Arms and Axilla Liposuction.pptx

Liposuction of Specific Regions:
Evidence Based Practice.
2002-2022
11/4/2022 email: askprof@moawadskininstitute.com 1

Dedication
The Journey of Liposuction
• This presentation is dedicated to the memory of my parents, Prof. M. Moawad,
and My mother, Iqbal S. They made me what I am today with encouragement and
sacrifices.
• To my family, my wife Salam. B., and my pride in life, my son Mo and my daughter
Noor with their unflagging support, turned the second part of my life journey into
success.

Acknowledgment
• Special acknowledgment is given
to Dr. Ibrahim El Dousky (M.D.,
IMRCS), not only because he is an
outstanding student but also
because he doomed me into the
life of plastic surgery with his
excellent work and experience.
• Dr. El Dousky is the general
secretary of ESCSL.

Acknowledgment
• Special acknowledgment is given
to Dr. M. Ramadan (MS., Ph.D.), a
brilliant scientist, chief of staff at
MSI and my right hand in all what I
do.
• Dr. Ramadan is on the board of
directors of ESCSL.

Appreciation
• The author would like to express his appreciation to the medical team at
L'institute (Riyadh, KSA) and Moawad Skin Institute (MSI) in Cairo, Egypt, for
taking care of the patient during the procedures.

Appreciation • To “PATIENTS” You’ve always believed in me
KEYWORDS: LIPOSUCTION., LIPOSCULPTURE., FAT GRAFTING, ADIPOSE FATTY TISSUES., BODY
CONTOURING

Introduction
email:
askprof@moawadskininstitute.com
• Concepts of beauty have
been continuously evolving
throughout the history of
humankind.
• Slimmer forms have
substituted the voluptuous
figure idealized by artists in
the past.
• With fashion promoting
body-revealing attire,
outdoor exposure, and the
emphasis on fitness and
good health, people have
sought to reflect these
trends by demonstrating
youthfulness and vitality in
their bodies.
11/4/2022 7

Introduction
email:
• On the other hand, a
sedentary lifestyle and
dietary excesses associated
with factors such as
genetic determination,
pregnancy, and the aging
process contribute to body
alterations that result in
the loss of the individual’s
body image, creating a
solid psychological
motivation for surgical
correction.
11/4/2022 8

Introduction
email:
• Localized fat deposits
may involve one
anatomical region and
extend to multiple body
regions.
• Therefore, it is
understandable that body
contouring surgery
includes most body
regions, including the
face, neck, and breast, in
all populations, be treated
by a one-stage operation
or require more complex
combined procedures.
11/4/2022 9

Introduction
• The current evidence-building
process in the healthcare industry is
riddled with conflicts of interest
regarding education, research, and the
practice of medicine.
• Medical specialists worldwide are
flooded with data they must collect,
process, and analyze.
• Medical images make up around 90%
of the data in healthcare.
• Experts across the globe point to the
harms of pervasive industry influence
on research, practice, and education in
healthcare, noting that it compromises
patient care.

Introduction
• The ESCSL, as an academic, non-profit
organization, is responsible for disseminating
unbiased findings to the industry, medical
health providers, and the public about
liposuction, among others.
• At the same time, it is entirely free of ties with
the industry.
• As the president of ESCSL, I retrospectively
reviewed patients' charts and photos
(thousands) who underwent body contouring
and fat grafting procedures in K.S.A. and Egypt
between 2002 and 2022.
• The unbiased evidence in this study is a way to
ensure that the benefits and harms of
liposuction are accurately reported.

Introduction
• It will guide members of ESCSL in delivering high-quality, evidence-based
practice and cost-effective surgery.
• During the journey, I developed my technique as any other medical provider;
trial and error, reading and seeing experts' techniques, and picking and choosing
what suited me based on science and skills.

Introduction
• As new techniques are introduced, we must temper
our enthusiasm and base treatment on solid scientific
evidence. The journey is ongoing. It is like riding a
bicycle; to keep balance, you should keep moving.
2021
2022

Introduction
• The data collected are given to those who want
to deliver the best care to their patients armed with
the most innovative techniques and the latest
technology in the battle of aging, rejuvenation, and
body contouring, in a reproducible and safe
outcome-driven manner.
• It also is given to novice(s) in professional and
educational standards.
• A compendium of the author’s practice, journal
publications, and books read will put the entire
liposuction process in a volume that surgeons
interested in this topic need to read.

