Exaggerated Distal Medial Arm Depression after Brachioplasty: A Newly Described Post-Brachioplasty Deformity and a Modification of Major Brachioplasty Operation to Prevent it

Document Type : Original Article

Authors

The Department of Plastic, Burn and Maxillofacial Surgery, Faculty of Medicine, Ain Shams University, Cairo, Egypt

Abstract

Egypt, J. Plast. Reconstr. Surg., Vol. 43, No. 2, July: 165-170, 2019
Exaggerated Distal Medial Arm Depression after Brachioplasty:
A Newly Described Post-Brachioplasty Deformity and a Modification
of Major Brachioplasty Operation to Prevent it
SHERINE M. ABOUL FOTOUH, M.D. and NAHED SAMIR, M.D.
The Department of Plastic, Burn and Maxillofacial Surgery, Faculty of Medicine, Ain Shams University, Cairo, Egypt
ABSTRACT
Background:
The dramatic progress in the surgical treat-
ment of obesity increases the demand for post-massive weight
loss (MWL) corrective operations including brachioplasty.
We describe a post-brachioplasty deformity not yet been
described in the literature. There is a naturally located antero-
medial depression of the distal third of the arm. This depression
is exacerbated after brachioplasty resulting in contour deform-
ity. A suggestive modification of major brachioplasty operation
to avoid this deformity is also studied.
Patients and Methods:
This is a prospective study of 15
MWL patients, 39-54 years old with advanced upper arm
sagging reaching the elbow. As a modification of major
brachioplasty, a triangular dermofat flap is created and buried
under the depression of the distal third of the arm aiming to
restore the roundness and firmness of this part. Pre- and post-
operative photographs are taken. Follow-up period ranged
from 6-12 months.
Results:
No contour deformity was recorded. Complication
rate was 10% in the form of delayed healing of one axilla and
hypertrophic scars of both sides in another patient.
Conclusion:
This modification is useful especially for
thin and elderly patients who are most likely exposed to this
unacceptable deformity.

Keywords

Full Text

The extraordinary rise of brachioplasty contin-
ues to be an important part of addressing the total
solution for MWL patients
[1]
.
Since brachioplasty was first described in the
1920s
[2]
, techniques have evolved to include lipo-
suction, excisional surgery, a combination of lipo-
suction and excision, single-versus multi-staged
procedures and, depending on the characteristics of
the deformity, even implants
[3-12]
. Lockwood em-
phasized the importance of secure tightening of the
superficial fascial system resulting in a smoother
contour, tighter closure and finer scar
[14]
.
In severe arm redundancy, post-operative im-
perfect contour isn’t uncommon. Under-reduction,
1
65
over-reduction, constriction arm band and depres-
sion deformity are different forms of unaccepted
contour defects. According to Wendy Chen et al.,
the constriction arem band deformity is a pre-
operative finding that can’t be corrected by brachi-
oplasty and even exacerbated post-operatively in
50% of cases. It is associated with higher current
BMI and larger resection weights. Most bands
were located in the middle (26%) or distal-third
(74%) of the upper arm and found bilaterally (68%)
[15]
.
In our study, another post-brachioplasty contour
deformity, not yet mentioned in the literature, is
described. It’s a triangular depression deformity
of the lower medial arm few centimeters proximal
to the medial epicondyle (Fig. 1). It’s an exagger-
ation of a naturally present mild depression due to
lack of soft tissue support at that area (Fig. 2). The
lower central part of the arm is occupied by the
biceps muscle anteriorly and brachialis muscle
posteriorly while the lower lateral part has the
origin of brachioradialis muscle leaving the medial
lower arm without significant soft tissue support.
After brachioplasty of severe arm redundancy, this
depression is highlighted and look like local stran-
gulation of the arm. This unaccepted deformity
gives the impression of thinner arm in relation to
the forearm because it affects the most distal part
of the arm.
We also suggested a prophylactic modification
of major brachioplasty operation
[18]
, especially
in severe arm redundancy, elderly and thin patients.
We selected MWL patients with severe arm redun-
dancy who were expected to be more prone to the
deformity after brachioplasty. They were good
candidates for major brachioplasty because of
severe arm redundancy extending from the elbow
to the axilla. They had no lateral chest skin redun-
dancy or not interested in its correction.
 
