Arm Lift (Brachioplasty)

Overview

Brachioplasty, commonly referred to as an arm lift, is a surgical procedure designed to remove excess skin and fat from the upper arms, often resulting from significant weight loss or the natural aging process. The goal is to enhance the contour of the arms by eliminating skin laxity and providing a smoother, more toned appearance. This procedure can significantly improve the aesthetics of the arms but requires careful consideration of scarring, nerve anatomy, and potential complications like lymphedema

Key Considerations

Medial antebrachial cutaneous nerve, which runs along the medial arm and is vulnerable to injury

The axillary lymphatic system should also be preserved to avoid lymphedema.

Surgical planning must balance removing excess tissue while minimizing visible scarring, typically placed on the inner arm for discretion

Other vital considerations include the degree of fat removal and contouring, as well as the management of skin laxity around the elbow and axilla.

Pre-Procedure Preparation

Equipment and Tools Checklist

Scalpel (No. 15 blade): For precise skin incisions.
Electrocautery (monopolar and bipolar): To control bleeding and dissect tissue layers.
Liposuction cannula (3-5mm): If combining with liposuction, this helps contour fat deposits in the upper arm.
Hemostatic agents: Such as Surgicel or Gelfoam for controlling diffuse bleeding.
Tissue forceps, fine-tipped scissors, needle holders: Essential tools for tissue handling and suture placement.
Absorbable sutures (2-0 Vicryl, 3-0 Vicryl): For deep tissue approximation.
Non-absorbable sutures (4-0 nylon, 4-0 Prolene): For the skin, particularly for areas requiring precision closure.
Surgical drains: Closed suction drains (e.g., Jackson-Pratt) if there’s a significant amount of tissue removed.
Compression garments: To apply post-op for arm contouring and edema control.
Marking pens: Preoperative marking is key to ensuring symmetry and contour.

Patient Preparation

Perform a complete medical history to identify any contraindications such as coagulation disorders or potential risks for lymphedema.
Conduct a physical examination of the upper arm, noting the degree of skin redundancy, fat deposits, and overall skin quality.
Preoperative photographs should be taken from various angles for comparison and documentation.
Informed consent: Explain the placement of scars, potential risks (nerve injury, infection, lymphedema), and the expected aesthetic outcome.
Skin preparation: A broad-spectrum antiseptic solution like chlorhexidine or povidone-iodine is applied from the shoulder to the elbow and surrounding areas.
Anesthesia: General anesthesia is typically preferred, although local anesthesia with sedation may be an option for smaller lifts. Consideration of nerve blocks (e.g., brachial plexus block) can help with postoperative pain management.

Positioning

The patient is positioned supine with the arms extended at 90 degrees from the torso, supported on padded arm boards.
The surgeon should ensure full access to the arm from axilla to elbow, and proper lighting must illuminate the entire surgical field.
Make sure the arm is elevated and rotated to provide exposure of the medial and posterior aspects.

Key Procedural Steps

Step 1: Incision Planning and Marking
- Mark the incision preoperatively while the patient is standing with arms relaxed at their sides. The incision is typically designed on the medial aspect of the arm, from the axilla to just above the elbow. Adjust the length and pattern of the incision based on the degree of skin excess.
- For patients with significant skin redundancy, a full-length incision (axilla to elbow) is recommended. This provides the best contour but results in a longer scar.
- In cases of mild to moderate excess, consider a limited incision in the axilla only (mini-brachioplasty), which avoids a visible scar but offers less skin excision.

Step 2: Skin and Fat Excision
- After infiltrating the arm with tumescent solution (a mixture of saline, epinephrine, and lidocaine) to reduce bleeding, use a No. 15 blade to make the incision.
- Dissect down to the deep fascia to avoid injuring the medial antebrachial cutaneous nerve, which runs in close proximity to the surgical field. Meticulous dissection in this layer preserves the nerve while removing redundant skin and fat.
- In cases of moderate fat accumulation, perform liposuction before excising skin. Liposuction is done using a 3-5mm cannula with small access incisions. Avoid excessive liposuction near the dermis to prevent skin necrosis.

