Novel Use of an Orthopedic Limb-Positioning Device for Brachioplasty

Sir: Gastric bypass surgery has led to a dramatic increase in the number of massive weight loss patients, with resultant skin and tissue redundancy under their arms, who ultimately seek the attention of plastic surgeons to perform brachioplasty. Recently, this upper contour aesthetic problem resulted in more than 20,000 brachioplasties performed annually.1 First introduced in 1954 by Correa-Iturraspe and Fernandez, brachioplasty techniques have evolved dramatically over the past four decades from upper arm single elliptical excisions to vast surgical variations on the procedure.2–4 Variations aimed to correct the ptosis of skin and tissue include Strauch's sinusoidal excision pattern; the L brachioplasty; and extended resections into the axilla combined with Z-, W-, or L-plasties. Segmental resection and closure approaches were introduced to address intraoperative complications of overly aggressive resections and tissue edema from prolonged operating times, both of which impede incision closure.2 Most recently, there has been a shift toward minimal incision brachioplasty, which hides incisions solely within the axilla. Other techniques advocate “ideal” algorithms and mathematical measurements that ensure a simplified approach, theoretically practical to even the inexperienced surgeon.3,4 All brachioplasty techniques stress the importance of carefully planned and consistent preoperative and intraoperative markings of the upper arm to produce satisfactory results and avoid complications.2–5 Despite pointing out the risks of misplaced incisions with resultant widened hypertrophic scars or even the inability to close, the proposed techniques do not adequately address how to deal with these difficulties. Regardless of careful adherence to each technique's blueprint, the reality of many brachioplasties is that the extensive volume, laxity, and redundancy of skin and tissue combined with poor patient positioning can disorient a surgeon, making identification of anatomical landmarks difficult. In addition, uncontrollable intraoperative tissue swelling and undesirable contours necessitate modifications to their planned brachioplasty approach. To facilitate intraoperative modifications, we would like to propose the use of orthopedic limb-positioning devices, such as the SPIDER (Tenet Medical Engineering, Calgary, Alberta, Canada) and the Schlein Ultra Shoulder Positioner (OSI, Del.). These devices, commonly used in combination for upper arm orthopedic procedures, lend themselves to brachioplasty for a number of reasons. First, they allow for 360-degree access and rapid repositioning of the upper extremity through its full range of motion to perform markings, liposuction, and resection of tissue and skin flaps (Fig. 1). Second, they allow for closer approximation to preoperative planning and intraoperative assessment of upper arm contour aesthetics. The patient's arms are held naturally off the operating table, which accounts for gravity and minimizes distortions such as posterior arm tethering that occurs when the arm lies flat in a two-dimensional plane (Fig. 2). Third, these devices are easy to use and reduce intraoperative time; they attach to the operating room table, use a foot pedal release and lock mechanism, and eliminate the requirement of an assistant to provide upward arm traction. Finally, the limb-positioning devices work with any brachioplasty technique chosen, which should account for the degree of skin laxity and epidermolipodystrophy. They ultimately help to achieve surgical goals by enhancing revision of marks and resections, proper scar placement, surgery time, and tissue edema, and therefore minimizing dreaded brachioplasty complications.Fig. 1.: Intraoperative use of the limb-positioning device. Intraoperative comparison of a patient positioned with the right arm supported by orthopedic limb-positioning devices, allowing 360-degree access and the left arm to be unsupported.Fig. 2.: Schematic illustration of patient and limb-positioning device use for a novel approach to brachioplasty. The patient is positioned supine and the upper limbs are supported by orthopedic limb-positioning devices; the arms are extended 90 degrees at the shoulder and flexed 90 degrees at the elbows as many brachioplasty approaches suggest.2–5 The limb-positioning device provides 360-degree access and easy repositioning of the patient's upper arms so that surgical marking, liposuction, and resection of skin and tissue with any brachioplasty technique can be performed.Don Hoang, B.S. Niclas Broer, M.D. Deepak Narayan, M.D. Department of Plastic and Reconstructive Surgery Yale University School of Medicine New Haven, Conn.

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