Explore Plastic Surgery - Dr. Barry Eppley

Plastic surgery is one of the marvels of modern medicine, with a wide range of options for face and body improvements. And today’s media outlets make it easier than ever before to gather information on the latest plastic surgery procedures. But how does this information apply to you and your concerns?

Every person is unique and has his or her own desires. What procedure or combination of treatments is right for you? And what can you really expect? EXPLORE PLASTIC SURGERY with Dr. Barry Eppley, Indianapolis plastic surgeon, who can provide you with a wealth of practical and up-to-date insights into the world of plastic surgery through his regular blog posts. In his writings, Dr. Eppley covers diverse topics on facial and body contouring procedures. You will be sure to find useful information that will help broaden and enrich your plastic surgery education.

Background:  The shape of the upper arm is primarily determined by the front (biceps) and the back (triceps) sides of it. While men are notoriously concerned about the biceps region, women are much more concerned about the opposing triceps region, particularly as they age. Loose and floppy skin on the back of the arm affects many women and a desire to undergo some treatment for it is common.

For minor amounts of upper arm fullness or loose skin, liposuction or non-surgical skin tightening can be effective. While armlifts create the most dramatic change in the shape of the arm, it should only be employed in the most severe sagging arm cases. The  scar of an armlift is simply not acceptable to most women, short of those who have had a lot of weight loss. This makes the bariatric surgery female the most likely to accept an arm scar as a better aesthetic problem than that of a low hanging skin on the back of the upper arm.

The severe sagging of many bariatric or extreme weight loss patients also presents another aesthetic problem. The amount of excess rarely stops in the arm or at the armpit. Rather it extends past the armpit down into the lateral chest wall to the side of the breasts. When planning an armlift in most bariatric patients, this excess skin outside of the arm must be factored into the excision pattern. Having a scar cross the armpit poses risks of tightening and restriction or painful abduction of the arm when lifted above shoulder level.

Case Study: This 40 year-old female had bariatric surgery (bypass) two years previously. She had lost over 120lbs. Besides her abdomen and waistline, her next most important concern was her arms. She was embarrassed by the floppy skin and how it swung back and forth with arm movement. She agreed to multiple body contouring procedures performed simultaneously including armlifts, an extended tummy tuck, and breast implants with nipple lifts.  

During her multiple bariatric plastic surgery procedures, an extended armlift was planned that had a cutout pattern that run from her elbow up to her armpit and then down to the side of her breasts. This was marked out just slightly in from the very backside of her arms toward the inner side of the arms. Skin and fat was excised down to the muscle fascia of the upper arm and into the subcutaneous fat of the armpit and the lateral chest wall. Closure of the long incision was done with subcuticular sutures without any z-plasty or break-up of the incision as it crossed the armpit. Drains were used for both sides.

Her drains were removed five days later and she wore compression wraps for three weeks after surgery. Her armlifts results were immediate and dramatically improved. At six months after her armlifts, she had scar that were still slightly red, had developed some widening but had no scar contracture or  restriction of movement across the armpits. Fading of the redness of her scars is expected to take up to one year after surgery.

The scar location could be seen to be completely on the back of her arms which was not apparent to her. But the scars can be seen from behind by others.

Case Highlights:

1)      Armlifts can produce a dramatic reduction in the circumference of the upper arm by removing excess skin and fat from the back (triceps) area.

2)      The most important consideration in an armlift is the patient acceptance of a scar trade-off. This scar is easy to accept in the bariatric patient who usually has a large amount of hanging arm tissue.

3)      The best location of the armlift scar is on the backside of the arm. This location also heals better with less scar widening than when it is placed on the inside or medial aspect of the arm.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

Indianapolis, Indiana

In youth, the upper arm has near equal proportions between the internal bone (humerus) and the skin on the front or back (arm held down by one’s side) or the top or bottom (arm held away from the body) of the arm. With age, the distance on the back of the arm (triceps) elongates and accumulates fat.  This change in the arm with age or weight gain has led to arm reshaping procedures, most commonly known as a brachioplasty.  

While once a very uncommon procedure, the armlift (brachioplasty) procedure is done routinuely today. Much of the reason is the popularity of bariatric surgery which has created a lot of loose floppy arm skin, unflatteringly referred to as batwings, as a result of extreme amounts of weight loss. In such large hanging arms, the trade-off of a long scar in the upper arm is very acceptable.

