eMedicine Specialties > Plastic Surgery > Body Contouring

Liposuction, Upper Arms

John YS Kim, MD, Assistant Professor, Department of Surgery, Division of Plastic Surgery, Northwestern Medical Faculty Foundation; Consulting Staff, Northwestern Plastic Surgery
Jane Lee Fansler, MD, Resident Physician, Stanford University/Kaiser Permanente Emergency Medicine Residency Program; Joanne Lopes, MD, Consulting Surgeon, Cosmetic Surgery Center for Women

Updated: Dec 17, 2008

Introduction

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.¹ 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.

Indications

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."²

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.³ 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.² 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.⁴

Table 1. Classification System of Teimourian

	Group I	Group II	Group III	Group IV
Fat	Minimal to moderate	Minimal to moderate	Excess	Minimal
Skin Laxity	Minimal	Moderate	Moderate	Moderate
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 90 º with the elbow flexed 90 º. 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.

Table 2. Categorization Based on Skin Excess and Fat Excess⁵

Group	Skin Excess	Fat Excess	Treatment
I	Minimal	Moderate	Liposuction (UAL* or SAL †)
II	Moderate	Minimal	Resection
III	Moderate	Moderate	UAL

*UAL - Ultrasound-assisted lipectomy
† SAL - Suction-assisted lipectomy

In conclusion, the guidelines above, with personal experience, can lead to marked personal and patient satisfaction.

Relevant Anatomy

In Body Sculpturing by Lipoplasty, Illouz and DeVillers discuss the anatomy and physiology of the arm.² 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.⁶ 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.⁷ 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.⁸

Contraindications

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.⁹

Treatment

Medical Therapy

Instruct the patient to stop using aspirin, nonsteroidal anti-inflammatory drugs, vitamin E, alcohol, and all tobacco products and to decrease sodium intake at least a week prior to surgery.

Surgical Therapy

After evaluation and proper selection of the surgical procedure, prepare the patient for surgery. Increasingly, liposuction is being used as an adjunct to formal brachioplasty. For instance, a method of performing aggressive liposuction directly under the area of skin that is to be removed is becoming increasingly popular. This method allows preservation of lymphatics while thinning out the flap of skin that is to be removed. However, caution should be exercised in liposuctioning in areas of brachioplasty flap elevation and inset. Compromising vascularity in this case can engender healing problems along an incision line already known for problems due to tension.

Preoperative Details

Preoperatively, mark the patient with the arm abducted 90° and flexed at the elbow 90°. Mark the incision sites posteriorly, proximal to the radial elbow and posterior axillary fold. The anterior axilla can also be marked for incision, if the anterior arm is to be treated.

Depending on the results of the patient evaluation, if circumferential liposuction is to be performed, additional access sites are needed to allow for cross-tunneling. Suggested sites are the posterior, medial, and lateral areas of the arms.

Intraoperative Details

Tumescent anesthesia with sedation is used. Place the patient in the supine or prone position depending on other procedures performed during the operation. Usually, the supine position allows adequate mobility of the arm. Using a No. 11 blade, make stab incisions in the preoperatively marked areas and infiltrate the wetting solution. The rate of infiltration should depend on patient discomfort. Patients with taut tissue might need a slower infiltration rate to minimize discomfort.

If suction-assisted lipectomy (SAL) alone is to be used, the cannula should be long enough to reach from the incision site to the most proximal area of the arm. For cross-tunneling, shorter and smaller cannulas are needed (usually, 2- to 4-mm; average, 3 mm). Eliminator or accelerator cannulas are preferred.

If superficial liposuction is performed, do so cautiously to avoid postoperative puckering and dimpling of the skin. Aggressive fat removal with grasping and lifting of the fat and downward pressure on the skin, forcing the fat into the cannula, is not necessary and can lead to postoperative contour deformities.

