History of the Procedure
Revolutionary to body contouring, liposuction was initially popularized in New York in the late 1970s. Prior to liposuction, Correa-Iturraspe and Fernandez first described arm reduction surgery, mainly brachioplasty, in 1954 in the South American literature.  Since that time, modifications of brachioplasty (ie, T-closure, Z-plasties, fascial system suspensions) have been the emphasis of upper arm contouring. With the introduction of liposuction to the United States in 1981 and the tumescent technique in the late 1980s, liposuction of the upper arms has gained popularity. Liposuction of the upper arms has also been used as an adjunct to body contouring after massive weight loss. [2, 3]
Illouz and DeVillers, who use both qualitative and prognostic tests, have proposed objective criteria to find the ideal patient for liposuction. They define the qualitative test as follows: "If sagging of the inferior dependent portion of the arm is equal to or less than the thickness of the dermosubcutaneous complex, satisfactory results may be anticipated." 
Lillis says that qualitative testing can be done with the patient extending his or her arms horizontally or with elbows bent to maximize posterior and posterior lateral compartment laxity.  Excess anterior and anterior medial fat is best evaluated with arms at the sides and is more prominent in patients who are significantly overweight.
Prognostic evaluation of the future appearance of the arms is determined simply by asking the patient to contract the biceps and triceps simultaneously. This creates a degree of retraction with ascension of the skin, which closely resembles the degree of retraction observed postoperatively. Realistic expectations must be stressed, and patients should be aware that the procedure will not affect the quality of their skin.
Illouz and DeVillers further classify patients into groups of favorable, poor, or borderline candidates.  Favorable candidates are patients who are young with good skin tone and moderate fat hypertrophy. Poor candidates are those who are older with sagging and excess fat hypertrophy, often caused by weight loss in addition to aging. Borderline candidates are patients with equivocal examination results. They can be treated with liposuction, but they must be warned that they may need additional surgical intervention. Teimourian has added a further classification system, as shown in Table 1 below. 
Table 1. Classification System of Teimourian (Open Table in a new window)
|Group I||Group II||Group III||Group IV|
|Fat||Minimal to moderate||Minimal to moderate||Excess||Minimal|
|Treatment||Circumferential liposuction||Suction lipectomy with or without axillary skin tightening versus skin excision with or without suction lipectomy||Circumferential liposuction without undermining and T incision with purse-string closure||Brachioplasty|
A simple measure to evaluate a patient as a candidate for liposuction is the pinch test; the patient should have at least 1.5 cm of fat when assessed with this test. Abduct the patient's arm 90º with the elbow flexed 90º. Measure the arm from below the border of the humerus. The ratio above and below the inferior border is approximately 1:1 in a young woman and increases with age.
With the advent of ultrasonic liposuction, further categorization can be based according to the skin excess and fat excess, as shown in Table 2 below.
|Group||Skin Excess||Fat Excess||Treatment|
|I||Minimal||Moderate||Liposuction (UAL* or SAL† )|
*UAL - Ultrasound-assisted lipectomy
† SAL - Suction-assisted lipectomy
In conclusion, the guidelines above, with personal experience, can lead to marked personal and patient satisfaction.
In Body Sculpturing by Lipoplasty, Illouz and DeVillers discuss the anatomy and physiology of the arm.  The upper arm contains a deep and superficial fat layer. The deep fat layer found in the posterior and deltoid region of the arm is thin. The superficial fat layer is circumferential and tends to hypertrophy, particularly in the posterior one third of the arm. A greater amount of fat is, therefore, found in the more proximal the area of the arm. Chamosa found that the anterior face and distal third of the upper arm tended to have less thick adipose tissue.  Occasionally, a specific lipodystrophic zone can be found on the posterior-external area of the arm, located between the proximal and medial thirds. The skin of the medial aspect of the arm is thin, devoid of hair follicles, and prone to sag. Overall, the skin is mobile and overlies loose, nonfibrous fat.
The aesthetic arm is considered to be lean, with an anterior convexity of the deltoid merging with the convexity of the biceps. The posterior surface should be slightly convex from the axilla to the elbow. Glanz and Gonzalez-Ulloa have demonstrated that with age, the inferior posterior curve of the upper arm progresses, with loss of superior structures leading to ptosis or the bat-wing appearance.  According to Lockwood, factors predisposing patients to soft tissue laxity of the arms include aging, heavy arm fat deposits, weight fluctuation, sun damage, and previous liposuction. 
The main contraindication to liposuction alone of the upper arms is minimal fat excess and moderate skin excess. Such patients are usually older and have lost a moderate amount of weight. In this patient population, some form of brachioplasty is usually required. Still, Lillis warns against immediate recommendation of brachioplasty except in extreme cases, as skin contraction can be very good, and liposuction may be attempted first to see if results are beneficial.