Brachioplasty (Arm Wedge Excision)
Description of Brachioplasty
A combination of age related relaxation of the soft tissues of the upper arm, weight fluctuations, and gravity can cause laxity of the skin of the upper arm. The upper arm then appears to have a loose hammock deformity. Associated fat deposits in the upper arm may also contribute to this deformity. This type of appearance of the arms may cause embarrassment to some people.
Many women choose to wear long sleeves to cover up their upper arms. There can be difficulty buying certain clothes with sleeves because they may not fit comfortably.
The procedure is done under general anaesthesia. The suture line runs from the armpit and extends down to the elbow. Excess skin and fat are removed and the wounds are sutured. Occasionally liposuction is also performed to help contour the arms.
At the time of surgery any tissue removed may be sent to pathology for testing. Costs incurred for this service will be the responsibility of the patient.
Wedge excision of the upper arms is an elective operation and one alternative is not to have any treatment at all.
Wearing appropriate clothing may hide the deformity.
Diet and exercise programs may be of benefit in the overall reduction of excess body fat.
Loss of weight will not usually help the deformity and sometimes may make it worse by making the skin looser.
Liposuction alone is not usually enough to give an adequate result. The main problem is usually one of skin excess and tightening of the skin of the upper arm after liposuction is unpredictable. Liposuction is usually not recommended alone for treatment of sagging upper arms. Liposuction however maybe useful for treatment of localised fatty deposits in the upper arm.
Risks and potential complications are associated with alternative forms of treatment that involve surgery.
Risks of Surgery
All surgery is associated with some risk
It is important that you understand that there are risks involved with any surgery. Whilst the majority of individuals undergoing surgery do not experience any complications, a minority do and there cannot be any guarantees in surgery. With every type of surgery the best possible outcome is sought. The importance of having a highly qualified surgeon and professional surgical team and facility cannot be overestimated.
Risk to benefit
The choice to undergo a surgical procedure should be based on the comparison of the risk to the potential benefit to you. Make sure that you take time to read and understand how each potential complication can impact on your life and try to make the risk to benefit comparison specifically for yourself.
Informed consent process
Before any surgery, your surgeon should explain to you the risks of the procedure and the possible complications that could happen. The informed surgical consent web site will help you to understand the risks that your surgeon has already discussed. It may also bring up other issues that will require a second surgical consultation to clarify. You should not feel that you are being an inconvenience by seeking another consultation and clarification of any questions that you may have. You should take the opportunity to read this informed surgical consent website carefully and at your own pace. The questionnaire at the end will help to clarify your understanding. There is also opportunity to make note of specific concerns and issues that may be relevant to you so that you can discuss these concerns with your surgeon.
Impact of complications
The risks of surgery involve possible inconvenience if a complication occurs. It may result in an extension of your recovery period and in some cases may need further surgery. Infrequently, complications may have a permanent effect on your final result.
Financial risks are involved with any surgery. Private health insurance is strongly recommended. If you do not have private health insurance then a complication or further surgery will add to the overall cost of your surgery.
Risks related to general health
Your general health will impact on the possible risks of surgery. Many of the risks associated with surgery can be predicted, however, your general health plays a vital role to the outcome of your surgery. Age carries a greater risk with any surgery. Being overweight carries a greater surgical risk. Other medical conditions such as high blood pressure, high cholesterol, diabetes, heart and lung disease may also increase your surgical risk. Smoking greatly increases all risks and complications of surgery.
Finally other factors, that may not be obvious, can influence the outcome of your surgery and the risks are beyond anyone's control.
Specific Risks of Brachioplasty
Poor scarring after an upper arm reduction (brachioplasty) is the most common problem encountered. There is a tendency for the body to develop poor scars in this area despite careful surgery. The scars may become wide, thick and raised and may not settle adequately with time. Although the scars are placed on the inside of the arm, they may still be visible.
It may be desirable to have further surgery to try to correct abnormal scars at 12 months after the initial procedure.
A "dumbbell" deformity may occur if more skin is removed from the central part of the upper arm in comparison to the upper and lower parts of the upper arm. This may need liposuction to correct.
