INTRODUCTION

The considerable increase in bariatric surgeries for the surgical treatment of morbid obesity has resulted in a greater demand for repairing procedures for sequelae caused by massive weight loss, such as abdominoplasty, mastopexy, and brachioplasty^1-5. Brachioplasty treats excess skin and localized lipodystrophy in the arms and armpits to obtain an attractive brachial contour, graceful and discreet scarring, and fewer possible complications, such as dehiscence, infection and seroma, hypertrophic scarring, and contractures cicatricials^3,4.

As most procedures for correcting post-weight loss brachial deformities are still incomplete and result in unsatisfactory scars^4,6, there is a need to improve the surgical technique⁷ and standardize surgical procedures^7-11. We created an intuitive classification that allows for better communication between surgeons, enabling the uniformity and standardization of assessing ex-obese patients with deformities in the arm and armpit region related to massive weight loss. Through this, we suggest the appropriate surgical treatment for each case to restore an adequate brachial contour. Prof. Ricardo Baroudi successfully adopted this standardization - Santa Casa de Campinas.

OBJECTIVE

Suggest a practical and useful classification for brachial deformities after severe weight loss, aiming to facilitate understanding and communication between plastic surgeons and jointly suggest possible specific management for each subtype.

MATERIAL AND METHOD

We performed a literature review, proposed an objective and practical classification encompassing all cases of brachial deformity found in our daily practice, and suggested the surgical treatment modality that could be applied to each subtype.

Currently, in the existing classifications, we find limitations, such as difficulty classifying and differentiating regions with lipodystrophy and/or skin laxity and using fixed values to determine ptosis, disregarding the patient’s body dimensions.

Considering that such classifications are unsatisfactory for standardizing an adequate surgical approach, we propose a classification that uses parameters easily assessed on physical examination and intuitively guides a treatment approach. Didactically, we divided such deformities into seven clinical entities, ranging from the simplest deformity with small lipodystrophy to the presence of cutaneous flaccidity along the entire length of the arm with the presence of lipodystrophy.

RESULTS

The proposed classification is based on evaluating the presence of lipodystrophy and cutaneous flaccidity in the region of the arms and armpits during the patient’s physical examination. After evaluating these parameters, it is possible to suggest appropriate surgical treatment for each case.

LC Classification

Clinical Entities

Lipodystrophy without sagging skin.

Skin flaccidity located in the axillary region without lipodystrophy.

Localized skin flaccidity from the axillary region to the middle third of the arm without lipodystrophy.

Localized skin flaccidity from the axillary region to the distal third of the arm without lipodystrophy.

Lipodystrophy with sagging skin located in the axillary region.

Lipodystrophy with localized skin flaccidity from the axillary region to the middle third of the arm.

Lipodystrophy with localized skin flaccidity from the axillary region to the distal third of the arm.

Considering each of the seven types of deformities described above, seven corresponding surgical treatments can be established.

Type L arm - Liposuction

Type C1 arm - Axillary incision only

Type C2 arm - Axillary incision going to the middle third of the arm

Type C3 arm - Axillary incision going to the medial epicondyle

Type LC1 arm - Liposuction + Axillary only incision

Type LC2 arm - Liposuction + Axillary incision going to the middle third of the arm

Type LC3 arm - Liposuction + Axillary incision going to the medial epicondyle

Skin demarcation for surgery should be performed with the patient in the supine position, arm abducted at 90º, and forearm flexed at 90° concerning the upper arm (Figure 1). The main anatomical points are identified: anterior and posterior axillary folds, medial epicondyle, and medial bicipital sulcus. Then, the marking begins based on the type of deformity the patient presents according to the classification proposed here.

Figure 1 - Ideal arm position for skin demarcation.

Figure 1 - Ideal arm position for skin demarcation.

Cutaneous demarcation showing the spindle drawing determined by bidigital clamping. Parallel lines guide cutaneous ears’ free closure (Figure 2).

Figure 2 - Markup example.

Figure 2 - Markup example.

Type L arm: On physical examination, we found that in type L arm, there is only lipodystrophy without flaccidity or excess skin. In this type of arm, only liposuction is indicated. Cutaneous demarcation should be performed only at the site to be liposuctioned using a classic topographic technique, and in surgery, due care should be taken with noble structures located deep in this region (Figure 3).

Figure 3 - Type L arm, only lipodystrophy is seen, without excess skin.

Figure 3 - Type L arm, only lipodystrophy is seen, without excess skin.

Type C1 arm: In this arm type, we see excess skin only close to the armpit, without fat accumulation. The middle and distal thirds of the arm are unchanged. In the type C1 arm, surgery to remove excess skin is indicated only in the proximal region of the arm; therefore, the demarcation of the incision must be made from the axillary fossa, reaching the medial third of the arm at most, in a line that is located 1cm cranial to the bicipital sulcus (Figure 4).

