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Archive for the ‘arm lift’ Category

Case Study: The Posterior Armlift after Extreme Weight Loss

Tuesday, November 30th, 2010

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 betweenthe 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

Indianapolis Indiana

Common Questions about Arm Lift Surgery (Brachioplasty)

Wednesday, January 6th, 2010

1.      How do I know if an arm lift is right for me?

 

Deciding about an arm lift (also known as a brachioplasty) is a balance between how much does a scar bother you versus how much does the way your arm looks now bother you. In other words, would a scar running down the inside of your arm be better than the floppy saggy skin that is there now? It is about trading off one ‘problem’ for another. You just have to make sure the new problem (scar) is preferable to the way the arm looks now.

 

2.      Would liposuction work as well as an arm lift?

 

In almost all cases, no. Liposuction only removes fat. And while some skin shrinkage (contraction) does occur with liposuction fat removal, that skin change is not nearly as much as the skin that is removed with an arm lift. When you look carefully at arms that are saggy, a lot of the problem for many patients is primarily loose skin which hangs down from the triceps area. While there certainly is some fat as well, the amount and stretched nature of the skin is usually the greater problem.

 

3.      Will an arm lift get rid of loose skin in my armpit or on the side of my chest?

 

In many upper arm problems, particularly after large amounts of weight loss after bariatric surgery, the skin problem extends beyond the arm into the armpit (axilla) and even down onto the side of the chest or breast. When this occurs, one needs a modification or extension of the traditional arm lift procedure. The cut out pattern must extend beyond the arm (horizontal component)to include this vertical excess as well. This is known as an extended arm lift. The transition area in the axilla poses the biggest potential postoperative problem as any scar that crosses a joint area is prone to developing a tight scar band. When this occurs in the axillary region, the full upward motion of the arm may be restricted and painful. Secondary scar revision may be necessary. 

4.      Where and how long is the scar on the arm?

 

The scar will be as long as the distance between your elbow and the armpit. In an extended arm lift, the scar will be double that length as the vertical length of the scar extending down from the armpit may be just as long as the horizontal arm scar. In my opinion, I would be less concerned about the length of the scar and more focused on how the scar will look. Arm scars do tend to get wide and be red for sometime after surgery. And I have rarely seen what I consider a great armlift scar. Because of the location of the scar and that it is closed under considerable tension, they never turn out to be great-looking scars. That being said, most armlift patients do not undergo scar revision as they usually feel that however the scar looks is preferable to what they had before. This is also the reason why one should not undergo an armlift unless the arm problem is fairly severe. These type of scars are not a good trade-off for a minor arm sagging problem.

 

5.      Is an arm lift painful?

 

Remarkably, no. The arm will feel tight and little sore, but there is no significant pain afterwards.

 

6.      How soon after can I shower and use my arms?

 

I have my patients remove their arm wraps and shower after 48 hours. All sutures are under the skin and the incision is covered with tapes. There is no harm in getting the tapes wet. They will be removed in one week. In some cases, I do place a drain which is usually removed in two or three days after surgery.

 

7.      Will insurance pay for my arm lift?

 

Unfortunately, no. While sagging arm skin is unsightly and does interfere with the wearing of certain clothes, its correction is not considered a medical necessity. The insurance companies do not see any medical benefit to be gained by its removal.

 

8.      How can I improve the arm scar if it looks bad?

 

Arm lifts scars can be revised six months to a year after surgery if a patient desires. Seconday revision always produces a better looking scar as the skin is more relaxed, less tissue is being removed compared to the original arm lift, and the incision is closed under much less tension. One can use topical scar creams after the original arm lift surgery but they tend to have limited benefit in the arm lift scar.

Dr. Barry Eppley

Indianapolis, Indiana

Different Approaches to Arm Lifts in Extreme Weight Loss Patients

Thursday, November 27th, 2008

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

Indianapolis, Indiana

Arm Lifts(Brachioplasty) in the Extreme Weight Loss Patient

Monday, November 24th, 2008

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

Indianapolis, Indiana

Arm Lifts in the Bariatric Surgery Patient

Monday, April 28th, 2008

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

Indianapolis, Indiana

Combined Armlift and Hysterectomy Surgery at IU Health West Hospital

Monday, February 11th, 2008

Combination Gynecologic and Plastic Surgery Procedure at IU Health West Hospital 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 IU Health West Hospital 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 concurrent hysterectomy-arm lift is a new combination for me. When surgeons work together, patients benefit!

Dr Barry Eppley

Indianapolis, Indiana


Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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