The Tumescent Technique By Jeffrey A. Klein MD
Tumescent liposuction of the arms provides excellent results. As surgeons become familiar with the technique, it becomes an increasingly popular procedure. Of all the areas that I treat by liposuction, the arms consistently yield the highest level of patient satisfaction. Although not every woman is a good candidate, the results are most gratifying for properly selected patients.
Older liposuction techniques often included brachioplasty, or direct excision of skin from the volar arm. The potential for significant aesthetic improvement was limited by the resulting unsightly scars. With microcannular tumescent liposuction, brachioplasty has become an anachronism.
Liposuction of the arms is almost exclusively a procedure for women. With age and a genetic predisposition, women may accumulate fat over the arms to a degree that many consider to be disproportionate and unattractive. Exercise does not reduce the volume of fat located on the arms. Microcannular tumescent liposuction of female arms easily and consistently yields results that are well proportioned and without visible surgical scars.
The goal of arm liposuction is to improve a disproportionate appearance of the arm while maintaining the aesthetic quality of female beauty. Most women do not want arms that appear muscular or masculine. The goal is for the patient to feel more comfortable and less self-conscious when wearing a sleeveless blouse.
Eliminating the pendulous appearance of the extensor aspect of the arm when it is abducted perpendicularly from the body is not sufficient. The goal is to achieve a thinner appearance of the arms when the arms are in a relaxed, dependent position alongside the torso. Whereas a heavy bulky arm augments the appearance of obesity, a thin svelte arm complements a woman’s figure and provides the appearance of a thinner body (Figure 39-1).
When a woman with bulky arms stands erect and stretches her arms out in a spread-eagle or horizontal fashion, the dependent tissue of the triceps area sags. The former surgical approach to treating apparently redundant arm skin has been to excise the tissue. This prompted surgeons to recommend a brachioplasty.
Women are rarely seen in a social situation with arms fully abducted in spread-eagle fashion. On the other hand, women are often seen with arms relaxed at their sides. It is in this position that the liposuction surgeon should seek to maximize cosmetic improvement.
For most women, tumescent liposuction of the arms can provide consistently dramatic and gratifying results. Even drooping extensor arm fat can be eliminated with simple liposuction (Figures 39-2 and 39-3).
The degree of improvement provided by liposuction of the arms is limited in certain patients, such as those with morbid obesity.
The guiding principle in tumescent liposuction of the arms is uniformly unweighting the skin of subcutaneous fat. In most patients this involves the liposuction of 75% (270 degrees) of the brachial circumference, avoiding only the arm’s volar aspect. In most prospective patients the volar aspect has relatively thin fat deposits. Only in the more obese patient is circumferential liposuction of the arms of any significant cosmetic benefit (Figure 39-4).
The surgeon must be cautious and avoid excessive liposuction of the arms. The goal of liposuction is to improve the cosmetic appearance of the patient; this goal is not necessarily achieved by removing the maximum amount of fat. Arms that are disproportionately skinny on a woman with an otherwise shapely body might appear deformed rather than attractive.
Gross Anatomy of Subcutaneous Fat
Except in obesity, the typical female arm has a distribution of fat that encompasses approximately three quarters of the arm’s circumference. The deep subcutaneous fat compartment of the arm extends over the biceps and triceps. The volar aspect of the female arm overlying the biceps has relatively little deep subcutaneous fat.
In most women, excellent cosmetic results can be obtained by limiting the area of liposuction to the 270 degrees of the arm’s circumference that contains the deep fat compartment. For the majority of women, liposuction of the medial 90 degrees of the arm’s circumference can be avoided while achieving excellent results.
The medial or volar aspect of the arm is relatively devoid of significant subcutaneous fat deposits. Because most of the important subcutaneous neurovascular structures of the arm are found in the medial compartment, liposuction surgery in this quadrant should be done with caution.
The largest mass of soft subcutaneous fat in the arm is found in the posterior or extensor compartment, overlying the triceps muscle. On careful palpation, however, it is evident that a significant amount of subcutaneous fat can be found extending anteriorly, overlying the biceps muscle. This fat is more fibrous than the fat of the triceps area.
Careful microcannular liposuction of the entire deep subcutaneous fat compartment of the arm will “unweight” the cutaneous tissues. Most women, even those with significant solar damage, have enough natural elastic recoil of the brachial skin for liposuction to yield gratifying results.
