**4. Preoperative evaluation**

## **4.1 Treatment algorithm**

Multiple algorithms for classification and treatment of arm deformities have been previously described [20–22]. These classifications all aim to address adipose and/or skin excess with liposuction, variations of brachioplasty, or a combination of these approaches. They do not incorporate energy-based methods of improving skin laxity and quality, which we find to be quite efficacious in improving arm aesthetics. Algorithms for assessment and management of the arm should be updated to accommodate new skin tightening procedures which may result in a decreased need or desire to proceed to more aggressive skin excision surgeries to achieve the patient's expected results. Theodorou et al. [11] proposed an algorithm that incorporates some energy devices to address arm adiposity, as well as skin laxity and quality, ranging from SAL, Laser-assisted liposuction (LAL), RF- assisted liposuction (RFAL), RFAL and staged skin excision, to brachioplasty. We expand upon this proposal by incorporating superficial and transdermal RF treatments as well as other adjuncts that are usually further required to improve poor skin texture and quality. **Figure 2** outlines our algorithm for assessment and treatment of arm aesthetics.

#### **4.2 Photography and documentation**

Preoperative assessment in liposuction is always the single most important step in proper surgical planning and the management of the patient's desires and expectations. Evaluation of the arms must not only include areas of excess fat but a

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

#### **Figure 2.**

*Our approach to assessment and treatment of patients presenting for arm enhancement. It is important to identify lipodystrophy as well as excess skin and other markers of skin photoaging for comprehensive improvement of arm appearance. Liposuction is coupled with other energy-based devices as necessary. In some patients, skin removal with brachioplasty is still considered gold standard and recommended.*

detailed examination of the quality and quantity of skin, as well as the underlining musculature. Furthermore, aesthetics of adjoining anatomical areas such as the lateral chest wall, anterior axillary fold, posterior axillary fold, and the forearm should be considered and treated if appropriate.

In obtaining a full analysis of the arm, it is imperative to ask the patient what disturbs them the most about their extremity and the view(s) in which they see the concern most prominently. Dynamic assessment of the arms is also important to establish the patient's desires and expectations. The terms "bat wings", "bingo arms", or "hello Helens" imply a significant amount of redundant and possibly pendulous skin in the upper arm which may require surgical excision to obtain a true decrease in the skin volume. Obtaining a preoperative video is an excellent way of documenting the amount and dynamics of loose skin. Such video can also help document the aesthetic concerns preoperatively and their improvements postoperatively. Preoperative measurement of arm circumference is helpful to assess asymmetries and to follow postoperative results. Assessment of skin tone, texture, stretch, loss of elasticity, and the presence of striae should be included and incorporated into the operative planning.

Standard photography of front and back with shoulders abducted and elbows flexed at 90 degrees, in front of an appropriate photographic background, is of critical importance. Close-up assessment of skin is also crucial both in the planning phase and in the photo documentation phase.

#### **5. Surgical technique**

#### **5.1 Marking**

The patient is marked in the standing position with the shoulders abducted and elbows flexed at 90 degrees. The position of the ulnar nerve is marked. The areas of excess fat where deep liposuction is required in the posterior zone, extending

anteriorly and internally as needed, are outlined. The extent of liposuction is confirmed from front and back, and with the arms adducted and abducted. Adjoining regions of excess fat such as in the anterior axillary fold, lateral chest wall, and distal arm/elbow region are also marked (**Figure 3a**).

The zones of skin laxity are marked next. Due to the thinness of the skin in the internal aspect of the arm, this is the focal area of treatment with skin tightening devices. Treatment zones may extend more anteriorly and posteriorly as needed and beyond the area of the planned liposuction. The thicker skin of the external arm typically does not require treatment with subdermal skin tightening devices. If photoaging is present, that can be marked for treatment with adjunct modalities (**Figure 3b**).

When muscular etching is planned, we follow Hoyos' approach [4]. Muscular etching should reflect the patient's complete body habitus. A patient with higher BMI and poor muscle definition elsewhere will appear incongruent if muscular etching is performed on their arms. When appropriate in men, muscular etching includes enhancement of all three large muscles of the arm (deltoid, biceps, and triceps). This may include small volume fat grafting (approximately 25-50 cc) to the muscles, primarily deltoid +/− biceps, to enhance bulk. In women, it is important to establish the patient's desired degree of perceived athleticism that is in balance with their body shape. Many women want a softer look, in which case muscular etching is not performed. A large portion of women desire a toned appearance of the arms, in which case only the deltoid muscle is highlighted. In a small subset of women who strive for a full muscular appearance of their arms, further etching of the tricipital groove and biceps is added; fat grafting is rarely used in our practice for female patients (**Figure 3c**).

#### **5.2 Preparation and anesthesia**

Liposuction of the arm can either be done under local anesthetic or general anesthetic, and with or without the addition of other procedures. Arm liposuction under local anesthetic is well tolerated by patients. The patient's ability to participate in positioning and movement is very beneficial when local anesthetic is used.

Our preferred method of local anesthesia entails a combination of MKO jelly lozenge (locally compounded Midazolam 3 mg, Ketamine 25 mg, Ondansetron 2 mg) with inhaled patient-administered nitrous oxygen (Pro-Nox, Inc.; CAREstream Medical Ltd., Oakville, ON, Canada). A small access incisions is placed 2 cm proximal to the olecranon in the midline or more radially thus avoiding the ulnar nerve. If more ulnar-sided access is necessary, an additional surgical incision may be placed anterior to the medial epicondyle and lateral to the biceps tendon insertion. To obtain access to the proximal arm and the anterior axillary fold, an incision can be placed behind the lateral edge of the pectoralis muscle in the axilla. Occasionally a posterior axillary incision may be necessary, especially when trying to obtain muscular etching of the posterior deltoid and the tricipital groove.

When arm liposuction is done in combination with other body contouring procedures or breast surgery, general anesthetic may be the best choice. All areas are locally infiltrated with a combination of xylocaine with epinephrine tumescent fluid with both local and general anesthetic cases (**Table 1**). When arm contouring is combined with other procedures that involve the patient being prone, the posterior axillary fold, deltoid, and tricipital groove definition can be treated from posteriorly. The remaining arm liposuction is performed with the patient supine. Draping of the arm must allow 360-degree access (**Figure 4**). The use of ear oximetry probes and leg blood pressure cuffs are helpful in patient monitoring while keeping field sterility even when the arm is moved.

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

#### **Figure 3.**

*Markings for arm lipocontouring. (a) Areas of excess fat for debulking are marked (purple). Fat excess build-up is mostly in the posterior zone of the arm in the deep layer and is the focus of liposuction. (b) Areas of poor skin laxity for treatment with subdermal RF are marked (pink). The region of skin tightening treatment can extend anteriorly and posteriorly beyond the region of liposuction as required. The path of the ulnar nerve is marked as a danger zone. Distal access incision is made away from the position of the ulnar nerve; similarly, VASER liposuction and subdermal RF are avoided in this area. (c) If muscular etching is required, the muscle borders are palpated and marked (green). In females, commonly the deltoid is enhanced with careful superficial liposuction. In men, muscular etching may involve enhancement of deltoid, biceps, and triceps muscles.*


**Table 1.**

*Composition of tumescent fluids used for local and general anesthetic (GA) case. Sodium bicarbonate is used as a buffer to decrease the pain of the acidic lidocaine when procedures are performed under local anesthetic. Accordingly, less lidocaine is required for analgesia when patients are under general anesthetic.*

**Figure 4.** *Draping allowing for sterile 360-degree access to the patient's arms used in both local and general anesthetic cases.*