PATIENTS AND METHODS
Fifteen MWL patients with severe arm redun-
dancy underwent major brachioplasty in the period
from 2016-2018 were involved in this study. They
were all females, 39-54 years old. Pre-operative
assessment included weight loss, BMI, general
condition, history of chronic diseases, routine
laboratory investigations, skin tone evaluation,
degree of redundancy and pinch test to quantify
the subcutaneous fat of the arm circumferentially.
Any pre-operative contour deformity was docu-
mented. Informed consent was signed.
Markings were drawn the day of the surgery
while the patient standing, with the arms abducted
to 90 degrees and elbow fully extended. The supe-
rior resection line was drawn connecting the points
representing axillary apex, bicipital groove and
medial epicondyle. The skin amount to be removed
was estimated through pinching the sagging medial
skin between the thumb and index fingers along
the line drawn. Now, the inferior resection line
could be marked meeting the superior line at the
medial epicondyle point and extending proximally
to the axilla. The proximal ends of the superior
166
Vol. 43, No. 2 / Exaggerated Distal Medial Arm Depression after Brachioplasty
and inferior resection lines at the axilla would be
further extended in the axillary hollow and met at
a point according to the skin laxity. Transverse
hatched lines were drawn across the resection
ellipse to guide skin closure. Areas for liposuction
were marked too. The plan was to avoid over
resection and tight closure in the distal arm espe-
cially, the distal third while perform quite tight
closure of the proximal arm. The markings should
represent this plan.
Markings of the expected deformity area: A
triangular depression can be identified on the
antero-medial aspect of the arm few centimeters
proximal to the cupital area (T) (Fig. 3). This
triangle together with a mirror image triangle (T’)
on the resection skin ellipse was marked.
Technique:
The patient was placed in supine position with
arms abducted 90 degrees on arm table with feasi-
bility for full abduction during surgery. Intra-
venous line and blood pressure cuff were placed
in the lower limb. General anaesthesia was a ne-
cessity for major brachioplasty. Both upper limbs
were prepared and draped routinely with hands
and distal forearms covered with sterile stockinette.
Infiltration of superwet fluid in posterior and
medial arm areas was done. Amount of liposuction
of posterior arm varied according to the degree of
lipodystrophy of each patient. Liposuction of me-
dial arm aimed to loosening the dissection plane
and providing tension free closure.
Before excision of redundant tissue, the triangle
T’ was de-epithelialized and dissected as a dermofat
flap with its base at the superior line (Fig. 4).
Undermining of triangle T at the subcutaneous
plane transformed the 2 triangles into a continuous
diamond shape flap with its lower triangular half
de-epithelialized. T’ was folded superiorly deep to
T and fixed to its through a pull out suture. This
technique aimed to augment the triangular depres-
sion (T) and prevent any possible depression de-
formity.
Fig. (1): (A): Arm redundancy. (B): Post-brachioplasty depression deformity (black arrow)
[16]
.
Fig. (2): Cubital fossa anatomy showing the natural lower
medial depression of the arm (black arrow) due to
lack of soft tissue support at that area superior to
the medial epicondyle bonny prominence
[17]
.
Radial nerve
Biceps
brachii
Bicipital
aponeurosis
Pronator teres
Median nerve
Brachial artery
Brachioradialis
 
Egypt, J. Plast. Reconstr. Surg., July 2019
167
The excision started by incising the superior
line of the ellipse (except across the diamond flap)
down to the superficial fascial system (SFS). Dis-
section was carried downwards deep to SFS using
the cutting cautery. Continuous re-evaluation by
pulling the free edge of the dissected flap upwards
and marking for resection was done to achieve the
proper tightness and contouring. The excision was
performed from distal to proximal with stapling
of the skin edges to close the wound and control
the edema after meticulous hemostasis. The SFS
was sutured with 2/0 vicryl followed by deep
dermal sutures with 3/0 vicryl then, sub-cuticular
closure with 4/0 monocryl. No drains were needed
(Fig. 5).
Pre- and post-operative standard medical pho-
tographs were taken. Patients were asked to eval-
uate their final results regarding arm size, contour
and symmetry together with quality and position
of the scar using a four-point numerical rating
scale, where 0 indicated no improvement and 3
indicated highly satisfied. In addition, patients
were objectively evaluated by 2 plastic surgeons
who were not involved in the treatment. These
surgeons compared pre- and post-operative (one
month and 6 months) photographs with regard to
size, contour, symmetry and quality and position
of the scar. Their evaluation was recorded as per-
centage of improvement on a quartile grading scale:
<25%: Mild improvement; 25-50: Moderate im-
provement; 51-75%: Good improvement and 76-
100%: Excellent improvement.
Fig. (3): Pre-operative marking: The excision ellipse, T
representing the natural depression in lower medial
arm, T’ representing the mirror image triangle.
Fig. (5): Pull out suture and closure.
2016-2018. Their average age was 49.6 years (range
39-54 years). The average weight loss was 33
kilograms (range 27-51 kilograms) with stable
body weight for at least 6 months. The average
follow-up period was 7.6 months.
Arm size, contour and symmetry together with
quality and position of the scar were the parameters
for results assessment. Early and late complications
were also documented.
No complaint regarding arm size, contour or
symmetry or scar position was recorded with sub-
jective evaluation revealing an overall high degree
of satisfaction in 13 of 15 patients (86.7%). Two
patients (13.3%) reported moderate satisfaction
(Figs. 6,7).
The objective aesthetic outcome was rated as
excellent in 12 patients (80%) and good in the
remaining 3 patients (20%).
RESULTS
Fifteen female patients with severe arm redun-
dancy after MWL were operated upon using the
modified major brachioplasty in the period from
Fig. (4): (A): Triangle T’ deepithelialized. (B): Dissected as dermofat flap. (C): Buried under undermined T.
(A)
(B)
(C)
 
168
Vol. 43, No. 2 / Exaggerated Distal Medial Arm Depression after Brachioplasty
Fig. (6A): Pre-operative right arm (front).
Fig. (6B): Pre-operative right arm (back) of 54 years old patient.
Fig. (6C): Post-operative right arm (front).
Fig. (6D): Post-operative right arm (back).
Fig. (7A): Pre-operative right arm (front).
Fig. (7B): Pre-operative right arm (back) of 40 years old
patient.
Fig. (7C): Post-operative right arm (front).
Fig. (7D): Post-operative right arm (back).
 
