Brachioplasty after bariatric surgery : evaluation of patient satisfaction

Introduction: Upper limb deformity caused by massive weight loss can be corrected by brachioplasty. This plastic surgery improves limb contour, facilitates hygiene, and enables use of certain clothing. Objective: To present the cases, describe interventions and complications, and evaluate the satisfaction of patients who underwent brachioplasty after bariatric surgery. Method: Herein, 34 patients (including 33 females) aged 46.6 ± 12 years, who underwent brachioplasty after bariatric surgery, were recruited for the study. Interventions and complications associated with the surgical procedure were described, and the satisfaction of 33 patients was evaluated by a qualitative interview and specific questionnaire. Results: As a minor complication, slight dehiscence was observed in five patients (14.7%), but no major surgical complications were seen. Some degree of satisfaction was reported by 81.8% of the Instituição: Serviço de Cirurgia Plástica e Queimaduras do Hospital das Clínicas da Faculdade de Medicina – USP. Artigo submetido: 6/1/2014. Artigo aceito: 4/3/2014. Rev. Bras. Cir. Plást. 2014;29(2):232-6 DOI: 10.5935/2177-1235.2014RBCP0043


INTRODUCTION
Bariatric surgery facilitates significant and sustained weight loss 1 .After bariatric surgery, body contours change; excess skin forms large folds on different parts of the body, such as the upper and lower extremities, abdomen, breasts, and face.This body dysmorphia impairs the quality of life of the patients who undergo this surgical procedure².
In the arms, this dysmorphia is characterized by the loss of cylindrical contour; this is caused by the development of a skin fold of variable size, which can extend from the elbow to the axilla or beyond, and even to the lateral wall of the chest (Figure 1).This deformity is due to the loss of fat content, the limited capacity of the skin to retract, and by sagging induced by distesion of the superficial fascia 3,4 .
Brachioplasty after bariatric surgery removes hanging excess skin-fat, and improves arm contour, making it more cylindrical and balanced; this results in greater amplitude of movement and encourages use of lighter clothing, such as T-shirts or sleeveless shirts 4,6 .Improvement of this surgical technique has resulted in increasingly satisfactory outcomes; the higher number of bariatric surgeries explains the growing demand for brachioplasty 7 .
For many years, the evaluation of plastic surgery outcomes was conducted by photography.Pre-and post-operative photographic analysis can be performed by surgeons, laymen, or a combination of the two.However, the importance of the surgical technique employed for the assessment of patient satisfaction was recently reported 8 .

OBJECTIVE
This study aims to present the cases of brachioplasty after bariatric surgery, describes the surgical complications observed, and evaluates patient using a questionnaire, which was developed for this purpose.

METHOD
The cohort in this retrospective study was composed of 34 patients, including 33 females, who had significant weight loss after bariatric surgery using the restrictive-malabsorptive Fobi-Capella technique 9 .Between 2007 and 2012, all patients underwent brachioplasty within 5 years (6.8 + 3.2 years) after bariatric surgery.
All patients who underwent brachioplasty maintained a stable weight for at least the prior 12 months.
Patients who lost weight with clinical treatments, such as diet and food reeducation, and those who did not complete the questionnaire, were excluded from the study.
We collected data on gender, age, time interval between bariatric surgery and brachioplasty (TBB), operative time (OT), hospitalization time (HT), and prebariatric surgery and prebrachioplasty body weight and body mass index (BMI) (Table 1).
Patients who only underwent brachioplasty (n=26, 76.5%) were hospitalized for a day and discharged with guidelines of postoperative care to be followed.Patients who underwent combined surgery (n=8, 23.5%) were hospitalized for 2 days.