However, in non-weight loss patients where the upper arm shape is not so severely distorted, long arm scars are usually not acceptable. This has lead to the need to use more non-excisional technologies, such as liposuction and other light or radiofrequency-based energies, to help skin contraction. In the right patient, this may eliminate the need for any scars or at the least a much shorter arm scar.

Brachioplasty for the non-bariatric surgery patient (or for the bariatric surgery patient with more modest arm deformities) has evolved to use shorter segments of skin and fat removal. This leaves more limited scars restricted to the upper arm or no further than the middle third of the arm. By tightening the deeper tissues of the upper arm with superficial fascial plication, and using some liposuction, visible improvements in arm shape can be achieved.

 What are the criteria that can be used to determine whom is a good candidate for the different types of brachioplasty? Evaluation of the arm includes a determination of how much skin is present and its amount of elasticity and the ratio of fat to skin in the enlarged or hanging triceps area. In addition, it is critical that a thorough presurgical education be done with emphasis on realistic expectations as to how much smaller the arm can be made and the location of scars if excision of skin is needed.

A large amount of loose skin and a minimal amount of fat, which is typical of a bariatric weight loss patient, will require a traditional long scar armlift. Slight skin excess and laxity with little fat may respond to radiofrequency- or high-intensity pulsed light (e.g., SkinTyte) treatments with some modest improvement. These type patients are quite uncommon although many patients wished they fit into this group. Good skin tone with substantial fat (tight arm) may do well with Smartlipo (laser liposuction) alone. The combination of fat and skin excess with mild laxity will probably respond best to a combined liposuction and skin excisional procedure.

Of these options, the mini-brachioplasty (short scar armlift) requires the most thought and consideration. The limited scar can be either a shorter horizontal scar, restricted to no further than 1/3 way done the inner arm, or an ellipitical armpit removal which results in a fairly hidden scar high up in the armpit. Who best fits this more limited brachioplasty approach? I make that determination based on how the triceps area hangs when the arm is held away from the body at 90 degrees, whether the forearm is held parallel or perpendicular to it. If the lowest point of sag of the arm is located past the central point of the triceps (halfway between the armpit and the elbow) or lower, significant improvement will only be obtained by a long scar armlift. If the lowest point of sag lies central or above, shorter scar armlifts can be considered.

Dr. Barry Eppley

www.eppleyplasticsurgery.com

Indianapolis, Indiana

Background: Most people pay little attention to the size and shape of their upper arms, unless they are too big or floppy. With extreme weight loss, aided by bariatric surgery or a very dedicated diet and exercise program, the upper arm skin will sag considerably. While the loss of fat deflates the volume of the upper arm, the enveloping skin will not usually shrink down in a linear fashion. This results in a flap of skin that hangs down off of the back of the arm.

Know affectionately as ‘bat wings’, this excess arm skin will usually extend beyond the junction of the arm and the armpit. It will not only go into the armpit but may reach all the way down into the side of the upper chest wall. This more commonly occurs in women and much less so in men. The greater the weight loss, the greater the bat wing will be.

The armlift procedure is the only approach to the bat wing problem that results from a lot of weight loss. While extremely effective, one has to be willing to accept the trade-off of a long scar in its place. While I have yet to find an extreme weight loss patient that it not willing to accept it as a replacement, it is still a goal to have the scar as less noticeable as possible. Armlifts scars can be placed either in inner or medial aspect of the arm, directly on the back of the arm (posterior), or between these two locations.

Case: This 38 year-old female was bothered most by her loose upper arm skin after her 150 lb. weight loss. While she had other loose skin issues, particularly on the breast, her arms were first priority probably due to her primary activity as a fitness instructor. Those outfits do not hide the upper arms very well.

The pattern of excision of the upper arm skin must be placed parallel to the desired final scar placement. Having done armlifts in all three arm locations, I have found that the best in my experience is between the inner aspect (medial) and back of the arms. This makes arm positioning in the operating room not unduly stressful on the patient or the surgeon. And it puts the scar in skin quality (thickness) that does much better than on the medial side of the arm in terms of healing and visibility.

Her arm skin excision removed 11 cms of skin and fat at its widest in the middle of the upper arm. The excision carried well past the armpit into the upper chest wall. Because it crossed the axillary skin crease, a z-plasty was done to break up the linear scar line and decrease the risk of scar tightening and contracture in this area.

