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Posts Tagged ‘arm lift’

Case Study – Arm Lifts in Bariatric Surgery Patients

Sunday, June 14th, 2015

 

Extreme arm sagging after weight lossBackground: Large amounts of weight loss, whether from bariatric surgery or from other non-surgical methods, creates a lot of secondary body issues. The loss of subcutaneous fat causes deflation of the overlying skin, resulting in skin sagging and often interference with numerous normal bodily functions. The arms are a classic example of this expected phenomenon with large amounts of loose skin hanging off of the back of the arm creating the classic ‘batwing’ appearance. Besides its unsightly appearance it often causes problems in fitting into shirts and other upper body wear.

Removal of excessive arm skin is done by the well known arm lift or brachioplasty procedure. This arm reshaping procedure has been around for a long time and not much has changed in how it has been performed. It involves removing the loose skin and fat that hangs below the arm when one has their arm extended out at 90 degrees from their body. There are no vital structures in this skin segment, not even any major artery or veins. An armlift does create a prominent scar but this is always a better aesthetic tradeoff in the extreme weight loss patient with true batwings.

The relevant issues about surgically planning an arm lift is the scar location and whether it should cross past the armpit into the side of the chest. The latter is simply decided by whether a web of skin extends between the arm and the chest wall. But the scar location has been a matter of surgical and patient discussion for years. The final arm lift scar can end up being placed on the inside (medial), the back side (posterior) and an intermediate location between the two. (posteromedial)  This is purely a function of how the excision of excessive arm tissue is oriented.

Case Study: This 42 year-old female had bariatric surgery three years previously with a stable weight loss of 110lbs. Her primary body shape concerns were her arms and stomach. Her breasts and thighs were less important and were planned for a second stage procedure

Left Armlift result front view Dr Barry Eppley IndianapolisLeft Armlift result back view Dr Barry Eppley IndianapolisUnder general anesthesia , she underwent a fleur-de-lis extended tummy tuck and armlifts. The armlifts were performed by a posterior excision of tissue that was marked upright before surgery. During surgery her arms were elevated, crossed and attached to a padded metal bar which allowed direct access to the arm excisions. The excess tissue was excised down to the deep arm fascia and just past the lower portion of the armpit. It was closed into two layers and no drain was used.

Right Armlift result front view Dr Barry Eppley IndianapolisRight Armlift results back view Dr Barry Eppley IndianapolisArmlift Scars Dr Barry Eppley IndianapolisHer postoperative arms showed a typical bariatric arm lift patient result with a dramatic improvement in the size of her arms and elimination of hanging skin. The back of the arm scars were only seen when the arms were raised and at certain angles from the back. There were typical arm lift scars, not great by plastic surgery standards, but would go in to fade considerably with further healing. (two month healing result)

The arm lift procedure is the single most satisfying of all the bariatric plastic surgery procedures. It is easy for patients to undergo, produces very satisfying results and is associated with few complications. It is an excellent body contouring procedure to do as part of a first stage bariatric plastic surgery program.

Highlights:

1) Arm lifts are an important part of bariatric plastic surgery after extreme weight loss and is often part of the first surgical stage of the body contouring procedures.

2) Of all the body contouring procedures after weight loss, arm lifts have the easiest and least painful recovery.

3) The excision of loose hanging arm skin can be done from multiple locations on the arm but the posterior approach offers the best arm lift scar location.

Dr. Barry Eppley

Indianapolis, Indiana

Combining Liposuction and Arm Lifts – The Brachiolipoplasty Procedure

Thursday, February 6th, 2014

 

Arm Reshaping Surgery Indianapolis Dr Barry EppleyArm lift or brachioplasty surgery had become very popular in the past decade, largely due to the preponderence of bariatric and weight loss surgery. While many women would like to have smaller and more shapely arms, liposuction remains the only surgical technique of arm reshaping in most non-weight loss patients due to the scar from arm lift surgery.

Arm lifts fundamentally involve a simple excision of skin and fat with the only nuance of how to orient the excision and the final placement of the arm scar. While plastic surgeons have various locations of the final scar (medial arm, posterior arm and posteromedial arm), one scar location over the other has never been proven to offer a superior scar result or less wound healing complications.

In the February 2014 issue of Plastic and Reconstructive Surgery, an article was published entitled ‘Avulsion Brachioplasty: Technique Overview and 5-Year Experience’. In this paper, 44 consecutive armlift patients over five years were reviewed based on a treatment combination of liposuction combined with skin resection. The average amount of liposuction aspirate was 340ml per arm and a skin resection average weight of 90 grams. Their results showed no after surgery complications of hematomas or infection. Only one patient had a seroma. Half of the patients needed dressing care for wound dehiscences. Nine (20%) of the patients had a scar revision within the first year after surgery.