Change in skin sensation
Altered, diminished, or loss of skin sensation is common after any body contouring surgery including brachioplasty. In most cases normal skin sensation will return after a period of time. Return of sensation may take up to 2 years. Uncommonly numbness or loss of skin sensation will be permanent.
Skin contour irregularities
Contour irregularities and depressions may occur after arm reduction. Visible and palpable wrinkling of skin can occur. Puckering at the end of a surgical wound can commonly occur. If small, puckers usually resolve with time. Further surgery to correct persistent or larger irregularities may be required.
Symmetrical body appearance may not result from body contouring surgery. Factors such as skin tone, fatty deposits, bony prominences, and muscle tone may contribute to asymmetry of the body and will affect the final result.
Seroma / Pseudobursa
Fluid accumulations (seromas) occur infrequently. The incidence is in the order of 5 in every 100 patients. Should a seroma form, repetitive needle drainage and a compression dressing will be required. A seroma that is not recognised or not drained may result in formation of a pseudobursa (or enclosed cyst) that will require surgical treatment.
Inadequate lifting/Long term effects
Skin and tissue limitations may limit the extent of the arm reduction. Subsequent alterations in body contour may also occur as the result of aging, weight loss or gain, pregnancy, or other circumstances not related to body contouring surgery. Additional surgery in some cases may be required.
Before Your Operation
Organise yourself for after your surgery
- Organise how you will get to and from hospital.
- Arrange to have someone at home with you for at least 2 or 3 days after you leave hospital.
- Organise help with your shopping, laundry, housework, pets, lawns, etc.
- Get all your pre-operative tests.
- Arrange leave from work and any financial chores as required.
Surgery and anaesthesia impose stress on your body.
The state of your health will be determined how well your body will cope with this stress.
It is important that you maximise your general health by exercising, not smoking and having regular checks with your GP, so that conditions such as hypertension, diabetes etc can be controlled.
Smoking increases the risk of post-operative complications after surgery. It is recommended that you stop smoking for 4 weeks prior to your surgery and for 4 weeks after.
If you need help to give up smoking, speak to your G.P. who can prescribe medication to help you, speak your chemist who can advise you about nicotine replacement therapies or call the national QUIT LINE on 13 18 48.
Depending on your pain tolerance and your home situation, it may be in your best interest to stay overnight in hospital. When in hospital you may have a drip for fluid. Dressings are likely to be removed before yare discharged from hospital.
Fasting, fluids, food
Fasting for surgery means that you cannot eat any food, or drink any fluid, after midnight the night before your surgery. A stomach full of fluid or food will mean that your anaesthetic may be dangerous and your procedure may be delayed or cancelled.
Adults who are fasting should have nothing solid to eat, and drink no milk-containing fluids for 6 hours prior to an operation. You may have up to 1 glass of water per hour up to 3 hours prior to surgery.
If you are in hospital a sign over your bed will read "fasting", "nil by mouth" or "NBM".
If you take medications in the morning, these should be taken as normal on the morning of your operation with a sip of water at 6 am.
NB. Diabetic tablets and insulin should be withheld while you are fasting. When you brush your teeth in the morning, spit out any water rather than swallowing it.
You will be required to list all your medications by writing down the name, the dose and the day each medication is taken. If this is too difficult for you, ask your regular doctor to make a list of your current medications for you.
It is important that you also bring all your medications to hospital with you.
Continue to take all your routine medications up to the time of admission to hospital EXCEPT blood thinning tablets like warfarin/coumadin. These medications must be stopped 5 days before surgery. You should discuss these medications with your surgeon.
Tablets like aspirin, astrix, plavix, iscover, cardiprin, and tablets for arthritis, rheumatism and gout, like brufen, Clinoril, feldene, indocid, orudis and voltaren must be stopped 10 days before surgery.
If you are not sure about your medications and the effect that they may have on your surgery please seek advice from your surgeon in advance of your surgery.
Antibiotics and small doses of blood thinning agents may be prescribed prior to your surgery.
If you have diabetes you must tell your surgeon prior to your admission date. You must also tell the staff at the time of your admission. Special arrangement will be made for you as necessary.
