why opt for an operation of the upper limbs?

Among other things, there may be sequelae voluntary weight loss or after bariatric surgery which are likely, in about 30% of cases, to cause anomalies arms and torso. There is excess skin that becomes awkward aesthetically and functionally; this explains why, in certain cases, Social Security can take charge of these operations after a request for the prior agreement procedure. This coverage may however only be partial when an aesthetic request is added, or else because the surgeon is approved in sector 2, that is to say that he has a legal right to exceed fees.

Finally, the aging of the hands is marked in certain cases by a digging between the tendons of the back of the hand, with a thin and fragile skin which excessively reveals the tendons, emphasizing the atrophic character of the tissues.

How is patient dissatisfaction manifested?

Patients may be unhappy with the appearance of their arms for various and more or less apparent reasons, in any case experienced as unbearable even if the deformities remain moderate.

These deformations can be characterized in several grades:

• sagging skin limited to the inside of the arms, in a relatively moderate way: re-tensioning is possible at the cost of a surgical procedure invasive, the intra-axillary brachial lifting, but which does not always give great satisfaction because it does not correct the excess cutaneous circular arms;
• a very large excess of skin of the entire arm, sometimes even of the forearm, giving the upper limbs a wing-like appearance bat. Only a large T-brachioplasty will be effective;
• too much fat in the postero-external part of the arms: a liposuction is indicated;
• the existence of large excess skin both inside the arm, but which also extend to the side wall of the thorax : lateral thoracic incisions should be used.

These different aspects encountered in the arms motivate a serious consultation with a surgeon plastic restorative and aesthetic. After listening to the patient's request, explaining the surgical possibilities represents essential information that each patient must understand, with the help of written information and explanatory diagrams.

The financial nature of an operation possibly envisaged takes the form of a complete estimate and the signing of mutual consent after acceptance of the information on the defects of healing possible, fortunately relatively rare and manageable by simple dressings, or exceptionally by a resumption of operation.

Significant deformations of the arms and torso, consequence of massive weight loss

We must isolate this particular problem which represents approximately 30% of patients operated on bariatric operation. Weight loss, with 40 to 100 kg skin excess, is so important that we had to imagine special designs to remove excess skin, with scars that can go from the wrist to the lateral part of the chest. These are important operations, which cannot be carried out in ambulatory, Hospitalization for at least one night will be necessary.

The consequences will, of course, be more significant, with the risk of small suppurations or small disunities in terms of sutures, swelling of lymphatic origin can also occur with, sometimes, flows towards the 18^e day, but with proper care, these small inconveniences gradually disappear until the healing complete which may take approximately two months.

Hand alterations are not to be neglected

Our precious gripping organ, the hand, also ages, sometimes depending on the characters. genetic and therefore family. The dorsal skin of the hand thins, revealing the veins and tendons, brown spots covering the back of the hand. This appearance becomes all the more debasing as some patients have had a cervico-facial facelift or a refreshing of the face, the appearance of the hand then betrays the real age that one would like to hide. The best solution is in this case to practice lipofilling of the back of the hand, and to associate an erasure of the spots by applications nitrogen liquid.

What are the different operating techniques that can be used during a brachioplasty?

The principle of surgical techniques resection cutaneous in matter Brachioplasty is to associate: scars that will be as hidden as possible in the shadow of the armpit arm and torso; to achieve the finest possible scars; finally, to consider simplified operating suites, to give this operation an easy-to-bear character such as, for example, by using only absorbable wires, to avoid the worry of theablation sons or staples.

We can thus separate several surgical operations from the least important to the most important:

• the liposuction of the postero-internal fatty bead: a liposuction will be enough to give a good volumetric result, the skin has the capacity to shrink by about 20%;
• axillary brachioplasty: it consists of removing the skin only inside the armpit, with a skin resection in the shape of a Napoleon hat;
• T-brachioplasty: it combines withexcision of skin in the armpit another time zone of skin along the inside of the arm;
• brachioplasties enlarged in the torso or forearm.

What care is useful postoperatively after brachioplasty?

• D + 1: the operation is a little more painful, pain treatment is practiced if necessary and the dressing is reinforced if there is little oozing or a little hemorrhage.
• D + 7: the dressings are changed systematically, the operating wound is disinfected and checked to see if all is well. There are some difficulties in moving the arm and lifting it over the shoulder.
• D + 21: the threads begin to subside, healing ointments are applied, there is no more dressing unless absolutely necessary.
• D + 60: the scars are red, they pull a little, the mobility of the arm has returned.
• A year later: the scars are fine, vaguely noticeable, if they have widened or of poor quality, a surgical touch-up will be discussed.

What are the indications for lipofilling associated with resections?

The advantage of lipofilling is to pad the dermal layer of the skin, especially if it is damaged and refined with stretched and cracked elastic fibers. We thus add a cell layer with fat cells about 2 mm in diameter, by tracer injections of fat which was taken from the patient. Among the transplanted cells, there are stem cells which have the capacity to regenerate and improve the appearance of the skin cover, to equalize it. A repairing lipofilling can be carried out either during the brachioplasty by placing the fat under the skin outside of the forearm, or by associating it by injection at the level of the neckline or the back of the hand, if the skin is wrinkled in these locations.

Are there any complications during a plastic surgery of the arms?

Complications from brachioplasty can be very diverse, but luckily they are rare.

• Insufficient skin resection, for example, a pure intra-axillary lift which did not remove the excess skin on the inside of the arm, making the patient dissatisfied: additional resection is therefore consider.
• Poor healing: it will be treated by local care, but which can lead to scar too wide for the patient's taste.
• Thread rejection at depth giving small abscess.
• A left-right asymmetry that displeases.
• Persistent lymphatic swelling, sometimes with lymphorrhea that oozes for several weeks, requiring an absorbent dressing.
• A local infection that can cause lymphangitis to be treated urgently with adjusted antibiotic therapy.

What to do when a brachioplasty is not successful?

It can be assumed that approximately 2 to 5% of people who undergo a brachioplasty will present an anomaly of scarring, or a small defect linked to the operating technique, insufficient resection, or an unexpected infectious complication. It is then advisable to practice a surgical retouching, this one, in general can be practiced in ambulatory. The problem is that of the costs, because the patient is reluctant to open his wallet again. When it is a question of an obvious technical fault, the surgeon will assume the cost of the operative act, but it will be necessary to defray the clinic and the anesthetist.

What advantage does brachioplasty bring to your figure?

The demand for brachioplasty occupies a very important place following weight loss operations, which are called bariatric operations. It also concerns many patients who have lost fifteen pounds voluntarily, and who nevertheless exhibit the persistence of mass postero-internal fatty tissue in the arm, or excess skin that bothers them deeply. It is not the initial operation that is most often requested: it takes place after the operation of the belly, breasts, complementary liposuction often necessary.

Some patients request the association of brachioplasty with other surgical procedures, for example an associated correction at the level of the chest, or with cruroplasty. These combined operations are frequently practiced, but you should know that an operation that lasts more than four hours under General anaesthesia increases the risk of phlebitis and embolism postoperative, and also exposes to more infections.

It is therefore advisable to explain to the requesting patients what is the best strategy in their case, to combine the operations in a clever way, but also while avoiding too long interventions.