Figure 4 - Type C1 arm presents only excess proximal skin without lipodystrophy.

Figure 4 - Type C1 arm presents only excess proximal skin without lipodystrophy.

Type C2 arm: This arm has excess skin extending from the armpit to the middle third of the arm, without lipodystrophy. In type C2, surgery is indicated to remove excess skin from the armpit extending to the middle third of the arm, demarcating a line located 1 cm cranially to the bicipital sulcus (Figure 5).

Figure 5 - Type C2 arm: excess skin from the armpit to the middle third of the arm.

Figure 5 - Type C2 arm: excess skin from the armpit to the middle third of the arm.

Type C3 arm: In this type of arm, a large excess of skin goes from the armpit to the medial epicondyle without lipodystrophy; therefore, there is no indication for liposuction. The incision is made in a line 1 cm cranial to the bicipital sulcus, from the axillary crease to the end of the deformity. The lower line is delimited by skin clamping encompassing excess skin. As a result, a spindle is obtained from the crease of the elbow, next to the medial epicondyle, extending to the axillary cavum (Figure 6).

Figure 6 - Type C3 arm, excess skin from the axilla to the medial epicondyle, without lipodystrophy.

Figure 6 - Type C3 arm, excess skin from the axilla to the medial epicondyle, without lipodystrophy.

The following types are a combination of the types already described:

LC1: type C1 arm, with excess skin from the armpit to the proximal third of the arm associated with lipodystrophy of the arm in any region. Therefore, in this type of arm, surgery to remove excess skin is indicated only in the proximal region of the arm, which goes from the axillary cave to a maximum of the medial third of the arm, in a line that is located 1cm cranial to the bicipital sulcus, associated with the liposuction (Figure 7).

Figure 7 - Type LC1 arm, with excess proximal skin associated with lipodystrophy.

Figure 7 - Type LC1 arm, with excess proximal skin associated with lipodystrophy.

LC2: Arm with excess skin from the armpit to the middle third of the arm associated with lipodystrophy. Skin resection is indicated from the axillary pit to the middle third of the arm, respecting the limit of up to 1 cm from the bicipital sulcus. Lipodystrophy is treated with liposuction (Figure 8).

Figure 8 - Type LC2 arm: excess skin up to the middle third of the arm associated with lipodystrophy.

Figure 8 - Type LC2 arm: excess skin up to the middle third of the arm associated with lipodystrophy.

LC3: Indicates the arm with flaccidity and excess skin and associated lipodystrophy. The resection will be taken up to the medial epicondyle. Lipodystrophy will be treated with liposuction (Figure 9).

Figure 9 - Type LC3 arm with flaccidity: lipodystrophy up to the distal region of the arm.

Figure 9 - Type LC3 arm with flaccidity: lipodystrophy up to the distal region of the arm.

DISCUSSION

The advent and popularity of liposuction expanded the range of options for improving body contour^6,9,12, including concerning brachioplasty⁶. The proposed classification infers the modality of surgical treatment from the preoperative clinical evaluation, and this is objective, comprehensive, and practical for all cases of brachial deformity in ex-obese patients^1,2,12. The classification proposal is the master plan for the knowledge of the types of existing deformities with the suggestion of surgical treatment necessary to correct each case. This classification highlights the main points to be observed in the surgical treatment of brachial deformity after severe weight loss, such as the need or not for liposuction,

The degree of deformity can be variable, and good surgical results should always take into account skin flaccidity and accumulation of subcutaneous tissue^2,7.

Among the existing scales, we have Temouriam and Malekzadeh, Appelt, Pitsbourgh, and El Khatip; the latter is the most used. All scales use skin laxity and lipodystrophy as parameters, but the previous classifications do not consider the particularities of the patient’s body.

El Khatip uses fixed numbers as points of reference; these points are unlikely to be universally applicable. Our classification uses non-fixed measures; therefore, we believe it can be applied to all post-bariatric patients with some degree of lipodystrophy and/or skin flaccidity in the arms and armpits. Due to its practicality and objectivity allows easy interpretation by the plastic surgeon and reliable registration in medical records, articles, and literature, facilitating communication between professionals. Finally, our scale proposes a suggestion for surgical treatment to provide the patient with a harmonious arm contour and discreet scars (Table 1).

Table 1 - Comparison between El Khatip¹¹ and LC scales.

CONCLUSION

The proposed scale offers a universal language for classifying alterations in the region of the arms and armpits in ex-obese patients based on the anatomical region where the lipodystrophy is located and the presence of concomitant skin flaccidity. Seven types of alterations were identified by evaluating such parameters, and based on these findings, the types of preexisting deformities are aligned with the respective surgical modality necessary for the correction of each case. An objective and practical classification facilitates communication between professionals and guides the best treatment, providing the patient with an attractive arm contour, graceful scar, and a lower rate of complications.