**9.7 Infection**

Less invasive approaches to arm contouring tend to be associated with less postoperative major complications than excisional approaches with brachioplasty. Although no studies that directly compare the two approaches in comparable groups have been conducted to date, trends can be drawn from available large population databases. Studies of patients enrolled in the CosmetAssure database from 2008 to 2013 [32, 33] revealed that major complications occurred in 0.7% of patients undergoing liposuction alone and in 1.3% of brachioplasties alone. When brachioplasty

was combined with liposuction, overall rate of major complications increased to 3.6% although the study was limited to liposuction as a procedure and not necessarily specific to liposuction of the arms per se. BMI equal or higher than 30 kg/ m2 was found to be an independent risk factor for infection. To minimize risk of infection with arm contouring procedures, complete sterile preparation and draping is required, even if a less-invasive approach is taken. Patients are encouraged to achieve a healthy BMI as lipocontouring is not a replacement for healthy lifestyle, and a normal BMI can optimize patients for better recovery as well as better results. Patients who are PDWL are at higher risk of nutritional deficiencies and are encouraged to undertake a complete healthy protein-rich diet prior to surgery [34].

## **9.8 Learning curve and management of surgeon/patient expectations**

As with the adoption of any new surgical technique or technology into one's practice, it is of paramount importance to recognize the learning curves associated with novel approaches and to proceed cautiously. Following mastery of the device itself—learning how to operate safely with balance of tumescence, zones of treatment, energy settings, depth of device placement and direction and speed of device manipulation—patient selection and management of expectations are key to success. Younger surgeons are encouraged to establish comfort with location and planes of deep versus superficial fat pockets in the arms and gain success with debulking of excess deep fat of the posterior region of the arm before attempting superficial liposuction and muscular etching to avoid unwanted irregularities and contours. Similarly, when implementing RF skin tightening, it is best to select cases of mild skin laxity and ptosis in which treatment response is likely to be in keeping with both patient and surgeon expectations. It is always the gold standard to offer excisional surgery to patients with significant skin laxity, striae, and/or severe photoaging, where the damaged dermis can be less reliable in terms of contraction and neo-collagenesis upon which RF depends. Depending on location of skin excess, whether it is mostly involving the axilla region, the entire dependent portion of the arm, extending to the elbow, or extending to the chest wall, the patient may be best treated with axillary short scar brachioplasty, traditional brachioplasty, extended brachioplasty to below elbow, or extended brachioplasty to lateral chest as indicated [25]. While patients may be deterred by the conspicuous brachioplasty scar, it is important to emphasize trade-off between scar and amount of arm contouring and skin tightness desired by the patient. A patient with significant skin excess who wants ideal arm contour and as much skin tightness as possible will never be satisfied with results achieved with RF skin tightening alone. Conversely, a patient who is completely intolerant of scars but is satisfied with even mild to moderate improvement of skin laxity, will be well-served with RF skin tightening. Although RF skin tightening can be safely combined with excisional surgery concurrently, we again advocate that the surgeon establishes comfort with the technology first. Furthermore, we recommend utilizing lower energy settings and avoiding application of energy within a 2-5 cm margin of incision edge to ensure skin viability and uncompromised wound healing.

## **10. Alternative treatment options and their limitations**

## **10.1 RF-assisted liposuction (RFAL)**

RF-assisted liposuction is an alternative means of utilizing RF energy to emulsify fat and tighten soft tissues as an adjunct to correction of lipodystrophy with

#### *Enhanced Lipocontouring of the Arms DOI: http://dx.doi.org/10.5772/intechopen.98807*

liposuction. Utilizing the RFAL technique, RF is applied to the subcutaneous tissues following infiltration with tumescence. Thereafter, excess fat and fluid is removed with SAL or PAL [35]. RFAL is a useful alternative technique that achieves many of the same goals as contouring with VASER liposuction and skin tightening with RF. There are two advantages to separating the process of lipocontouring and soft tissue tightening: one lies in the flexibility to harvest viable adipocytes with VASER liposuction that can then be utilized for fat grafting if needed [7, 8], and the second is the reduced disposable cost of utilizing the single-use RF handpiece only for patients that truly need additional skin tightening. Additionally, by performing liposuction prior to RF energy application, tissue heating is optimized as the volume of intervening heat-resistant fatty layer will be decreased, and the subdermis and FSN better exposed as desired targets of energy application [14].
