**5.5 Brachioplasty**

Surgical excision of excess skin of the arm is the gold standard in improving arm contour; however, the conspicuous and sometimes hypertrophic scarring in a publicly visible area can make this option undesirable. Previously, surgeons have attempted to describe limited brachioplasty approaches by varying the length and position of the surgical scar, ultimately at the expense of the improvement that can be achieved. Small scars such as axillary-only obtain limited changes in arm contour, whereas extended brachioplasty scars from distal to the elbow and including the lateral chest wall result in transformative changes to the patient's shape in their arm and chest. We recognize that excision of skin in some patients is unavoidable to achieve desired results. A detailed discussion of brachioplasty surgery is beyond the scope of this chapter [25].

We advocate and implement a two-stage approach in order to limit scar length without compromising the amount of improvement and arm contour. In patients with excessive fatty tissue who are unable to lose weight through lifestyle changes, we first perform liposuction with or without skin tightening to recruit as much skin retraction as possible. As a second stage, a brachioplasty procedure with possible further skin tightening can be performed, thus hopefully resulting in a shorter surgical scar. On many occasions, patients are satisfied enough with the results of the first stage, that they often decline skin excision and request further enhancement with liposuction with or without skin tightening.

### **5.6 Adjunct non-surgical treatments**

Treatment of sun damage to the skin with sunscreen, topical products, and laser treatments to improve skin texture and pigmentation changes should also be considered.
