Overview of Brachioplasty
Brachioplasty, also known as an ‘upper arm lift,’ is a procedure that has become increasingly popular, with about 20,000 surgeries performed in 2019, a 20% increase from 2015. This surgery is often done for patients who have lost a significant amount of weight. In fact, there were 256,000 weight loss surgeries in 2019, which is a 31% increase from 2015.
People might also consider this procedure after pregnancy or due to loose skin that comes with aging. Extra skin and sagging can cause problems like skin irritation, difficulties with hygiene, infections, and mental distress. Body shaping surgeries, such as an arm lift after weight loss surgery, can improve the way people feel about their bodies, their ability to function normally, and their quality of life. These surgeries can also help to lower body mass index (BMI) and support further weight loss.
Brachioplasty involves removing extra skin and abnormal fat distribution in the upper arm, which can sometimes extend to the side of the chest. It’s important for doctors to carefully evaluate each patient and figure out how much excess skin and fat they have. This helps them decide on the best approach for that patient. For some, liposuction or a mix of liposuction and brachioplasty might be the right choice. There are also various types of arm lift surgeries that differ based on where and how long the scar will be. Several systems help surgeons choose the best procedure for each patient.
Anatomy and Physiology of Brachioplasty
The upper arm is the area between your elbow and shoulder, which includes the armpit. The shape of your upper arm is defined by your muscles, in particular the deltoid, biceps, and triceps. In younger arms, the skin is smooth and firm with little fat.
Underneath your skin, there’s a type of fat called subcutaneous fat. It’s divided into a deep layer, prone to extra fat buildup, and a superficial layer. These two layers are separated by what we call the superficial fascial system. This system is connected to the tissue under the skin around your collarbone and armpit.
The inner side of the arm and forearm are served by two nerves that lie deep in this fat layer and provide sensation to these areas. These nerves go along with a large vein (called the basilic vein) down the arm.
The muscle-layer of the arm encapsulates the primary nerves controlling movement and sensation (median, ulnar, radial), major blood vessels like the brachial artery, and the muscles of the front and back side of the arm. The arm’s lymph system, which helps transport cell waste, also runs with the veins in the arm, and drains towards the armpit.
There is a system, known as Appelt’s classification, that categorizes the amount of fat and loose skin in the upper arm and side of the chest. Depending on how much fat or skin you have in these areas, different treatment recommendations are provided. These can include liposuction or various surgical procedures to shape and contour the arm.
Why do People Need Brachioplasty
Arm slimming treatments can include anything from liposuction, to cryolipolysis (a method that freezes fat cells), to non-ablative radiofrequency (which uses heat to treat the skin), and focussed ultrasound (which uses sound waves to target fat cells). All these procedures are good alternatives to brachioplasty, which is a surgery to remove extra skin from the arms, in the right cases.
Brachioplasty is often used for patients who have lost significant amounts of weight, as they’re left with excess skin. But it can also be used for people who have a lot of loose skin due to natural aging or pregnancy.
Choosing the right patients for these treatments and giving them proper advice is crucial for a successful outcome and a happy patient. If a patient has had bariatric surgery (a weight loss surgery), they should wait at least one year post-operation before undergoing a brachioplasty. They should also maintain a stable weight for at least 3-6 months.
The patient should have a current BMI (Body Mass Index, a measurement of body fat based on height and weight) of less than 30. But some surgeons might offer brachioplasty and other body contouring procedures to patients with a higher BMI. However, patients with a high BMI before weight loss, or those who have lost a significant amount of weight, might have a higher chance of complications if they’re having multiple body contouring procedures at one time.
Smoking cessation, or quitting smoking, is important for patients undergoing these types of procedures. This is because smoking increases the risk of complications. Many surgeons recommend patients quit smoking for at least four weeks before the procedure, but the longer the better. This is due to the fact that even the body’s mechanisms like the clearing of mucus from the nasal passage, can improve within 15 days of quitting smoking.
Also, it’s worth noting that patients who have lost a significant amount of weight are at a higher risk of complications. Therefore, some surgeons recommend abstaining from smoking for three months before any body contouring surgery.
Additionally, the surgeon will need to assess any other health conditions the patient has and work with other healthcare professionals to ensure these are well-managed. If a patient has diabetes, for example, it’s important to keep their blood sugar levels under control. They’ll also need to verify if the patient has a higher risk of blood clots or bleeding disorders, which could be caused by certain medications or conditions. Over-the-counter and herbal medications, which patients often forget to mention, can also affect surgery outcomes and should be stopped at least two weeks before the procedure.
A lot of patients who have lost significant amounts of weight are at risk of nutritional deficiencies, including iron, folic acid, Vitamins B12, A, D, E, K, and minerals such as zinc and selenium. The healthcare team should assess these nutritional risks, order a nutrition panel and manage any deficiencies to optimize the patient’s overall health before this elective surgery.
