• A discussion of different techniques in body contouring surgery including brachioplasty, liposuction, abdominoplasty, thigh lift, and lower body lift as well as general safety principles for combined and single procedures. This is a two part series to provide overviews of each technique.  

Brachioplasty 

• Anatomy: subcutaneous fat in the arms tends to collect posteriorly and inferiorly. There are two fascial systems in the arm: the superficial fascial system and the longitudinal fascial system. The superficial fascial system encases the fat of the arm from axilla to elbow; the longitudinal fascial system begins at clavicle and is known as the clavopectoral fascia. This extends to the axilla and is deep to the pectoralis. These fascial systems loosen with age and the result is ptosis.  The deep fascial system houses all important neurovascular structures and should not be violated.  
• Sensory nerves of the arm: these include the intercostobrachial and medial brachial cutaneous which supply middle third of arm (pierces fascia 7cm proximal to medial epicondyle), musculocutaneous nerve which supplies sensation to the lateral arm, and the medial antebrachial cutaneous nerve, which originates (middle/distal third and provides sensation to wrist and medial forearm. This pierces the deep fascia 14 cm proximal to medial epicondyle). The MABC runs with the basilic vein and divides into anterior and posterior branches. 
• Remember the MABC exits the lower cord of the brachial plexus 

• Patient Evaluation: Patient evaluation includes complete history including weight loss and weight gain, tobacco use and nutritional deficiencies.  
• Physical exam: this should include evaluation of the arms including range of motion, excess lipodystrophy or skin laxity. This will dictate the type of brachioplasty performed.  
• Classification of Upper Arm contouring: This is divided into three classes depending on skin and fat excess. Type I has minimal skin excess and moderate fat excess. Type II has moderate skin excess and minimal fat excess and further divides into location of skin excess (proximal, entire arm, arm and chest). Type III has moderate skin and moderate fat excess and has similar divisions into location of skin excess.  

• Remember I (minimal skin excess, moderate fat) II, moderate skin and minimal fat excess, III moderate both skin and fat excess.  
• Type I is best treated with liposuction alone. (>1.5cm pinch test) 

• Type II: if horizontal skin laxity alone, perform elliptical skin excision down length of arm. If horizontal and vertical may perform a T shaped excision. Extended brachioplasties on the chest wall are appropriate for chest laxity seen in MWL patients. 
• Type III: These patients usually require further weight loss prior to surgery. You may stage liposuction first followed by excision.  
• In general, when planning your excision patterns, it will be performed in the opposite vector from the direction of excess. 

• Techniques: 
• Liposuction: concentrated in the medial and posterior quadrants of the upper arm and can be performed for type I or III patients. This should be performed at an intermediate depth with 0.5cm of subcutaneous fat left on the skin to prevent contour deformities. Care is taken to stay away from medial epicondyle. 

• Minibrachioplasty/Limited Medial Incision Brachioplasty: this is indicated for patients with mild skin laxity and mild-to-moderate excess fat.  (type I).  A pinch test is used at the axilla and a small vertical incision is made (3-5cm in width) for vertical axillary skin excess. As a general rule, to prevent scar widening permanent sutures are placed from the superficial fascial system to the longitudinal fascial system (axillary fascia to clavopectoral fascia to dermis). This helps correct laxity and provide longevity of result. Good skin quality is of utmost importance for this technique. 
• Standard Brachioplasty: (stage II and stage III). This is indicated for moderate to severe excess skin. If there is excess fat perform liposuction first.  An incision 1cm superior from the biciptial groove from axilla to apex of the elbow is marked. A pinch test is performed to determine the amount of resection. The scar may be placed medially or posteriorly. A medial placed scar is less visible but more prone to widening. A posterior scar usually has a fine line scar but is more visible.  

• It is important to note that closure for a brachioplasty begins with reapproximation of the superficial fascial system, followed by subcuticular layers.  
• A layer of 1cm subcutaneous fat should be left between the middle and lower third of the upper arm to prevent damage to the MABC and basilic vein. 

• Brachioplasty in Massive Weight Loss Patients: The appearance of the arm after MWL is otherwise known as the “bat wing deformity” with laxity that extends from the olecranon across the axilla to the chest wall.  

• A standard brachioplasty is typically marked with extension onto the chest wall.  
• Minimal undermining should be performed to eliminate further skin laxity. 

• Post Operative Considerations: 
• Complications: include seroma, hematoma, infection, lymphocele, numbness, wound dehiscence, and hypertrophic scar.  
• Widening of the scar or hypertrophic scar is the most common complication in brachioplasty and occurs in up to 40% of patients. The most common reason for reoperation is hypertrophic scar. 

• Wound healing complications are more likely to occur in massive weight loss patients and those undergoing concomitant procedures 
• Even if not reached IBW, perform brachioplasty for posteriomedial skin laxity 

Thigh Lift: The next procedure we will discuss is the medial thigh lift.  

