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Andjelkov et al. Plast Aesthet Res 2018;5:18 I http://dx.doi.org/10.20517/2347-9264.2017.96 Page 3 of 7

Figure 1. The redundant flap is marked using a Pitanguy marking clamp

All patients fulfilled questionnaires evaluating their satisfaction with the final result 3 and 6 months post-
operatively. For those who were unable to attend the 6-month consultation, the questionnaire was completed
via email or telephone call.

The amount of redundant skin and proposed areas for fat grafting were marked. The skin pattern for short
scar brachioplasty typically removes skin in the longitudinal direction, with the scar well camouflaged in an
axillary crease for an improved aesthetic result.

The marked areas were infiltrated with saline solution of 1:200,000 epinephrine. A decision to perform
liposuction before skin excision was patient specific, depending on quantity of fat deposit (pinch test
[4]
> 1.5 cm) and amount of skin laxity . This was found to be necessary in the majority of cases classified as
IIIa and sometimes in IIa. Liposuction was performed in the deeper planes of the subcutaneous tissue at
the anterior and posterolateral parts of arm using Tulip® 3.0 cannulas (Tulip Medical Products, San Diego,
USA), and fat was processed using Puregraft® system (Bimini Technologies LLC, San Diego, USA). After
purification, an average amount of 40 mL per arm is injected into the anteromedial aspect of the upper arm
using Tulip injectors 1.2 mm. Fat grafting was performed in several layers, both superficial and deep; with
the aim to promote an expansion effect and encourage skin regeneration in the local region.

The demarcated flap is undermined and elevated superficially to the brachial aponeurosis and an axillary
[5]
fascial anchoring technique was performed as described by Lockwood . The use of fascial anchoring is
advantageous, ensuring the axilla maintains its contour. The redundant flap is marked using a Pitanguy
marking clamp, and a subsequent skin excision is performed as shown in the Figure 1.

For all patients we compiled information regarding their age, upper arm classification system and their
satisfaction rate 3 and 6 months post-operatively (graded as excellent, good and as fair result). Statistical
analysis of the data was performed using SPSS software and modern statistical methods.

RESULTS
In a course of 7 years (2009-2016) we treated 47 patients with this technique. All patients were female.
Age ranged between 45 and 65 years (average 55.2 ± 5.2). The surgical indication for all patients was senile
elastosis, or lipodystrophy of the upper arms. There was no significant statistical difference in the age
distribution of patients in the group, and also in number of patients in each group (P = 0.212), which shows
homogenous grouping when observing the age and upper arm deformity.

Our patient population according to the upper arm lipodystrophy classification is presented in Figure 2. The
satisfaction rates after 3 and 6 months after the surgery and their distribution depending on the upper arm