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Master the full spectrum of "body sculpting" procedures with Body Contouring and Liposuction by J Peter Rubin, MD, FACS, Mark L Jewell, MD, Dirk Richter, MD, PhD, and Carlos O Uebel, MD, PhD! From fat grafts and liposuction through total body lift following massive weight loss surgery, full-color photos and procedural videos show you exactly how to proceed, step by step, and achieve gratifying results.

  • Consult this title on your favorite e-reader with intuitive search tools and adjustable font sizes. Elsevier eBooks provide instant portable access to your entire library, no matter what device you're using or where you're located.
  • Exceed your patients' expectations thanks to expert, multimedia guidance from many of today's most accomplished experts in aesthetic plastic surgery.
  • Know what to look for and how to proceed thanks to videos and full-color illustrations demonstrating brachioplasty, breast reshaping after massive weight loss, thigh and buttock contouring, combining abdominoplasty and mastopexy, and other in-demand procedures.
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  • Access the complete contents online, as well as videos and downloadable illustrations, at www.expertconsult.com.



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Published 26 October 2012
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EAN13 9781455737963
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Body Contouring and
J. Peter Rubin, MD, FACS
UPMC Endowed Professor of Plastic Surgery, Chair,
Department of Plastic Surgery, Director, Life After Weight
Loss Body Contouring Program, University of Pittsburgh,
Pittsburgh, PA, USA
Mark L. Jewell, MD
Assistant Clinical Professor of Plastic Surgery, Oregon Health
Science University, Portland, OR
Jewell Plastic Surgery Center, Eugene, OR, USA
Dirk F. Richter, MD, PhD
Associate Professor, University of Bonn, Chief, Department of
Plastic and Reconstructive Surgery, Director of the
Dreifaltigkeits, Krankenhaus, Wesseling, Germany
Carlos O. Uebel, MD, PhD
Associate Professor, Division of Plastic Surgery, PUCRS
University, Porto Alegre, Brazil
S a u n d e r sTable of Contents
Instructions for online access
Cover image
Title page
List of Contributors
Introduction: Body contouring surgery – a fifty year perspective
Part 1: Patient evaluation and safety
Chapter 1: Patient safety in body contouring
Preoperative Assessment and Patient Selection
Intraoperative Management
Postoperative Management
Postoperative Nausea and Emesis (PONV)
Patient Safety in Your Practice
Complications and Their Management
Part 2: Upper extremity contouring
Chapter 2: Liposuction of the upper extremities
Preoperative Preparation
Surgical Technique
Optimizing Outcomes
Postoperative Care
Complications and Their Management
Chapter 3: Brachioplasty with bicipital groove scar
Preoperative PreparationSurgical Technique
Optimizing Outcomes
Postoperative Care
Complications and Their Management
Chapter 4: Brachioplasty – the double ellipse technique
Preoperative Preparation
Surgical Technique
Postoperative Care
Optimizing Outcomes
Complications and Their Management
Chapter 5: Brachioplasty with liposuction resection
Preoperative Preparation
Surgical Technique (Fig. 5.3)
Optimizing Outcomes
Postoperative Management
Complications and Their Management
Chapter 6: Limited scar brachioplasty
Preoperative Preparation
Surgical Technique
Optimizing Outcomes
Postoperative Care
Part 3: Breast
Chapter 7: Fat grafting to the breast
History of Fat Grafting
Principle of Low Pressure Fat Harvesting
Autologous Fat Grafting to the Breast
Postoperative Care
Fat Grafting for Implant FailureFat Grafting in Conjuction with Mastopexy
Fat Grafting for Augmentation
Fat Grafting Over Existing Implants
Fat Grafting for Breast Reconstruction
Fat Grafting for Congenital Breast Deformities
Optimizing Outcomes
Chapter 8: Ultrasound-assisted breast reduction
Preoperative Preparation
Surgical Technique
Optimizing Outcomes
Postoperative Care
Clinical Results
Complications and Their Management
Chapter 9: Combined abdominal contouring and mastopexy
Postoperative Remarks and Optimizing Outcomes
Complications and Their Management
Chapter 10: Breast reshaping using autologous tissues after massive
weight loss
Clinical Approach
Preoperative Preparation
Surgical Technique
Postoperative Care
Complications and Their Management
Chapter 11: Combined abdominoplasty and breast enlargement by
autologous tissue transfer or transabdominal implant placement
A Augmentation Mammaplasty by Reverse Abdominoplasty
B Transabdominal Breast Augmentation
Chapter 12: Mammaplasty with L-shaped scar
IntroductionProportions and Anatomy of the Beautifully Shaped Breast
Surgical Technique
Mammaplasty with L-Shaped Scar
Chapter 13: Breast reshaping after massive weight loss: Autologous
tissue techniques
Preoperative Preparation
Surgical Procedure
Optimizing Outcomes
Postoperative Care
Chapter 14: Breast reshaping after massive weight loss, implant based
Preoperative Preparation
Preoperative Planning – Primary Augmentation Mammaplasty
Surgical Technique
Optimizing Outcomes
Postoperative Care
Complications and Their Management
Part 4: Upper trunk contouring
Chapter 15: Liposuction of upper back/bra rolls
Anatomical Aspects
Surgical Treatment
Postoperative Care and Results
Chapter 16: Transverse upper body lift
Preoperative Preparation
Surgical Technique
Postoperative Care
Complications and ManagementConclusion
Chapter 17: Upper body lift with lateral excision
Preoperative Preparation
Surgical Technique
Optimizing Outcomes
Postoperative Care
Complications and Their Management
Part 5: Abdominal contouring procedures
Chapter 18: Aesthetic classification of the abdomen
Preoperative Preparation
Surgical Technique
Optimizing Outcomes
Postoperative Care
Complications and Their Prevention, Diagnosis, and Management
Chapter 19: Anatomy of the abdominal wall and aesthetic classification
Anatomy of the Anterior Abdominal Wall and its Surgical Implications on
Preoperative Preparation
Optimizing Outcomes
Postoperative Care
Local Complications and Their Management
Chapter 20: Lipomyosculpture
Preoperative Preparation
Morpho-Histology of Subcutaneous Adipose Tissue
Surgical Technique
Postoperative Care
ConclusionChapter 21: Classic abdominoplasty with adhesion tension sutures
Surgical Technique
Seven Comments
Chapter 22: Lipoabdominoplasty with previous flap resection
Preoperative Preparation
Surgical Technique
Postoperative Care
Complications and Their Management
Comments and Conclusion
Chapter 23: Reverse abdominoplasty
Preoperative Preparation
Surgical Technique
Optimizing Outcomes
Postoperative Care
Complications and Their Management
Chapter 24: Endoscopic plication techniques for the treatment of
abdominal contour
Basic Science
Diagnosis/Patient Presentation
Patient Selection
Surgical Technique
Postoperative Care
Outcomes, Prognosis, and Complications
Chapter 25: High lateral tension abdominoplasty
Preoperative Preparation
Surgical Technique
Postoperative Care
Optimizing Outcomes
Complications and Their ManagementConclusion
Chapter 26: Fleur-de-lis abdominoplasty including mons contouring
Preoperative Preparation
Surgical Technique
Postoperative Care
Complications and Their Management
Chapter 27: Panniculectomy in patients with super obesity
Preoperative Preparation
Surgical Technique
Optimizing Outcomes
Postoperative Treatment
Complications and Their Treatment
Chapter 28: Lipoabdominoplasty
Preoperative Preparation
Surgical Technique
Optimizing Outcomes
Postoperative Care
Complications and Their Management
Summary of Advantages
Summary of Disadvantages
Summary of Steps
Preoperative Preparation
Surgical Technique
Optimizing Outcomes
Postoperative Care
Complications and Their Management
Chapter 29: UmbilicoplastyIntroduction
Preparation, Diagnosis, and Patient Presentation
Surgical Technique
Postoperative Care
Outcomes, Prognosis, Complications
Chapter 30: Combining abdominal contouring with hernia repair
Preoperative Preparation
Surgical Technique
Optimizing Outcomes
Postoperative Care
Complications and Their Management
Chapter 31: Liposuction of the abdomen and trunk
Preoperative Preparation
Surgical Technique
Optimizing Outcomes
Postoperative Care
Complications and Their Management
Chapter 32: Belt lipectomy/circumferential abdominoplasty
Relevant Anatomy
Disease Process
Diagnosis and Presentation
Preoperative Preparation
Surgical Technique
Postoperative Care
Complications and Their Management
Chapter 33: Progressive tension sutures in abdominoplasty
Preoperative Preparation
Surgical Technique
Optimizing OutcomesPostoperative Care
Complications and Their Management
Part 6: Thigh, buttock and lower extremity contouring
Chapter 34: Transverse medial thigh lift
Preoperative Preparation
Anatomical Considerations
Surgical Technique
Optimizing Outcomes
Postoperative Care
Complications and Their Management
Clinical Cases
Chapter 35: Vertical medial thigh lift with liposuction
Preoperative Preparation
Surgical Technique
Optimizing Outcomes
Postoperative Care
Complications and Their Management
Chapter 36: Short vertical scar medial thigh lift
Applied Anatomy
Preoperative Preparation
Surgical Technique
Optimizing Outcomes
Postoperative Care
Complications and Their Management
Chapter 37: Autologous gluteal augmentation with mid-pedicle superior
pole perforator flaps
Preoperative PreparationSurgical Technique
Optimizing Outcomes
Postoperative Care
Complications and Their Management
Chapter 38: Liposuction and circumferential lower truncal
Preoperative Preparation
Surgical Technique
Optimizing Outcomes
Postoperative Care
Complications and Their Management
Chapter 39: Gluteal contouring and rejuvenation
Preoperative Preparation
Surgical Technique
Postoperative Care
Chapter 40: Buttock implants
Evolution of Technique
Why Is the Subfascial Plane Recommended?
Preoperative Preparation
Liposculpting and Gluteal Implants
Surgical Procedure
Optimizing Outcomes
Adjunctive Procedures
Postoperative Care
Outcomes and Results
Complications and Their Management
The Problems of Superficial Planes: Subcutaneous and Subfascial
The Advantages of the Intramuscular PlanePrinciples for Intramuscular Undermining
Surgical Technique
Postoperative Care
Implant Choice
Surgical Technique
Postoperative Care
Chapter 41: Buttock contouring with liposuction and fat injection
Preoperative Preparation
Preparation in OR
Fat Injections
Postoperative Care
Chapter 42: Liposuction of the lower extremities and leg reshaping with
Preoperative Preparation
Alternative Treatment
Optimizing Outcomes
Chapter 43: Calf and thigh implants
Materials and Methods
Surgical Technique
Postoperative Care
Complications and Their Management
ConclusionPart 7: Liposuction and fat grafting
Chapter 44: Lipoplasty – history and principles
Evolution of Lipoplasty
Lipoplasty Begins and Gains Popularity in the US
Fundamentals of Lipoplasty
Secondary Lipoplasty
Postoperative Management
Chapter 45: Tumescent local anesthesia for liposuction
Historical Background
Preoperative Preparation
Surgical Technique
Optimizing Outcomes
Postoperative Care
Complications and Contraindications
Chapter 46: Treatment of liposuction complications
Complications and Their Management
Chapter 47: Fat grafting in body contouring surgery
Preoperative Preparation
Surgical Technique
Optimizing Outcomes
Postoperative Care
Complications and Their Management
Chapter 48: Minimal scar breast augmentation using autologous fat
Preoperative Preparation
Surgical Technique
Preparation Procedures of Graft Materials
SVF Isolation ProcedureOptimizing Outcomes
Pre- and Postoperative Care
Complications and Their Management
Chapter 49: Principles of new invasive modalities
A Laser-Assisted Liposuction
B Cryolipolysis
C External Ultrasonic Devices
Chapter 50: Ultrasonic liposuction
Basic Physics of Ultrasonic Liposuction
Preoperative Preparation
Surgical Technique
Optimizing Outcomes
Postoperative Care
UAL Complications and Their Management
Part 8: Body contouring with HIFU or injectables
Chapter 51: High intensity focused ultrasound and non-invasive body
Ultrasonic Energy
Tissue Thermodynamics
Tissue Effect and Biology of Thermal HIFU
Thermal HIFU as A Noninvasive Body Contouring Device
Clinical Research Results
The Liposonix Process
The Business of Noninvasive Body Contouring
The Future
Chapter 52: Mesotherapy for body contouring and cellulite
Selection of Patients for Mesotherapy
PrepAration for Mesotherapy
InjectionsSide Effects and Treatment
Part 9: Special considerations for the massive weight loss patient
Chapter 53: Describing the deformities
Anatomic Considerations
Surgical Considerations
Chapter 54: Psychological and nutritional evaluation
Nutritional Considerations for the Post-Bariatric Patient
Perioperative Considerations
Psychological Considerations for the Bariatric Patient
Chapter 55: Staging and combining procedures
Understanding Body Image and Weight Loss
Preoperative Evaluation of the Massive Weight Loss Patient
Patient Selection
Overview of Staging Strategies
Lower Body Lift/ Vertical Medial Thigh Lift
Upper Body Lift/Brachioplasty
Upper Body Lift/Lower Body Lift
Abdominal Wall Reconstruction/Abdominoplasty
IndexC o p y r i g h t
SAUNDERS is an imprint of Elsevier Inc.
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This book and the individual contributions contained in it are protected under
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N o t i c e s
Knowledge and best practice in this 2eld are constantly changing. As new research
and experience broaden our understanding, changes in research methods,
professional practices, or medical treatment may become necessary.
Practitioners and researchers must always rely on their own experience and
knowledge in evaluating and using any information, methods, compounds, or
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mindful of their own safety and the safety of others, including parties for whom
they have a professional responsibility.
With respect to any drug or pharmaceutical products identi2ed, readers are
advised to check the most current information provided (i) on procedures featured
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To the fullest extent of the law, neither the Publisher nor the authors,
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ISBN: 978-1-4557-0544-3
E-ISBN: 978-1-4557-3796-3
Printed in China
Last digit is the print number: 9 8 7 6 5 4 3 2 1"