The underlying muscles of the arm include the triceps, biceps, and distal portion of the deltoid. With increasing obesity, fat of the arm may extend along the extensor aspect of the elbow over the proximal aspect of the long supinator muscle. The fat overlying the lateral portions of the latissimus dorsi, teres major, and teres minor (posterior axillary back) is often treated simultaneously with the contiguous fat of the arm.
For liposuction purposes the medial (volar) surface of the arm is defined as the area closest to the chest wall when palms are held flat against the lateral thighs. The definition of the anterior, lateral, and posterior surfaces of the arm is based on this position.
Anterior axillary–lateral pectoralis fat becomes more prominent with age. The fat pads of the posterior axillary–posterior shoulder and lateral back become more prominent with increasing degrees of obesity. These are areas of cosmetic concern for many women. The small focal collection of fat is accentuated by the compressive effects of a bra. Both these areas respond well to microcannular tumescent liposuction.
Marking the arms for liposuction requires the same careful attention to subtle detail as do other areas of the body. The volar arm overlying the biceps muscle is usually excluded from liposuction because this area has little fat. The volar fat overlying the triceps muscle is almost always included in the markings (Figure 39-5).
There is no single or ideal patient position for liposuction of the arm. At least two different positions are required to gain convenient access to the entire extent of the arm’s deep fat compartments.
Most of the fat may be suctioned with the patient lying in a lateral decubitus position. The arm may be positioned slightly akimbo by placing a folded towel between the elbow and the lateral chest wall. Liposuction of the anterior, lateral, and extensor areas of the arm is approached with the elbow somewhat bent and the hand resting somewhere along the lateral thigh and hip area, depending on the surgeon’s preference (Figure 39-6).
The volar fat overlying the medial triceps muscles may be easily approached by having the patient raise the elbow over the head and resting the palm on the pillow beyond the head. The anterior axillary fat pad area is treated with the patient supine and the arm at the side or raised over the head.
Tumescent infiltration of the arm is simple and relatively well tolerated.
Circumferential liposuction of the arm is usually not necessary but can be accomplished. Tumescent infiltration of the arm’s entire circumference is unlikely to produce a “compartment syndrome,” but some caution is required. The surgeon should avoid excessive tumescence that produces a functional tourniquet by elevating interstitial pressure beyond the arterial pressures of the upper extremity.
In practice, such an iatrogenic compartment syndrome is unlikely. Circumferential tumescence of the arm can exceed the brachial venous pressure, however, causing a distal capacitance or venous reservoir effect. If a small venule is lacerated during subsequent liposuction, the resultant bleeding might appear somewhat exaggerated (i.e., more than normally expected).
Microcannulas permit a decisive approach to liposuction of the arms while minimizing the risks of skin irregularities. Multiple small incisions or 1.5-mm adits give access to the arms’ entire circumference.
The surgeon should avoid unnecessary adits but should make extra adits if it will improve the smoothness or completeness of the results. The minuscule incisions required to accommodate 16-gauge and 14-gauge microcannulas produce virtually no scarring.
At the distal extent of the arm, two to four 1.5-mm adits are made. Additional adits along the long axis of the arm are placed judiciously for optimal access to the targeted fat pads but are distributed randomly to avoid more than two incisions along a straight line.
Fat over the proximal arm and overlying the distal deltoid muscle may often be approached from distal incisions. Because incisions over the deltoid have an increased incidence of scarring, the number of incisions in this area should be minimal.
Although one can begin with a 14-gauge microcannula, liposuction is usually initiated with a 16-gauge microcannula, which is used to establish the deepest plane of liposuction. The smallest cannulas permit the greatest accuracy and are the least likely to cause pain if the surgeon encounters an area of insufficient anesthesia.
Once the deepest plane of liposuction has been defined, the cannula is directed throughout the fat to perforate the fibrous tissue septa. This pretunneling with small cannulas will permit the use of larger cannulas with less resistance from fibrous tissue. The 16-gauge and 14-gauge microcannulas are sufficient for most female arms. Occasionally a 12-gauge cannula is required.
The paths of the microcannula along the arm are largely directed parallel to the long axis of the arm, using numerous oblique and diagonal strokes to ensure the smoothest results. Transversely directed paths are usually not necessary.
