**7.2 Case 2: liposuction and subdermal RF**

This 51-year-old woman presented to our practice with concerns regarding the size of her arms and avoided sleeveless shirts. She was 5′2″ and 163 lb. Her medical history was notable for a previous thyroidectomy and her only medication was levothyroxine. The patient was noted to have diffuse upper arm lipodystrophy with significant striae. The distance from the bicipital groove to the most dependent area was greater than 10 cm. She did not wish to undergo any excisional/scarring procedure, even though it was made clear this would be the gold standard of treatment in her situation.

The patient underwent arm liposuction, along with a concomitant facial procedures, under general anesthesia. Each arm was infiltrated with 750 cc of tumescent fluid using PAL system, then VASER UAL was performed (60%, VASER mode, 3 mm VASER probe) in both the deep and superficial planes. Liposuction was carried out with a 3 mm standard liposuction cannula to remove 650 cc of lipoaspirate on each side from each arm. Subdermal RF treatment was then performed with Renuvion (80%, 2 L/min, for 3 + 3 passes as described above). No drains were used. Pre- and post-operative results at 1 year are shown in **Figure 7**. The option of repeating the RF at one year to obtain further skin tightening was disclosed preoperatively. At one year post surgery, the patient was thrilled with her results and declined further RF or alternative treatments.

The typical operative sequence of arm lipocontouring with VASER UAL and subdermal RF is outlined in **Table 2** and demonstrated in Video 1 (https://drive.

#### **Figure 7.**

*Liposuction and subdermal RF of the arms (case 2). This 51-year-old woman with BMI of 29.8 presented with lipodystrophy, skin excess, and poor skin quality and striae. She was averse to brachioplasty scar. As such, a staged approach was proposed beginning with VASER UAL (650 removed from each arm) and subdermal RF (Renuvion). Results are shown pre-operatively and 1 year postoperatively on the left (a) and right (b) sides. She was very pleased with the outcome following the initial procedure and elected not to proceed with further liposuction and subdermal radiofrequency treatments as planned.*

#### **Summary of Operative Approach to VASER UAL and RF Skin Tightening**

#### **Pre-operative:**

Markings: Patient is marked for proximal and distal access incisions, zones of excess adiposity requiring VASER liposuction, and, if indicated, regions of RF skin tightening. If muscular enhancement is planned, the borders of the arm muscles (deltoids +/− triceps) are palpated and marked. The course of the ulnar nerve at the cubital tunnel is marked as a "no-go" zone.

#### **Intra-operative:**

Positioning: Patient is placed supine with arms extended on arm boards. The arm may be flexed at the shoulder and elbow at 90 degrees throughout the case as necessary to reach the posterior and external zones of the arm adequately. Under local anesthesia, patient can perform this movement by themselves; otherwise the limb is positioned by an assistant. To allow free movement, bilateral upper extremities and anterior chest are prepped and the extremities are free-draped.

Anesthesia: If the procedure is performed under local anesthesia, the patient is offered Pro-Nox for comfort, which they self-administer. Additionally, they may be offered MKO prior to the procedure as an anxiolytic and mild oral sedative. Alternatively, the procedure can be performed under IV sedation or general anesthetic.

Measurements: Arm circumference can be taken at 2 points along the upper arm prior to start of treatment and at the end of treatment with a sterile tape measure. These measurements are of particular benefit to denote and correct asymmetry between the two sides.

Incisions: Access incisions are infiltrated with local anesthetic and a 1 cm skin incision is made with scalpel. Care is taken to stay away from the ulnar nerve distally.

Tumescence: The zones of planned treatment are infiltrated with tumescent fluid until appropriate turgor is reached (variable between patients and dependent on body habitus). It is important that both the superficial and deep fat layers are adequately infiltrated.