Your blood sugar levels will be monitored from the time you start fasting until normal eating resumes. Do not take any diabetic tablets on the morning of your surgery.
You may be required to shower at home with an anti-bacterial soap such as sapoderm or gamophen prior to your surgery. The same soap can be used after your surgery as well.
You may be required to have a shower in hospital with an antiseptic solution before your surgery.
A responsible person
A responsible person may be required to accompany you home after surgery. A responsible person is an adult who understands the postoperative instructions given to them and is physically and mentally able to make decisions for your welfare when appropriate.
You will need to arrange for a responsible adult to drive you after your surgery. A suitable vehicle is a car or similar. A taxi is only acceptable if someone OTHER than the taxi driver accompanies you. Public transport such as a bus is NOT acceptable.
It is important that you maintain your fitness and you should continue your normal activities prior to your surgery.
If time permits you may try to increase your fitness level gradually. Your fitness will be of benefit to your overall recovery after surgery. Walking is an excellent way of improving fitness and is recommended.
Pain relief in hospital
It is expected that you will have pain and discomfort after your surgery. The amount and severity of pain will vary from person to person.
Narcotics (morphine, pethidine, fentanyl) are used to relieve pain. Narcotics are not addictive in the amounts required to relieve pain.
If pain is not controlled with tablets you may be given a PCA (Patient controlled analgesia).
A PCA allows you to regulate the amount of medication that you need to control your discomfort. This is achieved by pushing a button to administer a pre-prescribed dose of narcotic through your intravenous drip.
It is important to limit the amount of discomfort that you have, so that you are able to do your breathing and general exercises as directed.
Any initial severe pain and discomfort will be managed with intravenous medication such as morphine, pethidine or fentanyl. Removal of tubes and drains usually results in a significant reduction of pain. The PCA machine is usually replaced with pain relieving tablets before discharge from hospital.
Pain relief at home
Pain, aches and discomfort may still be present when you leave hospital and may continue for several weeks. It is important when you are at home to maintain control over your pain, aches and discomforts.
Drugs for pain relief vary in strength and can "generally" be related to pain severity, BUT remember also that individuals have differing responses to pain and pain relieving medications.
As a guide and for your knowledge, the range of medication by drug strength from weakest to strongest is as follows:
Mild pain relief will be required for mild pain. Such pain relieving medication includes panadol, paracetamol, panamax and panadeine.
Moderate pain relief may require medications such as digesic, panadeine forte, tramyl, endone or oxycodone. You need to be aware that some pain relieving medications may contribute to persisting nausea and vomiting and will contribute to constipation in the post-operative period.
Antiinflammatory drugs such as vioxx, celebrex, brufen, naprosyn and indocid will contribute to effective pain relief when taken with mild pain relieving tablets.
If you have persistent unrelieved pain you may need to be seen by a doctor to exclude another cause for the pain.
If you normally take medication for bowel problems you will need to bring these medications to hospital with you. It is common to develop constipation after surgery that may require treatment.
Prevention of constipation begins on the day of surgery and continues until the bowel returns to "normal" function, which is usually once the need for pain medication ceases.
Medications for constipation such as coloxyl and senna or lactulose can be purchased from the local chemist without a prescription. Eat fresh fruit and vegetables, take extra fibre and increase your exercise. Drink plenty of water, providing you are not on restricted fluids for any reason.
It is important that you try to retain your identity as a normal person whilst you are in hospital. Make sure that you ask plenty of questions about what is happening to you. Feel free to share your concerns with the nurses, doctors and other professionals that are involved in your care.
After Your Operation
You will have dressings and bandages on your arms. Your arms may be placed on pillows for elevation and comfort.
You can expect to have some discomfort when you wake up after brachioplasty. You will be placed in a position where your head is elevated and your arms will be on pillows.
You will need to remember to move your legs to keep the circulation flowing and to take deep breaths to expand the lungs.
Care should be taken when moving around in bed. Rolling from side to side is preferable to lifting your body. Lifting your body may place stress on the suture line because you will use your arms to help lift your body. Lifting or carrying objects should be avoided.
You will be fitted with TED stockings before your brachioplasty surgery and you will wake from surgery with the stockings on.