Arms Liposuction

Patients present for arm contouring are classified according to the scheme proposed by Teimourian and Malekzadeh
Arms Contouring

Teimourian and Malekzadeh
Classification
email: askprof@moawadskininstitute.com
• Minimal to moderate
subcutaneous fat with minimal
skin laxity.
• Patients generally have a
circumferential increase in fat
volume but good skin tone and
elasticity.
• These patients do well with
circumferential liposuction of
the arm and para-axillary area.
• Relatively small amounts of
fat are removed.
11/4/2022 17

Classification
• Generalized accumulation of
subcutaneous fat with moderate
skin laxity.
• Patients generally have an
increased volume of fatty tissue
circumferentially and a
noticeable loss of skin elasticity
with ptosis.
• Circumferential liposuction
encourages skin tightening.
• Power-assisted liposuction can
encourage enhanced skin
retraction, frequently reducing
the need for skin excision.
• Mini-Brachioplasty may be
required.
11/4/2022 18

Classification
• Generalized obesity and extensive skin
laxity.
• Patients generally have more significant
lipodystrophy and skin laxity.
• Obese patients accumulate a large fat
volume in the para-axillary and upper arm.
• The apparent length of obese arms is
usually shorter than the actual length
because of obese axillary and back areas.
• In addition, the shoulder looks more
comprehensive than the actual body
frame due to deltoid convexity.
• Mini- Brachioplasty confided to the
axilla is often needed for Group 3
individuals.
• The larger the volume of fat removal,
the better the prognosis for skin retraction
with arm liposuction and the shorter the
brachioplasty scar if required.
11/4/2022 19
Category 3

Teimourian and
Malekzadeh
Classification
• Minimal subcutaneous fat and extensive
skin laxity
• These individuals demonstrate marked
skin laxity and depletion of subcutaneous
fat.
• Full Brachioplasty can produce an
aesthetically pleasing contour of the arm
and straight inferior brachial border.
Category 4

Teimourian and
Malekzadeh
Classification
• Arm liposuction is done in all categories as a primary procedure or/ and in combination with brachioplasty.
• The goal of the liposuction surgeon is to reduce the bulk of fat all over the arm without creating a masculine
appearance for female patients.
• Liposuction of the arm varies according to the amount of fat excess and the location and severity of skin
redundancies.
• Although most complaints will be the inferior aspect of the arm, slenderizing (circumferential), the entire arm will
produce a more optimal result.
email: askprof@moawadskininstitute.com 11/4/2022 21

Arms
Liposuction
• The local distribution of fatty tissue in the arm is divided into 4 regions: (1) anterior, (2) external, (3) posterior,
and (4) internal.
• Localized fatty deposit is mainly concentrated in the posterior-external and anterior-external regions in the
upper and middle third of the arm.
• In regions 1, 2, and 4, the subcutaneous tissue consists of an areolar layer (superficial) and superficial fascia
(without lamellar layer), making these areas less prone to large fat deposits.
• In region 3 (the posterior arm), a distinctive lamellar layer (deep) increases with increased obesity.

Arms
Liposuction
• The arms are marked in the abducted position with 90° flexion at the elbow.
• Elevating the patient's arm at a right angle with the elbow bent, one can readily palpate
the fat and delineate it from the underlying muscle.
• Depending on the patient's biotype (fat, slim, athletic), the area was marked for deep
extraction or more superficial liposuction.
• A detailed exam of the subcutaneous fat distribution is essential, especially if superficial
arm liposuction or "liposculpture" is planned.

Arms Liposuction
• The dynamic marking can achieve athletic and natural
results that match the patient's gender, age, body type,
and wishes and resolve the problems accompanying
natural asymmetry.
• In men, more pronounced musculature is considered
more athletic and healthier
• Slender curves and toned, smaller muscle masses are
considered aesthetically pleasing for women.

Arms
Liposuction
• Puncture sites are marked at the anterior and posterior axillary folds and
medial and lateral distal arm 1.5 cm proximal to the olecranon.
• Be careful that the ulnar nerve is medial to the olecranon—extra access points
including ant-lateral, ant-medial, and post-lateral to cover sizeable arms.
• The ulnar and volar forearms, too, can be improved with liposuction, creating
a complete result, and can be accessed via the antecubital fossa.