Body contouring and liposuction is a wonderfully challenging and constantly
evolving eld at the intersection of surgical skill, artistry, and new technology.
Through this highly impactful practice, we reshape the bodies and the lives of our
This book was designed around a simple concept: to provide a comprehensive
reference for the full spectrum of principles and techniques in body contouring and
liposuction, as taught by the masters in the eld across the globe. The resulting
compilation truly covers all aspects of the specialty and puts into perspective
applied anatomy, physiology, patient selection, safety, technical aspects,
problemsolving, and management of complications.
The most up-to-date concepts are presented by leaders in the eld. Important
principles, some rooted in the early history of plastic surgery and others of more
modern origin, come together to form the foundation of current practice. It is
wonderful to see the evolution of this specialty, as well as the breadth and scope of
the creative solutions we can use to sculpt the human form.
The international editorial team is greatly indebted to the numerous
contributors from around the world who have so expertly composed the chapters in
this book. The high quality of this book is a result of the time and e ort they have
spent distilling their techniques into such clear and well written monographs.
Additional thanks goes to the talented members of the Elsevier sta who
shepherded this project from inception to final form.
J. Peter Rubin, MD
Mark L. Jewell, MD
Dirk F. Richter, MD, PhD
Carlos O. Uebel, MD, PhD
2013List of Contributors
José H. Aboudib, MD
Professor of Plastic Surgery
President of Brazilian Society of Plastic Surgery
Rio de Janeiro, Brazil
Al S. Aly, MD, FACS
Director of Aesthetics
Aesthetic and Plastic Surgery Institute
The University of California
Irvine Orange, CA, USA
Noriyuki Aoi, MD
Graduate student
Department of Plastic Surgery
University of Tokyo Graduate School of Medicine
Tokyo, Japan
Shannon D. Armstrong, MD
Chief Resident
Division of Plastic Surgery
GRMEP/Michigan State University
Grand Rapids, MI, USA
Ricardo A. Arnt, MD
Private Practitioner
Adjunct Secretary of Brazilian Society of Plastic Surgery
Porto Alegre, Brazil
Juarez Avelar, MD
Voluntary Assistant Professor
Plastic Surgery Unit
Medical School of Marilia
Marilia, BrazilSergio Fernando Dantas de Azevedo, MD
Specialist member
Brazilian Society of Plastic Surgery
Sao Paulo, Brazil
Ana Z.D. Badin, MD, MS
Technical Director
Department of Plastic Surgery
Athena Medical Center
Curitiba, Paraná, Brazil;
MS in Surgery Federal University of Paraná (UFPR)
Curitiba, Brazil
Ricardo Baroudi, MD
Private Practitioner
São Paulo, Brazil
Catherine Bergeret-Galley, MD, FACS
Plastic Surgeon
Private Practice
Paris, France
Reena A. Bhatt, MD
Assistant Clinical Professor
Department of Plastic Surgery
Miriam and Rhode Island Hospitals
The Warren Alpert Medical School
Brown University
Providence, RI, USA
Matheus Monseff Vieira Borela, MD
Department of Plastic Surgery
Santa Cecilia University
São Paulo, Brazil
Ronald P. Bossert, MD
Assistant Professor of Surgery;Director
Life After Weight Loss Program
University of Rochester Medical Center
Rochester, NY, USA
Antonio R. Bozola, PhD
Head of Plastic Surgery Department
University of Medicine
São José do Rio Preto, Brazil
Joseph F. Capella, MD, FACS
Chief, Post-Bariatric Body Contouring
Division of Plastic Surgery
Hackensack University Medical Center
Hackensack, NJ, USA
Jennifer M. Capla, MD
Division of Plastic Surgery
North Shore – LIJ Lenox Hill Hospital; Director
Body Contouring Surgical and Medical Associates, PLLC
New York, NY, USA
Robert F. Centeno, MD, MBA, FACS
Medical Director
St Croix Plastic Surgery & MediSpa;
Chief Medical Quality Officer
Governor Juan F Luis Hospital & Medical Center
Christiansted, VI, USA
Sydney R. Coleman, MD
Clinical Assistant Professor
Department of Plastic Surgery
New York University Medical Center
New York, NY;
Assistant Clinical Professor
Department of Plastic Surgery
University of Pittsburgh Medical Center
Pittsburgh, PA, USAPablo Silva Frizzera Delboni, MD
Member of the Brazilian Society of Plastic Surgery
Vitória, Espirito Santo, Brazil
Mauro F. Deos, MD
Private Practitioner
Porto Alegre
Rio Grande do Sul, Brazil
Barry E. DiBernardo, MD, FACS
Clinical Associate Professor
Department of Surgery
Division of Plastic Surgery
University of Medicine and Dentistry of New Jersey
Newark, NJ;
New Jersey Plastic Surgery
Montclair, NJ, USA
Kentaro Doi, MD
Graduate student
Department of Plastic Surgery
University of Tokyo Graduate School of Medicine
Tokyo, Japan
Susan E. Downey, MD, FACS
Clinical Associate Professor of Plastic Surgery
Keck School of Medicine
University of Southern California
Los Angeles, CA, USA
Hitomi Eto, MD
Graduate student
Department of Plastic Surgery
University of Tokyo Graduate School of Medicine
Tokyo, Japan
Antonio Luiz Rocha Gesualdi Fernandes Neto, MD
Plastic SurgeonAssociate Member of Brazilian Society for
Plastic Surgery
Hospital Mater Dei, Belo Horizonte
Minas Gerais, Brazil
Madelyn H. Fernstrom, PhD, CNS
Professor of Psychiatry, Surgery, and Epidemiology
Departments of Psychiatry and Surgery
University of Pittsburgh School of Medicine
Pittsburgh, PA, USA
Lydia M. Ferreira, MD, PhD, MBA
Head and Full Professor
Division of Plastic Surgery
Federal University of São Paulo
São Paulo, Brazil;
Coordinator Medicine III
CAPES/Researcher CNPq
Peter B. Fodor, MD, FACS
Private Practice
Los Angeles;
Associate Clinical Professor
Plastic Surgery
UCLA Medical Center
Los Angeles, CA, USA
James D. Frame, FRCS, FRCS(Plast)
Professor of Aesthetic Plastic Surgery
Anglia Ruskin University
Chelmsford, UK
Onelio Garcia, Jr., MD, FACS
Voluntary Assistant Professor
Division of Plastic Surgery
University of Miami
Miller School of Medicine
Miami, FL, USAAlberto di Giuseppe, MD
Associate Professor Lipoplasty
University of Austin
Austin, TX, USA;
Senior Surgeon
Plastic Surgery Department
University of Ancona
Ancona, Italy
Raul Gonzalez, MD
Associate Professor of UNAERP
Universidade De Ribeirao Preto
Ribeirão Preto, São Paulo, Brazil
Renato Nelson de Moura Guerra, MD
Plastic Surgeon
Associate Member of Brazilian Society for Plastic Surgery
Hospital Mater Dei, Belo Horizonte,
Minas Gerais, Brazil
Rodrigo Nelson de Moura Guerra, MD
Plastic Surgeon
Associate Member of Brazilian Society for Plastic Surgery
Hospital Mater Dei, Belo Horizonte
Minas Gerais, Brazil
Sebastião Nelson Edy Guerra, MD
Full member of SBCP – Sociedade Brasileira de Cirurgia
Plástica (Brazilian Society of Plastic Surgery);
Past President, Brazilian Society of Plastic Surgery
Chairman, Department of Plastic Surgery
Professor and Provost, Training Center in Plastic Surgery
Hospital Mater Dei, Belo Horizonte,
Minas Gerais, Brazil
Hüseyin Güner, MD
Aesthetic and Reconstructive Surgeon
Chief and General Manager
Plastic, Aesthetic and Reconstructive SurgerySuperplast Aesthetic and Eye Surgery Hospital
Nisantasi, Istanbul, Turkey
Eduardo I. Gus, MD
Private Practitioner
Porto Alegre
Rio Grande do Sul, Brazil
Moustapha Hamdi, MD, PhD
Professor and Chairman of Plastic and Reconstructive
Department of Plastic Surgery
Brussels University Hospital
Brussels, Belgium
Dennis C. Hammond, MD
Clinical Assistant Professor
Department of Surgery
Michigan State University College of Human Medicine
East Lansing;
Associate Program Director
Plastic and Reconstructive Surgery
Grand Rapids Medical Education and Research Center for
Health Professions
Grand Rapids, MI, USA
Charles K. Herman, MD, FACS
Chief Medical Executive
Department of Surgery
Division of Plastic and Reconstructive Surgery
Pocono Health Systems
East Stroudsburg;
Clinical Professor of Surgery
The Commonwealth Medical College
Scranton, PA;
Clinical Assistant Professor of Surgery
Albert Einstein College of Medicine
New York, NY, USAErik A. Hoy, MD
Breast and Aesthetic Surgery Fellow
Maxwell Aesthetics
Nashville, TN, USA
Joseph P. Hunstad, MD, FACS
Associate Consulting Professor
Division of Plastic Surgery
The University Of North Carolina
Chapel Hill;
Section Head of Plastic Surgery
Department of Surgery
Carolinas Medical Center
University Hospital, Charlotte;
The Hunstad Kortesis Center for Cosmetic Plastic Surgery
Huntersville, NC, USA
Dennis J. Hurwitz, MD, FACS
Clinical Professor of Plastic Surgery
University of Pittsburgh Medical Center
Pittsburgh, PA, USA
Harunosuke Kato, MD
Graduate student
Department of Plastic Surgery
University of Tokyo Graduate School of Medicine
Tokyo, Japan
Kim Youn Hwan, MD, PhD
Assistant Professor
Department of Plastic and Reconstructive Surgery
University of Hanyang
Seoul, South Korea
Jordan Jacobs, MD
Assistant Professor
Department of Surgery (Plastic)New York Medical College
Valhalla, NY, USA
James L. Jewell
Medical Student
University of Wollongong
New South Wales, Australia
Mark L. Jewell, MD
Assistant Clinical Professor of Plastic Surgery
Oregon Health Science University
Portland, OR;
Jewell Plastic Surgery Center
Eugene, OR, USA
Hwang Weon Jung, MD, PhD
Plastic Surgeon
J-One Aesthetic Clinic
Seoul, South Korea
Kamran Khoobehi, MD, FACS
Clinical Professor of Surgery,
Director of Aesthetic Surgery Training
Louisiana State University
New Orleans, LA, USA
Christopher D. Knotts, MD
Aesthetic Surgery Fellow
The Hunstad-Kortesis Center for Cosmetic Surgery
Charlotte, NC, USA
Bill G. Kortesis, MD
Hunstad-Kortesis Center for Cosmetic Surgery
Charlotte, NC, USA
Hermann Lampe, MD
Plastic Surgeon
Private PracticeFrankfurt, Germany
Angela S. Landfair, MD, MPH
Plastic Surgeon
Kaiser Permanente Medical Group
Walnut Creek, CA, USA
Peter Lin, MD
Chief Resident
University of California Irvine
Aesthetic & Plastic Surgery Institute
Orange, CA, USA
Michael Loffredo, MD
Plastic Surgeon
Cape and Islands Plastic Surgery
Hyannis, MA, USA
José Fernando López-Salguero, MD
Associate Professor
Institute of Plastic Surgery
Mexico City, Mexico
Alan Matarasso, MD, FACS
Department of Plastic Surgery
Manhattan Eye, Ear & Throat Hospital
Lenox Hill Hospital
North Shore-Long Island Jewish Health System
New York, NY, USA
Vinicius Aref M. Maykeh, MD
Division of Plastic Surgery
Federal University of São Paulo
São Paulo, Brazil
Constantino G. Mendieta, MD, FACS
Private Practice
Miami, FL, USAArnaldo L. Miró, MD
Plastic and Reconstructive Clinic
Private Practice
Curitiba, Brazil
Luis Montellano, MD
Associate Professor
Gama Fillho University of Rio de Janeiro
Rio de Janeiro, Brazil
Lea M. Moraes, MD
Plastic Surgeon
Special and Titular Member of the Brazilian Society of
Plastic Surgery;
Graduate, Federal University of Paraná (UFPR) Medical
Residency in General Surgery
Hospital of Our Lady of Grace Curitiba-PR; Residency in
Plastic Surgery
Hospital for Facial Defects
São Paulo, Brazil
Luis Humberto Uribe Morelli, MD
Plastic Surgery Department
Plastic Surgery Service
Sao Paulo, Brazil
Donald S. Mowlds, MD, MBA
Resident Physician
The Aesthetic and Plastic Surgery Institute University of
California, Irvine
Orange, CA, USA
Sang Myun Cha, MD, PhD
Plastic SurgeonSein Aesthetic Plastic Clinic
Seoul, South Korea
Fabio X. Nahas, MD, PhD, MBA, FACS
Associate Professor
Division of Plastic Surgery
Federal University of São Paulo;
Associate Professor, Division of Plastic Surgery
State University of Rio de Janeiro
São Paulo, Brazil
Pierre Nicolau, MD
Consultant Plastic Surgeon
Department of Plastic Surgery and Burns Unit
Saint Louis University Hospital
Paris, France
Mário Farinazzo de Oliveira, MD
Preceptor of Rhinology
Division of Plastic Surgery
Federal University of São Paulo
São Paulo, Brazil
Luiz Haroldo Pereira, MD
Consultant Plastic Surgeon
Department of Plastic Surgery
LH Clinic
Rio de Janeiro, Brazil
Ewaldo Bolivar de Souza Pinto Sr., PhD, MD
Chairman of the Department of Plastic Surgery
Santa Cecilia University
São Paulo, Brazil
Ivo Pitanguy, ISAPS, FICS, FACS
Plastic Surgery Department
Pontificial Catholic University
Carlos Chagas Institute of Post-Graduate Medical StudiesRio de Janeiro, Brazil
Harlan Pollock, MD
Private Practice
North Dallas Plastic Surgery;
Department of Plastic Surgery
The University of Texas Southwestern Medical School
Dallas, TX, USA
Todd Pollock, MD
Private Practice
North Dallas Plastic Surgery;
Department of Plastic Surgery
The University of Texas Southwestern Medical School
Dallas, TX, USA
Jason N. Pozner, MD, FACS
Affiliate Assistant Professor of Clinical Biomedical
Charles E. Scmidt College of Medicine
Florida Atlantic University
Boca Raton;
Adjunct Clinical Faculty
Department of Plastic Surgery
Cleveland Clinic Florida
Weston, FL, USA
Oscar M. Ramirez, MD, FACS
Clinical Assistant Professor
The Johns Hopkins University School of Medicine
Baltimore, MA;
Adjunct Clinical Faculty
Plastic Surgery Division
Cleveland Clinic Florida
Weston, FL, USA
Cassio Eduardo Raposo-Amaral, MDPlastic Surgeon
Institute of Plastic and Craniofacial Surgery-SOBRAPAR
São Paulo, Brazil
Lawrence S. Reed, MD
Clinical Assistant Professor of Surgery (Plastic Surgery)
Weill Cornell Medical College
New York, NY, USA
Dirk F. Richter, MD, PhD
Associate Professor
University of Bonn
Chief, Department of Plastic and Reconstructive Surgery
Director of the Dreifaltigkeits
Wesseling, Germany
Alberto Romão
Division of Plastic Surgery
Federal University of São Paulo
São Paulo, Brazil
J. Peter Rubin, MD, FACS
UPMC Endowed Professor of Plastic Surgery
Chair, Department of Plastic Surgery
Director, Life After Weight Loss Body Contouring Program
University of Pittsburgh
Pittsburgh, PA, USA
Neil S. Sadick, MD
Clinical Professor of Dermatology
Weill Cornell Medical College
New York, NY, USA
José Abel de la Peña Salcedo, MD, FACS
National Secretary
Ibero-American Federation of Plastic Surgery, Aestheticand Reconstructive (FILACP);
Director of the Institute of Plastic Surgery
Hospital Angeles de las Lomas
Col.Valle de las Palmas
Huixquilucan, Mexico
Cristianna Bonneto Saldanha, MD
General Surgery Service
Santa Casa of Santos Hospital
São Paulo, Brazil
Osvaldo R. Saldanha, MD
Plastic Surgery Service
São Paulo, Brazil
Osvaldo R. Saldanha Filho, MD
Plastic Surgery Service
São Paulo, Brazil
Renato Saltz, MD, FACS
Saltz Plastic Surgery and Spa Vitoria
Salt Lake City and Park City, UT, USA
Gerhard Sattler, MD
Darmstadt, Germany
Thomas Scholz, MD
Resident Physician
Department of Aesthetic and Plastic Surgery
University of California, Irvine
Orange, CA, USA
Jeffrey L. Sebastian, MDAssistant Clinical Professor of Surgery
David Geffen School of Medicine
UCLA, Los Angeles;
Private Practice
Santa Monica, CA, USA
Cemal enyuva, MD
Professor of Plastic, Reconstructive and Aesthetic
Private Practice
Istanbul, Turkey
Fernando G. Serra, MD
Plastic Surgeon
Department of General Surgery
Rio de Janeiro State University (UERJ)
Rio de Janeiro, Brazil
Marion Shapiro, MD
Private Practice
New York, NY, USA
Miguel A. Soto-Miranda, MD
Associate Professor
Institute for Plastic Surgery
Mexico City, Mexico
Aris Sterodimas, MD, MSc, PhD
Department of Plastic Surgery
IASO General Hospital
Athens, Greece
Alexander Stoff, MD, PhD
Assistant Professor
Department of Plastic and Reconstructive Surgery
University of Bonn
Dreifaltigkeits-Hospital WesselingWesseling, Germany
Berish Strauch, MD
Chairman Emeritus
Department of Plastic and Reconstructive Surgery;
Professor of Plastic Surgery
Albert Einstein College of Medicine
New York, NY, USA
Steven Teitelbaum, MD, FACS
Assistant Clinical Professor of Plastic Surgery
David Geffen School of Medicine
University of California
Los Angeles, CA, USA
Serhan Tuncer, MD
Associate Professor
Department of Plastic, Reconstructive, and Aesthetic
Gazi University Faculty of Medicine
Ankara, Turkey
Carlos O. Uebel, MD, PhD
Associate Professor
Division of Plastic Surgery
PUCRS University
Porto Alegre, Brazil
Ismael Santiago Vásquez, MD
Plastic Surgeon
Associate Member of Brazilian Society for Plastic Surgery
Hospital Mater Dei, Belo Horizonte
Minas Gerais, Brazil
Garrett A. Wirth, MD, MS, FACS
Associate Clinical Professor
Department of Plastic Surgery
Aesthetic & Plastic Surgery
University of California – Irvine Medical CenterOrange, CA USA
Scott Woehrle, MS, PA-C
Physician Assistant
Capella Plastic Surgery
Ramsey, NJ, USA
Marianne Wolters, MD
Plastic Surgeon
Private Practice
Frankfurt, Germany
Kotaro Yoshimura, MD
Associate Professor
Department of Plastic Surgery
University of Tokyo
Tokyo, Japan
V. Leroy Young, MD
Body Aesthetic Research Center
St Louis, MO, USA
Richard Zienowicz, MD
Associate Professor
Department of Plastic Surgery
Rhode Island Hospital
The Warren Alpert Medical School
Brown University
Providence, RI, USADedications
To my wife, Julie, whose love and support are boundless, and our children,
Eliana, Liviya, Zachary, and Talya, who teach me about the important things in life
every day.
J. Peter Rubin, MD
To Mary, the love of my life; our children, Mark II, James, and Hillary;
Shelley, and Reed.
Mark L. Jewell, MD
To my family with love; my wife Katja, my children Moritz and Leonie and
with respect and thanks to my parents.
Dirk F. Richter, MD, PhD
To my dear wife Walderez, who is a constant source of support and
encouragement to me. To our children Juliane and Hiddo; Paulo and Mariana; and
to our grandson Matheus who makes my life worthwhile.
Carlos O. Uebel, MD, PhD

Body contouring surgery – a fifty year perspective
Ivo Pitanguy
Body contouring surgery is a collection of procedures with the goal of volumetric
manipulation of super cial tissue, usually the adipose, with or without removal of
excess skin (dermolipectomies). Etiology of these deformities may be primary (i.e.,
congenital or constitutional) or secondary (i.e., weight gain or severe weight loss).
In a broader sense, this may include contouring of the face and breast. It is
therefore understandable that contouring surgery may include most of the
operations performed by the plastic surgeon.
Concepts of beauty have been continuously evolving throughout the history of
mankind. The voluptuous gures that were idealized by artists in the past have
been substituted by slimmer forms. Until the second half of the 20th century,
contour deformities were mostly hidden under heavy clothing and were reluctantly
accepted. With fashion promoting body-revealing attire and outdoor exposure, and
the emphasis on tness and good health, people have sought to re) ect these trends
by demonstrating youthfulness and vitality in their bodies. The subliminal as well
as overt message is that these are desirable requirements for maintaining
sensuality, social acceptance and professional success.
On the other hand, sedentary lifestyle and dietary excesses, associated with
factors such as genetic determination, pregnancy and the aging process, contribute
to corporeal alterations that result in the loss of the individual’s body image. This
creates a strong psychological motivation for surgical correction. Localized fat
deposits and skin ) accidity are sometimes resistant to the most sincere e. orts in
weight loss and sport activities. Bariatric surgery by itself has created a whole new
eld of medicine, where a multidisciplinary team will include the work of the
plastic surgeon.
Body contour deformities may involve one single anatomical region or extend
to multiple body regions. They may be treated by a one-stage operation or may
require more complex combined procedures. In some cases, multiple or severe
deformities will be approached serially, such as in patients who have undergone
dramatic weight loss. Planning and nal results must be carefully discussed with
the patient, as well as location and extension of scars.
As the reader will appreciate in this book, the ever-increasing request for
contour surgery has been met by safe and e1 cient surgical techniques, resulting in
a high degree of patient satisfaction. Personally, it has been fascinating to follow
the development of these procedures over the span of some 50 years.
The concepts and principles that we have proposed for body contouring are
based on preservation of function, acceptable location and extension of scars and
an esthetic correction of the deformity for a nal, pleasing result. This is
exempli ed by our approach to abdominoplasty. Many di. erent incisions had been
forwarded to correct the abdominal wall defect, with varying opinions regarding
muscle diastasis. Our methodology established an incision, following a natural
crease, which was adequately hidden under beachwear. Emphasis was given to thefunctional aspect, with plication of the rectus abdominis muscle without opening of
the aponeurosis. Likewise, other regions were addressed aiming to achieve a
satisfying, long-term result with preservation of function.
Breast reduction up until the late 1950s was usually performed with extensive
dissections and undermining that often resulted in large dead space with
subsequent collection and skin necrosis. Resections that involved the upper pole
caused early flattening and sagging, with an upward projection of the nipple.
I was also concerned with other anatomical regions that comprise body
contouring, including correction of other deformities of the breast (hypertrophy,
ptosis and hypomastia; gynecomastia, and deformities of the nipple–areola
complex), the abdomen (lipodystrophy and atypical deformities), the upper limbs,
and the lower limbs (lipodystrophy and ) accidity of the inner thighs and the
trochanteric region), and the “riding-breeches” (or “saddlebag”) defect.
Of course, many of these techniques were placed in a di. erent perspective
with the introduction of suction-assisted lipectomy. Rapidly, plastic surgeons
adopted this procedure to safely and e1 ciently remove localized adiposity through
minimal incisions. Seemingly overnight, gone were most of the indications for large
incisions and extensive procedures, with consequent faster recovery and reduced
problems of wound healing and unesthetic scars.
Currently, it is interesting to notice that a cycle closes. To address excess
cutaneous tissues in post-obese patients, plastic surgeons are bringing back
principles that were in vogue in the past. To cite two procedures that we proposed,
the thoracobrachial dermolipectomy and the “riding breeches” deformity,
fundamental concepts are being reviewed: no dead space is created by unnecessary
dissection, scars are planned in natural creases, and the positioning of
nonundermined flaps is done by rotation, instead of simply by pulling.
Finally, the precise methodology for combining procedures was also a matter
of interest, so as assure patient safety while at the same time optimizing surgical
timing and post-operative down-time.
I am honored by this opportunity to introduce the book Body Contouring and
Liposuction. As Dr. Rubin and his colleagues stated in their gracious invitation, I
have been a direct witness to the evolution of these myriad techniques, and have
seen paths that led to successful results and others that failed. In the end, we must
base our practice on basic principles: careful surgical indication with an open
discussion with our patient; planning incisions and number of proposed procedures,
including surgical revisions; and close postoperative care. As an almost
encyclopedic text, this book presents a culmination of years of development of
body contouring surgery, which is certain to remain the solid reference on this
subject. Congratulations to the editors – Drs. Rubin, Jewell, Richter and Uebel –
and their collaborators on this magnificent achievement.
Further Reading
Pitanguy I. Breast hypertrophy. In: Transactions of the 2nd Congress of the
International Society of Plastic Surgeons. 1960. p. 509.
Pitanguy I. An eclectic approach to breast problems. Rev Bras Cir. 1961;41:179–196.
Pitanguy I. Une nouvelle technique de plastique mammaire: Etudes de 245 cas
consecutifs et presentation d’une technique personelle. Ann Chir Plastique.
1962;7:199–208.Pitanguy I, Lima J. Treatment of some deformities of the lower extremity. In: Young
H, ed. The Year Book of Orthopedics, Traumatic and Plastic Surgery. Chicago: Mosby
Year Book; 1963:538–590.
Pitanguy I, Torres E. Histopathological aspects of mammary gland tissue in cases of
plastic surgery of the breast. Br J Plast Surg. 1964;17(3):297–302.
Pitanguy I. Trochanteric lipodystrophy. Plast Reconstr Surg. 1964;34:280–286.
Pitanguy I. Transareolar incision for gynecomastia. Plast Reconstr Surg.
Pitanguy I. Abdominal lipectomy: an approach to it through an analysis of 300
consecutive cases. Plast Reconstr Surg. 1967;40(4):384–391.
Pitanguy I. Surgical treatment of breast hypertrophy. Br J Plast Surg. 1967;20:78–85.
Pitanguy I. Thigh lift and abdominal lipectomy. In: Goldwyn RM, ed. Unfavorable
Results in Plastic Surgery. Boston: Little Brown; 1972:387.
Pitanguy I. Lipectomy abdominoplasty and lipodistrophy of the inner side of the
arm. In: Grabb W, Smith J. Plastic Surgery: a Concise Guide to Clinical Practice. 2nd
ed. Boston: Little Brown; 1973:1005–1013.
Pitanguy I. Abdominal lipectomy. Clin Plast Surg. 1975;2:401–410.
Pitanguy I. Correction of lipodystrophy of the lateral thoracic aspect and inner side
of the arm and elbow dermosenescence. Clin Plast Surg. 1975;2(3):477–483.
Pitanguy I. Personal preferences for reduction mammaplasty. Plastic and
Reconstructive Surgery of the Breast. Goldwyn RM, ed. Plastic and Reconstructive
Surgery of the Breast, vol.2. Little Brown: Boston, 1976:167–179.
Pitanguy I. Dermolipectomy of the abdominal wall, thighs, buttocks and upper
extremity. Reconstructive Plastic Surgery, 2nd ed. Converse JM, ed. Reconstructive
Plastic Surgery, vol.7. Saunders: Philadelphia, 1977:3800–3823.
Pitanguy I, Cavalcanti MA. Methodology in combined aesthetic surgeries. Aesth Plast
Surg. 1978;2:331–340.
Pitanguy I. Transareolar incision for augmentation mammaplasty. Aesth Plast Surg.
Pitanguy I. The breast. In: Aesthetic Plastic Surgery of Head and Body. Berlin:
SpringerVerlag; 1981:3–62.
Pitanguy I, Ceravolo M. Our experience with combined procedures in aesthetic
plastic surgery. Plast Reconstr Surg. 1983;71(1):56–63.
Pitanguy I. Reduction mammaplasty by the personal technique. In: Chang WHJ, ed.
The Breast: an Atlas of Reconstruction. Baltimore: Williams & Wilkins; 1984:75–160.
Pitanguy I. Aesthetic Surgery of Head and Body. Berlin: Springer Verlag; 1984.
Pitanguy I. Treatment of abdominal wall eventrations associated with
abdominoplasty techniques. Aesth Plast Surg. 1984;8:173–179.
Pitanguy I. Upper extremity: dermolipectomy. In: Aesthetic Surgery of Head and Body.
Berlin: Springer Verlag; 1984:153–158.
Pitanguy I. Body contour. Am J Cosm Surg. 1987;4:283–293.
Pitanguy I. Thigh and buttock lift. The Art of Aesthetic Surgery. Lewis JR, ed. The Art
of Aesthetic Surgery, Vol 2. Little Brown: Boston, 1989:1060–1067.
Pitanguy I. Personal preferences for reduction mammaplasty. In: Georgiade ND, ed.
Aesthetic Surgery of the Breast. Philadelphia: WB Saunders; 1990:167.
Pitanguy I. Reduction mammaplasty: a personal odyssey. In: Goldwyn RM, ed.
Reduction Mammaplasty. Boston: Little, Brown; 1990:95.Pitanguy I. Abdominoplasty: Classification and surgical techniques. Rev Bras Cir.
Pitanguy I, Radwanski HN. Philosophy and principles in the correction of breast
hypertrophy. In: Mang WL, Bull HG. Ästhetische Chirurgie. Germany:
EinhornPresse Verlag; 1996:216–232.
Pitanguy I. Evaluation of body contouring surgery today: A 30-year perspective. Plast
Reconstr Surg. 2000;105:1499.
Pitanguy I, Radwanski HN, Matarasso A. Approach to the face and neck after weight
loss. In: Rubin P, Matarasso A. Aesthetic Surgery after Massive Weight Loss. New
York: Elsevier; 2007:21–35.
Pitanguy I, Radwanski HN. Relative implant volume and sensibility alterations after
breast augmentation. Aesth Plast Surg. 2007:238–243.
Pitanguy I, Radwanski HN. The Pitanguy breast reduction. In: Aston S, ed. Aesthetic
Plastic Surgery. China: Elsevier; 2009:609–620.Part 1
Patient evaluation and safety
Chapter 1
Patient safety in body contouring
V. Leroy Young, Angela S. Landfair
Key Points
• Complications of tobacco use are avoidable with a concerted e ort by both the
patient and the surgeon. Preoperative and postoperative urine cotinine testing
make detection of tobacco use straightforward and not reliant on patient
• A thorough preoperative assessment should be performed well in advance of the
surgical date to allow adequate time for necessary behavior modi cation (i.e.,
tobacco cessation), medical modi cation (improved glycemic control in a
diabetic patient), preoperative tests (i.e., sleep study for undiagnosed sleep
apnea), and preoperative consultation with appropriate specialists (i.e.,
hematologist for family history of thrombophilia). Rushing to the operating table
can impede a meticulous and safe preoperative investigation.
• Hypothermia is a common preventable condition with straightforward
preoperative and intraoperative measures such as warm irrigation and
preoperative warming blankets. These measures are essential in long body
contouring cases with wide exposure.
• Surgical site infections should be prevented at every step, with appropriate
preoperative disinfection, perioperative antibiotics, and close glycemic control.
• Thromboembolic events are largely preventable with comprehensive
preoperative evaluation and appropriate consultation, mechanical and chemical
prophylaxis, patient education, and high levels of alertness and suspicion in the
postoperative period.
The current climate of plastic surgery engenders a culture of safety that promotes
careful patient selection, streamlined perioperative care, and structured systems of
safety measures in and out of the operating room. Ultimately, vigorous training of
medical professionals who can recognize, prevent, and appropriately treat potential
complications may play the most salient role in ensuring safe clinical practices.
Body contouring surgery is fraught with potential for complications due to the
lengthy and complex nature of the procedures and inherent patient demographics.
Appropriate patient selection and vigilant perioperative care is expected and
warranted. Body contouring is elective surgery in which the tolerance for
complications should be low.
In the end the science of human factors (HF) should be foremost in our minds
1in designing a system of checks and balances in a given clinical situation. A group

