Aesth Plast Surg (2023) 47:S159–S161
https://doi.org/10.1007/s00266-022-03122-z
LETTER TO THE EDITOR
Comment on: Ultrasound-Assisted Liposuction (UAL) Arm
Contouring in Non-post-bariatric Patients—No Rush
for Brachioplasty
Bishara Atiyeh1 • Saif Emsieh1
Received: 6 September 2022 / Accepted: 8 September 2022 / Published online: 28 September 2022
Ó Springer Science+Business Media, LLC, part of Springer Nature and International Society of Aesthetic Plastic Surgery 2022
Level of Evidence V This journal requires that authors
assign a level of evidence to each article. For a full
description of these Evidence-Based Medicine ratings,
please refer to the Table of Contents or the online
Instructions to Authors www.springer.com/00266.
Fusiform excision of skin and fat on the medial aspect of
the arm for the correction of pendulous arm deformity was
first described in 1930. Aesthetic brachioplasty was sub-
sequently reported by Correa-Iturraspe and Fernandez in
the 1950s. Since then, countless surgical techniques and
treatment algorithms have been proposed to correct bra-
chial lipodystrophy and contour deformity with attention to
scar aesthetics, reproducibility, and safety, with the goal to
create a proportional and functional arm contour. Unfor-
tunately, none of these techniques has been fully satisfac-
tory. Reported postoperative complication rates have been
as high as 40% with residual contour deformities and
unattractive scarring being the most common complica-
tions [1, 2]. Seroma, oedema, lymphocele, lymphedema,
and nerve injury are also possible disturbing complications.
Selection of the proper correction technique is of para-
mount importance to achieve optimum results. It must be
based on anatomic and aesthetic analysis of the degree of
arm lipodystrophy, severity of skin laxity and ptosis as well
as ratio between the excess fat and residual skin and
presence or absence of striae. Though redundant skin and
fat excision may be unavoidable for cases with grade 4
ptosis, particularly in massive weight loss patients who
often have poor skin quality, we agree with El-Fahar and
El-Gharbawi [3] that non-excisional aesthetic arm
& Saif Emsieh
saifimsieh@gmail.com
1
American University of Beirut Medical Center, Beirut,
Lebanon
contouring is preferable whenever possible and should be
considered as a valid alternative to excisional brachio-
plasty. Arm scars constitute a major concern to patients.
Though many if not most claim preoperatively not to be
concerned about the appearance of their arm scars, patient
concerns become readily apparent almost always after the
operation.
Though brachioplasty scars are often wide or hyper-
trophic and frequently require revision regardless of the
procedure used as mentioned by El-Fahar and El-Gharbawi
[3], not all scars are equal. With careful attention to final
scar position, scar quality may be greatly enhanced. It has
been shown that the posteromedial scar being subjected to
smaller stresses in amplitude and more limited stress dis-
tribution compared to scar placement at the medial brachial
sulcus, results in optimal correction with mostly incon-
spicuous scarring. By placing the scar in the most depen-
dent part of the arm when abducted, tension effect of
gravity may be totally eliminated. Moreover, this scar
position is the least visible anteriorly and posteriorly with
the arms abducted [4].
Liposuction, besides being an approved adjunctive
procedure in brachioplasty, can alone undeniably correct
successfully mild arm lipodystrophy and ptosis. For
patients with marked brachial ptosis and poor skin tone, the
benefits of liposuction are questionable, especially when
anticipated skin retraction is likely to be insufficient [1].
El-Fahar and El-Gharbawi [3] must be commended for
reporting their experience with ultrasound-assisted lipo-
suction (UAL) alone for arm contouring of grades IIA, IIB
and III lipodystrophy (El-Khatib classification[2]). Though
they have acknowledged that circumferential liposuction
may be required for some, the authors have restricted UAL
to the area below a line connecting the anterior axillary
fold to the medial epicondyle corresponding to the bicipital
123
S160
groove anteriorly and posteriorly below a line from the
posterior axillary fold to the lateral epicondyle.
Liposuction focused mainly on the posterolateral region
may lead however to lack of harmony between the aspi-
rated and unaspirated areas [5]. Nevertheless, El-Fahar and
El-Gharbawi [3] have reported a very high patients’ satis-
faction rate at 6 m post-operatively with a 23.5% reduction
in mid-arm circumference from the preoperative mea-
surement. Patients’ satisfaction is certainly a measure of
successful outcome, it remains however very subjective.