TED stockings help to prevent blood clots from forming in the legs. TED stockings should be worn whilst you are immobile and you may be required to wear the stockings for up to 2 weeks following surgery.
You will need to take painkillers as provided. It is recommended that you avoid aspirin or aspirin based products, as they will promote bruising and bleeding.
The usual medications given in the postoperative period consist of panadol, panadeine, panadeine forte, panamax, digesic, and endone. These medications may be combined with anti-inflammatory medications such as vioxx, celebrex, or brufen.
Make sure that you have a postoperative pain regime at the time of discharge and that you understand the medications that you are taking and what they are designed to do for you.
One or two sleeping tablets (normison, temazepam, ativan) may be taken at night, if necessary, to help with sleeping in the first few days after surgery.
Your surgeon may prescribe a course of prophylactic (preventative) antibiotics.
Nausea and vomiting
Nausea and vomiting may be due to the anaesthetic or post-operative medication (like pain killers or antibiotics).
Apart from being unpleasant, vomiting will cause pain in the arms around the suture line.
Medication to prevent nausea and vomiting may be required.
If prolonged, nausea and vomiting may be related to a complication like infection and may cause dehydration. You need to inform your surgeon of prolonged nausea and vomiting.
Bruising of the arms after brachioplasty surgery is usually maximal at approximately 48 hours after surgery. Most bruises will resolve by 2 weeks. Gentle massage with a moisturising lotion (sorbolene), or arnica cream may help to dissipate bruising.
Bleeding or ooze
There may be ooze of blood from any of the suture lines on the arms.
Any ooze should resolve within 24 to 48 hours. Persistent or offensive ooze should be reported to your surgeon.
Swelling can occur for 4 to 6 weeks after brachioplasty and sometimes, intermittent swelling may take up to 12 months to settle. Please ask your surgeon how long swelling should take to resolve. Swelling lasting longer than this time may be due to a complication, and should be reported to your surgeon.
At home a mouldable cold pack or a small bag of frozen peas wrapped in a tea towel may help to reduce swelling, bruising, and pain. Cold packs can be applied to the arms (for 20 minutes every 1 to 2 hours) in the first 48 hours after surgery to help minimise swelling and bruising. The cold packs should not hurt.
If cold packs are uncomfortable, don't use them as often. After a few days gentle daily massage with a bland moisturising cream after your shower will help to resolve bruising and any lumpiness.
Dressings and drains
Dressings following brachioplasty may be removed as early as 24 hours after your surgery. Please ask your surgeon how long the dressings need to stay on.
Steri-strips or tapes may be present on the suture line and will need to be changed regularly. Check with your surgeon if you are able to shower.
Sutures may be beneath the skin and will absorb with time. The aim of absorbable sutures beneath the skin is to provide wound support for a longer time than skin sutures, so that scar stretch can be minimised.
Occasionally the body will want to extrude these sutures. A sore or a pimple on the suture line may indicate an underlying suture trying to break through the skin. This suture can be removed as soon as it breaks through the skin. Antibiotic ointment or betadeine may be required along with a small dressing until the area heals. Infrequently a lump forms related to a suture that has not dissolved (a stitch granuloma). This stitch granuloma may need to be excised as a local anaesthetic procedure.
Sutures or staples may be present in the skin. These sutures or staples will require removal at some stage after your surgery. The normal time frame is anywhere between 5 days to 14 days. Suture removal is usually arranged with the surgeon.
Some surgeons place Steri-strips over the suture line. Steri-strips are meant to stay intact and are usually removed one week after surgery. You may be able to shower.
Blistering from Steri-strips may occur. If this happens the Steri-strips will be removed and an alternative dressing will be applied.
Having a shower and getting your sutures wet may be permitted by your surgeon after the dressings have been removed. An antibacterial soap (sapoderm, gamophen) may be recommended.
You will need to pay attention to washing the suture line. Suture lines should be carefully dried with a clean towel. If your suture line has steri-strips or tape, wash over the tape and dry it.
Occasionally the suture line may become red and ooze. Antibiotic ointment or betadeine may be required. Your surgeon may prescribe antibiotics as well.