of well-trained surgeons and health care professionals can still miss a step or two
among the hundreds we take from the time the patient enters the clinic for
preoperative consultation to the time the patient exits the clinic from the nal
postoperative visit. In every scenario: the initial consultation, the preoperative
assessment, the preop holding area, the operating room, the postoperative care on
the wards and in the o0 ce, a detail missed can lead to grave consequences. While
this chapter is in no way comprehensive, it should aid a surgeon in developing his
or her own standardized model for safe clinical practice.
Preoperative Assessment and Patient Selection
The value of comprehensive history taking at the initial consultation cannot be
overstated. Overlooking a critical detail in the patient’s medical history can lead to
mishap and preventable disasters. Our specialist colleagues should be brought into
consultation whenever the patient has signi cant comorbidities or when we suspect
an undiagnosed condition that can negatively impact surgical outcome.
Medical Assessment
Cardiac clearance is often a nebulous concept that may get glossed over. Cardiac
tests are doled out according to patient age and prior history, and too often,
according to institutional guideline. Often a “normal” electrocardiogram tells us
very little about the patient. The patient’s functional status should be assessed
using exercise tolerance, stress tests, and if deemed appropriate, a cardiology
consultation with further noninvasive and invasive studies. All too often, patients
are deemed “cleared for surgery” by a physician who is both unfamiliar with the
surgical procedure, as well as the duration of recovery and rehabilitation
afterwards. Family history is crucially important when a seemingly healthy patient
presents to us, since a patient with no apparent cardiac history in the family is a
di erent beast from the patient with three close relatives su ering an early cardiac
event. Hypertensive patients should be carefully monitored in the perioperative
period because their antihypertensive regimen may have to be changed during
2periods of fluid shifts, body weight change, and postoperative anemia.
Patients with signi cant cardiovascular history deserve special attention.
Elective surgery should be delayed until adequate preoperative clearance and tests
are attained. If a patient has undergone cardiac intervention, the timing of elective
surgery is crucial. Perioperative stent thrombosis is associated with high mortality
and morbidity and should not be taken lightly. Patients undergoing noncardiac
surgery within 1–2 weeks after placement of a bare-metal stent are at high risk of
stent thrombosis and death even if perioperative antiplatelet therapy is continued.
Perioperative thrombosis of drug-eluting stents has been reported as late as 21
months after stent implantation. A cardiologist should be consulted to determine
both the appropriate surgery date and the appropriate stop date for antiplatelet
agents. If elective surgery is pursued too quickly, patients are at risk for stent
thrombosis because of increased thrombotic state parlayed by surgery and by the
therapeutic absence of antiplatelet agents. In general, elective surgery should be
delayed until 6 weeks after balloon angioplasty or bare metal stents, and a year
after drug-eluting stents. Patients should be continued on their preoperative beta
3blockers throughout and post surgery, barring unexpected hypotension.Close attention must be paid to the patient’s personal and family history of
4coagulopathy (Tables 1.1 and 1.2). Hereditary thrombophilia is surprisingly
common – with approximately 5% of patients displaying factor V Leiden mutation
and 2–4% of the population testing positive for antiphospholipid syndrome. Recent
data suggest that the family history of a thrombotic event even in the absence of
hereditary thrombophilia signi cantly increases the likelihood that the patient will
have a postoperative thromboembolism. In women who smoke, hormone therapies
(including oral contraceptives) should ring warning bells, as should a history of
multiple miscarriages. Bleeding disorders are rarely life-threatening, but a 2%
incidence of Von Willebrand’s in the general population is no small gure. The risk
of bleeding should be carefully considered, especially if the patient is about to
undergo multiple procedures over large anatomic areas.
TABLE 1.1 Prevalence of Molecular Abnormalities
Healthy Subjects First VTE Episode
Antithrombin deficiency 0.02 1
Protein C deficiency 0.3 3
Protein S deficiency ? 1–2
Factor V Leiden 5 20–40
Prothrombin gene mutation 1–2 6
Fasting homocysteine >95th % 5 23
Anti-phospholipid antibodies 3 16
TABLE 1.2 Indications for a Laboratory Workup for Thrombophilia
Venous thrombosis before 40–50 years of age
Unprovoked thrombosis at any age
Recurrent thrombosis at any age
Unusual sites such as cerebral, mesenteric, portal, or hepatic veins
Positive family history for thrombosis
Thrombosis during pregnancy, oral contraceptives, or hormone replacement
therapy (HRT)
Unexplained abnormal laboratory test such as prolonged PTT
Connective tissue diseases are frequently under good medical control when a
patient is cleared for surgery. However, connective tissue disorders are independent
predictors of thromboembolic events and patients should be informed of this risk
factor. Steroids and other immunosuppressants are frequently used in medical

management of connective tissue disorders and can place a patient at risk for
5wound healing complications.
Pulmonary disease, especially when undiagnosed and undertreated, can have
grave consequences in the postoperative period. In patients with pre-existing
pulmonary conditions such as chronic obstructive pulmonary disease (COPD) or
asthma, their medical management should be optimized well before the patient is
placed on the surgical schedule. Perioperatively, these patients require a more
aggressive pulmonary toilet and often pharmacotherapy, regardless of whether they
took any at home.
Obstructive sleep apnea (OSA) is a frequently underdiagnosed condition that
a ects 24% of men and 9% of women. OSA diagnosis can pose a challenge in the
preoperative interview because, very frequently, the patients are unaware of the
symptoms. Physiologically, the parapharyngeal fat pads narrow the airway,
causing restrictive ventilation defects, and resulting in measurable decreases of
functional residual capacity and total lung capacity. Of note, over 80% of patients
with OSA are undiagnosed, and up to 80% of elderly patients may be a ected.
Periodic apnea/hypopnea can result in hypertension, arrhythmias, increased
6intrathoracic negative pressure, and decreased restorative sleep.
During the consultation, it is often more useful to ask a patient’s signi cant
other about the sleep habits, as patients themselves may be unaware. Male, obese,
hypertensive patients are at an elevated risk. When sleep apnea is suspected, the
symptom checklist should include choking, restless sleep, impaired sleep
maintenance, daytime sleepiness, frequent awakening, hypersomnia, depressed
mood or mood swings, fatigue, gasping, gastroesophageal reHux disease, and snort
arousals. Sixty to 90% of people with OSA are obese and frequently have a neck
circumference measuring >40 cm. While weight loss improves OSA symptoms,
many patients may have incomplete symptom relief and still require continuous
positive airways pressure (CPAP) postoperatively. There is no e ective
pharmacologic therapy for sleep apnea.
Close preoperative monitoring is especially important in patients with
7diabetes. While the presence of diabetes itself should not preclude surgery, poorly
controlled diabetes should halt surgery until better medical management is
achieved. HgbA1C is a useful screening tool to check for patient compliance and an
index of overall glycemic control, and should be included in the preoperative
workup. Even patients who are no longer on insulin will frequently require
perioperative insulin to compensate for the stress of surgery as well as diet
fluctuations in the postoperative period.
Clinical obesity is common in the body contouring population even after
massive weight loss. Many clinicians employ a BMI “cuto ” in their practice, but in
reality many patients will end up on the operating room table while still obese.
Obesity increases every type of surgical complication especially pulmonary,
thromboembolic, and wound complications. Undiagnosed obstructive sleep apnea
is frequent in obese patients and should be carefully assessed. Medication doses
should sometimes be adjusted as well to compensate for obesity. There is some
indication that obese patients should be treated with a higher dose of Lovenox
when used as a chemoprophylactic agent.
Nutritional AssessmentIn the bariatric population, preoperative screening should include nutritional
screening. Protein malnutrition is possible even in weight stable patients, and
routine screening of protein malnutrition is reasonable. Due to physiologic changes
and changes in their GI tract and their dietary patterns, anemia can result from
de ciencies in iron and vitamin B12. All massive weight loss patients need a
preoperative complete blood count prior to undergoing surgery.
Psychiatric and Behavioral
Tobacco use is an independent risk factor for wound complications and cessation
should be the rule in body contouring surgery. According to CDC data as of
November 2007, 20.8% of adults in the United States smoke cigarettes. The health
risks of habitual tobacco use are profound, but in the plastic surgery population,
the risk immediately impacts postsurgical outcome.
First and foremost, smokers are prone to pulmonary complications due to
chronic airway inHammation and decreased pulmonary function. Smokers are
more prone to postoperative atelectasis and hypoxia, even in the absence of a
diagnosis of COPD.
Second, tobacco impacts wound healing in numerous pathways. Tobacco use
reduces cutaneous blood How in a signi cant and meaningful way even in light
smokers by impairing microvascular vasodilation. Wound healing, immune, and
inHammatory responses are blunted in smokers, and collagen deposition and
remodeling are decreased. Smoking has been associated with increased wound
complications in both aesthetic and reconstructive patients. There is no consensus
as to when patients should quit smoking prior to surgery, as bene ts of quitting
have been found whether a patient quit for 3 weeks, 4–8 weeks, or greater than 2
months. There is no de nitive consensus that quitting for a longer period
necessarily improves outcome, but the current CDC recommendation is to halt
tobacco for 30 days prior to surgery. Self-report of smoking cessation is notoriously
unreliable, especially when a patient is incentivized to lie in order to attain the
goahead for plastic surgery. Objective tests of smoking cessation, such as urine
8–14cotinine, may be warranted in order to ensure patient safety.
While tobacco use is a behavior that can be monitored objectively, the plastic
surgeon is often faced with a patient who is medically stable, but displays poor
judgment, immaturity, unrealistic expectations, or psychiatric illness. Body
dysmorphic disorder (BDD) is a DSM diagnosis marked by obsession over a
perceived defect that results in compulsive behavior and illogical methods to hide
or transform the perceived defect. This is most commonly seen in rhinoplasty
patients, but is seen with greater frequency than in the general population among
cosmetic patients. BDD is a clear psychiatric contraindication for plastic surgery
and patients who are suspected of this condition should receive a psychiatric
15evaluation, not surgery.
Psychiatric history should be a routine part of the history and physical
examination. Body contouring patients are at an increased risk for depression and
anxiety disorders compared to the general population. These patients are often
labeled as having BDD, when in fact their concern is realistic based on the extreme
deformity after massive weight loss. These patients are often former over-eaters
who have a psychological barrier against self-discipline and equilibrium.
Occasionally, massive weight loss patients have di0 culty forming a marriage of
their former self image and the new image in the mirror before them. The plastic
surgeon should learn basic psychiatric assessment and ascertain that any prior
psychiatric illness is stabilized prior to embarking on surgical treatment.
One speci c concern for body contouring patients can be the high incidence of
maladaptive eating patterns, especially binge eating disorder. In concert with
nutritional di0 culties presented by the physiology of weight loss, this can lead to
poor perioperative nutritional status or weight Huctuations. Psychiatric history
should include eating and dieting patterns. Patients with a history of binge eating
disorder, in particular, should be carefully assessed to make sure that they have not
16recently engaged in pathologic eating behaviors.
Patients who have undergone massive weight loss are also at an increased
likelihood of having personality disorders compared to the general population.
These are di0 cult to diagnose and can prevent optimizing the postoperative
course. Personality disorders are often insidious and, unlike AXIS I disorders, are
pharmacologically untreatable. When faced with a particularly di0 cult patient,
surgeons should beware that a patient with personality disorder may be
particularly threatening to his/her reputation and o0 ce morale, and that these
patients’ disorders are at best slightly ameliorated by preoperative psychiatric
Intraoperative Management
Hypothermia has been shown to increase postoperative complications in body
contouring patients by inhibiting tissue oxygen delivery, impairing wound healing,
17and leading to a three-fold increase in wound infections.
Due to length of surgeries and large areas of physical exposure, body
contouring patients are at particular risk of hypothermia. Studies have shown that
unwarmed patients almost always become hypothermic. Maintaining
normothermia is an active process that should begin in the preoperative holding
area and be carefully checked throughout the perioperative period. Preoperative
warming with forced air for 60 minutes is the most e ective way of warming the
patient so that core temperature remains normal. Prewarmed patients cool at about
half the rate of patients who are not prewarmed, and core temperature can be
maintained even through a multi-procedure, lengthy operation. Other measures
should be engaged to maintain core temperature, including covering areas not
being worked on, continuous forced air heating, maintaining ambient room
temperature at 23°C (73°F), and warming the irrigation fluids.
Malignant hyperthermia is a rare but serious complication that has a 70%
mortality rate without proper treatment (Box 1.1). The surgeon should be aware of
the signs. A thorough preoperative history should ask about family history of
sudden death during or after anesthesia. The most consistent sign should be a rapid
rise in end tidal CO , along with high fever, rigidity, acidosis, and tachycardia. The2
surgery center should always be fully stocked with dantrolene, with the
understanding that obese patients require much more dantrolene for symptom
reversal than their nonobese counterparts.
Box 1.1
Questions to Ask About Malignant HyperthermiaRoutine Preoperative Questioning
All patients about to undergo general anesthesia should be asked these speci c
questions as part of a medical history:
• Is there a family history of MH?
• Have there been unexpected deaths or complications arising from anesthesia
(including the dental office) with any family members?
• Is there a personal history of a muscle disorder (e.g., muscle weakness)?
• Is there a personal history of dark or cola-colored urine following anesthesia?
• Is there a personal history of unexplained high fever following surgery?
Intraoperative Preparedness
The following precautions should be taken in order to detect MH in its early
stages, when it is usually amenable to treatment without sequelae:
Planning Ahead
• A written treatment plan should be posted in a conspicuous place. A plan is
available from the Malignant Hyperthermia Association of the United States
(MHAUS); http://www.mhaus.org
• A kit or cart containing drugs necessary for the treatment of MH should be
immediately available to all operating rooms. Each kit should contain 36 vials
of dantrolene, bacteriostatic water for injection, and bicarbonate. MHAUS
offers a brochure listing the recommended supplies.
• A refrigerator unit near the operating room should be stocked with iced saline.
Ready access to an ice machine is important.
• All operating and recovery room personnel should be trained in the
recognition and treatment of MH. Periodic dry-runs of an MH emergency are
recommended. In-service materials can be provided by MHAUS.
During Surgery
• Evaluate any unexpected hypercarbia, tachycardia, tachypnea or arrhythmia
(e.g., arterial and venous blood gases). Avoid suppressing tachycardia with
beta blockers until MH has been ruled out.
• Core temperature should be monitored in all patients given general anesthesia
for 30 minutes or more. Acceptable core temperature sites include: distal
esophagus, nasopharynx, axilla, rectum, bladder and pulmonary artery. Skin
temperature may not adequately reHect core temperature during MH
episodes. Consider MH in the differential diagnosis of any temperature rise.
• Stop inhalation anesthetic and succinylcholine if masseter rigidity occurs. If
surgery must continue, immediately switch to nontriggering anesthetics.
• Do not give triggering agents to patients with Duchenne dystrophy, central
core disease, myotonia and other forms of muscular dystrophy.
• Sudden cardiac arrest in a young male with normal oxygenation should be
considered as secondary to hyperkalemia and so treated.Treating the Known or Suspected MH-Susceptible Patient
Preoperative Preparations:
• Anesthesia machine:
• Remove vaporizers, if possible. Otherwise, drain and disconnect or tape in the
off position.
• Flow 10 l/m O through circuit for at least 20 minutes. If fresh gas hose is2
replaced, 10 minutes is adequate. During this time a breathing bag should be
attached to the Y-piece of the circle system and the ventilator set to inflate
the bag.
• Use new or disposable breathing circuit.
• Take a preoperative creatine kinase (CK) and CBC.
• Place a cooling blanket on the table.
Dantrolene Prophylaxis
Dantrolene prophylaxis should be considered on an individual patient basis but is
not recommended for most MH susceptibles. When used, dosage is 2.5 mg/kg IV
starting 30 minutes prior to anesthesia. For consultation, contact MHAUS.
NOTE: Dantrolene can worsen muscle weakness in patients with muscle
disease and should be used with caution. For procedures with local anesthesia
only, dantrolene prophylaxis may be omitted.
Intraoperative Considerations
• Techniques of choice
• Spinal, epidural, regional or local, if possible.
• Safe drugs
• Local: No local anesthetics trigger MH; thus any type of regional anesthesia is
safe for MH susceptibles.
• General: Benzodiazepines, opioids, barbiturates, propofol, ketamine, nitrous
oxide, etomidate. Pancuronium, atracurium, vecuronium, pipecuronium,
mivacurium, doxacurium, or curare may be used for relaxation. Neostigmine
and atropine are used for reversal by some; others disagree on their safety.
• Unsafe drugs/MH triggers
• Halothane, enflurane, isoflurane, desflurane, methoxyflurane, ether,
cyclopropane, sevoflurane, ether.
• Succinylcholine.
• Monitoring
• Essential: blood pressure, central temperature, ECG, pulse oximeter, and
capnograph or capnometer.
• Strongly suggest respirometer.
• Use arterial line, CVP or other invasive monitors as appropriate for the
Postoperative Procedure
• If the anesthetic course has been uneventful:
• Continue to monitor temperature and ECG for 1 to 2 hours. No furtherdantrolene is necessary.
• If MH has occurred:
• Recover patient in an ICU for 24–48 hours.
• Continue IV dantrolene for 48–72 hours, titrated to alleviation of muscle
rigidity, tachycardia, acidosis, and CK levels. Suggested dantrolene dosage is
at least 1 mg/kg q 6 hours IV. After that, 1 mg/kg may be given q 6 hours
orally × 24 hours.
• Monitor the patient’s coagulation status, watching for DIC.
• Look for myoglobinuria and renal failure, and treat as needed.
• Use potassium-containing solutions with caution.
• Monitor potassium and CK levels q 6 hours at least.
• Monitor urine output.
• Register patient with North American MH Registry. Forms are available by
contacting North American MH Registry, Pennsylvania State University,
College of Medicine, Dept of Anesthesia, PO Box 850, Hershey, PA 17033–
0850, (717) 531–6936.
• Alert family to the dangers of MH in other family members.
• Refer for testing at nearest center (list available from MHAUS).
This protocol may not apply to every patient and must of necessity be altered according
to specific patient needs.From the MHAUS website www.mhaus.org/
Prevention of surgical site infections is of utmost importance. Preoperative
antibiotics should be chosen based on type of organisms encountered, and the
patient’s unique infectious disease history. Too frequently, antibiotics are
administered as an afterthought after the operation has already begun. Surgical
patients should receive antibiotics 30 minutes to 1 hour prior to incision, and
before any tourniquet is applied, although this is less relevant in body contouring
surgery. Vancomycin and Huoroquinolones take longer to infuse and should be
started in the preoperative area, about 2 hours prior to incision time. A study of
over 3000 surgical patients found an increased rate of surgical site infections if the
antibiotics were administered more than 1 hour prior to incision, at the time of
incision, or after the incision was already made. Antibiotics should be re-dosed
during lengthy procedures and more frequently if there is signi cant blood loss
(>1.5 L). There is no evidence that shows continuing prophylactic antibiotics
beyond 24 hours postoperatively is bene cial. In fact, routine use of postoperative
antibiotics increases the likelihood of drug resistance and places the patient at risk
18,19for clostridium difficile infections.
Shaving increases (Table 1.3) the likelihood of surgical site infection (SSI)
fourfold. Clipping is less likely to increase surgical site infections, although the risk
is not zero. Locally, trauma to the epithelial barrier caused by both shaving and
clipping is likely to place the patient at risk for contamination and even infection.
Patients should be instructed not to shave the operative site the week prior to
TABLE 1.3 Hair Removal