Egypt, J. Plast. Reconstr. Surg., July 2019
169
Table (1): Complications.
Complication
Delayed healing
Hypertrophic scars
Total
Number
1 (3.3%)
2 (6.7%)
3 (10%)
One patient showed delayed healing in one axilla
(3.3%). The late complication was bilateral hyper-
trophic scar in another patient (6.7%) (Table 1).
No re-operation was needed to correct any of
the complications.
it as a posteriorly based flap; in an undermined
anterior pocket to provide esthetic arm fullness
and proper tightness which might be helpful in the
very thin arm and elderly patients. His clinical
series was 12 elderly thin women, only 3 of them
had lost weight; the remainder had never been
obese.
It’s not difficult to restore the proper contour
in the proximal arm with the traditional excision
technique due to the presence of adequate soft
tissue support all through the way. We confined
the use of the dermofat flap to the distal third of
the arm in our modification of major brachioplasty
operation. The dermofat flap is anteriorly based
providing the flexibility to readjust the extent of
excision posteriorly. Inserting the flap in its pocket
by folding it, further augments the incision line.
Brachioplasty as one of the body contouring
operations in MWL patients can be associated with
post-operative complications such as hematoma,
seroma, infection, delayed healing, unfavorable
scars and contour deformities. In the literature, the
rate of complications varied widely from 1.3% up
to 56%
[19-21]
. Other rare serious complications
include fluid overload, thromboembolism, fat em-
bolism and cardiopulmonary dysfunction most
frequently occurring if brachioplasty is performed
in conjunction with other body contouring proce-
dures
[7,8,22-24]
.
In our study, no complaint regarding arm size,
contour or symmetry or scar position was recorded.
The subjective and objective evaluations generally
showed good to excellent results. The rate of com-
plications was 10%. One patient showed delayed
healing in one axilla (3.3%) and another patient
had bilateral hypertrophic scar as a late complica-
tion (6.7%). No re-operation was needed to correct
any of the complications.
On combining body contouring surgeries, we
have to consider the time factor, presence of any
co-morbidity, patient’s age and amount of liposuc-
tion to fulfill the safety measures and avoid any
serious medical complications.
Conclusion:
In our current study, we described a post-
brachioplasty depression deformity not yet de-
scribed in the literature. We also presented a mod-
ification of the major brachioplasty operation
aiming to prevent this potential depression deform-
ity in severe arm redundancy in post MWL patients.
The modified technique was successfully applied
with satisfying arms contour and reasonable com-
plication rate.
DISCUSSION
Brachioplasty procedures have steadily im-
proved and now are routinely reaching patients’
goals. In markedly sagging arms, it’s somewhat
more difficult to produce a truly tight and perfectly
contoured result as well as an absolutely fine scar.
This is probably because these patients usually
have poor skin tone and elasticity
[18]
.
In 2015, we had two patients with post-
brachioplasty contour deformity. The deformity
was a triangular depression in the lower medial
third of the arm, few centimeters proximal to the
medial epicondyle. This was expressed by the
patients as “My arms became thinner than my
forearms”. This complaint was other patients’ fear
who had their friends or relatives underwent bra-
chioplasty by other plastic surgeons and have the
same deformity. Although, lipofilling of the de-
pressed area treated the deformity efficiently, it
wasn’t an uncommon problem and had to have a
solution.
This described deformity is different from the
arm band deformity that has been mentioned at
many national meetings and forums and lastly
reported in the literature by Wendy Chen et al.,
[15]
.
Actually, this triangular depression is a naturally
present depression due to lack of soft tissue support
proximal to a bony prominence (medial epicondyle)
which is accentuated after brachioplasty. To avoid
this deformity, conservative liposuction and skin
excision at that site was the prophylactic plan. This
succeeded in preventing the depression deformity
but resulted in loss of the taught, round and esthetic
contour of the lower third of the arm.
Goddio, described a brachioplasty technique
in which he de-epithelialize the skin excess ellipse
along the entire arm instead of excising it
[7]
. He
buried the de-epithelialized tissue; after dissecting
 
