Upper arm lifts are among the most complication-prone aesthetic procedures. In addition to hypertrophic and widened scarring, recurrences, wound dehiscence and wound infections must be expected in up to 40% of patients. Moreover the scar after an upper arm lift remains visible in everyday life at the cost of improved body contour.

The incision can be made medially (hidden scar position) or further dorsally (easier resection). In Regensburg we prefer a posterior-medial position, which is, in our opinion, the best compromise of both alternatives.

Depending on the tissue excess a limited, a standard horizontal or an extended L-shaped incision with an extension to the thoracic wall can be selected.

Liposuction is often necessary in addition to achieve the desired result.

Deformities of the upper arm occur due to the loss of skin elasticity as part of the aging process, due to weight fluctuations or after massive weight loss.  The upper arm lift places high demands on the plastic surgeon, because, compared to other aesthetic procedures (e.g. abdominoplasty or  breast reduction/augmentation), minor complications (e.g. hypertrophic and delayed or secondary wound healing) occur quite often (20-40 percent) and regardless of the surgical technique scares may be visible in the daily live.  This must be into consideration in the context of informed consent.

Regarding the surgical approach a distinction must be made between an excess of fat, an excess of skin or a combination of both. While a pure excess of fat can be treated by liposuction alone, an excess of skin always requires tissue resection.

In addition, the location of the tissue excess plays a decisive role in the choice of therapy.

The position of the incision significantly influences the aesthetic result and the extent of the resection.  A dorsal incision facilitates the resection in the area of the largest skin excess. However, a dorsal incision is clearly visible and therefore aesthetically problematic. In contrast a medial incision provides a hidden scar, but the skin-fat excess in the medial upper arm is only discretely pronounced. Consequently an adequate resection is only possible with a generous mobilization of the skin. Due to the skin tension after mobilization and the thin medial dermis, scars at the medial upper arm tend to widen and wound-healing disturbances are more often compared to the dorsal position.

An ideal classification and therapy algorithm of upper arm deformities was first published by Rohrich's working group in 1998 and modified in 2006. It takes into account all clinical characteristics and gives corresponding therapy recommendations for the individual clinical pictures.

Upper arm contouring can take the form of a tissue resection, liposuction or a combination of both techniques.The deformity is based on maasive weight loss,   loss of skin elasticity due to the aging process and high weight fluctuations.

The working group around Rohrich et al. was able to update their classification, first published in 1998, again in 2006.Besides the high clinical relevance, a simple therapy algorithm can be derived from it.

The skin of the upper arm is soft, elastic and very mobile. The dermis is clearly stronger dorsally than medially.

The superficial fascia surrounds the entire upper arm and its elasticity decreases in the aging process or after massive weight loss.

The deep fascia encloses the musculature as well as the relevant vascular-nerve structures and protects them from injury. To avoid serious complications, the deep upper arm fascia should never be injured during surgery.

Relevant fat rarely accumulates below the deep fascia and is predominantly localized in the dorsal upper arm. The effect of dorsal tissue excess is further enhanced by gravity-induced ptosis in the dorsal upper arm.

The relevant epifascial located structures that are in danger during dissection are the following sensitive nerves 

 And the following veins

Despite the subfascial position, the ulnar nerve is in danger of iatrogenic injury at the medial epicondyle. As the subcutaneous tissue is very discrete in this area, violation of the nerve is possible especially during liposuction.

The following key points should be considered in the preoperative assessment

Preoperative markings should be done preoperatively on the awake patient with a waterproof pencil (shoulder 90° abducted; elbow 90° flexion). It has to be considered that disinfectants containing alcohol can remove the preoperative marking completely. On the other hand disinfectants containing iodine cause a distinct discoloration of the skin and require a longer drying phase. 

There is controversy among plastic surgeons about the ideal position of the incision. While a medial localization can be better hidden in everyday life, wound-healing problems occur more often and resection is more difficult. In contrast tissue resection using a dorsal approach is easier and less prone to complications.

In Regensburg we prefer a posterior-medial incision described by Capella et al. or Chandawarkar et al.  This position is the best compromise of both techniques. This approach conceals the later scar and at the same time allows adequate resection in the best possible way.

The marking of the upper arm is identical to points 1 and 2 of the posterior-medial incision. In addition to the ellipsoid marking of the upper arm, resection is carried out on the thorax

In supine position both arms should be freely movable on an arm table. Even in pure upper arm lift or limited upper arm lift, at least the upper part of the thorax should be washed off.

The markings must be checked for completeness and redrawn if necessary. Orientation lines perpendicular to the incision should be drawn to ensure adequate wound edge adaptation after resection in order to avoid dog-ear configuration.

Frequent irrigation of the wound, bleeding or resection in combination with liposuction can wash away the orientation lines. Therefore the marking should be carried out far from the wound. Alternatively, temporary surgical staples could be placed to ensure subsequent alignment.

The extent of the resection should be reassessed and temporarily fixed with surgical staplers or clamps.

Final resection of the excess tissue can be performed in several steps to avoid overcorrection.

Liposuction can be performed as a two-stage procedure prior to brachioplasty or simultaneously