Step 3: Fascial Tightening (Optional)
- For patients with significant skin laxity, reinforce the superficial fascial system (SFS) with deep dermal sutures. This prevents long-term sagging and helps maintain contour integrity.
- Use 2-0 or 3-0 Vicryl to suture the superficial fascial system, creating a tighter structure underneath the skin excision.

Step 4: Skin Closure
- Deep dermal closure: Begin with a layered closure using absorbable sutures like 2-0 Vicryl to approximate the deep dermal layer. This reduces tension on the skin and decreases the risk of wide scarring.
- Subcuticular suturing: Place a 4-0 absorbable suture (e.g., Monocryl) in the subcuticular layer to ensure a smooth skin edge and minimize visible scarring.
- Non-absorbable sutures: If desired, use 4-0 Prolene for a precise skin closure, which can be removed after 7-10 days.

Step 5: Hemostasis and Drain Placement
- Achieve meticulous hemostasis using bipolar cautery to minimize the risk of postoperative hematoma or seroma formation.
- If significant tissue has been removed or there is concern about fluid collection, place closed-suction drains (e.g., Jackson-Pratt) in the surgical bed to prevent seroma formation. Drains are typically removed once output decreases to an acceptable level (usually within 3-5 days).

Step 6: Dressing and Compression
- Apply sterile dressings and ensure the surgical area is clean and dry.
- Apply a compression garment to the upper arm. Compression is essential for controlling postoperative edema and promoting better arm contouring.

Tips & Tricks

Challenges: Symmetry between the arms is crucial but challenging. Mark incisions with extreme precision preoperatively, and compare intraoperatively to ensure balanced tissue excision.

Tips: Use tumescent solution liberally during liposuction to reduce intraoperative bleeding. Maintain dissection planes close to the fascia to avoid injury to superficial nerves, especially the medial antebrachial cutaneous nerve.

Pitfalls: Poor placement of the incision can lead to highly visible scars. Ensure that scars are positioned on the medial arm where they are less likely to be seen when the arms are at rest.

Post-Procedure Considerations

Aftercare Instructions:
- Instruct the patient to wear compression garments for 4-6 weeks to manage swelling and improve arm contour. Garments should fit snugly but not impair circulation.
- Advise on limited upper arm movement for the first 2 weeks to avoid tension on the incision and support optimal healing. Patients should avoid heavy lifting for at least 4-6 weeks.
- Keep the surgical site clean and dry, changing dressings as needed.

Follow-up Recommendations:
- Arrange follow-up visits at 1 week, 2 weeks, and 6 weeks post-op to monitor wound healing, drain removal (if used), and progress.
- Monitor closely for signs of infection, hematoma, or seroma formation. If seromas develop, aspiration may be necessary.

Potential Risks and Complications:
- Nerve injury: Injury to the medial antebrachial cutaneous nerve can lead to sensory loss or neuropathic pain along the inner arm.
- Lymphedema: Damage to lymphatic channels in the axillary region can cause lymphedema. Preserve as much of the axillary lymphatic system as possible to mitigate this risk.
- Scarring: Hypertrophic scars are possible, especially in patients prone to keloid formation. Use silicone sheeting or scar creams as early as 2-3 weeks post-op to help minimize scar formation.
- Seroma or hematoma: Regularly check for fluid collections, especially in patients with large amounts of tissue excised.

✏️ Quick Review Checklist

✔️ Confirm precise preoperative markings for symmetric incision placement.

✔️ Perform liposuction before skin excision if fat removal is necessary.

✔️ Protect the medial antebrachial cutaneous nerve and axillary lymphatics during dissection.

✔️ Ensure meticulous hemostasis and consider drain placement for large excision.

✔️ Apply compression garments and monitor for complications during follow-up.