The end point of the suction is determined by the uniformity of a pinch test over the entire extent of the treated area. A thin layer of residual fat should remain to ensure a mature female appearance and the natural tactile softness of a female body. Overenthusiastic liposuction can produce masculine-appearing arms, which some may regard as a deformity.
Fat in the anterior axillary fold becomes more prominent with age. Using 16-gauge microcannulas and a deliberate effort to achieve smooth uniform extraction, the surgeon can achieve excellent results in this area. To achieve uniform liposuction throughout the targeted area, some of the adits or incisions should be located at least 2 to 3 cm beyond the proximal and distal peripheries of the targeted area.
Because only moderate compression is necessary for the arms, postoperative care after liposuction of the arms is relatively simple. Drainage infrequently lasts more than 24 to 48 hours after surgery. Although absorptive padding must be worn until all drainage ceases, typically only a minimal amount of padding is necessary after 24 to 48 hours.
Dressings consist of absorbent compression pads, initially held loosely in place by tubular elastic netting, over which are wrapped elastic nonadhesive Ace-type bandages. The patient can easily remove and reapply these dressings without assistance (Figure 39-7).
Postoperative improvement is rapid. Patients improve significantly within a few days after surgery; 90% of patients attain 90% improvement in 1 to 2 weeks.
Stiff compression garments are not necessary for the arms. They are difficult to apply without assistance and often cause edema of the forearms and hands.
The anterior axillary, posterior axillary, and scapular areas require absorptive padding for only 1 to 2 days. The absorptive pads are held in place with a torso compression garment (Figure 39-8).
Pitfalls and Special Considerations
Excessive liposuction causes the most common aesthetically adverse result. Some regard arms that are devoid of subcutaneous fat as neither attractive nor beautiful and not normal female arms. When liposuction of the arms is done too aggressively, some areas have no subcutaneous fat, whereas adjacent areas do have residual fat. Such overaggressive liposuction yields an unappealing lumpy result, which is grossly accentuated when the patient gains a minimal amount of weight.
The surgeon should avoid liposuction of the axilla, which has no cosmetically significant fat. Furthermore, whereas anterior, posterior, and thoracic axillary fat can be safely treated by liposuction, the axilla proper has important neurovascular structures that are vulnerable to liposuction trauma.
Hyperhidrosis. Some surgeons have advocated liposuction of the axilla as an effective treatment for axillary hyperhidrosis. The advantages of liposuction in the destruction of axillary apocrine sweat glands are questionable. The traumatic destruction of apocrine glands by liposuction causes some dermal necrosis and axillary scarring. Even with the tumescent technique, the risk of damaging important axillary neurovascular structures outweighs the purported advantages of liposuction.
The safest surgical approach for axillary hyperhidrosis is with tumescent local anesthesia, simple excision of more than 80% of the hair-bearing skin, and primary Z-plasty closure. Therapeutic results are excellent, healing is rapid, and risks are minimal.
Distal Fat Pad
The surgeon must carefully assess the entire arm for accessible subcutaneous fat. For example, it is easy to overlook the common localized collection of fat at the distal aspect of the extensor arm. This small fat pad often appears insignificant when examined preoperatively. If this fat is not specifically treated by liposuction, however, the patient will often comment on the oversight at a follow-up examination.
Anterior Axillary Fat Pad
The anterior axillary fat pad may become prominent with increasing age. Even in some relatively thin women, this fat pad can be disproportionately large. Careful, deliberate liposuction technique using Capistrano microcannulas can easily reduce the fat pad to a smooth and inconspicuous area (Figure 39-9).
The patient lies supine with the ipsilateral arm raised over the head, stretching the pectoralis muscle and making it taut and firm (Figure 39-10). Using this position, the surgeon can easily palpate and appreciate the difference between the fat and the subjacent muscle. Tumescent infiltration should be directed throughout the pad, as well as in a 2-cm periphery beyond the fat pad’s margins. Microincisions or adits are placed at both the proximal and the distal ends of the pads.
Tumescent liposuction using 16-gauge Capistrano microcannulas can provide excellent results. Liposuction tunnels should be distributed throughout the targeted tissue in proportion to the depth of the compartment. If a largediameter cannula is used, the surgeon may tend to remove too much fat in the midportion of fat pad and leave too much fat at the periphery. This limits the smoothness and the aesthetic appeal of the results. Often, this lack of finesse results in an unsightly crease through the middle of the fat pad, as well as residual fat at the periphery. When microcannulas are directed more accurately, results are smoother and more uniform.