She had a virtually painless recovery and took no pain medications after the first postoperative night. Her arms did feel tight and this tightness was most felt in raising her arms above her head. She had her covering tapes and armpit sutures removed two weeks later. Even with some residual swelling, the change in the appearance of her arms was dramatic. This photo shows her appearance at the time of her two week postoperative visit

Armlifts create a unique but temporary problem in the forearms and hands, what I call the ‘Popeye syndrome’. Because of the tightness of the upper arms after surgery, the lymphatic outflow from the forearms and hands is slightly impeded. This can cause the forearm to be temporarily bigger than the upper arm which is certainly an unusual appearance. It will resolve as the swelling of the upper arm subsides and the surrounding skin relaxes.

Case Highlights:

1) Significant sagging of the upper arms is almost always created by weight loss, whether created by bariatric surgery or diet and exercise. Liposuction is not an adequate treatment for the loose skin of arm ptosis.

2) The armlift involves direct excision of the loose skin of the upper arm. This usually requires extending the excision into the armpit area and onto the lateral chest wall due to the amount of loose skin.

3) Better scars and less postoperative wound complications occur when the excision pattern and closure is oriented more towards the back of the arm. The traditional inner armlift results in wider scars and more problems with wound separations.

Dr. Barry Eppley

www.eppleyplasticsurgery.com

Indianapolis Indiana

Arm lifts or Brachioplasty is a plastic surgery procedure that removes excess skin and fat from the arm. The trade-off for this skin removal and tightening of the upper arm  is a long scar that runs down the arm. This cut out of skin and the resultant scar can be done on either the inside or back of the arm. There are advantages and disadvantages  to either approach and I always leave the decision up to each patient. The arm lift can be done successfully with either approach.

The most common location for the skin and fat cut out for an arm lift is the medial approach on the inside of the arm. In theory, this places the scar on the most hidden part of the arm. That point is debatable in my mind as the scar would only be hidden if your arm is down and by your side. Certainly if you raise your arm and are in short sleeves, the scar is not hidden. A fair amount of skin can be removed with this approach but cutting out too much is a possibility, making for a very tight closure and the likelihood of having wound separation problems after. It is easy to take too much with this approach and a tight closure with the very thin skin on the inside of the arm makes for some wound healing issues which are common.

The other approach for an arm lift is on the back of the arm. The skin and fat cut out and final scar runs down the backside of the arm. In theory, the patient doesn’t see the scar but everyone else does. (at least if they are behind you) I think that more skin can be removed and better arm tightening can be obtained with this approach. My experience is that less wound healing problems occur when the arm lift is done this way, probably because the skin is a little thicker and holds sutures better.

With either approach it is often necessary to extend the skin excision into the armpit and even beyond. This is unique to the extreme weight loss patient. The sagging skin usually extends into the armpit and into the side of the chest.  Either the inside or back of the arm lift approaches can be extended downward  to include this area. By doing so, both approaches run the risk of creating a scar contracture or tight band where it crosses the attachment of the arm skin to the chest skin. This is noticeable only when one raises their arm, particularly above the level of their shoulders or above their heads.

Despite their subtle differences, both the inside and back of the arm approaches to the arm lift are equally effective. One should choose either approach based on which scar location one finds the most acceptable.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

The sagging skin that results from extreme weight loss does not spare the upper body, particularly the arms. Flabby upper arm skin, often referred to as ‘bat wings’, is a very troubling problem that makes many affected women wear long sleeves, even in warmer weather. It limits their clothing options and is a frequent source of embarrassment. In my experience it is always in the top two concerns of most extreme weight female patients.

Such an arm problem is a good candidate for an arm contouring procedure known as an arm lift or brachioplasty.This operation removes a large amount of excessive skin and fat from the upper arm. This is a fairly simple operation that causes little to no pain afterwards. The biggest decision for any one considering this procedure is whether they can handle the scar that results from the procedure. Unlike most body contouring plastic surgery procedures where the scars may be fairly well-hidden under clothes, this is a scar which will be visible. For this reason, the decision for some patients can be a difficult one. Is it better to have a flabby arm with no scar or a more tightened arm with a scar? While the temptation is to always assume that the scar may be better, it is important to know that the scars in the arm (in my opinion) are never great. They frequently end up after healing and time to be wider and more raised than we like. While some arm scars can look quite good, many will be simply acceptable in the vast majority of patients. Scars are the arm simply do not do as well, for example, as scars from a tummy tuck or a breast lift. Scar revisions after an arm lift can really make a big difference is problematic arm scars…but that is another operation as well.