Some surgeons will prefer you to keep the sutures dry. Please check with your surgeon and ensure you follow your surgeon’s instructions about wound care.
Brachioplasty is performed under general anaesthesia and can be performed as day surgery.
If you are going home after day surgery a family member or friend must drive you because you have had an anaesthetic and someone should stay overnight with you for the same reason. You may need help from a relative or friend at home during the first few days after your brachioplasty.
If you have any questions about these matters, please speak to your surgeon.
The effects of an anaesthetic may still be present 24 hours after your procedure, even if you do not feel them. Your reflexes will be slower and you are at risk of injury. It is illegal to drive while under the influence of a drug (even a prescribed one) and you could be charged.
Do not make important decisions or sign legal documents for 24 hours after an anaesthetic. Take care with alcohol intake after surgery because medications and alcohol may interact with the residual anaesthetic. Discuss your normal medications with the anaesthetist.
Readmission to hospital
Rarely you may need to be re-admitted unexpectedly to hospital. The most common cause is persistent nausea and vomiting, anxiety, the need for unexpected additional pain relief or for treatment of unexpected complications of surgery such as bleeding, wound problems or infection.
Too much activity too soon will risk delays in healing or increase the risk of complications. Try to sleep with pillows beneath the arms for two weeks after surgery. Try to avoid lifting, carrying or pushing objects as this will put stress on the suture lines.
You may go to the bathroom, walk around the house sit and watch TV, etc., but no matter how good you feel do not clean the house, engage in heavy manual work, go to the gym etc. for 4 weeks following your surgery. This also applies to sexual activity.
Slow walking on the flat for exercise is often therapeutic in the early post-operative period. Your body will dictate whether you are able to safely recommence your exercise program. More strenuous exercise like fast walking or running may commence after 4 to 6 weeks.
Other exercise that involves using the arms like tennis, swimming or contact sports can commence after 6 to 8 weeks. As a general rule: if it hurts, don’t do it. Please ask your surgeon when you can start exercising.
Localised sore areas are not uncommon and are usually due to the deep sutures under the skin.
If fresh scars are exposed to the sun, they will tend to become darker and take longer to fade. Sunscreen on sun-exposed scars can help to fade scars. Take extra care and precautions if you are planning to tan, as some areas of your body may be temporarily numb after surgery and you will not "feel" a sunburn developing.
Your post-operative diet should consist of fluids initially then soft food that is easy to prepare. If you have any postoperative nausea, carbonated sodas and dry crackers may settle the stomach. You will tend to feel fuller sooner after your surgery so small frequent meals may be more suitable and comfortable.
Although not proven, there is some suggestion that multivitamins prior to and after surgery may aid in wound healing. Avoid mega dosing on vitamins prior to surgery.
Smoking reduces capillary blood flow to the skin and may result in delays to wound healing or complications of your brachioplasty. Smoking not only affects wound healing; it also increases the risk of bleeding, wound infections, post-operative chest infections.
Any coughing may disrupt the muscle repair. Smoking also increases the risk of developing a blood clot in the legs that can travel to the lungs. It is recommended that you cease smoking at least 4 weeks prior to your surgery and for 4 weeks after.
Medications and alcohol may interact with the residual anaesthetic and prescription pain medicine.
Alcohol also dilates blood vessels and may increase the risk of postoperative bleeding.
It is recommended that you avoid alcohol for the first three days after surgery and restrict your alcohol intake for the first month.
It is recommended that you do not drive for several days after a brachioplasty.
To be able to drive safely you must have full use of your reflexes to drive, and any post-operative discomfort will inhibit your reflexes.
If pain will inhibit them, don't drive. In the interest of safety whilst driving, and legally, you must wear a seat belt across the chest.
You may resume driving when you feel you are able, but it is advisable to discuss this with your surgeon or check with the road traffic authority first.
You must allow yourself adequate recovery time. You must also allow sufficient time for your body to recover from the effects of anaesthesia and surgery. You will have restriction to moving your arms for up to 2 weeks.
Too much activity too soon will increase the risk of complications such as bleeding, infection and delayed healing. It would be wise to ensure you have adequate time off work.