Last but not least, the mental well-being of the patient is paramount. A patient might have unrealistic expectations or untreated mental health disorders. It’s reported that up to 40% of patients who have lost a large amount of weight, and around 15% of them might have body dysmorphic disorder (a mental disorder where a person is obsessively preoccupied with a perceived flaw in their appearance). If these conditions aren’t addressed, the patient may remain unsatisfied with the result of the brachioplasty, regardless of how good it looks or if there were no complications. Therefore, it’s a good idea to run a mental health screening before the procedure, and follow-up with a formal psychiatric consultation when necessary.
When a Person Should Avoid Brachioplasty
There are a few main reasons why someone might not be able to safely have brachioplasty, which is a type of arm surgery. Some of these reasons include having a condition called lymphedema (swelling in the arms), having problems with blood flow in the arms (peripheral arterial ischemia), and having trouble with veins in the arms (venous insufficiency). People who are at risk of getting lymphedema like those who have had surgery on the armpit (axillary dissection) or radiation therapy also might not be able to have this surgery.
There are also other things that doctors consider which might make the surgery less advisable. These include things like, a high body mass index (BMI) over 30, unstable weight, smoking, health problems that are not well-managed such as diabetes, lack of nutrition, and untreated or poorly managed mental health disorders.
More specifically, some people may not be the best candidates for brachioplasty because they have too little loose skin on their arms or too much extra fat that has not been reduced by major weight loss (MWL). Some patients may be better suited for a short-scar brachioplasty, which involves a smaller cut and removing less tissue, while others may benefit more from an extended brachioplasty, which involves a larger cut and removing excess tissue from the side of the chest. The best type of surgery or if surgery is the right choice at all, depends on a very thorough examination before surgery and a plan that is made to best suit individual needs.
Equipment used for Brachioplasty
No special equipment is needed for an arm lift surgery, also known as brachioplasty. Most of the time, the tools used for common plastic surgery procedures will do the job. However, if fat removal using liposuction is part of the procedure, the necessary equipment for that should also be ready to use. This often depends on the doctor’s usual practice and where the surgery is being done.
In addition, a special numbing solution, like Klein’s tumescent solution, is usually used when liposuction is being done at the same time as the arm lift. This fluid helps numb the area and makes the fat easier to remove.
Who is needed to perform Brachioplasty?
Having a team in the operating room that understands the surgery, knows the specific benefits and intricacies of the operation, and is familiar with the surgeon’s usual way of doing things can make a big difference. This team effort becomes especially helpful for complex procedures like brachioplasty and other body shaping operations.
Surgeons usually prefer to work with familiar staff who know the ins and outs of the procedure. This not only enhances the safety of patients but also reduces the surgeon’s stress and creates a better working environment. At the very least, the team will include a surgeon, someone to give the anesthesia (which could be general anesthesia where you’re fully asleep, or conscious sedation where you’re relaxed and drowsy), and a circulating nurse, who makes sure everything runs smoothly during the operation.
There might also be another specialized nurse or technician for preparing and maintaining surgical instruments and helping during the surgery, also known as a scrub nurse, along with a surgical assistant or a second surgeon.
Preparing for Brachioplasty
To make surgery a safer process and minimize any negative effects, it’s important for patients who have lost a significant amount of weight and need several body shaping operations to have these surgeries spaced out over time. Spacing out these procedures by at least three months can reduce not only the amount of time in surgery and under anesthesia, but also blood loss, staff fatigue, and potential complications.
The number of separate surgeries needed can change from patient to patient and is influenced by factors like the number of surgeons, the operating room staff and their availability, and the patient’s health risks. When a patient is only having surgery on their arms, the surgical risks are reduced. However, having two surgical teams working on each arm at the same time can further minimize these risks.
During surgery, a number of factors need to be carefully managed. This includes looking after the patient while they’re under general anesthesia, managing any other existing medical conditions they may have, and paying careful attention to how they’re positioned, keeping them warm, and managing the risk of blood clots.
In arm surgery, patients are placed on their back with their arms out and elbows bent at a right angle. Their forearm and hands are covered and secured in a sterile covering. This allows for easy movement of the arm during surgery. Pressure points on the body where nerves are close to the skin should be protected with special gel pads to minimize the risk of nerve injury. Keeping the patient warm is important and can be achieved through various methods like heated gel pads, warm blankets, keeping the surgical area covered as much as possible, and giving warmed fluids through an IV line.
Blood clots are a serious and unwelcome complication of surgery. To lower this risk, devices that apply sequential compression, similar to a massage, can be placed on the calves during surgery. Medicines that thin the blood may also be used after evaluating the patient’s risk. But most importantly, patients should be encouraged to start moving as early as possible after the surgery. This helps to prevent blood clots as well. Patients should be informed about these steps before surgery so they understand the importance of getting up and moving after the procedure.