Ultrasonic liposuction is another popular modality for upper arm contouring. In general, ultrasonic liposuction is performed in the inferior (lower) one third of the arm and SAL is performed in the superior (upper) two thirds of the arm.

With the patient in the prone position, perform ultrasonic liposuction through the posterior axillary fold incision and SAL at the radial elbow away from the ulnar nerve. With the patient in the supine position, perform ultrasound-assisted lipectomy (UAL) at the radial elbow and SAL evacuation through the posterior axillary fold incisions.

As with ultrasonic liposuction in other areas of the body, perform the procedure with wetting solution, skin protection, long radial strokes with a long cannula, and final contouring with 3-mm SAL cannulas both proximally and distally.

Be aware of the fat overlying the medial epicondyle, the fibrous fat proximal to the elbow, and the fat located in the proximal one-half of the upper arm, as these areas, if insufficiently treated, can lead to patient dissatisfaction. Failure to adequately suction the most proximal fat can lead to poor skin contraction.

Rohrich et al have suggested 4 keys to maximize contour and prevent irregularities. These are (1) uniform delivery of subcutaneous infiltration, (2) long radial UAL strokes using a blunt-tip cannula, (3) long radial evacuation strokes using a small-diameter SAL cannula, and (4) circumferential contouring using SAL for the upper one third of the arm and UAL for the lower two thirds of the arm.

An approximate amount of infiltrate for the upper arm is 300-350 mL of wetting solution. UAL time ranges from approximately 2 min 30 s to 3 min, with an approximate UAL removal of 50-100 mL. The subsequent SAL contouring volume removed is approximately 250 mL, with treatment times of 4 min 10 s and 5 min 15 s.

Postoperative Details

Sutures are not placed to allow external drainage of fluid. Postoperatively, as with many liposuction procedures, the patient wears a compression garment for 4-6 weeks to minimize swelling.

Follow-up

Patient follow-up care is at 1 month, 3 months, 6 months, and 1 year. At these appointments, evaluate the patient for symmetry, waviness, and contour deformities. Generally, revisions are not performed until 3 or more months have passed.

Complications

Poor skin retraction, waviness, contour deformity, and ulnar nerve neurapraxia from UAL are the major complications. Other complications can include seromas, hematomas, and infection.

Lillis believes that if significant loose skin remains after an initial session, a second liposuction often provides additional skin contraction.⁹ He also believes that brachioplasty should not be considered until 3-6 months after aggressive liposuction and should be delayed until a second liposuction procedure has been performed.⁹

Outcome and Prognosis

Upper arm contouring with liposuction yields a high degree of patient satisfaction with minimal morbidity. Often skin retraction can be greater than expected. Good patient selection, maintaining realistic expectations, and using the proper treatment modality are extremely important to obtaining satisfactory results.

For excellent patient education resources, visit eMedicine's Procedures Center. Also, see eMedicine's patient education article Liposuction.

Multimedia

Media file 1: Preoperative arm.

Media file 2: Postoperative arm 6 months after liposuction only.

References

Correa-Iturraspe M, Fernandez JC. Dermolipectomia Braquial. Prensa Med Argent. 1954;34:2432.
Illouz Y-G, DeVillers Y. Body Sculpturing by Lipoplasty. New York, NY: Churchill Livingstone; 1989.
Lillis PJ. Liposuction of the arms, calves, and ankles. Dermatol Surg. Dec 1997;23(12):1161-8. [Medline].
Teimourian B, Malekzadeh S. Rejuvenation of the upper arm. Plast Reconstr Surg. Aug 1998;102(2):545-51; discussion 552-3. [Medline].
Rohrich R, Beran S, Kenkel J, eds. Ultrasound-Assisted Liposuction. St. Louis, Mo: Quality Medical Publishing; 1998.
Chamosa M, Murillo J, Vazquez T. Lipectomy of arms and lipograft of shoulders balance the upper body contour. Aesthetic Plast Surg. Nov-Dec 2005;29(6):567-70. [Medline].
Glanz S, Gonzalez-Ulloa M. Aesthetic surgery of the arm. Part I. Aesthetic Plast Surg. 1981;5(1):1-17. [Medline].
Lockwood T. Brachioplasty with superficial fascial system suspension. Plast Reconstr Surg. Sep 1995;96(4):912-20. [Medline].
Lillis PJ. Liposuction of the arms. Dermatol Clin. Oct 1999;17(4):783-97. [Medline].
Asken S. Refinements in the technique of liposuction. J Dermatol Surg Oncol. Oct 1988;14(10):1165-72. [Medline].