• Anatomy: The medial thigh has two fascial systems. Beneath the skin and dermis the subcutaneous fat is separated by an attenuated superficial fascial system. Below this, the colles fascia lies and is a strong thick fascia. This fascia attaches to the isciopubic ramus, scarpas fascia and the posterior border of the urogenital diaphragm. Lateral to the colles fascia lies the femoral triangle (borders are inguinal ligament, adductor longus, sartorius). 
• Patient Evaluation: A complete history and physical exam is taken. Lipodystrophy of abdomen and thighs are noted. Any skin laxity of abdomen should be corrected first. Concurrent liposuction of lateral thighs or lower torso may be performed.  
• Classification of lipodystrophy of the medial thighs is as follows. Type I includes lipodystrophy with no sign of skin laxity. Liposuction alone may correct this deformity. Type II has lipodystrophy and skin laxity of the upper third of the thigh. This is treated with liposuction and horizontal skin excision. Type III includes lypodystrophy and moderate skin laxity beyond upper third. This is typically treated with liposuction as well as a horizontal and vertical component of skin excision. Type IV contains skin laxity along the length of the thigh. A longer vertical incision is usually required. And finally Type V contains severe laxity and lipodystrophy and is treated with a two staged approach including liposuction in the first stage and excisional thigh lift in the second.  
• Procedures: We will review the most common thigh lift operations including the classic thigh lift with transverse skin excision, modified thigh lift for MWL patients. For medial thigh lift, dissect superficially over femoral triangle to avoid injury to lymphatics, anchor inferior flap to perineum or colles fascia to give more reliable results (decreases labial widening etc). 

• A traditional thigh lift includes a transverse component at the medial thigh crease from the pubic tubercle to the perineal thigh crease. A pinch test is used to determine the amount to be removed. Make sure to anchor the superficial fascial system to the colles fascia. Suspension of the superficial fascial system in thigh buttock lift improves: frequency of complications, including widening and inferior migration of scars, traction deformity of the vulva, and early recurrence of thigh ptosis. A vertical incision creating a “t” component may be added if additional longitudinal laxity exists.  
• A modified medial thigh lift after MWL patients are typically performed after other body contouring procedures. These patients typically have severe longitudinal skin laxity which is addressed by a vertical incision.  
• Complications: The most common complication of a total vertical thigh lift is edema. Other complications may include skin irregularities, hypertrophic scars, distribution of the vulva, lymphedema, recurrence of thigh ptosis. 
• Post-operative care: Generally compression garments are applied in the operating room and worn for 2-4 weeks. Ambulation should be encouraged. Drains are typically placed and removed within the first week.  

• Body Contouring in Massive Weight Loss:  

• Timing of BC after MWL: The timing of body contouring after massive weight loss is an important factor and should be delayed until weight has stabilized for at least 6 months. This corresponds to 12-18 months after bypass. For safety, BC is restricted to those with a BMI <35. Those >35 should be encouraged to lose weight. 
• Staging procedures is an important conversation to have with the patient has it decreases risks of complications. These should be staged 3-6 months apart. The highest risk combination surgery according to Grotting et al is a body contouring, breast, and abdominoplasty procedure.  
• Pre-Operative Evaluation: A full history should be taken as well as co-morbid conditions. A history of DVT/PE should be an indication for a hematology consult. The most common hematologic abnormalities in body contouring is Factor V Leiden. This predisposes patients to venous thromboembolism and is due to resistant inactivation of factor V. Nutritional deficiencies are common and include iron (most common), B12, Calcium, Zinc, Fat soluble vitamins and proteins.  
• Protein requirements should be 70g per day particularly after MWL (60-100) 
• Vitamin B1 deficiency may cause wernicke’s encephalopathy and is seen in massive weight loss patients and alcoholics. 

• Intra-Operative Guidelines: It is important to maintain patient safety during body contouring. The same guidelines for general body contouring or abdominoplasty apply for the massive weight loss population. 
• Current guidelines for VTE prophylaxis include chemical prophylaxis for those with caprini score >7. Lovenox 40mg should be given 6-8 hours after the procedure and for the duration of the hospital stay. Some providers recommend continuing lovenox for 7 days post operatively.   
• Current SCIP (surgical care improvement project) recommends no shaving and no using of razors, IV antibiotics 30-59 minutes prior to incision, post operative antibiotics for 24 hours, no elective surgery if A1c >7, and prevention of intraoperative hypothermia. 
• The University of Pittsburgh Protocol is designed to prevent intraoperative hypothermia. Recommendations include pre-operative warmer, OR temperature of 70 degrees or 21 Celsius. Active warming during surgery, and warm preparations of fluids.  
• Techniques: Techniques for body contouring after MWL depends on patient characteristics. In general, for the trunk, circumferential or lower body lifts or fleur de lis abdominoplasty is the treatment of choice and are performed first before any breast or extremity contouring procedures.  

• LBL:   The lower body lift treats the circumferential nature of the trunk. It allows for complete circumferential excision. The anterior portion is completed like a traditional abdominoplasty. Liposuction is performed on the lateral thighs to release the zones of adherence (lateral gluteal depression). A posterior resection and lift is now performed. Gluteal flaps my be used for buttock augmentation.  
• Other procedures such as thigh lift and brachioplasty may be performed. Those procedures for massive weight loss have been described earlier in this podcast.  
• Complications:  
• Complications are generally the same for any body contouring procedures. Factors that increase the incidence of wound complications include tobacco use, diabetes, systemic steroid use, and BMI >40. 
• Remember, nicotine causes increased microvascular vasoconstriction, increases carboxyhemoglobin, increases platelet aggregation, increases blood viscosity, decreases collagen deposition, and decreases prostacyclin formation 

• Wound dehiscence after lower body lift can be from patient movement (early), seroma (late); wound dehiscence and seroma most common complications