Arti cial nails are another potential source of SSI. The glue used to adhere the
arti cial nail to the nail plate rapidly becomes colonized with bacteria and patients
often run their ngers over their incisions and can inoculate their wounds with the
colonized bacteria which are often Gram negative. Arti cial nails should be
removed at least 1 week before surgery and surgical sta should never wear
artificial nails or jewelry in the operating room.
There is great debate as to (1) how long is too long and (2) how many procedures
are too many. Unfortunately, there is no simple answer. On the plus side,
combining procedures is simply more convenient and more cost e ective-, for both
20the patient and the surgeon. In a healthy patient who presents a low risk overall,
combining procedures is unlikely to lead to serious detriment. However, surgical
site infections and thrombotic risk are shown to increase along with the length of
operation and these risks should not be taken lightly.
Postoperative Management
Postoperative Antibiotics
SSI is a common adverse event in the plastic surgery patient, and is particularly
devastating when the surgery was elective and cosmetic in nature. Plastic surgeons
are apt to place patients on antibiotic regimens based upon anecdotal evidence.
Large studies have shown no decrease in SSI with postoperative antibiotics. So far,
practices such as placing patients on oral antibiotics due to a new implant or while
21drains are in place have no scientific evidence to support them.
DVT Prophylaxis
Assessment of thromboembolic risk is the most crucial part of reducing events.
However, simple maneuvers should be undertaken (making sure sequential
compression devices (SCDs) are in fact on the patient and functioning
preoperatively) to continue to reduce risk. Daily rounds should include ensuring the
patient has adequate assistance to get out of bed and ambulate in the hallway, and
that ambulation is happening as often as can be tolerated. Chemoprophylaxis is
frequently indicated, especially in instances where patients are relatively immobile
due to postsurgical pain. At this time, there is no evidence that chemoprophylaxis
increases the risk of postoperative return to the operating room for a bleeding
event. The details of assessing thromboembolic risk and perioperative management
will be covered in greater detail in Chapter 4.
Antiplatelet and Beta-blockers
While it is universally agreed that patients should stop certain medications and
herbal supplementation that can increase bleeding risk, there is less certainty about
medically necessary medications. Antiplatelet agents should not be stopped
perioperatively for 1 year after stents, and should be restarted quickly after
surgery. If the planned surgery does not require a great deal of undermining,
continuing one antiplatelet agent (i.e., hold Plavix but continue aspirin) may be a
3safe and viable option.
Beta-blockers should be continued throughout the perioperative period with
22hold parameters for hypotension. Numerous studies and large meta-analyses
have shown that beta-blockers are cardioprotective when used in the perioperative
period in patients with cardiac risk factors. Beta-blocker therapy appears e ective
when started several weeks prior to surgery, and long-acting agents appear more
successful than short-acting agents. Currently there is no reason to start a
betablocker for a healthy patient without significant cardiac risk factors.
Glycemic Control
Patients with diabetes are at an increased risk for wound infection due to impaired
immunity, microvascular changes and delayed healing mechanisms.
Hyperglycemia before and after surgery increases the likelihood of surgical sight
infection by three to fourfold. According to Olsen et al, a serum glucose level of
greater than 125 before or after surgery parlayed into a more than fourfold
19increase in surgical site infections. In addition, diabetics are also at risk of
noninfectious complications including seromas and ischemic necrosis. HgbA1C
should have been included in the preoperative workup. The standard diabetic
sliding scales would accept glucose levels of 125. Therefore, tight glycemic control
(glucose <_11029_ should="" be="" the="" goal="" of="" medical=""
protocol="" postoperatively.="" if="" a="" standard="" sliding="" scale="" is=""
deemed="" inadequate="" or="" patient="" has="" history="" di0 cult=""
glycemic="" _control2c_="" iv="" insulin="" and="" endocrinology=""
consultation="" utilized="" in="" immediate="" postoperative="">
Postoperative Nausea and Emesis (PONV)
PONV, while not life-threatening, can delay patient clinical course and discharge
from hospital care, and can negatively impact patient satisfaction. Risk factors for
PONV include female gender, history of motion sickness, history of PONV,
preoperative opioids, and nonsmoking (Table 1.4).

TABLE 1.4 Important Risk Factors for VTE
Prior history of DVT/PE
Malignancy (active or in patient history)
Thrombophilia disorders (inherited or acquired)
Obesity (risk may be highest for those younger than 40)
General anesthesia (risk rises with each hour in surgery, regardless of
Age ≥40 years (risk rises as age rises)
Use of estrogen-containing drugs
Varicose veins
Abdominal surgery
Recent surgery of any kind
Prolonged travel by air, train or car
The plastic surgery population usually has several risk factors for PONV, and
the outcome of PONV can be temporary hypertension and increased risk of
bleeding. The best method of PONV prevention appears to be employment of
multiple agents. The triple cocktail of Benadryl, dexamethasone, and Zofran
appears to be 98% e ective in preventing PONV. Emend, an oral agent taken
preoperatively, appears to be as e ective as IV Zofran and has an e ect lasting for
2348 hours.
Respiratory Management
In patients with a diagnosis of obstructive sleep apnea, CPAP should be made
immediately available at the preoperative settings. The patient should be carefully
monitored in PACU for their respiratory status. Supine position is suboptimal and
should be avoided even during sleep. Supplemental oxygen should be expected.
Patients with obstructive sleep patterns have a respiratory status that is more
sensitive to pain medications and sedatives. Additional monitoring may be
necessary in a patient who has undergone a lengthy and painful procedure and
requires narcotics in the postoperative period.
Patient Safety in Your Practice
A well choreographed preoperative, intraoperative and postoperative clinical
regimen should optimize risk reduction. During the rst visit, a thorough history
should be taken so that any “warnings” in the history can generate a proper
workup (Fig. 1.1). While it’s tempting to have the patient obtain medical clearance
from his or her internist, additional specialists should weigh in prior to a complex
surgery with a long recovery. Age-based preoperative labs and testing may not
apply to the massive weight loss population with multiple comorbidities.FIG. 1.1 Two-group comparison of prewarming.
Complete smoking cessation is ideal and patients should be educated fully on
the wound healing complications of nicotine use. Getting in the habit of checking
patients for tobacco use with cotinine urine tests the month prior to surgery can
eliminate guesswork.
Skin folds of massive weight loss patients can harbor high bacterial colony
counts and yeast infections that can predispose to surgical site infections. Topical
creams and powders should be religiously applied to get rid of yeast infection
before surgery. Patients should be provided with Hibiclens with which to shower
prior to surgery, and instructed not to shave in or near surgical zones the week
prior to surgery.
In the preoperative area, forced-air prewarming for at least 45 minutes prior to
the operation can deter hypothermia. Intermittent pneumatic compression devices
(IPCs) should be on and functioning on the patient at least 30 minutes prior to
surgery to allow for optimal fibrinolysis.
Appropriate parenteral antibiotics should be administered within 60 minutes
before incision. The drug protocol to prevent PONV should be initiated.
Once the patient reaches the operating room, the battle against hypothermia
begins. The room temperature should be set at 23°C (73°F). Continuing active
warming with forced air throughout surgery will help, as well as keeping parts of
the body that do not need to be visualized during a portion of the operation
covered. Using warmed (41°C) irrigation and/or IV Huids can help, particularly if
incisions are large and the patient’s core is exposed for a significant period of time.
Weight loss patients who have recovered from diabetes may need insulin
during and brieHy after surgery. Glucose should be checked periodically and IV
insulin utilized to keep the patient normoglycemic (Fig. 1.2 and Table 1.5). A Foley
catheter should be utilized in longer body contouring cases, particularly when large
volume liposuction is planned and guidelines for catheter removal followed. Proper
padding and gel heel protectors to prevent traction or pressure injury should be
used, and all pressure points should be rechecked when patient position is changed
during surgery. If the patient is prone, the face should be checked periodically to
make sure there is (1) no pressure over the globe and (2) no pressure from the
endotracheal tube or tubing against skin surface.FIG. 1.2 Impact of postoperative glucose control on SSI rates after beginning
tight insulin protocol.
From Furnary AP, Zerr KJ, Grunkheimer GL, et al. Continuous intravenous insulin
infusion reduces the incidence of deep sternal wound infection in diabetic patients after
cardiac surgical procedures. Ann Thorac Surg 1999;67:352–62.
TABLE 1.5 Tight Glucose Control and SSI
HbA1c Level (%) Plasma Glucose Level (mg/dL)
6 135
7 170
8 205
9 240
10 275
11 310
12 345
Maintaining a HbA1c level
Odds ratio of 2.13.
95% CI.
P value of 0.007.
From Dronge AS, Perkal MF, Kancir S et al. Long-term glycemic control and
postoperative infectious complications. Arch Surg. 2006;141:375–80.
Two hours before the end of surgery, Zofran should be administered for
patients at high risk of PONV (Table 1.6). Continuing 80% FiO for 2 hours with a2
nonrebreather face mask can reduce the risk of pulmonary complications. The
pneumatic compression devices should be on and continuing to function in the
postoperative period.
Risk Factors
Female gender
History of PONV or motion sickness
Perioperative opioid treatment
PONV Risk Stratification
# of Risk Factors Risk of PONV
0 10%
1 20%
2 40%
3 60%
4 80%
Many of our patients have at least 3 risk factors: female gender, nonsmoking, and
perioperative opioids.
In the postoperative period, the focus should be on adequate pain control,
maintenance of Huid balance, and early ambulation. If PONV develops, alternate
agents to the ones that have already been used should be employed. Continued
supplemental oxygen throughout hospitalization to maintain SpO > 90% is ideal.2
In OSA patients, a CPAP device should already be in the hospital room if the
patient utilizes one at home.
Incentive spirometry and pneumatic compression devices should not only be
ordered, but the surgeon should check to make sure these devices are being utilized
properly. Beginning chemoprophylaxis at 12 hours postop is ideal, barring any
bleeding complications.
The Foley catheter should be discontinued as soon as it is reasonable, to
prevent catheter-related urinary tract infections. Antibiotics should not be given for
more than 24 hours after a routine clean elective body contouring operation.
Complications and Their Management
Nowhere is a cliché truer than this: the best way to manage complications is to
prevent them from happening in the rst place. Risk prevention, not risk
management, is the primary objective. Problems occur when the surgeon is too
hasty in his or her decision to operate and misses a vital piece of information, or
over-relies on others to carry out the risk-prevention protocols. Even despite our
best e orts, complications can occur in the practice of the most careful clinician.
The key is to make the steps of the risk-prevention easily administered, orderly,clearly laid out, and unvaried from patient to patient.
The study of HF is a division of psychological studies that exclusively deals
with the inevitability of human error in all systems. The science is used to create
systems that optimize performance and minimize error. Simple steps such as
always arranging pneumatic compression and a warming blanket to arrive to the
preoperative area with the patient, making standardized order forms always
available for DVT prophylaxis and antibiotics, and having automatic urine cotinine
test administered routinely, can contribute to minimizing patient risk.
This chapter should serve as a rough guideline toward developing one’s own
clinical protocol to optimize safety and minimize risk. While surgery itself is an
imperfect art, it is amenable to continued improvement. The art of minimizing risk
and optimizing perioperative management should advance along with the
techniques to achieve optimal surgical outcomes.
1 Reason J. Understanding adverse events: human factors. Qual Health Care.
2 Eagle KimA., Chair., Task Force Members: Raymond J. Gibbons, Elliott M. Antman,
Peter B. Berger et al. ACC/AHA Guideline Update for Perioperative
Cardiovascular Evaluation for Noncardiac Surgery – Executive Summary. Anesthes
Analges. 2002;94(5):1052–1064.
3 Grines CL, Bonow RO, Casey DE, et al. Prevention of premature discontinuation of
dual antiplatelet therapy in patients with coronary artery stents. A science
advisory from the American Heart Association, American College of Cardiology,
Society for Cardiovascular Angiography and Interventions, American College of
Surgeons, and American Dental Association, with representation from the
American College of Physicians. Circulation. 2007;115:813–818.
4 Friedman T, Coon DO, Michaels JV, et al. Hereditary coagulopathies: practical
diagnosis and management for the plastic surgeon. Plasts Reconstr Surg.
5 Harris EN, Boey ML, Mackworth-Young CG, et al. Anticardiolipin antibodies:
detection by radioimmunoassay and association with thrombosis in systemic lupus
erythematosus. The Lancet. 1983;322(8361):1211–1214.
6 Jain SS, Dhand R. Perioperative treatment of patients with obstructive sleep
apnea. Curr Opin Pulm Med. 2004;10(6):482–488.
7 Jacobers SJ, Sowers JR. An update on perioperative management of diabetes. Arch
Int Med. 1999;159:2405–2511.
8 Centers for Disease Control and Prevention (CDC). Smoking and tobacco use: fact
sheet. Online. Avaialbe lfrom
http://www.cdc.gov/tobacco/data_statistics/fact_sheets/index.htm (accessed 20
March 2012)
9 Monfrecola G, Riccio G, Savarese C, et al. The acute effect of smoking on
cutaneous microcirculation blood flow in habitual smokers and non-smokers.
Dermatology. 1998;197:115–118.10 Manassa EH, Hertl CH, Olbrisch RR. Wound healing and problems in smokers and
non-smokers after 132 abdominoplasties. Plast Reconstr Surg. 2003;111:2082–2087.
11 Theadom A, Cropley M. Effects of preoperative smoking cessation on the
incidence and risk of intraoperative and postoperative complications in adult
smokers: a systematic review. Tob Control. 2006;15:352–358.
12 Spear SL, Ducic I, Cuoco F, et al. The effect of smoking on flap and donor-site
complications in pedicled TRAM breast reconstruction. Plast Reconstr Surg.
13 Bluman LG, Mosca L, Newan N, et al. Preoperative smoking habits and
postoperative pulmonary complications. Chest. 1992;113:883–889.
14 Warner MA, Offord KP, Warner ME, et al. Role of preoperative cessation of
smoking and other factors in postoperative pulmonary complications: a blinded
prospective study of coronary artery bypass patients. Mayo Clin Proc.
15 Sarwer DB. Awareness and identification of body dysmorphic disorder by
aesthetic surgeons: Results of a Survey of American Society for Aesthetic Plastic
Surgery Members. Aesthet Surg J. 2002;22(6):531–535.
16 Kinzl JF, Trefalt E, Fiala M, et al. Psychotherapeutic treatment of morbidly obese
patients after gastric banding. Obes Surg. 2002;12(2):292–294.
17 Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to reduce the
incidence of surgical-wound infection and shorten hospitalization. Study of Wound
Infection and Temperature Group. New Engl J Med. 1996;334:1209–1216.
18 Classen D, Menlove RL, Burke JP, et al. Surgical site infections. N Engl J Med.
19 Olsen MA, Nepple JJ, Riew KD, et al. Risk factors for surgical site infection
following orthopaedic spinal operations. J Bone Joint Surg Am. 2008;90:62–69.
20 Cárdenas-Camarena LMD, González LEMD. Large-volume liposuction and
extensive abdominoplasty: a feasible alternative for improving body shape. Plast
Reconstruct Surg. 1998;102(5):1698–1707.
21 Perrotti JA, Castor SA, Perez PC, et al. Antibiotic use in aesthetic surgery: a
national survey and literature review. Plast Reconstruct Surg. 2002;109(5):1685–
22 Auerbach AD, Goldman L. Beta blockers and reduction of cardiac events in
noncardiac surgery. JAMA. 2002;287:1435–1444.
23 Peach MJ, Rucklidge MWM, Lain J, et al. Ondansetron and dexamethasone dose
combinations for prophylaxis against postoperative nausea and vomiting. Anesth
Analg. 2007;104(4):808–814.Part 2
Upper extremity contouring

Chapter 2
Liposuction of the upper extremities
Cemal enyuva, Hüseyin Güner
Key Points
• Patient selection is crucial and the skin quality of the target region should be
• Deformities should be classi ed, and simultaneous or late excisional surgery
should be discussed with the patient.
• Conventional technique can be used or energy delivering technology can be used
to get better skin retraction.
• Gentle surgical technique should be used and soft tissue thickness should be even
and esthetic contours should be achieved at the end of the procedure.
• To get a smooth result the surgery should be extended to the entire esthetic unit
of the arm.
The basic principles of arm liposuction are no different from those for other parts of
the body. A plastic surgeon should also assess the skin tone, quality, topographic
mapping of fat deposits, retraction capacity of the skin, and the general health of
the patient. The patient should be informed that a brachioplasty could be needed
during the initial procedure or later on if the liposuction cannot produce acceptable
Preoperative Preparation
Patient Selection
Patients with fat deposits in their arms are candidates for arm liposuction. Body
mass index is an important factor in liposuction, along with general health.
Morbidly obese patients who need bariatric surgery are not candidates for arm
1The classi cation of Teimourian has been generally accepted for esthetic
deformities of the arm (Table 2.1). Besides Teimourian, other classi cations
2 3reported by El Kathib and Appelt can also be used. While liposuction can be used
alone in class 2 deformities, it can be used alone or can be combined with a
brachioplasty technique in class 3 deformities.
TABLE 2.1 Teimourian Classification

Group Minimal to moderate subcutaneous fat with minimal skin laxity
Group Generalized accumulation of subcutaneous fat with moderate skin
2 laxity
Group Generalized obesity and extensive skin laxity
Group Minimal subcutaneous fat and extensive skin laxity
4Chamosa’s cadaver study on fat deposits supports our clinical ndings. Fat
deposits in the arms are mostly located at the posterior area. Super cial fascia
separates the fat layer into super cial and deep compartments and the storage of
fat occurs in each compartment. Skin retraction is better in super cial liposuction
technique. When combined with the use of internal ultrasonic and laser systems,
better skin retraction is obtained due to increased dermal thermal energy.
Surgical anatomy may di3er in fat and thin patients. In fat patients, increased
fatty tissue is observed in the whole posterior compartment, part of the
brachioradialis, deltoid, triceps and, rarely, the lateral head of biceps regions. In
thin patients, there is more fat accumulation in the posterior compartment and less
in the brachioradialis and triceps regions. Treatment of the whole fat
accumulation, more or less, is important for a perfect result.
Surgical Technique
Preoperative drawings are done while the patient is standing. Deformities will be
evident with the upper arm abducted 90° and lower arm 8exed 90°. Photographs
should be taken from front and back in this position and should involve both arms
together and also separately. Arm circumferences should be measured at the
proximal and distal 1/3 levels of the arms. Anterior and posterior arm pinch tests
should also be applied to the proximal and distal 1/3 levels of the arms.
We usually use liposuction in the posterior half of the arm to avoid the
irregularities caused by circumferential liposuction and because accumulation of
fat occurs in the posterior arm. Lesser amounts of fat could be taken from the
lateral region of the deltoid and triceps muscles, brachioradialis and sometimes
from the posterior region of the lateral head of biceps. The brachial groove in the
medial arm and the groove between the biceps and triceps in the lateral arm
should be marked.
The procedure is performed under general anesthesia. Sedation with local
anesthesia may be preferred if only liposuction is going to be performed. Multiple
procedures may be started under local anesthesia and sedation; general anesthesia
may be administered if needed from the beginning of the treatment.
The techniques currently being used are the conventional suction-assisted
lipectomy (SAL), the third generation solid probe ultrasonic-assisted liposuction
system (UAL; VASER), or laser-assisted techniques.

The Toomey or a vacuum-motored technique may be used. A stab incision located
on the elbow should be su cient. Rarely, a secondary stab incision located on the
proximal arm is necessary for the cross tunnel technique. A wetting solution
including 1/1 000 000 epinephrine (adrenaline) and local anesthetic is in ltrated
with blunt cannulas. The amount of in ltration is calculated in accordance to soft
tissue turgor or with a super wet technique (1 ml in ltration for 1 ml aspiration).
Liposuction cannulas which are used parallel to the arm axis and skin surface and
2, 3, or 4 mm in diameter are preferred.
There are two basic operating positions during in ltration and liposuction. The
arm should be held perpendicular and the forearm should be 8exed into the rst
position (Fig. 2.1). In this way, the posterior arm can be kept stretched to ease the
operation. In the second position, the surgical assistant should lift the arm to a 90°
degree angle by holding the wrist. In this way, contours of the posterior arm
become visible due to gravity. Using the pinch test, the thickness of adjacent
esthetic units, which is the target thickness, can be gauged. The procedure should
carry on until the desired thickness is achieved. After the desired thickness and
esthetic contour has been achieved, four tests should be applied, which are similar
to those applied to other body parts. After rubbing, pinch, active pinch and
comparison tests, additional adjustments should be done to complete the procedure
if needed. Stab incisions may be closed as two layers with separate 5/0 Monocryl
sutures or kept open for drainage. A liposuction arm corset should be applied to the
FIG. 2.1 The basic position with the arm held in vertical position and forearm
held in flexion to ease the operation.

Third-generation solid probe ultrasound liposuction systems that were introduced
in 2001 for use in other body parts may also be used for the correction of arm fat
deposits. In this procedure, fat fragmentation and emulsi cation is obtained by
ultrasound energy in the rst step. For this purpose, 2.9 or 3.7 mm diameter probes
may be used. The 2.9 mm probes include three rings, which enable penetration and
delicate shaping. The 3.7 mm probes may include one, two, or three rings. Probes
with one ring have more penetration ability and the ultrasound energy is denser at
the tip of the probe. The energy is higher at the sides in the probes with three rings.
The same arm positions and stab incisions are used as for the SAL technique. Skin
protectors should be used and should be sutured with 3/0 silk materials to prevent
the incision edges from heat trauma. Klein solution is in ltrated. At least 100 ml
wetting solution in ltration is recommended for each 1 minute of ultrasound
Probe choice is determined according to the brous content of the fat tissue
and also the resistance to the probe. Energy amplitude (ranged 0–100) and mode
of energy transfer (continuous or intermittent) is set. VASER application for the
posterior arm usually lasts between 3 and 4.5 min. VASER is carried out with
depletion of the resistance in fatty tissue and the second phase is initiated.
Aspiration is made with 3, 3.7, and 4.6 mm blunt-windowed VentX® liposuction
cannulas in the second stage.
Lipoaspiration is terminated when desirable esthetic contours are achieved and
the pinch test thickness is equalized with adjacent esthetic units. Stab incisions may
be closed as two layers with separate 5/0 monocryl sutures or kept open for
drainage. A liposuction arm corset should be applied to the arm.
Laser-Assisted Liposuction (LAL) and Laser Tissue Interaction
The laser method has two main aims:
1. To selectively break down fat cells and separate fat lobules into small pieces.
2 . To stretch and remodel the dermal collagen and the dense nondermal
collagen, which is found in the connective tissue between muscle and dermis.
The distinctive features of laser treatments are their selectivity. Laser therapies
are selective, unlike other techniques. There are two target chromophores in our
area of liposuction: triglyceride and water. Fat cells and lobules are composed of
90% triglyceride and all other tissues are 60% water. With the wet technique,
triglyceride concentration in fat cells decreases to 80% and water concentration in
other tissues increases signi cantly to 80–90%. For the wet technique, there are
two chromophores with the same concentrations subcutaneously.
According to the laser laboratory studies, it has been seen that although the
924 nm laser beam is absorbed very well by triglyceride, it is absorbed less well by
water – the other chromophore in the operative area. This type of photothermal
selectivity allows for the absorption of the light into the targeted adipose tissue,
while leaving the adjacent tissue relatively undamaged. This type of selectivity is
particularly useful when in the super cial layer of the tissue, near the dermal
junction. As the dermal tissue contains a large amount of water, any water-only
absorption-based system (YAG laser based) can present problems with burns or


necrosis as a result of overheating.
The goal is to minimize thermal damage on the peripheral tissues while
melting fat with 924 nm laser. This way, selective laser lipolysis can be done. By
heating the water with 975 nm laser, the deep dermis and dense collagen tissue in
the connective tissue are stimulated. Both acute and augmented dermal and
subcutaneous retraction is targeted. There is an additional e3ect of the di3usion of
the heat created in the adipocytes from the 924 nm laser by selective absorption
into the triglyceride. As the connective tissue is 90% embedded in the fat cells, this
type of di3usion allows for a more controlled method of collagen contraction. In
the SlimLipo system, these two wavelengths are transferred to subcutaneous fat
tissue by a 1.5 mm beroptic cable. The power may be set to 0–20 W for 924 and
975 nm, which is 40 W in total. We can accomplish a safe lipolysis and dermal
subdermal retraction by using those two laser wave lengths separately or
simultaneously with this laser liposuction system.
Surgical Technique for LAL on the Upper Arm
LAL resembles classic liposuction. It is important that the operation be done under
slight sedation for the patient to maintain position. A good result in liposuction
surgeries very much depends on good patient positioning. For the posterior upper
arm, the best position is while the patient is lying down lateral supine, the shoulder
is on 90° abduction and 8exion, the elbow is 8exed 90°, and the patient is holding
the other forearm with the operative side hand. The entire operation can be done in
this position. While the fat tissue on the deltoid or brachioradialis area is treated,
the arm is simply adducted and the forearm is extended so that the operation can
continue smoothly.
At the start of the operation, 1/500 000 epinephrine (adrenaline) and 0.8 g/l
lidocaine Ringer’s lactate solution is in ltrated in such a manner that the lidocaine
dosage is not over 55 mg/kg. Following the in ltration, laser is started by inserting
a 1.5 mm fiber into the subcutaneous fatty tissue.
For arms with thick fat and su cient turgor, 3040 W blend mode of 924 and
975 nm laser is used together in equal amounts or in di3erent ratios. In total, 15–
20 kJ is applied equally to the overall area. Following this, a su cient amount of
liposuction must be done by inserting a 2 mm suction cannula. As su cient tissue
heating and retraction may not always be achieved with the 924 nm wavelength
alone, the 975 nm wavelength is also available to be combined or used
independently. The 975 nm wavelength is highly absorbed by water, and as there
is su cient water content in the tissue adjacent to the adipocytes, this high
absorption coe cient allows for some rapid heating. It is important to remember
that this water-absorption based heating is rather hard to contain as there is high
water content in much of the adjacent tissue. The 975 nm wavelength should not
be used in high wattage in the super cial levels of tissue nearest the dermal tissue.
External cooling can help with overheating.
Older patients or those with a medium amount of fat and diminished skin tone
and who do not want an incision are generally di cult cases. Conventional
liposuction will not produce a satisfactory outcome. For these patients no
suctiononly laser liposuction application or laser liposuction application with less suction
will result in better outcomes. While the fat tissue is discharged in months, the skin
will be retracted slowly. This application must be done very carefully. The 924 nm
wavelength must be used at about 10–20 W and no tissue other than fat tissue

must be harmed. If the fat amount in the arms is large, and for faster heating,
975 nm wavelength can be added in small doses. In careful and delicate
applications there will be controlled fat necrosis and fat cell apoptosis. Since
vascular and lymphatic tissues and connective tissue in the same compartment will
stay intact, fat necrosis will be absorbed in weeks. It may take several months to
produce the nal outcome. These patients must be well documented
photographically and must understand that results come over time.
The incisions are immediately sutured with 6/0 Prolene or Monocryl following
the surgery and the patient dressed with an upper arm corset.
A forearm application is rarely done. Most of these patients are over 60 years old.
Their complaints are mostly not being able to wear a watch or jewelry.
While the patient is lying down supine, the forearm is placed on the surgical
table and the wrist is 8exed slightly. Following local solution in ltration with
1/500 000 epinephrine (adrenaline), laser liposuction is applied with 924 nm
wavelength at about 10–20 W alone or with blending of the 975 nm wavelength,
not exceeding 4–8 W. Following the application, suction from the forearm and/or
dorsum of the hand is done with a 1.5 mm blunt-faced cannula. Incisions are
closed with 6/0 Prolene and a hand wrist bandage with mild compression is
applied to the dorsum.
Optimizing Outcomes
Patient selection is important. Also, the patient should have realistic expectations.
The surgery should be performed smoothly and a gentle surgical technique should
be used. To get skin retraction and a smooth surface without waviness the surgery
should be performed on the whole esthetic arm unit extensively and soft tissue
thickness should be even at the end of the operation (Figs 2.2–2.4).
FIG. 2.2 Arm liposuction: preoperative and postoperative view of the patient.

FIG. 2.3 Axillary lipodeposits before and after LAL.
FIG. 2.4 Patient with lipodeposits on her forearms: preoperative and
postoperative view after LAL.
Postoperative Care
A special arm corset should be applied to the arm postoperatively. If the patient
has an intravenous line in the upper extremity, a corset on that side should be
deferred until the removal of the intravenous line. In this case, the upper arm is
wrapped with cotton and bandaged loosely. Except for showering, the arm corset
should be used for 2 weeks continuously. Progressive soft tissue indurations and
alterations in sensation regress after the third postoperative week. In the third
postoperative month, a visit should be arranged for photographing, and arm
circumference and tissue thickness measuring.
Complications and Their Management
Careful patient selection and accurate surgical planning is essential for a good
esthetic result in arm liposuction. Complications such as bleeding, infection,
prolonged soft tissue indurations, burns, or seroma may occur. However, in our
clinical experience, seroma is the only complication that is observed in other parts
of the body and none of those complications have been observed in our clinical
experience on the arm. None of our patients who had arm liposuction necessitated
or demanded additional brachioplasty.
In conclusion, liposuction in the arm region is a simple surgical procedure and
anatomic structures are avoided as long as the procedure is applied to the
suprafascial plane. SAL, VAL, or laser liposuction may be used alone for patients
without soft tissue laxity and ptosis. Patients with minimal ptosis and loose skin
may bene t from VAL or laser liposuction, which provide better skin retraction. In
patients with ptosis, liposuction is used only to facilitate brachioplasty.
1 Teimourian B, Malekzadeh S. Rejuvenation of the upper arm. Plast Reconstr Surg.
2 El Khatib HA. Classification of brachial ptosis: Strategy for treatment. Plast Reconstr
Surg. 2007;119:1337–1342.
3 Appelt EA, Janis JE, Rohrich AJ. An algorithmic approach to upper arm conturing.
Plast Reconstr Surg. 2006;118:237–246.
4 Chamosa M, Murillo J, Vazquez T. Lipectomy of arms and lipograft of shoulders
balance the upper body contour. Aesth Plast Surg. 2005;29:567–570.>
Chapter 3
Brachioplasty with bicipital groove scar
Susan E. Downey
Key Points
• The patient must be willing to accept the possibility of visible and even poor
• Improvement in contour must be significant to justify the visible scarring.
• The arm must be adequately deflated before brachioplasty.
• If there is laxity on the lateral chest wall consideration should be given to
extending the excision to the inframammary fold.
• In massive weight loss patients, a Z plasty is not usually necessary in the axilla.
The increase in obesity in the United States of America and the concurrent meteoric
rise in bariatric surgery has led to an increasing interest and popularity of the
brachioplasty procedure. Statistics from the American Society of Plastic Surgeons
have borne this out, with an increase in the number of brachioplasties from 2516 in
11997 to 16 102 in 2009. Massive weight loss patients make up the bulk of
brachioplasty patients. As is true in all parts of the body after massive weight loss,
the deformities can be highly varied. Some patients do not have much loss of fat
from their arms and require debulking before a formal brachioplasty. Other
patients have truly de. ated arms and describe “pinching” of the loose skin as it is
folded into their clothing.
Esthetic brachioplasty was 2rst described by Correa-Inturraspe and
2 3Frenandez in 1954. Lockwood (1995) described the super2cial fascial repair of
the arm, but as was the case with his work on lower body lifts, most of his patients
were complaining of aging and not massive weight loss. However, until the
avalanche of massive weight loss patients entered the plastic surgeon’s o ce there
was little interest in the procedure. That said, many plastic surgeons were still
reluctant to perform the procedure due to concerns about scars and axillary
contractures. The massive weight loss patients have helped change the plastic
surgeons’ minds, focusing the improvement of contour with fewer concerns about
scars. Plastic surgeons of course, however, continue to try and improve the scars
and argue about scar placement. Some plastic surgeons advocate a scar along the
4most inferior point of the upper arm and others have recommended a sinusoidal
5type of scar placement. At polls taken during plastic surgery meetings the most
common scar placement has been reported to be within the bicipital groove
(Downey S, personal communication). A survey taken of the general public, plasticsurgeons and patients confirmed that the most acceptable position of a scar is along
6the bicipital groove. Many plastic surgeons are now continuing the excision
7proximally into the axillary area and in some massive weight loss patients this
8,9excision may be extended down the trunk to the inframammary fold.
Preoperative Preparation
The evaluation of patients presenting for brachioplasty involves consideration of
how much residual fat is present and the looseness of the skin. One of the 2rst
considerations will be whether there is enough laxity to justify a scar from elbow to
axilla or longer (Figs 3.1 and 3.2). Patients with minimal looseness may bene2t
from looking at pictures of patients who have undergone brachioplasty in order to
understand the length of the scars and the typical “rope-like” appearance of the
scar near the elbow. Some clinicians have advocated drawing the proposed scar on
the patient so they can live with the proposed scar for a while and see if it is
something that they can accept.
FIG. 3.1 Preoperative massive weight loss patient before brachioplasty.
FIG. 3.2 Six weeks following bicipital groove brachioplasty.
The second type of patient is the opposite – the patient who has had minimal
de. ation of their arms. These patients will not have a satisfactory result from a
brachioplasty without de. ation. Attempts to perform a brachioplasty will lead to
an arm still very full, but now with the addition of a long scar. There are twoschools of thought: liposuction at the time of brachioplasty, and liposuction or
de. ation followed at a later interval (usually several months) by the formal
excision. In many cases the arms are not the patient’s first priority and the deflation
can be combined with the 2rst excisional procedure the patient is undergoing (for
example, an abdominoplasty) and then the formal brachioplasty could occur at a
later time. Often this is a very acceptable plan for the patient as the de. ation will
allow the patient to wear more normal clothes or clothes that better 2t their torso
even though the arms are still loose (Fig. 3.3).

FIG. 3.3 Massive weight loss patient before (A) and after (B) de. ation
(liposuction) of arms.
The third type of patient has adequate de. ation and enough looseness that
they will have enough improvement in contour to justify the scar. Evaluation of
these patients needs to include the skin of the forearm as well as the excess and
laxity of the lateral chest wall. Rotation of the skin/fat . ap in an upwards and
inwards manner will somewhat improve the loose skin of the forearm, but not
signi2cantly. This upward/inward rotation will leave an excess or dog-ear in the
axilla. To excise this dog-ear and to give patients an even better outcome the excess
can be excised down to the inframammary fold. Patients often consider this a real
9bene2t as they object to the “bra roll” fat. This fat or roll may not be visible to the
plastic surgeon unless the patient has on or puts on their bra during the
consultation. Even male weight loss patients may bene2t from this extension down
the chest wall as many male shirts now are more body revealing and a smooth
contour in this area is desirable. Even in these patients who will have a signi2cant
improvement in contour it is advisable to show them pictures of brachioplastypatients so that they are aware of the length of the scars, the scar position, and the
length of time that it will take the scars to mature.
Preoperative consultation not only should include discussions as to the
improvement to be seen in the arms but also the limits. Many patients are
concerned about the lower arm. Often the lower arm exhibits laxity but not enough
looseness to justify extending the incision below the elbow. Many patients who
have experienced extreme weight loss will always have more laxity to their skin
and no surgical procedure to date will improve this. The scar of a brachioplasty
needs to be discussed in detail with patients. In general, the scar closest to the
axilla will do the best while the scar closest to the elbow will do the worst (Figs 3.4
and 3.5). This is, of course, opposite to what the patient (and surgeon) wishes.
Although the scar close to the elbow will eventually settle down and become flatter,
it is often a long process and may require not only a lot time but topical therapy
such as taping or even steroid injections. In some cases the scars are thick and wide
(Fig. 3.6).
FIG. 3.4 Preoperative massive weight loss patient before brachioplasty.
FIG. 3.5 Postoperative scars 3 months following bicipital groove brachioplasty.
Note scar is better in axillary area and worsens as the scar approaches the elbow.FIG. 3.6 Extensive scarring after brachioplasty.
Surgical Technique
The markings for a brachioplasty should be done with the patient in the standing
position (Fig. 3.7). Patients should hold their arms at 90° to their body with the
elbow . exed. A horizontal line should be drawn from the axilla to the elbow
marking the desired position of the 2nal incision line along the bicipital groove.
The high point of the axilla should be marked. This will represent the high point
position of the . ap to be excised from the upper arm as it is rotated up and in. A
horizontal line should be marked, which corresponds to the inframammary fold, to
mark the end of the lateral chest excision. The excess tissue of the back should be
pulled forward and then a vertical line drawn, which now represents the desired
position of the 2nal incision line along the lateral chest. The excess skin and fat of
the chest wall should then be pinched, utilizing the marked posterior line as the
2nal extent of the excision. Care should be taken to observe the breast to make sure
that the breast tissue is not pulled posterior and the lateral aspect of the breast is
not violated. The excess tissue to be excised is then marked. This excision of the
lateral chest wall tissue allows the skin and fat of the upper arm to be rotated up
and in and the resultant dog-ear to be excised along the lateral chest wall.
FIG. 3.7 Preoperative markings for bicipital groove brachioplasty.
For female patients, the excision within the axilla will include all or most of
the hair-bearing skin. For male patients this needs to be modi2ed as the normal
male has hair in his axilla (Fig. 3.8). The incision can be moved posterior to leave
behind hair-bearing skin, which also helps camouflage the scar.FIG. 3.8 Positioning of scar in axilla of male patient to maintain normal
hairbearing pattern.
For massive weight loss patients a Z plasty has not been found to be necessary
in the axilla. The incision and eventual scar in the axilla will recruit some of the
residual laxity from the surrounding upper thorax area, which adds to the eventual
cosmetic outcome of the procedure (Figs 3.9 and 3.10).

FIG. 3.9 Male massive weight loss patient after brachioplasty with extension
down thorax to inframammary fold.FIG. 3.10 Full extension of arm after brachioplasty without Z plasty in axilla.
The procedure is done with the patient in the supine position with both arms
extended. The arms should be prepped circumferentially to allow for movement
and the lateral chest prepped and draped as well. The incision is made along the
markings and dissection is carried down to the fascia of the arm musculature. At
this juncture the loose inferior skin and fat is elevated oH the arm musculature
dissecting towards the inferior aspect of the arm. The skin and fat is then rotated
up and in, in order to improve looseness around the elbow as well as remove the
excess of the lower upper arm. This maneuver creates a dog-ear in the axilla, which
is then taken out with the upper lateral chest excision. Once the excess skin and fat
is elevated, the assistant should hold the upper skin and fat in place so that the
incision lies in the desired position along the biciptial groove. The excess skin and
fat can then be marked for excision without any fear of inability to close the
wound. The excess of the upper lateral chest is excised directly using the
preoperative marking. Once the excess skin and fat is excised then the wound is
closed over a closed suction drain which is exited through the inferior portion of
the lateral chest excision. Closure can be done in a single layer. Use of barbed
sutures can make the closure quicker (Fig. 3.11). If cyanoacrylate is used to seal
the wound then no dressings are needed. Many surgeons have found that patients
do well without compression garments. Compression garments may pinch the arm
skin, especially around the axilla and can in some cases cause areas of uneven
swelling. A drain may be placed and, if it is used, the drain should exit along the>
chest wall for the patient’s comfort.
FIG. 3.11 Intraoperative view.
Optimizing Outcomes
1 . Manage expectations with detailed preoperative counseling on scar length,
position, and quality.
2. Modify the excision for male patients to leave some axillary hair-bearing skin.
3. On-table marking of excision prevents over-resection and inability to close.
Postoperative Care
Early on in the experience with brachioplasty many surgeons advocated
compression garments or wrapping the arms. In some patients this led to pinching
of the skin especially when ace wraps were used. From the experience of patients
who could not tolerate the wrapping, the technique has evolved to not using
compression garments. With the use of cyanoacrylate as a wound sealant, dressings
are also unnecessary and the avoidance of dressings means less chance of pinching
and asymmetric swelling.
If a drain is used then it can be removed when the surgeon feels that the
drainage has decreased su ciently. Most patients are able to undergo this
procedure, when done alone, as an outpatient. The most common complaint is
tightness under the axilla, which generally resolves in a few weeks to months.
As mentioned earlier, the scars from a brachioplasty can take a long time to
settle down. The scars nearer the axilla improve earlier than the scars near the
elbow. This is frustrating to both the surgeon and the patient as the scars near the
axilla are less visible. The patient will need to be reassured that the scars near the
elbow will eventually settle down as well, although this process may take up to a
year or even longer. Steroid injections, taping of the scars and/or silicone sheeting,
massage and other usual scar management modalities can help the process along.
Complications and Their Management>
Wound dehiscence can be seen primarily in the axillary area where the wound is
under tension; the area can be moist and the movement of the arm can lead to
disruption. In most cases these areas are small and can be handled with local
wound care only.
Hematomas can occur and should be dealt with if possible as soon as
identi2ed. If the hematoma is not fully evacuated there can be scar contracture,
which is a more di cult problem in the long term. Seromas are sometimes seen as
well. Seromas are usually small and most often are seen near the elbow although
they can occur anywhere along the incision. Serial aspiration of the small seromas
usually is adequate.
Despite not using a Z plasty in the axilla, scar contracture is rarely seen in the
axilla in the massive weight loss patient. Some patients report feeling tight across
the axilla in the 2rst few weeks following the operation. In these patients stretching
exercises can help the natural relaxation of the scar. Massive weight loss patients
typically have a lot of looseness to their upper torso and the body recruits this
surrounding loose tissue to relax the scar. The side bene2t to this process is an
improvement in the contour of the upper torso.
1 American Society for Aesthetic Plastic Surgery. Online. Available from
http://www.surgery.org/sites/default/files/Stats2010_1.pdf (accessed 8 March
2 Correa-Inturraspe M, Fernandez JC. Dermatolipectomia braquial. Prensa Med
Argent. 1954;34:24–32.
3 Lockwood T. Brachioplasty with superficial fascial system suspension. Plast Reconstr
Surg. 1995;96:912–920.
4 Lockwood T. Brachioplasty with superficial fascial system suspension. Plast Reconstr
Surg. 1995;96:912–920.
5 Aly A, Cram A. Brachioplasty. In: Aly A, ed. Body Contouring after Massive Weight
Loss. St. Louis: QMP, 2006.
6 Strauch B, Greenspun D. Approach to the arm after weight loss. In: Rubin JP,
Matarasso A. Aesthetic Surgery after Massive Weight Loss. Oxford: Elsevier, 2007.
7 Samra S, Sawh-Martinez RM, Kiu Y, et al. Plast Reconstr Surg. 2010;126:77.
8 Rubin JP, Michaels J. Correction of arm ptosis with a medial bicipital scar. In:
Strauch B, Herman C. Encyclopedia of Body Sculpting after Massive Weight Loss. New
York: Thieme, 2010.
9 Downey S, Gross J. Lateral thoracic excisions in the post massive weight loss
patient. Clin Plast Surg. 2008;35(1):115–120.

Chapter 4
Brachioplasty – the double ellipse technique
Al S. Aly, Peter Lin
Key Points
• Upper arm excess in massive weight loss patients most often crosses the axilla onto the
lateral chest wall.
• Since upper arm excess most often crosses the axilla onto the chest wall, the resection
needs to cross the axilla.
• The arm is a cylindrical structure with a hard inner core that is noncompressible.
• It is important to account for the distance between the pinched ngers in the marking
process to prevent over-resection during the operative procedure.
• A complete tailor tacking of the arms prior to making the incisions during brachioplasty
will prevent over-resection and banding.
• It is dangerous to leave the arm wound open for any considerable time during a
brachioplasty procedure.
• The advantages of a posterior scar in brachioplasty include less visibility in normal life
animation and less risk to important anatomic structures.
Individuals that have experienced massive weight loss will often present with signi cant
upper arm deformities. As with the other areas of the body such as the breasts, abdomen,
buttocks, and thighs, signi cant fat reduction in the upper arms results in excess hanging
skin and varying amounts of remaining fat. Many patients will call these their “bat
wings.” These deformities can lead to embarrassment, rashes, and discomfort in clothing.
Patients are unhappy with this stigma of their previous obesity, which has led to the
authors’ development of the presented technique.
In the development of the presented technique, the senior author had to recognize
the basic nature of the deformity in the upper arm of the massive weight loss patient. The
excess was noted to be located within the posterior axillary fold as it extends from the
axilla to the upper arm. Thus, since the posterior fold traverses from the upper arm to the
axilla and onto the lateral chest wall, the excess also involved the upper arm, axilla, and
the lateral chest wall (see Fig. 4.1). This was a major advancement in knowledge, which
led to the authors’ technique of crossing the axilla with the resection. Other authors have
since developed other methods of resection, but they are all based on the need to cross
the axilla with the resection onto the chest wall.

FIG. 4.1 The typical “bat wing” deformity in a massive weight loss patient.
The yellow mark demonstrates how the excess crosses from the upper arm onto the lateral
chest wall.
Another important concept that the senior author introduced to brachioplasty
surgery is the understanding of the anatomy of the arm as it relates to the dynamics of
surgery. The arm is a cylindrical structure with a hard non-compressible inner core made
up of the musculoskeletal system. The inner core is covered by the skin–fat envelope,
which makes up a small percentage of the entire cross-sectional area of the arm. This
creates a potentially dangerous situation because the skin–fat envelope cannot tolerate
even a moderate amount of swelling, as the hard inner core will not compress to
accommodate that swelling. Thus this led to the discovery that allowing the arm to
develop any signi cant amount of swelling while performing a brachioplasty can lead to
one of two bad outcomes. First, if the technique allows adjustment for intraoperative
swelling then less tissue is resected than ideal. Second, if the surgeon commits to the
proposed amount of resection and swelling is allowed to occur in the skin–fat envelope,
then the wound will not close.
The technique presented here accounts for these two major discoveries: the resection
should cross the axilla and minimal to no swelling should be allowed to occur during the
Preoperative Preparation
Included in the initial evaluation of the patient is a thorough examination of the arms.
The upper arm meets the chest wall at a junction bordered by the anterior and posterior
axillary folds and the hair-bearing axilla. The degree of horizontal and vertical excess is
noted as well as the degree of skin laxity. The quality of the skin envelope is analyzed in
relationship to the overall bulk of the arm.
Photographs of the patient should be taken with the arms abducted at 90° from the
lateral chest wall, with elbows straight and then bent at 90°. Anterior and posterior views
should be obtained. Lateral views with the elbows at 90° are also advisable. A careful
assessment of the arms will reveal the redundant tissue is in the posterior axillary fold,
which, as discussed above, crosses the axilla onto the lateral chest wall.
Patients may be categorized into three subsets. The rst group of patients is those
with signi cantly de8ated arms and a thin layer of remaining subcutaneous fat. These
patients are ideal candidates for excisional brachioplasty. The second group of patients
presents with a large amount of persistent subcutaneous fat in their arms following
massive weight loss. These patients should be treated in a staged fashion with aggressive
liposuction of the upper arms as the rst procedure. Then in 3 to 6 months they can
undergo an excisional procedure, as a second stage. The third group of patients presents
with an intermediate amount of subcutaneous tissue. These patients may choose between
undergoing excisional brachioplasty with a less-than-ideal result or a staged procedure

with liposuction first.
The goals of the brachioplasty procedure are to remove the horizontal upper arm soft
tissue and skin excess that occur from massive weight loss and create a smooth transition
from the lateral chest wall to the upper arm. The authors prefer placing the scar on the
most inferior aspect of the arm in the abducted position because, when facing an
observer and animating the arms, this area is least visible. Final scar position will di; er
based on surgeon preference.
Surgical Technique
Regardless of the brachioplasty technique chosen, the surgeon must strike a balance
between resecting enough skin and soft tissue to create an attractive contour and
overresecting at the risk of not being able to close the wound. As mentioned above, the upper
arm should be thought of as a cylinder with a hard, noncompressible inner core
composed of bone and muscle mass, surrounded by soft tissue and skin. Aggressive
resection will result in compression of soft tissues against the hard, noncompressible inner
core, leading to increased risk of neurovascular compromise and possibly even inability to
close the defect. To avoid this complication we employ the “double ellipse marking
technique”. The outer ellipse is based on anatomic reference points that outline the extent
of the upper arm deformity including the lateral chest wall and, if necessary, across the
elbow. The inner ellipse is based on the outer ellipse but adjusted to allow closure of the
wound around a cylindrical core.
Preoperative Markings: Double Ellipse Technique
1. Patient seated with arms abducted to 90° and elbows flexed at 90°.
2. At the axillary crease, located at the junction of the arm with the chest wall, excess
skin and subcutaneous tissues are pinched just below the musculoskeletal complex.
The anterior and posterior margins of this pinch are marked.
3 . This process of pinching just below the musculoskeletal system is repeated at
multiple points along the entire upper arm. In some patients the excess will have to
be followed past the elbow.
4. The pinching of excess tissue is continued onto the lateral chest wall.
5. The marks are then all connected, both anteriorly and posteriorly, to create the rst
ellipse. This ellipse does not account for the distance between the pinching ngers
and if used to resect tissues will not allow enough skin to be left behind to close the
6. A second ellipse is created, based on the rst ellipse, which accounts for the distance
between the pinching ngers. Thus at multiple points along the upper arm, this
pinch is repeated and the distance between the pinched ngers is noted. Marks that
move in from the original ellipse edges by half the distance of the pinch are then
7. This process is repeated along the extent of the arm but not the lateral chest wall,
since the resection is not around a cylinder at this point.
8. The second set of marks is then connected to create the inner ellipse.
9. Horizontal hatch marks are made at varying distances along the length of the ellipse
to assist with final closure (see Fig. 4.2).
FIG. 4.2 The double ellipse markings.
The outer ellipse is based on the pinch of the soft tissues just below the musculoskeletal
anatomy of the arm. The inner ellipse is created as an adjustment of the outer ellipse,
based on the need to leave enough skin behind to account for the distance between the
pinched ngers. Note that once the resection moves onto the lateral chest wall, the outer
ellipse is reverted to.
Surgical Sequence
1 . If a brachioplasty alone is to be performed the patient is placed in the supine
position, with arm tables on either side, so that the arms can be manipulated in a
variety of positions during the surgery. In the case of combining brachioplasty with
an upper body lift, the patient is placed in the lateral decubitus position and turned
to the other side when the other side is approached.
2. Intravenous lines should be avoided in the upper extremities. If a line in the arm is
required for induction of general anesthesia, this should be moved to the foot or
other location prior to prepping.
3. Assistants during surgery are required to stand above the head of the patient so the
patient’s head is either turned 180° away from anesthesia or the operating room
table is moved away from the anesthesia machine to allow the assistants enough
4 . The inner ellipse is injected with a small amount of epinephrine-containing
anesthetic to reduce bleeding at incision and the patient is prepped and draped.
5 . The inner ellipse is then tailor tacked with staples in its entirety, simulating a
complete resection and closure. With the tailor tack in place, the entire arm is
observed for the tightness and evenness of the proposed resection. The markings are

adjusted to avoid areas of under-resection and over-resection. It is especially
important to avoid areas of “spot tightness” which will lead to tight bands if not
appropriately adjusted for with the markings. After the markings are adjusted, the
staples are removed. This tailor tacking step virtually eliminates the chance of
6. The resection starts distally by incising both sides of the ellipse up to the rst hatch
mark. The skin and underlying fat are elevated o; the underlying muscle fascia,
starting at the distal end of the ellipse and up to the hash mark. There should be no
vital neurovascular structures in this layer.
7 . After obtaining excellent hemostasis, the skin edges of the ellipse are
reapproximated using temporary skin staples.
8. This same process of resecting and temporarily closing the wound with staples is
repeated from hash mark to hash mark in what the authors call the “segmental
resection-closure technique”. While the arm is open, swelling can and will occur,
thus it behoves the surgeon to work eC ciently till the temporary staples are in place.
The temporary closure prevents any further swelling from taking place.
9. In the region of the axilla, the resection should be more super cial than the muscle
fascia to preserve as many lymphatics as possible.
10. After the entire resection is complete and the temporary staples are in place, they
are replaced with sutures. The authors prefer to use 2-0 long lasting nonpermanent
mono lament interrupted/inverted sutures that re-approximate all of the deep soft
tissues in one layer, interspersed with subcuticular nonpermanent staples. Sometimes
a more super cial 3-0 mono lament short-lasting suture is placed in a continuous
subcuticular fashion. The skin is then covered with glue.
11. Drains are not utilized.
Postoperative Care
At the conclusion of the procedure the arms are elevated on multiple pillows with a slight
bend at the elbow. No compression sleeves or wrappings are used. The arms are kept
elevated above the heart for 2 to 3 weeks but patients are allowed to lower them for brief
periods of time to perform necessary activities. Swelling in the arms and hands is not
uncommon and typically resolves in 1 to 2 weeks. Patients can usually return to normal
vigorous activity 3 to 6 weeks after surgery.
It is not unusual for patients to experience small areas of wound separation,
especially in the axilla. The authors prefer to leave a few external skin staples around the
axilla, to help reduce that risk.
Optimizing Outcomes
Because of the nature of closing around a cylinder the resultant healing scar often has a
scalloped appearance that tends to resolve over a 6 to 12 month period. Patients are often
concerned about scalloping unless they are counseled about its likely presence for a
period of time after surgery. It is also the authors’ experience that scar quality takes
longer to reach maturity than most scars in the body. The technique described in this
chapter leads to a more posteriorly positioned scar when compared to the previously
more popular bicipital groove scar. The position of the scar in brachioplasty is a matter of
surgeon preference, with no right or wrong position. The authors’ preference for a
posterior scar is based on a number of issues. First, the most visible aspect of the arm
during normal animation of an individual facing an observer is the bicipital groove. The
posterior scar is essentially invisible in that situation. Second, resections that are centered

on the bicipital groove may injure the medial antebrachial cutaneous nerve, as well as a
relatively lymph-rich area of the arm. The potential negative aspect of a posterior scar is
that an observer standing behind a patient may see part of the scar.
The technique described in this chapter is quite e; ective in reducing upper arm
access, reducing axillary laxity, and because of the lateral chest wall component of the
excision, can also be utilized to decrease horizontal thoracic excess. In the authors’
experience the technique is far more e; ective than the previously popular “T” type
3,4brachioplasty technique, especially when the excess is of a severe nature. A typical
early postoperative result of the technique discussed in this chapter is shown in Fig. 4.3.
FIG. 4.3 A patient is shown preoperatively (a) and early in the postoperative period (B)
after brachioplasty performed utilizing the technique discussed in this chapter.
Complications and Their Management
General risks of surgery should always be discussed with the patient, including infection
and bleeding. Speci c to brachioplasty, super cial nonhealing areas tend to be the most
common complication. They often occur in the region of the axilla and can mostly be
allowed to heal by secondary intention. Deeper dehiscences are less frequent in the
experience of the authors and may or may not require formal closures.
Patients should also be made aware of the risks of potential seromas, which tend to
occur right above the elbow, but can be located anywhere. They are treated initially by
repeated aspirations, progressing to the use of sclerosing agents, and nally they are
exteriorized by opening the scar over the area of the seroma and leaving a wick in place
to allow for drainage and closure from deep to super cial. Infections are uncommon but
tend to occur in association with seromas. Initial treatment is decompression and
antibiotic treatment and then exteriorization.
Historically, poor scarring has always been a problem with brachioplasty. Even with
the use of deep sutures to support the super cial fascial system, scars often appear raised
and cordlike. It is presumed that the etiology of poor scaring is tension on closure but it is
not clear that this is more of a problem with the arms than other areas of the body. Thus
it may also be related to the intrinsic nature of arm skin. Despite the poor quality of
many arm scars, especially within the rst year, it is the impression of the authors that
they eventually mature, similar to other scars, but take considerably longer, up to 2 years,
to mature.
A distal dog-ear can result distally if there is considerable forearm excess. In those
instances, the authors do not hesitate to cross the elbow. This can be performed during
the original brachioplasty operation or revised in a subsequent procedure. If the excess
extends all the way to the wrist, the resection is limited to 8 to 10 cm below the elbow in
the preliminary procedure. Subsequently, after the lymphatic drainage of the arm is
reestablished, a secondary final excision can be undertaken in a secondary procedure.
While the brachioplasty resection is performed super cial to the muscle fascia, thus