On the other hand, though circumference reduction is an
objective measure of arm volume reduction, errors and
inaccuracies in measurement are common [5]; furthermore,
it cannot be considered an objective measure of morpho-
logic aesthetic outcome. Based on evaluation of patients’
photographs by an independent plastic surgeon, aesthetic
outcome was reported by the authors to be 92.86% excel-
lent and 7.14 % very good compared to 8 % excellent, 72
% good, and 18 % moderate, and 2% poor results reported
by Theodorou and Chia [6]. This marked reported differ-
ence in outcome aesthetic quality is nevertheless irrelevant.
Assessment by the independent plastic surgeon who most
probably was not blinded to the procedure performed is
certainly subjective and highly biased in the absence of
clearly defined objective criteria for outcome measure-
ment. For the patient illustrated in figure 4, marked
asymmetry can be noted at 1 year post-operatively; it
would be interesting to know how aesthetic outcome of this
patient was judged by the independent observer.
It is obvious that final outcome of a body contouring
liposuction procedure depends on skilful liposculpture in
addition to largely on skin retraction. Many techniques to
address post-aspiration laxity and stimulate skin and soft
tissue retraction have been described including aggressive
superficial liposuction (SupL), laser-assisted liposuction
(LAL), and radiofrequency-assisted liposuction (RFAL) in
addition to UAL [7]. 35% soft tissue contraction at 12
months has been reported with heat generating RFAL
compared with 8.1% observed with non-thermal traditional
SAL. However, applied to arm contouring, both RFAL and
aggressive SupL result in sustained marked skin retraction
with good contour. Though heat generating technology
may be an alternative to traditional vacuum aspiration, it
comes with higher complication rate, risk of contour
deformity difficult to correct subsequently, and a steeper
learning curve as well as with higher cost to the patient [7].
It is reported that third-generation ultrasound-assisted
liposuction (third UAL) is a minimally invasive modality
for both deep and superficial lipectomy offering improved
skin retraction and reduced rate of complications [8]. In a
review comparing UAL and LAL to standard suction-as-
sisted liposuction (SAL), equivocal results have been
reported in the literature with no clear benefit to set one
123
Aesth Plast Surg (2023) 47:S159–S161
apart from the other. Apparently, except for few excep-
tions, in particular the superiority of LAL over SAL for
skin tightening in select areas such the submental area,
there is generally no demonstrable added benefit of either
UAL or LAL over SAL that would urge a change in
practice patterns [9]. Similar and even better results may be
obtained with superficial and standard SAL as reported for
the multi-positional circumferential arm liposuction
(MCAL) technique [5].
It must be recognized as well that restricting liposuction
to the posterolateral arm region as described by the authors,
has a limited effect on skin retraction compared to cir-
cumferential liposuction that results in the formation of a
circular scar in the superficial fascia layer causing a dra-
matic decrement in cross-sectional area. According to a
recent report, suction-assisted circumferential arm lipo-
suction can result in significant improvement in patients
with arm types I, II, and III with mild to moderate skin
laxity [5]. Furthermore, the claim by the authors that pre-
served adipocyte-derived stem cells (ADSCs) by UAL
might play a role in quiescent skin retraction is an ill-
founded assumption. Despite documented histologic
improvement, ADSCs injections hardly seem to clinically
improve skin quality as confirmed by a recent review [10].
As for liposculpture, it entails in many cases fat removal
in addition to fat injection. It is unfortunate the authors
have overlooked the report of Abboud et al. [1] about
brachioplasty by power-assisted liposuction and fat trans-
fer. El-Fahar and El-Gharbawi [3] have avoided liposuction
over the medial bicipital groove for fear of injury to the
medial cutaneous nerve of the arms and forearms, basilic
vein, and its branches in addition to the medial nerve, ulnar
nerve, and brachial artery. In fact, as demonstrated by
Abboud et al. [1] addition of volume by fat grafting to the
bicipital triangle can resolve wrinkling and lift tissue cre-
ating an aesthetically pleasing contour of the medial arm.