There are two types of arm lifts or brachioplasties. A full (extended) and a limited (short scar) arm lift. The difference is in the amount of skin removed and the resultant length of the final scar. In every extreme weight loss patient that I have seen, they all need an extended or the full arm lift due to the amount of skin. While I usually never cross the scar past the elbow, it is almost always necessary to carry the upper part down into the armpit if not further down into the chest wall and back.  The arm lift scar can be placed either on the inside of the arm or on the back of the arm. There are arguments to be made for either scar placement,. neither approach is necessarily better than the other. Both locations of skin and fat removal will do the job.  I leave the scar location decision up to the patient since they are the one who has to live with the final result.

While arm lifts cause very little pain afterwards, they do create some temporary swelling in the hands and forearms. The combination of upper arm skin tightening and circumferential dressings (loosely applied) causes some temporary lymphatic obstruction which resolves in less than a week after surgery. Healing of the incision is sometimes slow in the armpit area and it is not rare to have to drain a seroma in the elbow in the few few weeks after surgery. Beyond these short-term troublesome issues, arm lifts produce good results with a relatively uncomplicated postoperative course.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

Of the many bariatric surgery patients that I have seen over the years who have lost 100 or more pounds, the concern over their saggy arms is often a top concern. I would have to say that the arm concern combined with the stomach or waistline are almost always the top two priorties of the massive weight loss patient. I should add one caveat, the arms are an issue exclusively for women. I have yet to see a male patient who has put forth this concern to me. That does not mean that men don’t develop flabby arms after bariatric surgery, it just doesn’t cause the same problems that it does for women.

Because of high arm concerns, most female bariatric surgery patients often undergo a combination of an arm lift (brachioplasty) and an abdominoplasty as the first stage of their body contouring. Full arm lifts, which all bariatric surgery patients require, always result in a long arm. The patient can choose whether this scar ends up on the inside of the arm or on the back of the arm. There are arguments for its placement in either location. It is a choice of whether you see the scar but others not so much so (inside of the arm) or whether others see it but you can’t. (back of the arm) Either way, I caution patients that, from my perspective, I have seen very few good-looking scars. Scar from arm lifts seem to do rather poorly in terms of their width, redness, and their tendency for hypertrophy. (raised scar) I think it is the very thin skin and the tension that it is under from the tight closure that makes them often appear fairly unsightly. While they can be raised revised later, from which they turn out much better, an arm scar that parallels the vertical axis of the arm is one of the poorer scar outcomes from body contouring in the bariatric surgery patient. Then there is the scar banding (contracture) issue that can occur as the scar crosses from the arm into the axilla. (armpit) It is always necessary to bring the skin excision pattern into the armpit and often down into the side chest wall. Like all scars that cross areas of movement, a tight band often develops. Sometimes I have incorporated a Z-plasty into the skin cutout and other times, I have just waited to see whether a bothersome scar contracture develops. For most patients, the degree of improvement in the shape of their arms seems to overshadow significant concerns about an axillary scar contracture.

One of the nicest things about an arm lift procedure is that it is associated with little to no postoperatve pain and recovery from it is fairly quick. Other than some mild swelling in the hands during the first few days after surgery, most problems with arm lifts are relatively minor including snall fluid collections (seromas), spotty areas of delayed incisional healing, and the scar issues previously mentioned. For these reasons, an arm lift is a perfect compansion to other more major body contouring procedures in the bariatric surgery patient such as tummy tuck, circumferential body lift, and breast lift/implants.

Dr Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

Combination Gynecologic and Plastic Surgery Procedure at Clarian West Medical Center in Avon, Indiana

As the field of medicine and surgery continues to advance, I am continually amazed at how different surgical procedures are being done, not only during the same surgery, but at exactly the same time. This is of great benefit to the patient and maximizes valuable operating room time and resources.

An example of such a case was on February 12, 2008 at the Clarian West Medical Center in Avon, Indiana. A female patient was initially seen by me in Plastic Surgery for contouring of her arms to get rid of the flabby skin that inevitably results after a lot of weight loss.. She required formal arm lifts (brachioplasties) combined with liposuction of the area for improvement. She had a gynecologic issue with heavy bleeding and also needed a hysterectomy. The Gyn surgeon and myself worked out a time when we could do the surgery together. Because the operative fields were at ‘opposite ends’ so to speak, we were also able to work at the same time effectively cutting down the total operative time in half.

I have seen over the years a lot of different combinations of surgeries combined with plastic surgery, but a combination hysterectomy-arm lift is a new combination for me. When surgeons work together, patients benefit!

Dr Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis