouring includes the pinch test todetermine the amount of skin to be resected. When per-forming this test, have the patient stand with his or herarms abducted.

Surgery is performed under sedation and local anes-thesia; the patient is prone, with arms abducted at about80 degrees. The specic technique lipoplasty, surgicalexcision, or both is carried out in accordance with theplan made before surgery.

Even though we havebeen performing lipoplastysince 1981, it did notbecome part of our standardapproach to brachioplastyuntil after 1988. Since then,we have routinely usedlipoplasty in selectedpatients undergoing bra-chioplasty. In the past 6years, we have also used 2other techniques to improveresults. First, we performconservative skin undermin-ing only on the area to beresected to avoid deadspace. Second, patients with redundant skin in the elbowregion are treated with elbowplasty, which we perform ina manner similar to the procedure described by Lewis.6

Elbowplasty may be combined with brachioplasty in thesame surgical stage.

Conservative Skin Undermining

When skin dissection is to be performed, the skin apis stretched above the superior limit of the incision toestimate the amount of skin to be resected. Three-zeroisolated intradermal absorbable stitches are placed allalong the upper nondissected skin edge, and the dissectedlower limit, to avoid dead space and irregular tension onthe suture. Then resect the excess skin (Figure 2).

Finish suturing with a running intracuticular 4-0absorbable material. Straight and zigzag suture lines havedemonstrated similar scar quality. In long-term follow-up, we have found that suture tension results in broaden-ing of scars. Scar widening is more evident in patientswith thin dermis.

Excess elbow skin is common in older patients and inslim patients with lax skin. In contrast to Lewis proce-dure, which looks like an elliptical resection, we performa horseshoe-type resection for excess skin (Figure 3).This has resulted in generally acceptable scars. The scar

Ricardo Baroudi, MD, SoPaulo, Brazil, is a member ofthe Brazilian Society of PlasticSurgery.Co-author Carlos Alberto A.Ferreira, MD, So Paulo.Brazil, is a member of theBrazilian Society of PlasticSurgery.

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may resemble one of the remaining elbow-skin folds; abroader and somewhat less desirable scar may result,depending on individual healing characteristics. In allpatients, the scar remains reddish for months.

References1. Vogt PA. Surgery of the upper arm. Lipoplasty Newsletter 1994;11:24.

2. Baroudi R. Dermatolipectomy of the upper arm. Clin Plast Surg1975;2:485.

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 AestheticSurgery. St. Louis, MO: Mosby; 1978:232.

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

Figure 1. Schematic representation of the triangular and elliptical incisions for resection of excess skin. XX represents the internal brachial sulcus. It isimportant 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 stepto avoid unnecessary undermining. B, Isolated absorbable 3-0 sutures are applied all along the upper incision edge to the limits of the underminedskin. C, Excess skin is resected. D, Routine 4- 0 absorbable running intracuticular skin suture.

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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.

Copyright 2003 by The American Society for Aesthetic Plastic Surgery, Inc.

1090-820X/2003/$30.00 + 0

doi:10.1067/maj.2003.63

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 thebrachial internal sulcus. E, Preoperative view demonstrates cutis laxa of the elbow. Patient is marked for a horseshoe-like skin incision similar to thatdescribed in Lewis procedure.6 F, The pinch test is performed. G, Demonstrates the dissection and the excess skin to be resected. H, The patient hasbeen 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.

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Arm ContouringConservative Skin UnderminingReferences