sparing the deep vital structures, some skin sensory nerves are necessarily resected. This
will cause some degree of sensory loss in the upper arm that is difficult to avoid.
The lymphatic drainage of the arm is often temporarily compromised after
brachioplasty, which can lead to early postoperative edema. This usually resolves in 1 to
2 weeks. However, if extensive lymphatic interruption occurs, which is more likely to be
associated with bicipital scar position, there is potential for permanent lymphedema. To
help reduce the risk, leaving behind some intact lymphatics in the axilla is advantageous.
Inability to close a brachioplasty incision is a diC cult problem. It may manifest as a
very tight closure that compromises skin vascularity or loss of distal pulses. Once
encountered, the area of greatest constriction has to be identi ed and the sutures in that
segment released. An option at this juncture is to utilize some of the resected skin as a full
thickness skin graft to bridge the gap. Another option, especially if the problem is felt to
be secondary to intraoperative swelling rather than over-resection, is to lightly wrap the
arm for a few days to allow the swelling to resolve, then attempt closing the arm without
tension. Of course, it is best to avoid this problem in the rst place by following some of
the recommendations mentioned in this chapter.
Another problem with a brachioplasty closure that is overly tight is compression of
the deeper motor nerves, particularly the ulnar nerve. This can create a scenario similar
to compartment syndrome. Treatment of this requires release of the tension and close
follow up to evaluate the extent of injury as well as to monitor return of function.
Massive weight loss patients often present with a “bat wing” deformity that extends to the
lateral chest wall. This type of deformity requires that the resection cross the axilla from
the upper arm onto the lateral chest wall to allow for maximal improvement. Multiple
checks during the marking process and the surgical procedure allow for accurately
approximating the amount to be resected and prevention of problems with under- or
over-resection. EC cient surgical technique will also prevent intraoperative swelling
leading to an inability to close the arm. Finally, although scar position in brachioplasty is
a matter of surgeon preference, placing the scar in a posterior aspect of the arm
e; ectively hides the scar during normal daily activities and avoids potential medial
antebrachial cutaneous nerve injury and may lead to less injury of the lymphatics of the
upper arms.
1 Aly AS, Cram AE. Brachioplasty. In: Aly AS, ed. Body Contouring after Massive Weight Loss.
St Louis: Quality Medical Publishing; 2006:303–333.
2 Aly A, Pace D, Cram A. Brachioplasty in the patient with massive weight loss. Aesth Surg
J. 2006;26:76–84.
3 Lockwood T. Brachioplasty with superficial fascial system suspension. Plast Reconstruct
Surg. 1995;96(4):912–920.
4 Baroudi R. Body sculpturing. Clin Plast Surg. 1984;11(3):419–443.!
Chapter 5
Brachioplasty with liposuction resection
Dennis J. Hurwitz
Key Points
• Include the deformity of the axilla and upper chest in the arm reduction plan.
• Close the excision along the posterior half of the medial arm and zigzag across the
• Fully remove excision site fat and reduce excess fat elsewhere through liposuction.
• Anchor the proximal posterior flap to deltopectoral fascia.
• Close in two layers using barbed sutures.
The female arm has a smoothly full but adherent skin covering that re ects the
underlying musculature. The sensuous and undulating axillary hollow is created by
retention of strands of fascia emanating from the chest wall to the clavipectoral fascia.
Aging as well as weight loss lead to undesirable excess skin and fat. When severe, the
hanging skin is hard to cover and painful during waving. There is a canopy-like sagging
of the posterior upper arm, which can be weighted down further by excessive adipose.
The posterior arm junction to the chest descends, creating a broad wing-like attachment.
The lateral chest has transversely oriented sagging rolls of skin lateral to the breast.
1The operative strategy relates to the magnitude of deformity. For the vast majority
2–4of presentations, arm skin reduction surgery is needed from the axilla to elbow.
Experience with severe arm and upper body deformity after massive weight loss (MWL)
led to the design of the inclusive L-brachioplasty, so named for the L shaped pattern of
excision with the long limb from the elbow to the axilla and the short limb extending at
5,6right angles through the axilla and along the lateral chest.
Preoperative Preparation
Suitable candidates for L-brachioplasty desire correction of their excess skin and fat of the
arm and axilla and at times the upper lateral chest. These patients accept the possibility
of long, possibly hypertrophic scars, asymmetry, inadequate resections, scar contracture
across the axilla, delayed wound healing, and the general medical risks inherent in this
operation. Poor candidates have excessive adiposity. Arms distended by adiposity, or
chronic swelling due to lymphatic and/or venous incompetence are contraindications.
Meticulous surgical markings permit expeditious conservative excision of the excess
skin and fat, leaving symmetrical closures. The free hand markings are followed by linear
distance measurements, creating equal lengths of anterior and posterior incision lines.
Thus, there should be little need for intraoperative skin adjustment, except for the
heavier, adipose laden arms, requiring considerable liposuction (see video
demonstration). At the time of closure, if the resection proves to be inadequate then!
another centimeter excision along either resection line perimeter can be performed.
The L-brachioplasty marking begins with a hemi-elliptical skin excision of the medial
arm, with the anterior straight line at or slightly above the bicipital groove and the
descending curved line along the posterior arm. The six critical points are found with the
patient’s arm abducted and the forearm exed 90°. Ink dots are made at point 1 at the
deltopectoral groove, point 2 at the widest portion of the mid arm near the bicipital
groove, and point 3 the termination of the brachioplasty about the medial elbow or
beyond. The straight or slight bowed line connecting these points is the anterior incision
line (Fig. 5.1). The width of the mid-arm excision is determined next by gathering and
pinching excess skin and fat posterior to the mid-arm point 2 to mark point 4 along the
mid-posterior margin of the arm (Fig. 5.1, upper). With the arm raised and the skin put
on stretch, a straight line is drawn from that widest posterior arm point 4 to meet the
anterior line termination at point 3. The proximal portion of the posterior incision line is
then drawn by finding the critical point 5 that can be advanced to the deltopectoral point
1. Pinching the approximation of point 5 to the deltopectoral groove point 1 advances
the posterior axillary fold to tightly suspend the posterior arm (Fig. 5.1, lower). So far an
incomplete hemi-ellipse has been drawn. The anterior incision from deltopectoral groove
point 1 to the elbow point 3 is measured by tape measure to con9rm it is equal in length
to the curved posterior incision from elbow point 3 to the advancement point 5. With the
arm extended, the posterior line continues across the axilla, staying several centimeters
away from the posterior axillary fold to descend to a tapered lateral chest point 6 as the
posterior incision line of the lateral chest. The length of this line (points 5 to 6) will vary
according to the skin laxity and rolls of the lateral chest. A line roughly perpendicular to
1–3 descends from the deltopectoral groove through the axilla and posterior to the lateral
pectoral fold to taper to point 6. The skin excision between these last two lines (5–6 and
1–6) removes the excess skin of the axilla and lateral chest (Fig. 5.2).
FIG. 5.1 These are color-coded preoperative markings for the L-brachioplasty.
The ink dots 1–6 are placed sequentially freehand as described in the text. The dots are
connected to create upper arm hemi-elliptical and lateral chest elliptical excisions. After
the lines are drawn the linear distances are measured and adjusted so that 1–3 equals the
distance from 3–5, and the distance 5–6 equals the distance from 1–6. Inset shows that
the outstretched arm better demonstrates these relationships. If the arm deformities aresymmetrical then these measured distances, as well as the width from point 2 to point 4,
will be the same or otherwise adjusted.
FIG. 5.2 (A) The advancement point 5 is being dotted with a surgical marker, as it is
found along the posterior incision line by pinch approximation to the deltopectoral
groove. (B) Connecting the dots point 4 to point 5 completes the descending limb of the
Surgical Technique (Fig. 5.3)
If brachioplasty is an isolated procedure, the arms, axillas and upper chest are prepped
while the patient is sitting and then dressed in a paper surgeon’s gown. Lay the patient
supine, and abduct the arms about 80° on arm boards. Under deep sedation of general
anesthesia, sterile draping is completed. We avoid arm intravenous infusion. The width of
resection is rechecked. About 150 ml of saline with 1 mg of epinephrine (adrenaline) and
30 ml of 1% Xylocaine per liter are infused through a thin multiholed, blunt tipped
needle. If only excision site liposuction (ESL) is being done, limit the infusion to within
the borders of the planned excision so the closure is not compromised. The subcutaneous
fat within the arm excision site is suctioned as completely as possible, and the author
favors preliminary application of ultrasonic energy. The remainder of the arm can have
fat suctioned as needed, with care taken to minimize trauma to the closure margins (see
FIG. 5.3 Operative sequence for L-brachioplasty.
(A) The right arm has been marked and then circumferentially prepped. The patient was
dressed in a paper surgeon’s gown, which was cut open after being positioned supine and
the arm was placed on an arm board angled 80 ° from the operating room table. (B)
Complete liposuction of the excision site is being completed as the 4 mm multiple holed
suction cannula is pulled up against the dermis, revealing the thinned tissues. (C) The
perimeter incision has been completed through the skin and subcutaneous tissue and with
about a centimeter of undermining of the wound edges. (D) The full thickness skin and fat
excision of the right lateral chest has been done. (E) The skin excision is completed with a
scalpel assisted avulsion from proximal to distal. A lattice work of connective tissue with
preserved neurovasculature lies in the wound bed. (F) The subcutaneous layer has been
closed using a single Quill #1 PDO 30 cm long suture. A second layer of 3-0 Monoderm
The 9nal adjustment for the adequacy of the width of resection is aided by
temporary staple or towel clip closure. Then the posterior arm incision is made through
the skin and super9cial fascia with traction anteriorly on the arm skin. Once through the
fascia the incision pops open and then is undercut about 1 cm. The posterior incision is
then continued across the axilla and along the lateral chest to the tapered end at point 6.
The anterior straight line arm incision is similarly made, undermined, and continued
across the axilla and descends as the anterior incision of the lateral chest to a depth of the
serratus fascia. If breast augmentation or a spiral ap breast reshaping is to be
performed, the anterior limb of the chest ellipse is not incised until the mastopexy/
augmentation is completed, because the recruitment of skin aps in a breast
7augmentation reduces the need for lateral chest skin resection.
The skin resection begins with thick full thickness skin and subcutaneous tissue
resection from the chest and continues through the thin axillary tissues over the
clavipectoral fascia. Stay immediately subdermal to avoid entering the axilla and
damaging neurovasculature. Distal traction of the arm skin produces avulsion removal,
assisted by scalpel along the exposed dermis. Little bleeding is encountered as the arm
skin is removed like a full thickness skin graft. Super9cial veins, lymphatics, and sensory!
nerves are preserved on the arm, within a latticework bed of connective tissue nearly
empty of adipose tissue.
A nonundermined proximal posterior triangular ap is advanced to the deltoid fascia
at the groove with the pectoralis using several 2-0 braided absorbable sutures.
Undermining of this ap threatens the vitality of this precarious skin blood supply. Upon
closure across the axilla there will be fullness that over time will recontour to a natural
axillary hollow. Using the preoperative hatch marks as a guide, the incisions are then
aligned with towel clamps. Excess skin can be resected along the wound edge if needed.
While any continuous horizontal running 2-0 absorbable suture could approximate
the subcutaneous fascia, the author prefers the even and reliable long-term retention of
the knotless, 0 or #1 PDO double armed barbed Quill (Angiotech Pharmaceuticals,
Vancouver, British Columbia, Canada). The 24 cm long #1 barbed PDO comes on a
38 mm tapered needle that is passed through as a running horizontal mattress suture,
starting from the center of the wound and advancing distally (elbow) and proximally
(deltopectoral groove). To start the closure, two horizontal bites are taken away from the
center with each needle and the Quill suture is pulled taut. After two passes of the suture
on either side of the wound, the barbed suture is cinched and secured under the
appropriate tension. As the suturing proceeds, the barbs keep the closure from slipping.
Thus there is no segmental slippage as may occur with other running sutures. At the end
of the wound, the barbed suture is returned back for several throws, forming a J, and the
end is then cut. The series of dermal dimpling caused by the horizontal suture pull of the
subcutaneous fascia to the dermis will disappear over several months. A second
continuous barbed intradermal suture closure follows, using 3-0 Monodern Quill SRS.
Dermal glue or taping completes the closure.
Only late lymphoceles, rather than early seromas, can be a problem. As such, suction
drains are unnecessary and we believe are contraindicated as negative pressure
encourages ow from damaged lymphatics. The operative time for each arm is
approximately 40 minutes. The incisions are covered with foam dressing and then
wrapped in ace bandages with the hands elevated. Before and after photographs are seen
in Figs 5.4–5.6. The result of an L-brachioplasty with circumferential liposuction is seen
i n Figs 5.7–5.9. Please see the accompanying video for this chapter for this surgical
FIG. 5.4 Before and 7 months after L-brachioplasty frontal views with a 7 kg (15
pound) weight gain for the 51-year-old patient (BMI 28) seen in the operative sequence in
Fig. 5.4. The preoperative drawings are seen. The hanging posterior skin is gone. The
incompletely faded scar curves from the axilla down to the mid arm and then slightly
ascends to the elbow.FIG. 5.5 Before and 7 months after L-brachioplasty posterior views for the patient seen
in the operative sequence in Fig. 5.4. Despite her 7 kg (15 pound) weight gain, her arms
are smaller and better shaped.
FIG. 5.6 Before and 7 months after L-brachioplasty left oblique views for the patient
seen in the operative sequence in Fig. 5.4. The full course of the brachioplasty scar is seen
as it crosses the axilla and descends on the chest. The arm, axilla and lateral chest are
well shaped and reduced.
FIG. 5.7 Before and 1 year after frontal views of a L-brachioplasty with circumferential
liposuction in a 48-year-old MWL patient with a BMI of 35.5. The upper arm sagging skin
has been improved.!
FIG. 5.8 Before and 1 year after left oblique views of a L-brachioplasty with
circumferential liposuction in the same 48-year-old MWL patient with a BMI of 35.5. The
axillary and chest wall improvement is seen.
FIG. 5.9 Before and 1 year after posterior views of a L-brachioplasty with
circumferential liposuction in the same 48-year-old MWL patient with a BMI of 35.5. The
overall arm and arm to chest attachment improvement is seen.
Optimizing Outcomes
1 . The positioning and precise geometry of the surgical markings are standardized,
thereby increasing symmetry, expediting the operation, and leaving the least
conspicuous scar.
2 . The posterior V-shaped advancement ap is 9rmly secured to the deltopectoral
fascia, assisting vertical lift and minimizing distal scar drift.
3 . Thorough excision site liposuction (ESL) of the anticipated hemi-elliptical arm
excision allows for excision of skin only, preserving the neurovasculature; thereby
eliminating chronic edema and lymphoceles.
4 . A two-layered absorbable horizontal running barbed suture closure reduces
operative time, improves wound retention and the incidence of delayed healing.
Postoperative Management
The arms are elevated on pillows for 3 days. The sponge and ace bandages are removed!
and replaced with securely 9tting elastic sleeves at 3 days. Complete maturation of the
scars with massage and a variety of topical agents takes over 2 years.
Complications and Their Management
While under-resection results in inadequate treatment, partial recurrence can result even
with adequate resection, from inherent tissue laxity, which is common after MWL.
Overresection of skin is diI cult to close and can lead to incision line dehiscence or vascular
compromise to the hand. Skin edge necrosis and delayed wound healing may lead to
widened and hypertrophic scars, and contractures across the axilla. Chronic swelling,
lymphoceles, sensory loss and muscular paralysis due to radial nerve and
musculocutaneous nerve injury and pain are recognized but uncommon complications.
Since using the modi9cations described here, complications have been reduced and
satisfaction improved. The markings are more precise, leading to expeditious surgery. The
anchoring to deltopectoral fascia is more secure with less distal drifting of the axillary
scar. Over the past 4 years, there were 13 women and 2 males treated. There have been
no seromas or lymphoceles. Appreciable swelling has resolved in all cases within a
month, with no cases of prolonged edema.
Incision dehiscence was limited to less than 1 cm in 9ve patients. Tip necrosis of the
V advancement ap occurred in three arms, leaving small wounds in the axilla to heal
secondarily. Secondary skin reduction was not needed. There were no contractures across
the axilla in this group of patients.
5The originally designed L-brachioplasty is commonly used for the MWL arm deformity.
With our better understanding of the esthetics and the four modi9cations described
6herein, we have improved our results and lowered complications. We have gone beyond
7the concept of arm reduction surgery to sculpturing a region to esthetic beauty. It is
better to leave a little extra tissue than compromise shape or hazard serious
8complications. Already a commonly accepted procedure, with the improvements in
shape, scar placement, and reduced complications, L-brachioplasty can take its place as
the optimal cosmetic operation for moderate to severe skin and fat redundancy of the
upper arm.
1 El Khatib HA. Classification of brachial ptosis; strategy for treatment. Plast Reconstr Surg.
2 Aly A, Soliman S, Cram A, et al. Brachioplasty in the massive weight loss patient. Clin
Plast Surg. 2008;35:141–147.
3 Lockwood T. Brachioplasty with superficial fascial system suspension. Plast Reconstr Surg.
4 Pitanguy I. Correction of lipodystrophy of the lateral thoracic aspect and inner side of
the arm and elbow. Clin Plast Surg. 1975;2:477–483.
5 Hurwitz DJ, Holland SW. The L Brachioplasty: An innovative approach to correct excess
tissue of the upper arm, axilla and lateral chest. Plast Reconstr Surg. 2006;117:403–411.
6 Hurwitz DJ, Jerrod K. L-Brachioplasty: an adaptable technique for moderate to severe
excess skin and fat of the arms for featured operative techniques. Aesth Plast Surg. J.
7 Hurwitz DJ, Agha-Mohammadi S. Post bariatric surgery breast reshaping: the spiral flap.Ann Plast Surg. 2006;569(5):481–486.
8 Symbas L, Losken A. An outcome analysis of brachioplasty techniques following massive
weight loss. Ann Plast Surg. 2010;64(5):588–591.&
Chapter 6
Limited scar brachioplasty
Lawrence S. Reed
Key Points
• Good for many, but not all, cases of brachial dermatolipodystrophy in non-massive
weight loss patients. The vertical height from the mid-humerus to the most dependent
portion of the mid-upper arm (with the arm at 90° to the body) should be no greater
than 10 cm. For excessive upper dermatolipodystrophy, the traditional method should
be used.
• The tailor tack method should always be used intraoperatively to con rm the accuracy
of the preoperative markings. This should be done after any liposuction, if necessary,
is performed. Corrections or modi cations can be made at this time. The tailor tack
closure should always be checked with the patient in the upright position and the arm
at a 90° angle to the lateral chest.
• A super cial plane should be used for the resection of the involved area, taking only a
thin layer of fat with the resected specimen.
• The elbows should not be raised above the level of the shoulders until 3 weeks
• During the preoperative marking, the transverse axis width of the incision (in the
axillary fold) should stop at 1.5–2 cm medial to the visible portion of the axillary
crease on the anterior and posterior shoulder. This helps in preventing the nal scar
from extending into visible areas.
• Undesirable anterior axillary and post-axillary fullness can also be corrected during this
• 12% of patients need some form of revisional surgery performed at 1 year or later. The
most common reason is for scar correction.
There is an ever increasing demand, mainly in women, for correction of brachial
dermatolipodystrophy. Most patients, however, are not willing to accept the traditional
brachioplasty scar that extends, in various con gurations, from the axilla, running along
1the inner arm to the elbow. Following the seminal paper by Pollock, which described his
technique for the treatment of hidradenitis suppurativa by excision of the involved
axillary area followed by direct closure, I began to adapt this approach for esthetic
brachioplasty. I now have 25 years of experience with this approach. There have been
1–8numerous re nements over the years. The minimal incision brachioplasty (MIB)
technique is the preferred approach for most patients that I see, save for those with
excessively dependent dermatolipodystrophy of the upper arms (as commonly seen in
massive weight loss patients). In all other cases, it provides predictably good results that
are equal to those achieved in comparable patients with the traditional approach. I am
most frequently asked how simply tightening the skin of the axilla, in the minimal
incision approach, can replicate the result achieved when the customary extended&
incision method is employed. This is best demonstrated by referring to the mechanics of
the classic bamboo nger trap (Fig. 6.1), which when pulled on just one end
circumferentially tightens the entire length of the tube.
FIG. 6.1 The bamboo nger trap aptly demonstrates the principle of the transaxillary
brachioplasty in which traction in the axilla narrows the circumference of the upper arm.
(A) Finger trap with no traction on it. (B) Traction on one end of nger trap narrows its
entire circumference.
Preoperative Preparation
Patients are instructed not to shave their axillary hair for 48 hours before surgery.
Standard preoperative laboratory testing is performed, as indicated by age and medical
Surgical Technique
1 . Marking is performed in the preoperative holding area with the patient in the
upright position. With arms against sides, mark the anterior and posterior shoulders
at the junction of the axilla with the shoulder. The nal scar should not be visible
beyond these markings (Fig. 6.2A).
2 . Mark longitudinal axis from central inner arm, through center of axilla, to the
midlateral chest area (Fig. 6.2B).
3. Mark the transverse axis from anterior shoulder to posterior shoulder in the axillary
crease or fold. This line should stop 1.5–2 cm medial to the anterior and posterior
axillary crease–shoulder junction. This helps avoid a scar that will extend into a
visible area of the shoulder (Fig. 6.2B).
4. Determine the longitudinal length of excision using the pinch technique. First, move
the skin of the triceps towards the transverse axis line until the arm has a pleasing
contour. Then move the lateral chest skin towards the transverse axillary line. It is
important to advance the lateral chest skin towards the transverse axillary crease to
fix and stabilize the upper arm correction (Fig. 6.2C, D).
5. Mark areas that require liposuction. These should include, if indicated, the area of
lipodystrophy of the upper outer breast/anterior axillary area as well as the posterior
shoulder/axillary area. Both of these areas of lipodystrophy – which patients
frequently point out as being of concern – can be easily corrected during the MIB
procedure by liposuction and the subsequent axillary skin tightening. =

FIG. 6.2 (a) With the patient standing with arms at the side (adducted), the visible
portions of the anterior and posterior axillary folds are marked with a triangle. This mark
is used to determine the transverse diameter of the planned exposure, which extends 1 to
1.5 cm medial to the point of each triangle. (b) The arm is su ciently abducted to mark
the axillary hollow or crease apex. This line is then shortened so that it stops about 1.5 cm
before hitting the axillary fold marks. The line is bisected and carried up the arm and
down the chest wall to mark the meridian of the axilla. (c) The arm is abducted 90°, and
the excess skin of the triceps area is forcefully advanced toward the axillary crease and
marked as point A. (d) Next, the skin of the chest wall is next similarly advanced toward
the axillary crease with force adequate to balance the tension (point B). The points are
connected to make an oval area of proposed resection.
The Procedure&
1. Place patient on operating room table with arms outstretched.
2. Circumferentially prep arms and chest and apply appropriate draping.
3. Infiltrate tumescent solution into the areas to be liposuctioned (approximately 1 : 1).
4 . In ltrate dilute local anesthesia (1% Xylocaine plain 50 ml and 0.25% Marcaine
50 ml, 1 ml 1 : 1000 epinephrine (adrenaline) plus 150 ml normal saline) into areas
of planned surgical resection.
5. Carry out liposuction on both upper arms.
6. Use the tailor tack method to check the accuracy of the preoperative markings. It is
important to check the tailor tack closure with the patient in the upright position and
the arm at 90° to the lateral chest. Make any revisions necessary in the initial
preoperative markings. At this time also check for any abnormal folds or rotations in
the skin of the arm. Adjust the tailor tack suture placements to correct these as well.
After necessary adjustments have been made, remark the planned surgical site (Fig.
7 . Remove the tailor tack sutures or Adairs, and with the patient in the recumbent
position, excise the involved area with just a thin layer of fat attached (Fig. 6.3B).
8. Clean area with 5% Betadine and mark out the area of the axillary crease (Fig.
9. Wound closure:
a. First layer 1 Vicryl which incorporates the base of the wound in the area of the
axillary fold (Fig. 6.4)
b. Two layered closure with 2-0 14×14 PDS Quill suture
c. Final layer running 3-0 plain gut vertical mattress suture.
10. Concealing the scar: In many cases the closure of the surgical site can cause the
nal scar to extend into the visible portions of the anterior or posterior shoulder, or
both. This should be addressed at the time of closure using the purse string
a. Undermine the involved area and defat if necessary (Fig. 6.5)
b. Use a 2-0 7×7 Quill suture anchored in the axillary fold to bring the visible portion
of the scar back into the axillary fold. This will leave some bunching and a dog-ear.
These largely disappear in 3–6 months (Figs 6.6 and 6.7)
c. After the purse string correction, complete the closure in the standard fashion (Fig.
11. Selective use of bolster dressing. In those cases where it is felt that the axillary fold
may be di cult to recreate or there is obvious tension, use a bolster dressing made
from a rolled up ABD pad.