The extraordinary rise of brachioplasty contin-
ues to be an important part of addressing the total
solution for MWL patients
[1]
.
Since brachioplasty was first described in the
1920s
[2]
, techniques have evolved to include lipo-
suction, excisional surgery, a combination of lipo-
suction and excision, single-versus multi-staged
procedures and, depending on the characteristics of
the deformity, even implants
[3-12]
. Lockwood em-
phasized the importance of secure tightening of the
superficial fascial system resulting in a smoother
contour, tighter closure and finer scar
[14]
.
In severe arm redundancy, post-operative im-
perfect contour isn’t uncommon. Under-reduction,
1
65
over-reduction, constriction arm band and depres-
sion deformity are different forms of unaccepted
contour defects. According to Wendy Chen et al.,
the constriction arem band deformity is a pre-
operative finding that can’t be corrected by brachi-
oplasty and even exacerbated post-operatively in
50% of cases. It is associated with higher current
BMI and larger resection weights. Most bands
were located in the middle (26%) or distal-third
(74%) of the upper arm and found bilaterally (68%)
[15]
.
In our study, another post-brachioplasty contour
deformity, not yet mentioned in the literature, is
described. It’s a triangular depression deformity
of the lower medial arm few centimeters proximal
to the medial epicondyle (Fig. 1). It’s an exagger-
ation of a naturally present mild depression due to
lack of soft tissue support at that area (Fig. 2). The
lower central part of the arm is occupied by the
biceps muscle anteriorly and brachialis muscle
posteriorly while the lower lateral part has the
origin of brachioradialis muscle leaving the medial
lower arm without significant soft tissue support.
After brachioplasty of severe arm redundancy, this
depression is highlighted and look like local stran-
gulation of the arm. This unaccepted deformity
gives the impression of thinner arm in relation to
the forearm because it affects the most distal part
of the arm.
We also suggested a prophylactic modification
of major brachioplasty operation
[18]
, especially
in severe arm redundancy, elderly and thin patients.
We selected MWL patients with severe arm redun-
dancy who were expected to be more prone to the
deformity after brachioplasty. They were good
candidates for major brachioplasty because of
severe arm redundancy extending from the elbow
to the axilla. They had no lateral chest skin redun-
dancy or not interested in its correction.
 
PATIENTS AND METHODS
Fifteen MWL patients with severe arm redun-
dancy underwent major brachioplasty in the period
from 2016-2018 were involved in this study. They
were all females, 39-54 years old. Pre-operative
assessment included weight loss, BMI, general
condition, history of chronic diseases, routine
laboratory investigations, skin tone evaluation,
degree of redundancy and pinch test to quantify
the subcutaneous fat of the arm circumferentially.
Any pre-operative contour deformity was docu-
mented. Informed consent was signed.
Markings were drawn the day of the surgery
while the patient standing, with the arms abducted
to 90 degrees and elbow fully extended. The supe-
rior resection line was drawn connecting the points
representing axillary apex, bicipital groove and
medial epicondyle. The skin amount to be removed
was estimated through pinching the sagging medial
skin between the thumb and index fingers along
the line drawn. Now, the inferior resection line
could be marked meeting the superior line at the
medial epicondyle point and extending proximally
to the axilla. The proximal ends of the superior
166
Vol. 43, No. 2 / Exaggerated Distal Medial Arm Depression after Brachioplasty
and inferior resection lines at the axilla would be
further extended in the axillary hollow and met at
a point according to the skin laxity. Transverse
hatched lines were drawn across the resection
ellipse to guide skin closure. Areas for liposuction
were marked too. The plan was to avoid over
resection and tight closure in the distal arm espe-
cially, the distal third while perform quite tight
closure of the proximal arm. The markings should
represent this plan.
Markings of the expected deformity area: A
triangular depression can be identified on the
antero-medial aspect of the arm few centimeters
proximal to the cupital area (T) (Fig. 3). This
triangle together with a mirror image triangle (T’)
on the resection skin ellipse was marked.
Technique:
The patient was placed in supine position with
arms abducted 90 degrees on arm table with feasi-
bility for full abduction during surgery. Intra-
venous line and blood pressure cuff were placed
in the lower limb. General anaesthesia was a ne-
cessity for major brachioplasty. Both upper limbs
were prepared and draped routinely with hands
and distal forearms covered with sterile stockinette.
Infiltration of superwet fluid in posterior and
medial arm areas was done. Amount of liposuction
of posterior arm varied according to the degree of
lipodystrophy of each patient. Liposuction of me-
dial arm aimed to loosening the dissection plane
and providing tension free closure.
Before excision of redundant tissue, the triangle
T’ was de-epithelialized and dissected as a dermofat
flap with its base at the superior line (Fig. 4).
Undermining of triangle T at the subcutaneous
plane transformed the 2 triangles into a continuous
diamond shape flap with its lower triangular half
de-epithelialized. T’ was folded superiorly deep to
T and fixed to its through a pull out suture. This
technique aimed to augment the triangular depres-
sion (T) and prevent any possible depression de-
formity.
Fig. (1): (A): Arm redundancy. (B): Post-brachioplasty depression deformity (black arrow)
[16]
.
Fig. (2): Cubital fossa anatomy showing the natural lower
medial depression of the arm (black arrow) due to
lack of soft tissue support at that area superior to
the medial epicondyle bonny prominence
[17]
.
Radial nerve
Biceps
brachii
Bicipital
aponeurosis
Pronator teres
Median nerve
Brachial artery
Brachioradialis
 