Arm Lift Dr Barry Eppley IndianapolisThis article highlights to specific and distinct points about this arm lift technique. First, it demonstrates the value of doing liposuction to aid arm lift surgery. Besides helping to debulk the arm and making for a better reduction in its circumference, it also helps to better preserve the lymphatics and decrease after surgery swelling. With a lot of skin removal in the upper arm, a tight closure due to thick skin flaps can increase the risk of wound dehiscences.

The second important point is that armlift surgery is associated with a fairly high risk of minor wound dehiscences and scars that are unpredictable in their quality. This is due to the very thin skin of the upper arm which is unlike most other areas of trunk and extremity surgery. While all go on to heal without the need for surgical intervention, it it a process that can take up to 6 to 8 weeks after surgery to have complete incisional healing and the cessation of any suture extrusion. (spitters)

The location of the incision and the resultant scar in arm lifts, as this article as discussed, is best done in the posteromedial upper arm location. I have evolved to this location over the years as it offers the best aesthetic location between when one raises their arms or has them down at their sides. Being halfway between the side and the back of the upper arm, it offers the greatest amount of concealment in a location where the concept of a completely hidden scar is not realistic.

Dr. Barry Eppley

Indianapolis, Indiana

Common Questions on Bariatric Plastic Surgery (Body Contouring after Massive Weight Loss)

Wednesday, January 13th, 2010

1.      How soon after my weight loss can I get plastic surgery done?

 

Large amounts of weight loss, generally 75 to 100 lbs or greater, will cause significant loose skin on multiple areas of the body. It does not matter whether that amount of weight loss is from dieting, gastric bypass, or lapband surgery, the skin can not shrink back done in most people.

 

Because body contouring surgery is about removing as much excess skin as possible, one should have maximized their weight loss and proven that this new weight is stable. For some patients, that may be 9 to 12 months. For others, it could be much longer than a year.

 

The other benefit to waiting until your weight loss is stable is to make sure you are in  a good nutritional state. Weight loss, no matter how it is done, depletes one’s body of vital nutrients and other stores that are needed for the healing of long surgical incisions and extensive wounded tissues.

 

2.      At what weight should I before I can have body contouring surgery?

 

Many extreme weight loss patients have a specific target weight in mind. Whether they make it or not depends on a lot of factors and one of those is certainly time. Whether any patient will hit their weight target is unknown. But at some point one will realize a point when their weight will not get any lower. Once one has bounced around at a low weight for awhile, then you can be certain this is where your body will live. Once you are comfortable that you have found this weight, and can keep it, then you are ready for surgery.

 

3.      What’s the difference between a tummy tuck and a circumferential body lift?

 

The one body area that bothers all extreme weight loss patients is the abdomen or waistline area. Loose skin is always present in front of, over, and behind the hips. For some patients, a skin overhang is only present in the front. For many others, the skin excess extends around the waistline and across the back, resulting in sagging of the buttocks and posterior thighs as well. These concerns are almost always addressed first in most bariatric plastic surgery treatment plans.

 

When the excess skin overhang is primarily in the abdominal area, a tummy tuck or abdominoplasty is all that is needed. While it can be a conventional horizontal elliptical excisional pattern, the amount and stretched out quality of the skin may need  a modified pattern to provide optimal tightening. This may require the horizontal cutout to go further back along the waistline or to include a vertical skin wedge resulting in an invert T or anchor closure pattern. (fleur-de-lis tummy ruck)

 

When the loose skin incorporates the entire waistline, a circumferential or 360 degree cutout is needed. This is known as a circumferential body lift. It is a lot like ‘pulling up your pants’. The scar will run completely around your waistline. In some cases, the front side of the circumferential body lift may include the fleur-de-lis cutout pattern as well.

 

4.      How can I reshape my saggy breasts…or my manboobs?

 

One of the most challenging of all body parts to reshape after extreme weight loss is the female breast and the male chest. The female becomes essentially a deflated bag of skin with severe sagging and the nipple often pointed downwards. The male chest also loses volume, although less so than the female, but the chest skin shifts and sags downward with a lower than normal  nipple position.

