290 A ESTHETIC S URGERY J OURNAL ~ July/August 2003 Second Thoughts Arm Contouring The authors have updated their brachioplasty tech- nique, adding conservative skin undermining in the treatment area only and, in some instances, elbowplasty. Patients are divided into 3 distinct groups for treatment planning on the basis of skin quality and fat deposits. (Aesthetic Surg J 2003;23:290-292.) W e divide patients undergoing brachioplasty into 3 groups, according to their characteristics. Group 1 comprises patients with moderate to firm skin and voluminous upper-arm fat deposits. We perform lipoplasty with specific limitations on how much fat is removed based on the patient’s skin turgor. These principles are the same as those advocated by Vogt. 1 Group 2 comprises patients with flabby skin and fat deposits. Treatment includes lipoplasty and skin resec- tion in the same stage. Surgery begins with lipoplasty. We perform skin undermining superficially, preserving the subcutaneous tissue to avoid severing of lymphatic vessels and superficial nerves. Group 3 comprises patients with flaccid skin and no fat deposits. Resection of excess skin is the only indica- tion for this group. In almost all of these patients, we resect an elliptical or triangular shaped piece of skin flap, saving the internal brachial sulcus as reference. We place the suture and final scar 1 to 3 cm above or below this sulcus (Figure 1). The amount of axillary skin resected is based simply on redundancy. It is imperative, however, that the scar is placed at the inner aspect of the upper arm; otherwise it will be exposed. 2–5 The general preoperative evaluation for any patient undergoing arm contouring includes the “pinch test” to determine the amount of skin to be resected. When per- forming this test, have the patient stand with his or her arms abducted. Surgery is performed under sedation and local anes- thesia; the patient is prone, with arms abducted at about 80 degrees. The specific technique — lipoplasty, surgical excision, or both — is carried out in accordance with the plan made before surgery. Even though we have been performing lipoplasty since 1981, it did not become part of our standard approach to brachioplasty until after 1988. Since then, we have routinely used lipoplasty in selected patients undergoing bra- chioplasty. In the past 6 years, we have also used 2 other techniques to improve results. First, we perform conservative skin undermin- ing only on the area to be resected to avoid dead space. Second, patients with redundant skin in the elbow region are treated with elbowplasty, which we perform in a manner similar to the procedure described by Lewis. 6 Elbowplasty may be combined with brachioplasty in the same surgical stage. Conservative Skin Undermining When skin dissection is to be performed, the skin flap is stretched above the superior limit of the incision to estimate the amount of skin to be resected. Three-zero isolated intradermal absorbable stitches are placed all along the upper nondissected skin edge, and the dissected lower limit, to avoid dead space and irregular tension on the suture. Then resect the excess skin (Figure 2). Finish suturing with a running intracuticular 4-0 absorbable material. Straight and zigzag suture lines have demonstrated similar scar quality. In long-term follow- up, we have found that suture tension results in broaden- ing of scars. Scar widening is more evident in patients with thin dermis. Excess elbow skin is common in older patients and in slim patients with lax skin. In contrast to Lewis’ proce- dure, which looks like an elliptical resection, we perform a “horseshoe-type” resection for excess skin (Figure 3). This has resulted in generally acceptable scars. The scar Ricardo Baroudi, MD, São Paulo, Brazil, is a member of the Brazilian Society of Plastic Surgery. Co-author Carlos Alberto A. Ferreira, MD, São Paulo. Brazil, is a member of the Brazilian Society of Plastic Surgery.