Egypt, J. Plast. Reconstr. Surg., July 2019
167
The excision started by incising the superior
line of the ellipse (except across the diamond flap)
down to the superficial fascial system (SFS). Dis-
section was carried downwards deep to SFS using
the cutting cautery. Continuous re-evaluation by
pulling the free edge of the dissected flap upwards
and marking for resection was done to achieve the
proper tightness and contouring. The excision was
performed from distal to proximal with stapling
of the skin edges to close the wound and control
the edema after meticulous hemostasis. The SFS
was sutured with 2/0 vicryl followed by deep
dermal sutures with 3/0 vicryl then, sub-cuticular
closure with 4/0 monocryl. No drains were needed
(Fig. 5).
Pre- and post-operative standard medical pho-
tographs were taken. Patients were asked to eval-
uate their final results regarding arm size, contour
and symmetry together with quality and position
of the scar using a four-point numerical rating
scale, where 0 indicated no improvement and 3
indicated highly satisfied. In addition, patients
were objectively evaluated by 2 plastic surgeons
who were not involved in the treatment. These
surgeons compared pre- and post-operative (one
month and 6 months) photographs with regard to
size, contour, symmetry and quality and position
of the scar. Their evaluation was recorded as per-
centage of improvement on a quartile grading scale:
<25%: Mild improvement; 25-50: Moderate im-
provement; 51-75%: Good improvement and 76-
100%: Excellent improvement.
Fig. (3): Pre-operative marking: The excision ellipse, T
representing the natural depression in lower medial
arm, T’ representing the mirror image triangle.
Fig. (5): Pull out suture and closure.
2016-2018. Their average age was 49.6 years (range
39-54 years). The average weight loss was 33
kilograms (range 27-51 kilograms) with stable
body weight for at least 6 months. The average
follow-up period was 7.6 months.
Arm size, contour and symmetry together with
quality and position of the scar were the parameters
for results assessment. Early and late complications
were also documented.
No complaint regarding arm size, contour or
symmetry or scar position was recorded with sub-
jective evaluation revealing an overall high degree
of satisfaction in 13 of 15 patients (86.7%). Two
patients (13.3%) reported moderate satisfaction
(Figs. 6,7).
The objective aesthetic outcome was rated as
excellent in 12 patients (80%) and good in the
remaining 3 patients (20%).
RESULTS
Fifteen female patients with severe arm redun-
dancy after MWL were operated upon using the
modified major brachioplasty in the period from
Fig. (4): (A): Triangle T’ deepithelialized. (B): Dissected as dermofat flap. (C): Buried under undermined T.
(A)
(B)
(C)
 
168
Vol. 43, No. 2 / Exaggerated Distal Medial Arm Depression after Brachioplasty
Fig. (6A): Pre-operative right arm (front).
Fig. (6B): Pre-operative right arm (back) of 54 years old patient.
Fig. (6C): Post-operative right arm (front).
Fig. (6D): Post-operative right arm (back).
Fig. (7A): Pre-operative right arm (front).
Fig. (7B): Pre-operative right arm (back) of 40 years old
patient.
Fig. (7C): Post-operative right arm (front).
Fig. (7D): Post-operative right arm (back).
 
