S-Shaped Brachioplasty

Sir:FigureUpper arm contour deformities are common with aging and after weight loss, for which the specific operative approach must correspond to the degree of the deformity in each patient.1 Since brachioplasty was first described by Thorek in 1930,2 many techniques and modifications have been developed.3 Despite the diversity of these techniques, there is no universal technique that addresses all arm contour deformities. With the introduction of liposuction, brachioplasty results improved further because liposuction allows more aesthetic sculpturing of the entire arm and loosens the subcutaneous tissue plane through discontinuous undermining, making flap dissection easier.4 The arm, when viewed as a sleeve, has a width and length. Thus, the effect of aging and weight loss should be in two planes; the excess width is the most important problem and is usually addressed with a vertical excision in the arm (in the anatomical position). The excess length could not be addressed with the most traditional brachioplasty (vertical) techniques except with extending the incision to the axilla or toward the chest in the form of an L.4 The S brachioplasty is an S-shaped pattern of excision that can address the deformities in two planes, with a resultant scar in the form of a lazy S. In this design, the transverse limbs of the S will resect the vertical or longitudinal excess and the longitudinal limbs will correct the horizontal or transverse laxity. During the past 3 years, we have applied the S-shaped brachioplasty successfully for 18 female patients with different stages of brachial contour deformities1 limited to the arm area. During follow-up, all patients were asked about their satisfaction with surgical outcome regarding the arm contour and the location and quality of the scar. This was graded as very satisfied, satisfied, or unsatisfied. The preoperative markings are performed with the patient in the standing position with the arm raised and abducted 90 degrees. A line is then drawn along the axis of the arm from the medial epicondyle to the center of the axilla. Another S-shaped line extending from a point 5 cm proximal and medial to the biceps tendon insertion and ending on the posterior axillary fold just proximal to the axillary crease is carried out. Around this line, two lines are drawn so that the distance between them should be equal to the estimated excision of excess skin and fat in the form of an S-shaped ellipse (Fig. 1).Fig. 1: A 27-year-old female patient with arm lipodystrophy and redundancy. (Left) Preoperative marking of S-shaped ellipse around an axis extending from the axilla to the medial epicondyle. (Right) Photograph obtained 7 months postoperatively (frontal view) showing good contour and fine noncontracting scar. It is clear here that the axilla remains untouched and free from scarring.Liposuction is performed as a routine step to reduce the volume without damaging lymphatics, other vessels, and nerves, and to give better tissue mobilization.5 The skin resection begins distally with full-thickness skin and subcutaneous tissue resection superficial to the underlying muscle fascia in the liposuction plane to the proximal end of the S at the posterior axillary fold. No undermining is required because tissues are very mobile around the arm. Careful hemostasis should be performed before closure, which is accomplished in two layers using long-lasting but absorbable 3-0 suture after application of a drain bilaterally. A lipoelastic compression garment is applied for at least 3 months. All patients were satisfied and happy with the overall results. There were no major complications encountered in this series. Only minor complications such as seroma, scar hypertrophy, and contour irregularities occurred and were treated with conservative measures. None of these patients required any form of surgical intervention (Table 1). The results were also satisfactory to the author regarding the final contour and the shape and site of the scar (Figs. 1 and 2).Table 1: Demographic Characteristics and Postoperative Details of the PatientsFig. 2: A 23-year-old female patient with isolated arm lipodystrophy and redundancy. (Left) Preoperative photograph back view showing grade 3 arm ptosis. (Right) Photograph obtained 3 months postoperatively with the same view showing excellent arm contour and satisfactory scar.In conclusion, the S brachioplasty technique provides excellent overall arm contour with favorable scar. Although it is long, it simultaneously addresses the vertical redundancy and the transverse one. This technique is suitable for patients with any degree of arm lipodystrophy with excess fat and skin redundancy limited to the arm area. Ahmed Mabrouk Aboul Wafa, M.B.B.Ch., M.Sc., M.D. Ain Shams University, Cairo, Egypt, [email protected] DISCLOSURE The author has no financial interest to declare in relation to the content of this communication.