How is Brachioplasty performed
If you’re going to have a brachioplasty, which is a surgical procedure that helps reshape and improve the appearance of your upper arms, it’s good to know what to expect. To get you in the best position for this operation, the doctors will have you lie flat on your back with your arms spread out and bent at a 90-degree angle. It’s also part of the preparation to make sure any points of your body that might feel pressure are protected with squishy gel pads and special compression devices are placed on your calves (lower leg) to help prevent dangerous blood clots.
During the surgery, only your arms, armpits, and sides of your chest will be exposed and you’ll be kept warm. You may also be given a single dose of a type of antibiotic, like amoxicillin-clavulanate, about half an hour before the surgery begins to help prevent infection. Unless the surgery takes more than 4 hours or you lose more than 10% of your blood, you won’t need any additional antibiotics.
The surgeon often starts the procedure by getting rid of any extra fat in the area before they remove any skin. The surgical scar can be hidden in the middle of your arm when you bend your elbow. Some surgeons use different shapes for the surgical cut including straight, “W,” “S,” “L” shapes, and even a special “Z” shape in the armpit to prevent the skin from tightening too much as it heals.
A ‘short-scar’ brachioplasty might also be an option as this method limits the surgical cut to your armpits only. This is usually for patients with less saggy skin on the arms. In a study of this method, about 12% of patients needed another surgery to fix the scar after a year.
Other surgeons prefer to make the surgical cut along the back of the arm, making it less noticeable when your arms are spread out, but more visible when your arms are down. After the cut, the surgeon removes any extra fat and shaves off just enough skin off your arm, taking care not to cut too deep and harm any important nerves.
The surgeon will then figure out how much extra skin needs to be removed by stretching the skin together along the cut. Once this is done, they will close the wound carefully in layers. The top layer is the most important to reducing the tension on the skin and is closed in three points to ensure even tension and minimize the chance of space filling up with fluid (this is called ‘dead space’). The surgeon doesn’t use any drainage tubes in this method.
After the surgery, your arm is covered with bandage tapes and compression garments, which are tight-fitting clothes that help reduce swelling. The same procedure is then performed on your other arm.
To manage any pain or discomfort after the surgery, local anesthesia is used during the operation, and you will be given pain medications like paracetamol or codeine to take home.
For two weeks after the surgery, try to avoid any strenuous activities and driving. Wearing your compression garment for about four weeks is also recommended. Most patients are allowed to go home the same day and have a follow-up appointment in just a week. You can clean your wounds regularly, as long as there’s no sign of them reopening or getting infected.
Possible Complications of Brachioplasty
Discussing the operation thoroughly with the patient before surgery is crucial. It can help prevent misunderstandings, set realistic hopes, and prepare patients for the possibility of complications or needing additional surgery. Patients who have lost a large amount of weight often have loose skin and fat distribution issues in various areas like the arms, chest, back, tummy, and thighs. Because of this, they are more likely to face complications when undergoing multiple procedures in one operation. The risk is even higher for those who have lost weight through bariatric surgery (surgery that reduces the size of the stomach).
A study of 29 other studies which comprised nearly 1600 patients found that the most common issues after surgery included scarring (9.9%), sagging skin returning (7.8%) and wounds reopening (6.9%). The occurrence of fluid build-up in the upper arm (seroma) and infection were 5.9% and 3.6% respectively. More uncommon problems were related to nerves (2.5%), lymphoedema or lymphocele (swelling caused by a blockage in the lymphatic system, 2.5%), skin cell death or slow wound healing (2.3%), and internal collection of blood (hematoma, 2%). In 7.5% of patients, further surgery was needed to improve appearance, while reoperation for non-appearance related reasons was rare (1.6%). Using liposuction (a procedure that sucks out fat) alongside brachioplasty (arm lift surgery) reduced the chances of complications.
In another study of almost 2,300 patients who were undergoing brachioplasty, the researchers found that hematoma and infection were the most common severe complications, occurring in 1.7% and 1.1% of patients respectively. The findings also showed that males and patients undergoing combined procedures had a higher risk of hematoma, while patients with a Body Mass Index (BMI) of 30 or higher had an increased risk of infection.
Therefore, the choice of patient and edifying patients about increased risks where relevant, enables comprehensive discussion before surgery and helps shape patient expectations.
What Else Should I Know About Brachioplasty?
Most people who have a brachioplasty, which is a surgical procedure to remove loose skin or extra fat in the upper arm, are usually happy with how their arms look and function after the surgery. However, sometimes, a second operation might be needed to improve the appearance of the arms. It’s vital to let patients know about potential issues with scarring. It’s normal for scars from this type of surgery to take longer to fade and settle down, unlike scars in other parts of the body. It can take up to a year for a brachioplasty scar to fully mature and fade.