 

 The breast often requires a combination of an implant, for volume replacement, and a lift (mastopexy)to reduce the amount of sagging skin and bring the nipple back up to a more central position of the breast mound. This is a difficult operation, from an artistic standpoint, and it often requires two separate surgeries to get the best result.

 

The sagging chest in the male, while not trying to make a mound like in the female, is complicated by trying to limit scarring. There are no natural creases or folds to hide scars in the flat male chest. Getting the nipple back up on the chest and tightening the skin requires a compromise between the result and the amount of scarring. The chest lift in a man is done differently than a breast lift in a woman.

 

5.      I hate my ‘batwing’ arms, what can I do about them?

 

Loose skin in the arms is another common extreme weight loss problem. In the back of the upper arms (triceps area), loose skin and fat hang off and below the humerus bone. This creates a large fold of hanging skin. It often extends into and past the armpit and down into the side of the chest. In some cases, I have seen the skin excess goes past the elbow into the forearm.

 

The good news is that arm recontouring, known as brachioplasty, is the ‘simplest’ of all body contouring procedures. The arm’s circumferential measurement can be measurably reduced.  Skin and fat is removed longitudinally along the arm and the cut out often takes a right turn into and past the armpit. The bad news is that it does result in a long scar in an unnatural area on the inside of the arm. Scar healing problems are not uncommon in the moist and moveable armpit area.

    

6.      How bad are the scars from bariatric plastic surgery?

 

Body contouring after extreme weight loss is about making a trade-off…scars for improved contours. Depending upon the body area, scars tend to turn out somewhat different. Breast and abdominal scars generally look best while arm and thigh scars tend to become wider. Most of these scars are more than just fine or pencil-line in width and some of them will end up becoming hypertrophic or wide due to the tension placed on the wound closure.

 

Regardless of how the scars may look, there can be a lot of them if multiple body areas are treated. Despite the plethora of this new skin ‘problem’, weight loss patients universally prefer them to their prior ‘sharpee’ body look.

 

7.      Will insurance cover my skin removal surgeries?

 

While third-party payors often pay for surgical and non-surgical weight loss treatments, such widespread coverage for body contouring is not so generous. The line between cosmetic and reconstructive procedures for removal of excess skin is a judgment call that does vary amongst different insurers. Ultimately they are looking for functional problems that this skin causes, such as infections, to determine medical necessity for the operation. In general, the most commonly covered procedure is the abdominal panniculectomy or frontal abdominoplasty. The procedures never covered are breast and chest reshaping.

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

The Elbow Lift – An Extension of the Upper Arm Lift

Friday, November 28th, 2008

The elbow lift, or removing excess skin from around the elbow (middle) area of the arm, is an uncommon procedure in body contouring surgery. Most of the time an upper arm lift ( between the elbow and the armpit) is enough to take care of one’s arm concerns. But the extreme weight loss patient can present with loose skin that passes below the elbow area.

When it is obvious that a lot of excess skin sags beyond the elbow area with the arm horizontally extended, then an ‘extended’ upper arm lift can be done and the arm problem can be solved in a single operation. The length of the scar, however, can understandably make some patients hesitant to extend the scar that long in a noticeable area even if it is obvious that the shape of the arm can so benefit.  Other times, the amount of loose skin in that part of the arm is not so evident or the patient does not express concern until after an upper arm lift has been done.

The elbow lift removes skin around and beyond the elbow into the forearm area. The cut out of skin and the resultant scar can be done on the back of the arm or on the inside part of the arm. Like the medial (inside) upper arm lift, the scar continues across the elbow into the inside of the forearm. Because it is on the inside of the arm, it is less visible. Because it crosses the bendabale elbow area, however, it may develop a tight scar. A small z-plasty can be done at the crease of the elbow to prevent this potential problem although I have found this concern more theoretical than one I have actually seen.

The elbow lift can also be done on the back of the arm crossing the thickened pad area with the prominent underlying elbow bone. (humerus) The concern about crossing this area with potential wound problems is a very real one. The skin is thick in this area for a reason, it is the one spot where the traction and sheering from elbow motion is the greatest. And after surgery, patients must bend their arms putting a lot of stress on the wound edges, Wound separation is a not uncommon problem with wounds that cross this area. For this reason, I perform a bilobed or figure-of-eight skin cutout, removing the least width of skin around the elbow area in the longitudinal cut out pattern.

The uncommon elbow lift is a simple procedure that is less in magnitude than an upper arm lift. It can be done on either  the inside or back of the elbow area. Special care of how much skin is removed around the elbow is important to avoid wound separation when the back of the elbow approach is used.

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


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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