Surgical procedure
First, a straight line is drawn on the medial arm, which remains hidden as much as possible when the arms are placed next to the body.With a bidigital clamping technique, and with the arm abducted to 90° and elbow flexed at 80º, elliptical lines were drawn in a spindle pattern, corresponding to excess skin to be resected without excess tension.This spindle pattern usually extended from the anterior axillary line to 2cm proximal to the medial epicondyle.Along the axillary pre-hairline and parallel to it, a second spindle of skin is demarcated perpendicular to the first, for resection of skin flaps.After rigorous hemostasis, superficial fascial suspension is carried out by plication of the fascia and synthesis by planes 10 .This demarcation will result in a "T"-shaped scar, with or without extension to the chest (Figures 2 and 3

Figure 3 (A) -"T" Technique extending to the chest -Method of excess skin demarcation. (B) -Immediate post-operative
period showing a detail of the plastic surgery and axillary "Z".

Satisfaction Questionnaire
Satisfaction with plastic surgery outcomes was estimated using a questionnaire that was specifically developed for this study.Five items were evaluated: surgical outcome vs. expectation, improvement in social and emotional life, improvement in body self-care, and satisfaction with arms after brachioplasty.Each item was answered "yes" or "no." In all cases, general anesthesia and prophylactic antibiotic therapy was administered, and all patients were operated on by the same surgical team.Complications associated with brachioplasty were tabulated and classified as major or minor (Chart 1).

Large dehiscences
2) Was there an improvement in social life after brachioplasty? 23 10 3) Was there an improvement in emotional life after brachioplasty? 16 4) Was there an improvement in body self-care after brachioplasty?21 5) Are you satisfied with your arms after surgery?27 6

Statistics
All scores obtained were tabulated and statistically analyzed.Numerical results are presented as average ± standard deviation.

RESULTS
No major complications associated with brachioplasty were observed.However, five cases of small dehiscences were a minor complication (14.7%), with no cases of seroma or atelectasis.
The satisfaction questionnaire was administered to 33 patients.Of these, 23 patients (69.7%) stated that the outcome obtained was close to their expectations, 23 (69.7%) reported an improvement in social life, 16 (48.5%)reported an improvement in emotional life, 21 reported improved body selfcare (63.6%), and 27 (81.8%)were satisfied with their arms after plastic surgery (Table 2).

DISCUSSION
Brachioplasty is a technically well-established surgery and is specifically indicated in patients with massive weight loss.However, issues such as positioning of the scar 14 , among others, remain subjects of discussion.
The most used classifications, such as those of Teimourian 15 and El Khatib 16 , correlate the type of deformity to the indicated surgical treatment.El Khatib 16 clinically classified brachial ptosis into five groups, which aids planning of the surgical approach.
This study evaluated postoperative satisfaction with the arms in patients with brachial ptosis stages 3 and 4; these patients underwent extensive brachioplasty, with or without extension to the chest.
In this study, there were no major surgical complica-tions; minor complications included five cases of small dehiscence, which resolved spontaneously.
The questionnaire evaluated patient satisfaction after brachioplasty, and indirectly assessed improvement in the quality of life.
Most patients were satisfied with the results (81.81%) and the outcome that was most appreciated was the ability to wear lighter clothing.Of six dissatisfied patients (18.2%), one complained about a hypertrophic scar and the other about the asymmetry between limbs, complications inherent to the surgical procedure.Four patients reported excess skin as the cause of dissatisfaction.
Ten patients (30.3%) reported that the outcome was far from expectations, claiming persistent brachial sagging.These patients had a prebariatric surgery BMI greater than 42 kg/m 2 , and four were morbidly obese, with a BMI above 50 kg/ m 2 ; this may explain the difficulty in removing excess skin.
Patients who denied an improvement in social (30.3%) or emotional life (51.5%)after brachioplasty claimed that any improvement was due to the bariatric surgery, with no positive or negative benefit from subsequent plastic surgery.
Of the 33 patients interviewed, 21 (63.6%) reported improvement in body self-care after brachioplasty, attributing this to the removal of excess skin and an increase in selfesteem.The remaining patients (36.4%) reported no change in body self-care, with no influence by plastic surgery.

CONCLUSION
The results obtained in this series of patients permits an inference that postbariatric brachioplasty can be considered a safe procedure, which may be indicated in patients with stable weight and upper extremity dysmorphia due to excess skin.

Figure 1 (
Figure 1 (A).Excess skin in the right arm after a weight loss of 49 kg -Frontal view.

Table 2 .
Responses to the satisfaction questionnaire