FIG. 6.3 (a) Final determination of the amount of tissue to be removed is made
during surgery, using the tailor tack method. (b) Intraoperative view of axillary area of
resection measuring 17 × 9 cm. (c) This intraoperative view demonstrates the amount
of tissue removed as well as the remarking of the axillary crease with methylene blue.
Note the presence of subcutaneous fat remaining on the axillary fascia.&
FIG. 6.4 After the axillary tissue is excised, the axillary crease is marked again. The
fold is recreated during closure, incorporating the fascia into each stitch, using 1.0
FIG. 6.5 The extended visible portion of the incision is rst undermined and then
defatted to the dermis before executing the purse string closure.&
FIG. 6.6 After the incision is defatted at its ends in the subdermal plane, it is closed
with a purse string stitch, using 2.0 Quill suture, thus pulling the wound edges further
back into the axilla. This bunched tissue usually settles in 3 to 6 months.
FIG. 6.7 Area of gathered skin at the wound after the purse string suture closure. This
area usually settles out after 3 to 6 months.
FIG. 6.8 View of nal closure with purse string correction of elongated anterior
axillary incision.
Prior to beginning closure of the wound, place four #1 retention sutures, placed&
3 cm from the wound edges. These sutures should pass carefully through the base of
the wound. After the nal closure, these sutures will be used to snug the bolster
dressing in place. The bolster is normally left in place from 2 to 4 days. No drains are
used. Bacitracin and gauze are placed on the surgical sites. No arm wraps or surgical
arm garments are used (Fig. 6.9).
FIG. 6.9 Bolster dressing in place at end of procedure helps to recreate axillary fold.
Optimizing Outcomes
1 . Patient selection. Ideal candidates have skin laxity that can be well corrected by
axillary skin excision alone. Patients with excessive skin laxity should be counseled
about a standard brachioplasty.
2. Careful preoperative markings.
3. Always employ the tailor tack method prior to surgical excision and check it in the
upright position with the arm at 90° to the lateral chest. Any abnormal folds of the
upper arm skin can also be addressed at this time.
4. Do not be timid in executing the correction. Remember you will check the accuracy
of your preoperative markings with the tailor tack method.
5. If the axillary fold is not well de ned or in more fatty arms, a bolster dressing should
be considered. It may be necessary to defat the area of the axillary fold for better
definition using direct excision or liposuction.
Postoperative Care
1. No surgical dressings or garments.
2. Encourage patients to limit arm motion as much as possible.
3. Wash surgical area 24 hours after surgery unless bolster dressing is in place. In thosecases, area should be kept dry until bolster is removed, normally in 2 to 4 days.
4 . Use Purell® or similar waterless sanitizer or rubbing alcohol four times a day on
incision sites.
5. Do not raise elbows above level of shoulders for 3 weeks.
6. After 3 weeks, begin active (no passive therapy) elevation of arms.
Complications in a series of 650 cases have included two infections, both of which
responded to conservative antibiotic therapy. In 8% of patients small wound separations
(1–2 cm) occurred, usually after 14 days. All healed by secondary intention after
wet-todry dressings and topical antibiotic ointments.
Two complete wound dehiscences; both after an arm was fully extended above the
shoulder, occurred at 7 and 10 days post operation. These were corrected on the days of
the injuries and went on to uneventful, satisfactory healing.
In 10% of patients, hypertrophic or unacceptable scarring occurred. All revisions on
nonacute surgical complications are carried out at 1 year.
There may be bow-stringing or “bat wing” deformity secondary to tension. This is
treated with a Z plasty or other skin lengthening technique with scar release. We use
bolster dressings for 3–5 days. The more commonly seen presentation is bow-stringing or
“bat wing” deformity secondary to distraction or separation of the axillary skin from the
base of the wound. One can check for distraction by seeing how easily the involved area
of skin can be pushed up into the axillary hollow. This is treated with scar excision only.
Place sutures for the bolster dressing and tack the edges of the wound to the axillary base
in line with the axillary fold. Close the incision and leave the bolster dressing in place for
3–5 days. The bow-string deformity is not uncommonly seen in patients with
macromastia or heavy pendulous breasts. For these patients, wearing a good, supportive
bra will lessen or eradicate the bow-string presentation. A reduction mammoplasty should
also be considered. It is important to recognize this phenomenon and discuss these
options with the patient during the initial consultation.
No hematomas or seromas were observed. No neurovascular, lymphatic, or
musculoskeletal problems occurred.
The minimal incision transaxillary brachioplasty should be the procedure of choice for all
those patients requesting recontouring and rejuvenation of the upper arm who do not
have excessively dependent dermatolipodystrophy. Please refer to Figs 6.10–6.14 for a
representative selection of before and after surgery results. It is a simple procedure that
delivers predictably good results, comparable to those results achieved with the
traditional approach, while confining the scar to the axillary area.

FIG. 6.10 (A–D) Views of 63-year-old woman before surgery and 4 months
FIG. 6.11 (A, B) Views of 47-year-old woman before surgery and 6 months

FIG. 6.12 (A, B) Views of 32-year-old woman before surgery and 11 months

FIG. 6.13 (A, B) Views of 43-year-old woman before surgery and 5 months
FIG. 6.14 (A, B) Views of 43-year-old woman before surgery and 5 months
1 Pollock WJ, Virnelli FR, Ryn RF. Axillary hidradenitis suppurativa: a simple and effective
surgical technique. Plast Reconstr Surg. 1972;49:22–27.
2 Correa-Iturraspe M, Fernandez JC. Dermolipectomia braquial. Prensa Med Argent.
3 Teimourian B, Malekzadeh S. Rejuvenation of the upper arm. Plast Reconstr Surg.
1998;102:545–551. discussion 552–3
4 Abraham DL. Minibrachioplasty: minimizing scars while maximizing results. Aesth Surg J.
5 Richards ME. Reassessing minimal incision brachioplasty. Aesth Surg J. 2004;25:175–179.
6 Richards ME. Minimal incision brachioplasty: a first choice option in arm reduction
surgery. Aesth Surg J. 2001;21:301–310.
7 Trussler AP, Rohrich RJ. Limited incision medial brachioplasty: technical refinements in
upper arm contouring. Plast Reconstr Surg. 2008;121:305–307.
8 Reed LS, Hyman JB. Minimal incision brachioplasty: refining transaxillary arm
rejuvenation. Aesth Surg J. 2007;27(4):433–441.Part 3
Chapter 7
Fat grafting to the breast
Kamran Khoobehi
Key Points
• Fat harvesting should be done with maximum care and minimal negative pressure to
prevent damage to the fat cells.
• Patient selection and education to manage expectations will maximize patient
• The fat should be injected in multiple layers to prevent pooling and cyst formation.
• The use of 3D imaging will help to quantify the pre- and post-injection breast volume.
This will help to measure the fat survival percentage.
• Fat harvested from di erent donor sites should be mixed before injection to have a
similar fat cell population in both breasts.
For additional online content visit http://www.expertconsult.com
Autologous fat grafting is a well-established technique that is practiced by many plastic
surgeons. Fat cell abundance and ease of harvesting make fat grafting a logical choice for
soft tissue defect restoration and augmentation. The technique of fat grafting varies from
surgeon to surgeon, and there are no standardized harvesting, preparation and injection
The current popularity of fat grafting, in many ways, is because of the work done by
Dr. Sydney Coleman. He popularized the technique for harvesting the fat using a
1handheld syringe and centrifuging for compaction.
The need for large volume fat harvesting and injection could not be met by the
current techniques due to the length of time needed to harvest fat and centrifuge the fat.
The average time for harvesting, processing and injecting fat by the Coleman technique is
3 2100 cm of fat in 1 hour.
History of Fat Grafting
3The history of fat grafting goes back to 1893 when Neuber used it for facial defects. In
41895, Czerney used fat grafting for chest wall deformity post mastectomy. The early
experimentation with fat grafting was not popular because, at a time when little was
known about tumescent liposuction, most fat harvesting was performed by excision. The
use of tumescent liposuction has given us the ability to harvest large amounts of fat with
minimal donor site morbidity.
5,6In 1987, Mel Bircoll published his work on fat grafting to the breast. The
shortcomings of his work were poor long-term follow-up and a lack of mammographic=
7studies as indicated by letters to the editor from 1987. American Society of Plastic
Surgeons (ASPS) published a position paper in 1987 “Deploring the use of fat injection in
8breast augmentation” due to the fear of interference with breast cancer detection. The
main concern at that time was that calci cation from necrotic fat would cause
interference with breast tissue evaluation by mammogram. At the same time published
9,10 11,12papers stated that surgical procedures such as breast reduction, augmentation
and any breast procedure can also cause calci cation. Further studies indicated that
calci cation from fat necrosis is easily distinguished from breast cancer
There was a long gap before any work was published on fat grafting to the breast.
Dr. Coleman published his work on fat grafting to the breasts in 2007. His results were
2remarkable and showed long-term survival of the injected fat.
In 2007, ASPS and The American Society for Aesthetic plastic surgery (ASAPS)
jointly and strongly supported the ongoing research e orts that would improve the safety
21and e cacy of the procedure but also cautioned against fat grafting for breast
The future of fat grafting depends on the establishment of a standardized harvesting,
processing, injection technique, long-term follow up for safety and e cacy, and also
establishment of a data base for all the fat grafting patients.
Principle of Low Pressure Fat Harvesting
Handheld syringe aspiration is accepted as a gentler technique for fat harvesting. There
are no published data to support this claim. We at LSU division of Plastic and
Reconstructive Surgery undertook the study to nd out the negative pressure that is
generated by handheld syringes and liposuction machines. The graph in Fig. 7.1 shows
the in-situ maximum pressure within the 1, 3, 5, 10, 30 and 60 cc syringes. Negative
pressures were measured in vitro and in situ with 1, 2, 3, and 10 cc pull on a 10 cc
LuerLock syringe as well as a conventional liposuction machine at 254 mmHg, 381 mmHg,
and 762 mmHg (Figs 7.1, 7.2, and 7.3).
FIG. 7.1 The graph shows the in-situ maximum pressure within the 1, 3, 5, 10, 30, and
60 cm3 syringes.#
The graph shows the negative pressure produced in a 10 cm3 syringe to be asFIG. 7.2
high as 660 mmHg with full pull and 280 mmHg with only 1 cm3 pull on the 10 cm3
FIG. 7.3 Negative pressure measurements for liposuction machine at di erent setting in
The graph in Fig. 7.2 shows the negative pressure produced in a 10 cc syringe to be
as high as 660 mmHg with full pull and 280 mmHg with only 1 cc pull on the 10 cc
The constant negative pressure at the low setting (254 mmHg) by a liposuction
machine is 220 mmHg. This is less than the negative pressure in a 10 cc syringe only
3pulled back 1 cm . Most liposuction machines have a control for adjusting the negative
In order to evaluate the extent of damage to fat cell caused by all harvesting
techniques, lipoaspirant samples were analyzed using lactate dehydrogenase (LDH) and
triglyceride levels (Fig. 7.4). Glucose-3-phosphodiesterase (G3PD) assay was used to
measure cell viability (Fig. 7.5). LDH and triglyceride are intracellular components and
their presence in the aspiration Euid indicates cell damage and cell wall disruption. The
results suggests that the samples harvested with the low negative pressure liposuction
machine were lower in LDH and triglycerides. The G3PD assay suggests cell viabilities
were high in samples from the low-pressure liposuction machine in comparison to the
handheld syringe, which indicates more viable cells by the low pressure technique.FIG. 7.4 Basis of fat grafting – biochemical markers.
FIG. 7.5 Assessment of viability – G3PD activity.
Harvested fat cells were stained with Euorescent dyes for imaging using scanning
electron and confocal laser electron microscopes (Fig. 7.6). The slides show the outer cell
layers bursting from the negative pressure.
FIG. 7.6 Basis of fat grafting – microscopic analysis.
The low-pressure liposuction method removes the human factor and variation of the
pull on the syringe and provides consistent negative pressure that helps to decrease
operating room time and also prevents the surgeon’s hand fatigue. This technique yields
large volumes of fat in a short period of time and minimizes the damage to the fat cells.=
Autologous Fat Grafting to the Breast
In June 2008 at Louisiana State University Health Science Center in New Orleans, we
started an IRB approved study on fat grafting to the breast. So far we have had more
than 276 patients in this study and collection of the data has started for the follow up
studies. Currently, fat grafting to the breast is a treatment option in conditions such as
micromastia, breast ptosis, post mastectomy breast reconstruction, asymmetric breast,
congenital malformation of the breast, and for treatment of complications associated with
implant augmentation mammoplasty.
Local Infiltration
3 3The solution that is used is 20 cm of lidocaine 1% with epinephrine, plus 2 cm
epinephrine 1/1000 in 1 liter of lactated Ringer. The volume of tumescence is 10–20%
more than the aspirate. It is imperative to wait 20 min. post in ltration to maximize
vasoconstriction and minimize blood loss.
A blunt 5 mm Mercedes tip cannula is used for harvesting the fat. The common belief is
that a large cannula will damage the donor site, but our experience with large cannulae
has been the opposite. The other belief is that a large cannula will produce large particles
of fat, which will make it hard to reinject with a small cannula (11 gauge) but our
experience also has been contrary to current belief.
Fat Cell Preparation
The process of centrifugation increases the risk of contamination and cell damage. One
advantage of centrifugation is to compact the fat cells. Another advantage of
centrifugation is the ability to separate damaged cells from intact cells. Centrifugation at
a low speed for a short period (100 g/30 s) will give the same compaction as a higher
speed and longer period (1400 g/3 min). Refer to Fig. 7.7. The other observation is the
lack of oil on the top of the syringe with low pressure fat harvesting. This observation is
consistent with our study showing that the fat cells harvested by low pressure are
damaged less, and less oil leaks out.
FIG. 7.7 The picture shows the lack of free oil on the top after centrifugation at 100 g
and 1500 g.=
The drawback of not centrifuging the fat is overestimation of the amount of actual
injected fat. We adjust the actual injected fat by 20% to correct for this if we do not
centrifuge the fat before injection.
Fat Injection
After the fat has been decanted, the Euid in the bottom of the jar is discarded and the fat
3 3 3cells transferred to 30 cm syringes and then from 30 cm to 10 cm syringes with a
male-to-male connecter. Fat cells are then injected in a multilayer technique while
3withdrawing. Each 10 cm syringe will require at least ve to seven passes to nish. The
cannula for injection is an 11 gauge blunt tip single-side port cannula. A double-sided
port causes trapping of the ligaments and clogging. Injection is started in the
submuscular plane, then at the subcutaneous layer and finally, the subglandular planes.
FIG. 7.8 For patients with saline implants the implants are deEated under local
anesthesia 2 weeks before the planned surgery to give the tissue time to contract.
Postoperative Care
In our practice the recovery from fat grafting is fast and much less painful than with
implant breast augmentation. Most patients complain more about the donor site than the
breast pain. There is usually swelling that resolves in a few weeks. The breast volume will
nalize at 3 months post injection. Massaging of the breast is discouraged during the rst
few days to prevent pooling of the fat.
A preoperative mammogram, 3D imaging and photographs are obtained on all
patients as well as a postoperative mammogram and 3D imaging a year after the surgery.
Patients follow the American Cancer Society guidelines for follow up breast cancer
Our experience with patient satisfaction has centered around long-term volume
retention. Most patients are concerned about the loss of volume. The use of 3D imaging,
patient education and also consistent photographic documentation is a must. Patients
emphasizing the size rather than the quality of the result are not good candidates for fat
Fat Grafting for Implant Failure
The use of the implant for breast augmentation is the accepted treatment that works well
in the majority of patients. Complications from augmentation include capsularcontracture, rippling, bottoming out, infection, palpable implants, visible implants, and
an unsatisfactory shape and size. The use of silicone gel has helped in certain patients to
decrease rippling and palpable implants. For patients that do not want implants
anymore, or have failed with these treatments, fat injection is an alternative.
For patients with saline implants, these are deEated under local anesthesia 2 weeks
before the planned surgery to give the tissue time to contract (Fig. 7.8B, C). Figure 7.9
shows the same patient 2 weeks later. The amount of tissue retraction and improvement
is impressive.
FIG. 7.8 For patients with saline implants the implants are deEated under local
anesthesia 2 weeks before the planned surgery to give the tissue time to contract.
FIG. 7.9 (A) Patient 5 years post saline breast augmentation by another surgeon. (B)
Immediate post saline implant deEation under local anesthesia. (C) 2 weeks post
deflation only.
FIG 7.8B, C, 7.9, 7.10, 7.11. APPEARS ONLINE ONLY
During the surgery the fat graft is performed rst and then the deEated implant is
removed and a drain placed in the pocket. The protocol is di erent for patients with
saline implants (Fig. 7.10) vs. silicone gel implants (Fig. 7.11). For silicone gel implants, I
would remove the implants and capsule rst with limited fat grafting to prevent fat
collection in the explanted implant pocket. The nal fat grafting is performed 3 months
FIG. 7.10 (A) Sub glandular saline implant. (B) Immediate post deEation. (C) 1 year
post one session of fat grafting (R 350 cc and L 430 cc).
FIG. 7.11 (A) Patient 25 years after silicone gel breast augmentation,capsular
contracture and implant rupture. (B) One year post implant removal and fat grafting (R
267cc and L 280 cc) in one session.
The mammograms before explantation show minimal breast parenchyma
visualization and blockage of the breast tissue by the implant. In mammograms after
explantation and fat grafting, full breast tissue can be evaluated. Figures 7.12 and 7.13
show mammograms before and 1 year after fat grafting.
FIG. 7.12 Mammogram before and one year after implant removal and fat grafting.FIG. 7.13 Mammogram before and 1 year after fat grafting.
Fat Grafting in Conjuction with Mastopexy
The aim of any mastopexy operation is repositioning of a sensate and viable nipple to an
esthetically pleasing point on the breast mound with minimal scars and augmentation or
creation or improvement of upper pole fullness with minimal scars. Therefore, the ideal
approach to rejuvenate and lift the breast requires the surgeon to address the issue of
simultaneous volume augmentation. The concept of a single stage mastopexy with
implant augmentation is an attractive concept but raises debates amongst most plastic
22surgeons. The complications are attributed to the contradicting forces that the breast
parenchyma is subjected to during an augmentation/mastopexy, along with the
alteration in the architecture of the breast and the blood supply to the mammary tissue
and its nipple–areola complex. The complications range from dehiscence, poor scarring,
recurrent ptosis, areola asymmetry, nipple ischemia, deEation, capsular contracture,
misplacement, and infection. In fact, Spear et al reported a complication rate of 17.4%
with a revision rate of 8.7% for primary augmentation/mastopexy in his 3-year review.
Another recent publication reported a complication rate of 10.6% with a revision rate of
2314.6% for augmentation/mastopexy over a 14-year period.
Furthermore, superior pole fullness is usually lacking in the majority of patients
undergoing this procedure and postoperative “bottoming out” of the implant is a
common long-term problem. In order to avoid the use of implants with mastopexy,
multiple procedures are reported in the literature utilizing various Eaps to provide
superior pole fullness along with repositioning of the nipple and tightening of the skin
Preoperative Preparation
Patients are instructed to not gain or lose weight before surgery. All patients are prepped
with antibacterial soap the night and morning of the surgery. We require a preoperative
mammogram and postoperative mammogram 1 year after surgery.
Surgical Technique
Fat harvesting is performed based on the described protocol. Fat injection is performed
with a blunt 11 gauge cannula through small 2 mm stab incisions on the medial and
lateral aspects of the breasts. Liposculpting is performed by deploying the fat in a
layering fashion into the subpectoral and prepectoral planes as well as into the
3subcutaneous planes. With each pass approximately 1–2 cm of fat is deposited into the