Egypt, J. Plast. Reconstr. Surg., July 2019
169
Table (1): Complications.
Complication
Delayed healing
Hypertrophic scars
Total
Number
1 (3.3%)
2 (6.7%)
3 (10%)
One patient showed delayed healing in one axilla
(3.3%). The late complication was bilateral hyper-
trophic scar in another patient (6.7%) (Table 1).
No re-operation was needed to correct any of
the complications.
it as a posteriorly based flap; in an undermined
anterior pocket to provide esthetic arm fullness
and proper tightness which might be helpful in the
very thin arm and elderly patients. His clinical
series was 12 elderly thin women, only 3 of them
had lost weight; the remainder had never been
obese.
It’s not difficult to restore the proper contour
in the proximal arm with the traditional excision
technique due to the presence of adequate soft
tissue support all through the way. We confined
the use of the dermofat flap to the distal third of
the arm in our modification of major brachioplasty
operation. The dermofat flap is anteriorly based
providing the flexibility to readjust the extent of
excision posteriorly. Inserting the flap in its pocket
by folding it, further augments the incision line.
Brachioplasty as one of the body contouring
operations in MWL patients can be associated with
post-operative complications such as hematoma,
seroma, infection, delayed healing, unfavorable
scars and contour deformities. In the literature, the
rate of complications varied widely from 1.3% up
to 56%
[19-21]
. Other rare serious complications
include fluid overload, thromboembolism, fat em-
bolism and cardiopulmonary dysfunction most
frequently occurring if brachioplasty is performed
in conjunction with other body contouring proce-
dures
[7,8,22-24]
.
In our study, no complaint regarding arm size,
contour or symmetry or scar position was recorded.
The subjective and objective evaluations generally
showed good to excellent results. The rate of com-
plications was 10%. One patient showed delayed
healing in one axilla (3.3%) and another patient
had bilateral hypertrophic scar as a late complica-
tion (6.7%). No re-operation was needed to correct
any of the complications.
On combining body contouring surgeries, we
have to consider the time factor, presence of any
co-morbidity, patient’s age and amount of liposuc-
tion to fulfill the safety measures and avoid any
serious medical complications.
Conclusion:
In our current study, we described a post-
brachioplasty depression deformity not yet de-
scribed in the literature. We also presented a mod-
ification of the major brachioplasty operation
aiming to prevent this potential depression deform-
ity in severe arm redundancy in post MWL patients.
The modified technique was successfully applied
with satisfying arms contour and reasonable com-
plication rate.
DISCUSSION
Brachioplasty procedures have steadily im-
proved and now are routinely reaching patients’
goals. In markedly sagging arms, it’s somewhat
more difficult to produce a truly tight and perfectly
contoured result as well as an absolutely fine scar.
This is probably because these patients usually
have poor skin tone and elasticity
[18]
.
In 2015, we had two patients with post-
brachioplasty contour deformity. The deformity
was a triangular depression in the lower medial
third of the arm, few centimeters proximal to the
medial epicondyle. This was expressed by the
patients as “My arms became thinner than my
forearms”. This complaint was other patients’ fear
who had their friends or relatives underwent bra-
chioplasty by other plastic surgeons and have the
same deformity. Although, lipofilling of the de-
pressed area treated the deformity efficiently, it
wasn’t an uncommon problem and had to have a
solution.
This described deformity is different from the
arm band deformity that has been mentioned at
many national meetings and forums and lastly
reported in the literature by Wendy Chen et al.,
[15]
.
Actually, this triangular depression is a naturally
present depression due to lack of soft tissue support
proximal to a bony prominence (medial epicondyle)
which is accentuated after brachioplasty. To avoid
this deformity, conservative liposuction and skin
excision at that site was the prophylactic plan. This
succeeded in preventing the depression deformity
but resulted in loss of the taught, round and esthetic
contour of the lower third of the arm.
Goddio, described a brachioplasty technique
in which he de-epithelialize the skin excess ellipse
along the entire arm instead of excising it
[7]
. He
buried the de-epithelialized tissue; after dissecting
 
The extraordinary rise of brachioplasty contin-
ues to be an important part of addressing the total
solution for MWL patients
[1]
.
Since brachioplasty was first described in the
1920s
[2]
, techniques have evolved to include lipo-
suction, excisional surgery, a combination of lipo-
suction and excision, single-versus multi-staged
procedures and, depending on the characteristics of
the deformity, even implants
[3-12]
. Lockwood em-
phasized the importance of secure tightening of the
superficial fascial system resulting in a smoother
contour, tighter closure and finer scar
[14]
.
In severe arm redundancy, post-operative im-
perfect contour isn’t uncommon. Under-reduction,
1
65
over-reduction, constriction arm band and depres-
sion deformity are different forms of unaccepted
contour defects. According to Wendy Chen et al.,
the constriction arem band deformity is a pre-
operative finding that can’t be corrected by brachi-
oplasty and even exacerbated post-operatively in
50% of cases. It is associated with higher current
BMI and larger resection weights. Most bands
were located in the middle (26%) or distal-third
(74%) of the upper arm and found bilaterally (68%)
[15]
.
In our study, another post-brachioplasty contour
deformity, not yet mentioned in the literature, is
described. It’s a triangular depression deformity
of the lower medial arm few centimeters proximal
to the medial epicondyle (Fig. 1). It’s an exagger-
ation of a naturally present mild depression due to
lack of soft tissue support at that area (Fig. 2). The
lower central part of the arm is occupied by the
biceps muscle anteriorly and brachialis muscle
posteriorly while the lower lateral part has the
origin of brachioradialis muscle leaving the medial
lower arm without significant soft tissue support.
After brachioplasty of severe arm redundancy, this
depression is highlighted and look like local stran-
gulation of the arm. This unaccepted deformity
gives the impression of thinner arm in relation to
the forearm because it affects the most distal part
of the arm.
We also suggested a prophylactic modification
of major brachioplasty operation
[18]
, especially
in severe arm redundancy, elderly and thin patients.
We selected MWL patients with severe arm redun-
dancy who were expected to be more prone to the
deformity after brachioplasty. They were good
candidates for major brachioplasty because of
severe arm redundancy extending from the elbow
to the axilla. They had no lateral chest skin redun-
dancy or not interested in its correction.
 