VASER UAL: Access ports are inserted to protect skin incisions. VASER pre-treatment is performed first with typical settings of 60% on VASER mode in superficial fat layer. Deep fat layer may be treated with 60% on VASER or Continuous mode, depending on amount of adipose excess. End point is loss of tissue resistance to VASER probe. Liposuction is then performed with a small (3 mm cannula). Care is taken to debulk in the deep adipose layer only. Superficial liposuction is performed carefully and only in areas where the muscle border is intended to be enhanced.

RF Skin Tightening: Next, RF skin tightening is performed if indicated. We prefer Renuvion and use settings of 80% power and 2 L/min of helium gas flow. Treatment is performed with 3 passes initially followed by another 3 passes a few minutes later to allow sufficient tissue thermal relaxation (total of 6 passes). Alternatively, if Bodytite is utilized, we typically use internal and external temperature cut-offs of 70o C and 40o C. Skin is continuously monitored for overheating, redness, and end-hits are avoided with all technology devices. Minimal liposuction is performed afterwards to remove any debris and gas.

Closure: Proximal incisions are closed with deep-dermal 4-0 Monocryl suture. Typically, the distal incision is left open and dressings are used to soak up excess drainage. If necessary, a 7 mm Jackson-Pratt drain may be utilized, exiting from distal excision.

#### **Postoperative:**

Garment & Drain: Patient is placed in compression garment for 6 weeks postoperatively. Typically, the distal incision is left open and dressings are used to soak up excess drainage. If any drains are used, they are removed after 30 cc or less of serosanguinous drainage in a 24 hour period has been reached.

#### **Table 2.**

*Summary of our typical approach to arm lipocontouring with VASER UAL and subdermal RF skin tightening.*

google.com/file/d/1lUFLpe7koOBtZf7dCtcGFkU-RBsieNQq/view?usp=sharing) for a different patient.

#### **7.3 Case 3: liposuction, subdermal RF, and brachioplasty**

This 53-year-old woman was seen in consultation for changes to her arms following massive weight loss of 130 lb. through healthy lifestyle changes in diet, and exercise. She was 5′7″ and 183 lb. at time of assessment. The patient was concerned with the quantity of excess skin, as well as the poor quality, noted by striae, poor elasticity, and pendulous excess skin. After discussing the advantages and disadvantages of various procedures, the decision was made to proceed with

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

bilateral extended brachioplasty with UAL liposuction and subcutaneous RF to improve the quality of the remaining skin. The nature of the scarring involved was discussed in detail.

Under general anesthesia, 1000 cc of tumescence fluid (**Table 3**) was infiltrated into each arm and lateral chest wall using a small basket PAL cannula. A 3 mm VASER probe was used for fat emulsification, followed by liposuction to remove 400 cc from each arm. Surgical excision of the redundant skin was carried out to remove 588 g of tissue from the right arm and 515 g of tissue from the left arm. Subdermal RF (Bodytite) was used to heat the remaining skin prior to final subcuticular closure to achieve further skin tightening. A drain was used on each side. Pre- and post-operative results at 1 year are shown in **Figure 8**.


#### **Table 3.**

*Intraoperative measurements and weights of tissue excised from case 3. Circumference of the arm is taken prior to surgery (PRE) and intraoperatively following liposuction and excision (POST) to ensure relative symmetry at the end of the procedure. These measurements also help highlight pre-existing arm size asymmetries and differences in relative amount of tissues excised from each side.*

#### **Figure 8.**

*Liposuction and subdermal RF of the arms coupled with extended brachioplasty. This 53-year-old PDWL woman presented with lipodystrophy and significant skin excess and poor quality of the arms and extending to the lateral chest wall. She underwent VASER UAL and extended brachioplasty. The remaining skin regions anterior and posterior to the brachioplasty excision were treated with subdermal RF (Bodytite) for further improvement in skin retraction and quality. Results are shown pre-operatively and 1 year-postoperatively from a left anterior (A), right posterior (B), and bilateral posterior (C) perspective.*