Keywords

upper arm liposuction, body contouring, brachioplasty, fat removal, arm reduction surgery, T-closure, Z-plasty, fascial system suspension, upper arm contouring, suction lipectomy, circumferential liposuction, ultrasound-assisted liposuction, UAL, ultrasonic liposuction, suction-assisted liposuction, SAL, ultrasonic lipectomy, ultrasound-assisted lipectomy, suction lipectomy, suction-assisted lipectomy, batwing appearance, bat-wing appearance, bat wing appearance, bat wings, batwings

Contributor Information and Disclosures

Author

John YS Kim, MD, Assistant Professor, Department of Surgery, Division of Plastic Surgery, Northwestern Medical Faculty Foundation; Consulting Staff, Northwestern Plastic Surgery
John YS Kim, MD is a member of the following medical societies: American College of Surgeons and American Society of Plastic Surgeons
Disclosure: Nothing to disclose.

Coauthor(s)

Jane Lee Fansler, MD, Resident Physician, Stanford University/Kaiser Permanente Emergency Medicine Residency Program
Jane Lee Fansler, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Emergency Medicine Residents Association, and Phi Beta Kappa
Disclosure: eMedicine None None

Joanne Lopes, MD, Consulting Surgeon, Cosmetic Surgery Center for Women
Joanne Lopes, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, American Medical Women's Association, American Society for Aesthetic Plastic Surgery, and American Society of Plastic Surgeons
Disclosure: Nothing to disclose.

Medical Editor

Rodrigo Santamarina, MD, Attending Plastic Surgeon, Berkshire Medical Center, Assistant Professor of Surgery, Plastic and Hand Surgeon, Division of Plastic Surgery, University of Massachusetts Medical School
Rodrigo Santamarina, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, Massachusetts Medical Society, New York Academy of Sciences, and Society of American Gastrointestinal and Endoscopic Surgeons
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Alan Matarasso, MD, FACS, PC, Clinical Professor of Plastic Surgery, Albert Einstein College of Medicine; Immed Past President of New York Regional Society of Plastic and Reconstructive Surgery
Alan Matarasso, MD, FACS, PC is a member of the following medical societies: American Association of Plastic Surgeons, American College of Surgeons, American Medical Association, International College of Surgeons US Section, New York Academy of Medicine, New York County Medical Society, Pan American Medical Association, and Pan-Pacific Surgical Association
Disclosure: Nothing to disclose.

CME Editor

Nicolas (Nick) G Slenkovich, MD, Director, Colorado Plastic Surgery Center
Nicolas (Nick) G Slenkovich, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Society of Aesthetic Plastic Surgery, American Society of Plastic Surgeons, and Colorado Medical Society
Disclosure: Nothing to disclose.

Chief Editor

Jorge I de la Torre, MD, FACS, Professor of Surgery and Physical Medicine and Rehabilitation, Residency Program Director, Division of Plastic Surgery, University of Alabama at Birmingham; Director, Center for Advanced Surgical Aesthetics
Jorge I de la Torre, MD, FACS is a member of the following medical societies: American Association of Plastic Surgeons, American Burn Association, American College of Surgeons, American Medical Association, American Society for Laser Medicine and Surgery, American Society for Reconstructive Microsurgery, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, Association for Academic Surgery, and Medical Association of the State of Alabama
Disclosure: Nothing to disclose.

Further Reading