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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 5 of 7
are maintained.

In groups IIa and IIb the final surgical result 6 months after the surgery was considered good or excellent by
more than 88% of patients, and no revision surgeries required. Patients were satisfied with the whole aspect
of upper arm contouring, specifically with the hidden scar and improvement of the skin quality in areas
where the fat grafting was performed. Satisfaction of the final surgical result for group III was graded as
either good or excellent in 58.3% after 6 months.

There were no significant complications. Two cases (4.2%) of isolated wound dehiscence occurred, which
were all resolved conservatively with dressings and antibiotics.

DISCUSSION
The increased number of post-bariatric patients has popularised a whole range of body contouring
procedures. Great weight loss is coupled with increased overall body skin laxity. When considering
brachioplasty for this group of patients, the usual findings of severe brachial ptosis and skin laxity, with
relatively little amount of adipose tissue are observed. The only suitable technique for these patients is
[7-9]
traditional brachioplasty with or without extension depending on the quantity of excess chest skin . There
is no doubt among surgeons in the required treatment of this group of patients classified as group IIc and III
[10]
by Rohrich Classification System, or group III and IV by Teimourian and Malekzadeh .
Also there is unique opinion when good skin quality is present with moderate amount of fat excess. Solely
[7]
liposuction of the upper arm is the treatment choice of this group, known as group I .
However, when it comes to classification and treatment of patients in-between these two extreme groups,
there are certain differences in approach. Surgical treatment ranges from limited incision, limited incision
with liposuction to the traditional brachioplasty [7,11] . Furthermore, there are several methods described
in literature that address the moderate skin laxity in upper arms with reduced scars such as laser-assisted
[12]
liposuction in order to provoke skin retraction . The idea of augmentation brachioplasty using small
silicone implants has also been preconized by some plastic surgeons . Importantly, the use of concomitant
[13]
procedures does not significantly increase complication rates, and we believe our proposed use of fat grafting
preserves this opinion [2,9,13] .

The regional anatomy favours our proposed operation, since there are no vascular or nerve structures in the
trajectory of the incision, nor are these structures localised under or over the muscle; that could be impaired
[13]
by compression exerted by the inclusion . This technique can be used in selected cases of biceps brachii
hypoplasia associated or not with a low degree of skin flaccidity in the posterior region of the arm. The
volume augmentation in the anterior direction submits the posterior skin to traction.

Fat has well known filling and regenerative properties. It aids in the correction of sagging skin and improves
skin quality, with only a minimal scar requirement. Furthermore, advantages of low complication rates,
minimal surgical and recovery downtime, and in addition to good satisfaction and acceptance rate among
patients have been reported. The described technique of harvesting, processing and injecting the fat provided
predictable results that were maintained along the first year after small incision brachioplasty. This technique
ensures an even contour is maintained, promoting patient satisfaction with the final result.

Three cases (6.4%) of revision surgery after 6 months were required in our patient population, all of whom
belonged to group III. For all revision cases we performed traditional brachioplasty in order to remove the
remaining excess skin. In consideration of treating those patients classified as group III, it is imperative to
analyse the skin elasticity. Limited brachiolpasty procedures only address skin excess in the longitudinal