Abboud et al. [1] have described a novel classification
system of brachial deformities based on four treatment
zones: the anteromedial/anterolateral arm (zone 1), the
bicipital triangle (zone 2), the posteromedial/posterolateral
arm (zone 3), and the para-axillary region (zone 4) and
proposed a surgical algorithm for patients with grade 2 and
3 ptosis. Gratifying results can be achieved with liposuc-
tion of zone 3 combined with autologous fat transfer to the
bicipital triangle.
Despite some scepticism about the presumed advantages
of liposuction advanced technology, we agree with El-
Fahar and El-Gharbawi [3] that contrary to the claims that
except for minor deformities excisional brachioplasty is the
only way to achieve arm contouring, non-excisional bra-
chioplasty may be applicable to more advanced deformities
than what has been classically believed. For many none
massive weight loss patients, adequate arm contouring by
Aesth Plast Surg (2023) 47:S159–S161
liposculpture with fat removal and fat transfer should be
considered before rushing to brachioplasty. Furthermore,
though brachioplasty may be more effective in some
patients, residual deformity with none-excisional modality
must be weighed against disadvantages of surgical
approaches and unavoidable scars. Although obviating skin
excision and consequent scarring may not be the most
effective approach, it is nevertheless reasonable to propose
aesthetic modalities to patients that address their appre-
hensions and reasonably meet at the same time their
expectations.
Declarations
Conflict of interest The authors declare that they have no conflicts of
interest to disclose.
Human or Animal Rights This article does not contain any studies
with human participants or animals performed by any of the authors.
Informed Consent For this type of study informed consent is not
required.
References
1. Abboud MH, Abboud NM, Dibo SA (2016) Brachioplasty by
power-assisted liposuction and fat transfer: a novel approach that
obviates skin excision. Aesthet Surg J 36(8):908–917. https://doi.
org/10.1093/asj/sjv277
2. El Khatib HA (2007) Classification of brachial ptosis: strategy for
treatment. Plast Reconstr Surg 119(4):1337–1342. https://doi.org/
10.1097/01.prs.0000254796.40226.92
S161
3. El-Fahar MH, El-Gharbawi AH (2022) Ultrasound-assisted
liposuction (UAL) arm contouring in non-post-bariatric patients:
no rush for brachioplasty. Aesthet Plast Surg. https://doi.org/10.
1007/s00266-022-03070-8
4. Atiyeh BS, Habr N (2022) Letter-to-the-editor: lipobrachiopexy:
cosmetic outcomes and limb lymphatic function of a novel bra-
chioplasty technique in massive weight loss patients. Aesthet
Plast Surg 46(Suppl 1):70–73. https://doi.org/10.1007/s00266-
021-02641-5
5. Gu Y, Kang N, Lv Q, Qi Y, Liu Z, Chen W, Sun X, Chen H, Ma
GE, Qi Z (2021) Application of a proposed multi-positional cir-
cumferential arm liposuction method and quantification of its
clinical efficacy evaluation. Aesthet Plast Surg 45(3):1115–1124.
https://doi.org/10.1007/s00266-020-02121-2
6. Theodorou S, Chia C (2013) Radiofrequency-assisted liposuction
for arm contouring: technique under local anesthesia. Plast
Reconstr Surg Glob Open 1(5):e37. https://doi.org/10.1097/GOX.
0b013e3182a58c80
7. Chia CT, Theodorou SJ, Hoyos AE, Pitman GH (2015)
Radiofrequency-assisted liposuction compared with aggressive
superficial, subdermal liposuction of the arms: a bilateral quan-
titative comparison. Plast Reconstr Surg Glob Open 3(7):e459.
https://doi.org/10.1097/GOX.0000000000000429
8. Tran BNN, Didzbalis CJ, Chen T, Shulzhenko NO, Asaadi M
(2022) Safety and efficacy of third-generation ultrasound-assisted
liposuction: a series of 261 cases. Aesthet Plast Surg. https://doi.
org/10.1007/s00266-022-02992-7
9. Collins PS, Moyer KE (2018) Evidence-based practice in lipo-
suction. Ann Plast Surg 80(6S Suppl 6):S403–S405. https://doi.
org/10.1097/SAP.0000000000001325
10. Brooker JE, Rubin JP, Marra KG (2019) The future of facial fat
grafting. J Craniofac Surg 30(3):644–651
Publisher’s Note Springer Nature remains neutral with regard to
jurisdictional claims in published maps and institutional affiliations.
123