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Posts Tagged ‘arm lifts’

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

The Outcomes of Armlift (Brachioplasty) Surgery

Friday, April 12th, 2013

 

Armlifts have a surprisingly long history dating back well over fifty years ago when it was initially described. While once only done as an occasional procedure for the diet-induced weight loss patient, the number of armlifts now done has virtually exploded since the increase in bariatric surgery procedures. While once done as an isolated procedure, armlifts are now more commonly done in conjunction with other body contouring procedures as part of a multiple-operation body contouring procedure.

While armlifts are very effective at reducing the circumferential size of the upper arm, they do place a scar in a disadvantageous location that is prone to wound breakdown, scar hypertrophy and prominent scar visibility. As a result, the desire for a revision of an armlift is not rare to improve the appearance of the scar or remove more arm tissue.

In addition, another change in armlift surgery has been the concomitant use of liposuction to get a better result. Removing fat from parts of the upper arm that are not affected by the tissue excision, as well as around the shoulder, helps produce a better upper arm contour. Whether concomitant liposuction increases the risk of armlift healing problems has not been well studied.

Since many armlifts today are done in conjunction with other body procedures, it would be relevant to know if this impacts their results, incidence of complications and need for revision. In the April 2013 issue of the journal of Plastic and Reconstructive Surgery, a review of armlift (brachioplasty) outcomes was reported. From a multipractice pool of 69 patients, half had an armlift done as part of a collection of body contouring procedures and half had arm liposuction done as part of their armlift. Major complications occurred in 18% of the patients and included hypertropic scarring and infection. Revisions of the armlifts were done in over 20% of the patients.

This study found that combining armlifts with other body contouring procedures did not increase the risk of complications. In addition, the use of liposuction in armlifts did not increase the risk of complications either. Higher complications rates were found, however, in patients who previously had bariatric surgery.

The revelance of this study supports what I counsel my Indianapolis armlifts patients in regards to what they can expect after surgery. Armlifts are easy to go through and are extremely effective…but at the price of a scar that can be problematic and may require a scar revision later if one is seeking the best apppearance of it as possible. The incisional closure is also prone to minor wound healing problems most commonly seen up near the armpit area. The change that I have done in my armlift surgery technique was to place the excision and scar on the back of the arm rather than on the inside of the arm where the skin is thinner.

Dr. Barry Eppley

Indianapolis, Indiana

The Differing Types and Indications for Armlift Surgery

Monday, April 4th, 2011

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

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


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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