Postoperative compression is necessary only for approximately 24 hours. The sleeves of the torso garment hold the absorptive pads in place and provide adequate compression.
The goal of tumescent liposuction of the arms is to achieve an improved appearance of proportionality in size and shape between the body and the arms. Careful tumescent liposuction using microcannulas can consistently achieve this goal (Figure 39-11).
Figure 39-1 A, Topographic contour diagrams indicate relative depth of fat on arms, posterior axillary back, and infrascapular back (flanks). B and C, Preoperative posterior and lateral views. Note bulkiness of proximal posterior deltoid area and appearance of obesity. D and E, Postoperative posterior and lateral views. Note that patient appears much thinner.
Figure 39-2 Large, sagging arms improved by tumescent liposuction; skin excision is unnecessary. A, Lateral view of topographic contour diagrams indicates relative depth of fat. B, Preoperative view of pendulous arm. C, After tumescent liposuction totally by local anesthesia using microcannulas.
Figure 39-3 Disproportionately bulky arms give overall appearance of obesity. A, Lateral view of topographic contour diagrams of arms and abdomen. Preoperative views: B, lateral; C, posterior; D, anterior. Postoperative views: E, lateral; F, posterior; G, anterior. Note thinner and more proportionate appearance of arms.
Figure 39-4 Topographic contour diagrams of arms demonstrating 75% (270 degrees) of brachial circumference targeted for microcannular tumescent liposuction: A, anterior view with arms spread horizontally; B, anterior view with arms at side; C, lateral view. D, Preoperative lateral view. E, One day after surgery.
Figure 39-5 A and B, Topographic contour diagrams of arms demonstrating more than 75% of circumference targeted for microcannular tumescent liposuction. C and D, Preoperative and postoperative anterior views with arms held horizontally. E and F, Preoperative and postoperative posterior views. G and H, Preoperative and postoperative lateral views.
Figure 39-6 Arm liposuction requires two positions to ensure easy access to all 270 degrees (75%) of arm circumference. For both, patient is in lateral decubitus position. A, For extensor portion of arm fat pad that overlies triceps and biceps, arm rests on patient’s uppermost side. B, For volar or axillary portion of arm fat that overlies medial triceps, arm is raised, with ipsilateral hand resting over or behind head. Large, sterilized, superabsorbent surgical table sheet (not shown) placed immediately beneath arm helps control intraoperative drainage.
Figure 39-7 Postliposuction care of arms. A, Cut sufficient length of tube netting with appropriate diameter, then cut small “bite” out of proximal end. B, Place absorptive pads over arms, covering all treated areas. Use tape to secure position of pads until tube netting can be pulled into place. C, Place absorptive pads over posterior axillary area, if suctioned. D, Move tube netting over arm, on top of absorptive pads. E, Place loop of netting over head. F, Arrange netting so that it fits comfortably around neck. Use torso garment to provide compression over proximal arm and axillary back. Arm compression is achieved by wrapping 15-cm (6-inch)–wide elastic bandage around tube netting.
Figure 39-8 Arm dressings for open drainage immediately after surgery. A, Absorptive pads are secured to arms and posterior axillary back with paper tape until elastic bandage is applied. B, Placement of elastic compression bandage on top of pads, which cover arm and anterior and posterior axillary areas. Arms require compression only for about 24 to 36 hours, until drainage has ceased. C, After arms have been wrapped, torso garment provides sufficient compression over anterior and posterior axillary areas and lateral back and secures absorptive compression pads.
Figure 39-9 Bulging anterior axillary pads are easily reduced to a smooth and inconspicuous area with tumescent liposuction using 16-gauge and 14-gauge Capistrano microcannulas. A, Preoperative view. B, Postoperative results.
Figure 39-10 Surgical position for liposuction of anterior axillary fat pad.
Figure 39-11 Goal of tumescent liposuction of arms is to achieve more slender appearance when patient’s arms are held normally alongside body. A, Preoperative view. Bulky proximal arm contributes to appearance of generalized obesity. B, Postliposuction view. Natural appearance of thinner upper arm is more proportional to rest of patient’s body size and weight.