PATIENTS AND METHODS
Fifteen MWL patients with severe arm redun-
dancy underwent major brachioplasty in the period
from 2016-2018 were involved in this study. They
were all females, 39-54 years old. Pre-operative
assessment included weight loss, BMI, general
condition, history of chronic diseases, routine
laboratory investigations, skin tone evaluation,
degree of redundancy and pinch test to quantify
the subcutaneous fat of the arm circumferentially.
Any pre-operative contour deformity was docu-
mented. Informed consent was signed.
Markings were drawn the day of the surgery
while the patient standing, with the arms abducted
to 90 degrees and elbow fully extended. The supe-
rior resection line was drawn connecting the points
representing axillary apex, bicipital groove and
medial epicondyle. The skin amount to be removed
was estimated through pinching the sagging medial
skin between the thumb and index fingers along
the line drawn. Now, the inferior resection line
could be marked meeting the superior line at the
medial epicondyle point and extending proximally
to the axilla. The proximal ends of the superior
166
Vol. 43, No. 2 / Exaggerated Distal Medial Arm Depression after Brachioplasty
and inferior resection lines at the axilla would be
further extended in the axillary hollow and met at
a point according to the skin laxity. Transverse
hatched lines were drawn across the resection
ellipse to guide skin closure. Areas for liposuction
were marked too. The plan was to avoid over
resection and tight closure in the distal arm espe-
cially, the distal third while perform quite tight
closure of the proximal arm. The markings should
represent this plan.
Markings of the expected deformity area: A
triangular depression can be identified on the
antero-medial aspect of the arm few centimeters
proximal to the cupital area (T) (Fig. 3). This
triangle together with a mirror image triangle (T’)
on the resection skin ellipse was marked.
Technique:
The patient was placed in supine position with
arms abducted 90 degrees on arm table with feasi-
bility for full abduction during surgery. Intra-
venous line and blood pressure cuff were placed
in the lower limb. General anaesthesia was a ne-
cessity for major brachioplasty. Both upper limbs
were prepared and draped routinely with hands
and distal forearms covered with sterile stockinette.
Infiltration of superwet fluid in posterior and
medial arm areas was done. Amount of liposuction
of posterior arm varied according to the degree of
lipodystrophy of each patient. Liposuction of me-
dial arm aimed to loosening the dissection plane
and providing tension free closure.
Before excision of redundant tissue, the triangle
T’ was de-epithelialized and dissected as a dermofat
flap with its base at the superior line (Fig. 4).
Undermining of triangle T at the subcutaneous
plane transformed the 2 triangles into a continuous
diamond shape flap with its lower triangular half
de-epithelialized. T’ was folded superiorly deep to
T and fixed to its through a pull out suture. This
technique aimed to augment the triangular depres-
sion (T) and prevent any possible depression de-
formity.
Fig. (1): (A): Arm redundancy. (B): Post-brachioplasty depression deformity (black arrow)
[16]
.
Fig. (2): Cubital fossa anatomy showing the natural lower
medial depression of the arm (black arrow) due to
lack of soft tissue support at that area superior to
the medial epicondyle bonny prominence
[17]
.
Radial nerve
Biceps
brachii
Bicipital
aponeurosis
Pronator teres
Median nerve
Brachial artery
Brachioradialis
 
Egypt, J. Plast. Reconstr. Surg., July 2019
167
The excision started by incising the superior
line of the ellipse (except across the diamond flap)
down to the superficial fascial system (SFS). Dis-
section was carried downwards deep to SFS using
the cutting cautery. Continuous re-evaluation by
pulling the free edge of the dissected flap upwards
and marking for resection was done to achieve the
proper tightness and contouring. The excision was
performed from distal to proximal with stapling
of the skin edges to close the wound and control
the edema after meticulous hemostasis. The SFS
was sutured with 2/0 vicryl followed by deep
dermal sutures with 3/0 vicryl then, sub-cuticular
closure with 4/0 monocryl. No drains were needed
(Fig. 5).
Pre- and post-operative standard medical pho-
tographs were taken. Patients were asked to eval-
uate their final results regarding arm size, contour
and symmetry together with quality and position
of the scar using a four-point numerical rating
scale, where 0 indicated no improvement and 3
indicated highly satisfied. In addition, patients
were objectively evaluated by 2 plastic surgeons
who were not involved in the treatment. These
surgeons compared pre- and post-operative (one
month and 6 months) photographs with regard to
size, contour, symmetry and quality and position
of the scar. Their evaluation was recorded as per-
centage of improvement on a quartile grading scale:
<25%: Mild improvement; 25-50: Moderate im-
provement; 51-75%: Good improvement and 76-
100%: Excellent improvement.
Fig. (3): Pre-operative marking: The excision ellipse, T
representing the natural depression in lower medial
arm, T’ representing the mirror image triangle.
Fig. (5): Pull out suture and closure.
2016-2018. Their average age was 49.6 years (range
39-54 years). The average weight loss was 33
kilograms (range 27-51 kilograms) with stable
body weight for at least 6 months. The average
follow-up period was 7.6 months.
Arm size, contour and symmetry together with
quality and position of the scar were the parameters
for results assessment. Early and late complications
were also documented.
No complaint regarding arm size, contour or
symmetry or scar position was recorded with sub-
jective evaluation revealing an overall high degree
of satisfaction in 13 of 15 patients (86.7%). Two
patients (13.3%) reported moderate satisfaction
(Figs. 6,7).
The objective aesthetic outcome was rated as
excellent in 12 patients (80%) and good in the
remaining 3 patients (20%).
RESULTS
Fifteen female patients with severe arm redun-
dancy after MWL were operated upon using the
modified major brachioplasty in the period from
Fig. (4): (A): Triangle T’ deepithelialized. (B): Dissected as dermofat flap. (C): Buried under undermined T.
(A)
(B)
(C)
 