Discuss the expected time for recovery with your surgeon prior to your surgery and allow plenty of time for adequate recovery.
Everyone heals at a different rate. The ability to heal is variable and depends upon a number of factors such as your genetic background, your weight, your overall state of health and lifestyle (exercise, diet, smoking, drinking, etc.). Your attention to preparing yourself for surgery will be manifest in your post-operative recovery. Many people believe the surgeon "heals" the patient. Not one person can make another heal. Your cooperation and close attention to pre and post-operative instructions is extremely important and is in your best interest.
A major factor in the course of healing is whether you follow the instructions given by your surgeon and the nurses in the surgery. Such guidelines are designed to promote the healing process and to prevent the occurrence of anything that may interfere with your recovery.
It is imperative that you recognise that you are a partner in this process and have a responsibility to follow instructions carefully.
The instructions, based on broad experience, are designed to give you the best opportunity for healing without delay or surprise.
Depression is a normal reaction to surgery. The third day following your surgery may be the worst. You may be teary. It is not uncommon to experience a brief period of "let-down" or depression after any surgery.
You may subconsciously have expected to look and feel better "instantly," even though you rationally understood that this would not be the case.
Day 3 post surgery may be the worst but as healing occurs, these thoughts usually disappear quickly.
If you feel depressed, understanding that this is a "natural" phase of the healing process may help you to cope with this emotional state.
Support from family and friends
Support from family and friends can be very helpful, but because they may not understand what constitutes a normal postoperative course, their comments may unintentionally create emotional turmoil for you.
The staff at the surgery and your surgeon will tell you honestly how you are doing and what to expect.
Please trust in your surgeon’s knowledge and experience when your progress is discussed with you.
Complications are infrequent. When complications occur, it is seldom a consequence of poor surgery or poor postoperative care. Complications are more likely to be a result of the variable healing capacity or a failure to follow post-operative instructions. You will be assisted in every way possible if a complication occurs.
Should the unexpected occur, please understand that it is important to follow the advice of your surgeon and nursing staff in order to treat it as effectively as possible. Your surgeon and the nursing staff will ensure that you have support and assistance during this difficult time
It is very important that you follow the schedule of appointments established for you after surgery. Appointments to see the nurse or the surgeon should be made before or immediately after discharge from hospital.
The review appointment may be the next day or up to one week following surgery.
If no appointment has been made, you must ensure that you contact your surgeon and make a follow up appointment. If you have any concerns don’t feel that you are bothering the surgeon or the staff.
If need be, you can be seen prior to any arranged review appointment to sort out any concerns.
Occasionally the result of your surgery may not be totally perfect. If you feel that you can focus on the overall degree of improvement instead of any small lack of perfection, then you will reap the benefits of the results of your operation. If small imperfections will prevent you focusing on the degree of improvement after your surgery you probably should not have had an operation.
Your surgeon will use their expertise and experience in their surgical techniques to achieve the best results and ensure their patients receive the most advanced surgical techniques available. They keep updated by attending, national and international aesthetic conferences and seminars regularly.
The surgery performed may not necessarily relate to the methods that are sometimes promoted, or advertised in popular magazines, newspaper articles or on television.
The rate of revisional surgery, even in the most skilled surgical hands, can never be zero because patient and surgeon can control only some aspects of the outcome.
Minor adjustments or additional revisions following cosmetic surgery may be necessary in up to 5% of patients.
Revisional surgery is performed after the first postoperative year (12 months after surgery) because resolution of swelling and stabilisation of the final appearance takes at least that long.
During the first year after surgery irregularities, asymmetries or poor contours may sufficiently improve without surgery, so very small imperfections following surgery should not be revised.
Revisional procedures are less predictable and involve more risks. You must consider any revisional surgery carefully after discussion with your surgeon.
If revisional surgery is required you may incur further surgical, anaesthetic, pathology and hospital fees.
These fees may be covered if you have private health insurance, depending on your level of cover.
These fees will be your responsibility and you will need careful financial planning you before you embark on any form of cosmetic surgery. Private Health Insurance is strongly advised for any cosmetic surgery.
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