S-Shaped Brachioplasty

Sir: We read with interest the article by Aboul Wafa entitled “S-Shaped Brachioplasty: An Effective Technique to Correct Excess Skin and Fat of the Upper Arm”1 published recently in the Journal. In the article, the author proposes a procedure granting good contour and a fine noncontracting scar, resembling an S line located on the medial side. He also agreeably states that there is no universal technique addressing all arm contour deformities. In fact, attention must be paid in case of surgically induced massive weight loss patients, whose extreme tissue laxity deserves proper management. Our team, greatly experienced with bariatric patients, recently proposed an innovative, safe, and repeatable surgical technique, called “kris knife” brachioplasty, recalling the name of the Asian wavy blade.2 As demonstrated previously, the aforementioned category of patients is at higher risk for complications. Therefore, the safety and reliability of any body contouring techniques should be tested on them. In our study, on 33 patients, only six minor complications were recorded. According to our technique, preoperative skin markings are better defined by Steri-Strips (3M, St. Paul, Minn.), used to evaluate the skin excess to be removed. After infiltration with a solution of 200 cc of cold saline and 1 mg of adrenaline, liposuction is performed. Brachial incision is drawn so that the axis line, which will be the final scar after closure, results not in a straight line but in a sort of S-shaped, tension-free pattern. An ellipse is also drawn in the axilla, to correct ptosis and skin excess. By joining the lateral edge of the axillary ellipse with the brachial one, it is possible to create two V flaps (Figs. 1 and 2).Fig. 1: Preoperative view: the skin markings divide the upper arm into three imaginary portions, allowing a sectorial management and lifting. In addition, the double-V flap incision in the axilla further allows its lifting to be maximized by preventing aesthetic impairment.Fig. 2: Postoperative view: the kris knife pattern elicits a normal contour throughout, minimal stretching of tissues, with a good distribution of acting forces, reducing postoperative retracting strengths.Despite an apparently similar incision, a few points differ and deserve mention. It is mandatory to define in advance the amount of skin excess to be removed. In particular, we proposed the use of Steri-Strips, minimizing the risk of overresection or underresection. Moreover, to better deal with vertical and transverse redundancy, we opted for an elliptical resection in the axilla too. No scars are visible and a better lift effect is elicited. In addition, the brachial skin incision does not reach the anterior side of the arm; thus, the result can be easily hidden. Liposuction is agreeable, reducing skin retraction, facilitating tissue undermining, and minimizing nerves and lymphatic structure injury. Minimal undermining results in no dead space, no effusion, and proper healing. Moreover, brachial compressive dressings can minimize the accumulation of fluids and secretions. As a result, the incidence of seromas also decreases. Another very important element contributing to our low complication rate is probably the limited use of electrocautery, as we prefer a cold blade. In fact, this approach prevents tissue from necrotizing and ischemic action and possible drawbacks such as skin necrosis. Accurate hemostasis is mainly guaranteed by initial infiltration with adrenaline, allowing a bloodless operating field. The technique described in this communication has shown usefulness for correcting arm deformities in post–bariatric surgery patients, providing stable results. It is safe and reliable and linked to a low rate of complications, which have been minor. DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. Marco D’Ettorre, M.D. Roberto Bracaglia, M.D. Stefano Gentileschi, M.D. Damiano Tambasco, M.D.