168
Vol. 43, No. 2 / Exaggerated Distal Medial Arm Depression after Brachioplasty
Fig. (6A): Pre-operative right arm (front).
Fig. (6B): Pre-operative right arm (back) of 54 years old patient.
Fig. (6C): Post-operative right arm (front).
Fig. (6D): Post-operative right arm (back).
Fig. (7A): Pre-operative right arm (front).
Fig. (7B): Pre-operative right arm (back) of 40 years old
patient.
Fig. (7C): Post-operative right arm (front).
Fig. (7D): Post-operative right arm (back).
 
Egypt, J. Plast. Reconstr. Surg., July 2019
169
Table (1): Complications.
Complication
Delayed healing
Hypertrophic scars
Total
Number
1 (3.3%)
2 (6.7%)
3 (10%)
One patient showed delayed healing in one axilla
(3.3%). The late complication was bilateral hyper-
trophic scar in another patient (6.7%) (Table 1).
No re-operation was needed to correct any of
the complications.
it as a posteriorly based flap; in an undermined
anterior pocket to provide esthetic arm fullness
and proper tightness which might be helpful in the
very thin arm and elderly patients. His clinical
series was 12 elderly thin women, only 3 of them
had lost weight; the remainder had never been
obese.
It’s not difficult to restore the proper contour
in the proximal arm with the traditional excision
technique due to the presence of adequate soft
tissue support all through the way. We confined
the use of the dermofat flap to the distal third of
the arm in our modification of major brachioplasty
operation. The dermofat flap is anteriorly based
providing the flexibility to readjust the extent of
excision posteriorly. Inserting the flap in its pocket
by folding it, further augments the incision line.
Brachioplasty as one of the body contouring
operations in MWL patients can be associated with
post-operative complications such as hematoma,
seroma, infection, delayed healing, unfavorable
scars and contour deformities. In the literature, the
rate of complications varied widely from 1.3% up
to 56%
[19-21]
. Other rare serious complications
include fluid overload, thromboembolism, fat em-
bolism and cardiopulmonary dysfunction most
frequently occurring if brachioplasty is performed
in conjunction with other body contouring proce-
dures
[7,8,22-24]
.
In our study, no complaint regarding arm size,
contour or symmetry or scar position was recorded.
The subjective and objective evaluations generally
showed good to excellent results. The rate of com-
plications was 10%. One patient showed delayed
healing in one axilla (3.3%) and another patient
had bilateral hypertrophic scar as a late complica-
tion (6.7%). No re-operation was needed to correct
any of the complications.
On combining body contouring surgeries, we
have to consider the time factor, presence of any
co-morbidity, patient’s age and amount of liposuc-
tion to fulfill the safety measures and avoid any
serious medical complications.
Conclusion:
In our current study, we described a post-
brachioplasty depression deformity not yet de-
scribed in the literature. We also presented a mod-
ification of the major brachioplasty operation
aiming to prevent this potential depression deform-
ity in severe arm redundancy in post MWL patients.
The modified technique was successfully applied
with satisfying arms contour and reasonable com-
plication rate.
DISCUSSION
Brachioplasty procedures have steadily im-
proved and now are routinely reaching patients’
goals. In markedly sagging arms, it’s somewhat
more difficult to produce a truly tight and perfectly
contoured result as well as an absolutely fine scar.
This is probably because these patients usually
have poor skin tone and elasticity
[18]
.
In 2015, we had two patients with post-
brachioplasty contour deformity. The deformity
was a triangular depression in the lower medial
third of the arm, few centimeters proximal to the
medial epicondyle. This was expressed by the
patients as “My arms became thinner than my
forearms”. This complaint was other patients’ fear
who had their friends or relatives underwent bra-
chioplasty by other plastic surgeons and have the
same deformity. Although, lipofilling of the de-
pressed area treated the deformity efficiently, it
wasn’t an uncommon problem and had to have a
solution.
This described deformity is different from the
arm band deformity that has been mentioned at
many national meetings and forums and lastly
reported in the literature by Wendy Chen et al.,
[15]
.
Actually, this triangular depression is a naturally
present depression due to lack of soft tissue support
proximal to a bony prominence (medial epicondyle)
which is accentuated after brachioplasty. To avoid
this deformity, conservative liposuction and skin
excision at that site was the prophylactic plan. This
succeeded in preventing the depression deformity
but resulted in loss of the taught, round and esthetic
contour of the lower third of the arm.
Goddio, described a brachioplasty technique
in which he de-epithelialize the skin excess ellipse
along the entire arm instead of excising it
[7]
. He
buried the de-epithelialized tissue; after dissecting
 

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