Arms
Liposuction
Preoperative markings divide the arm and contiguous para-axillary
regions into:
• The anteromedial/anterolateral arm
• The medial (biceps triangle)
• The posteromedial/posterolateral arm
• The para-axillary region formed from the lateral pectoral zone and the upper
Back.
Each zone is handled differently

• Zone 1 (green) corresponds to the anteromedial/anterolateral arm is treated with
superficial liposculpture.
• Zone 2 (yellow) corresponds to the bicipital triangle is treated by lipofilling.
• Zone 3 (orange) and zone 4 (purple) correspond to the posteromedial/posterolateral
arm and the para-axillary region, respectively. These zones are treated with liposuction
and liposculpture.
Arms
Aesthetic
Units

Arms Liposuction
• Small-volume arm liposuction cases can be performed with local
anesthesia, with or without mild sedation.
• Complex, large-volume arm liposuction, and combined instances
can be performed under general anesthesia
• The arms are placed on arm boards at 85° abduction
• The arms should not be strapped to the table since mobility may
be necessary
• Although arm contouring can be performed in the prone and
supine positions, access to the para-axillary region is limited.
• The lateral decubitus position allows for circumferential
treatment.

Arms Liposuction
• Pretunneling, liposhifting, and superficial
liposuction are done in zone one, from the
olecranon and axillary sites along the
longitudinal axis.
• No liposuction is performed under the
anteromedial skin, as it is prone to wrinkling,
especially near the axilla.
• The surgeon must smoothly transition
between different treated areas of the arms.
Zone 1 is the anteromedial/anterolateral arm.

Arms
Liposuction
• If the patient presents with depressed Zone
2; in that case, fat grafting can be added to
achieve better results and places upward
tension on zone 3, thereby supporting and
redraping ptotic skin and restoring a
pleasing arm contour
• Between 50 and 100 mL of fat is usually
required.
Zone 2 is the bicipital triangle

Arms
Liposuction
• The process starts with circumferential
pretunneling and liposhifting using a spatula
before suction.
• Improved results are often observed with
the release of fibrous attachment of superficial
fat to deeper tissue
• I use the PAL technique with a 3 mm
powered cannula through the posterior axillary
incision.
• The direction of the suction is a crisscrossing
pattern parallel to the long axis of the arm to
create a 10–15 mm final pinch test.
Zone 3: The posteromedial/posterolateral arm

Arms Liposuction
• After deep fat removal, I move superficially to
accomplish circumferential arm liposuction.
• The larger the volume of fat removed, the
greater the potential for skin retraction.
• The tissues are checked with pinching to
compare each side
• The amount of aspirate from each arm is
measured separately to remove nearly equal
amounts.
• Use the handmade roller to milk out any excess
tumescent solution and even the fatty blanket.
• Sutures are not applied to the entry points for
better drainage.
Zone 3: The posteromedial/posterolateral arm

Arms
Liposuction
• Like the posterolateral area, liposuction
zone 4 occurs in all planes.
• The fat is evacuated with a 3-mm
powered cannula after pretunneling.
• More aggressive liposuction is performed
to encourage the formation of a confluent
layer of collagen forming circumferentially
around the arm connecting to the trunk.
Zone 4: para-axillary

Arms Liposuction
• Compression absorbing pads, ace-wraps,
from the base of the fingers are wrapped
upwardly to the axilla with lessening pressure,
and a compression garment is applied.
• If the skin is loose and sagging posteriorly,
pull it anterolaterally to smooth any wrinkles
and then fix it with silicone foam.
Immediate Post-op elastic
bandage over absorbing pads

Arms Liposuction
• Gradual adherence and shrinking of the subcutaneous
wound are initiated, resulting in a global three-dimensional
wound contraction and a horizontal subcutaneous scar
• Circumferential liposuction permits better skin contraction
on the x-axis and the y –axis.
• The result is decreasing the diameter of the upper arm.

Axilla (hyperhidrosis) Liposuction

Axilla Liposuction
• Eccrine glands are located at the superficial
subcutaneous plane.
• Liposuction has been safely and effectively
performed for many years in treating
hyperhidrosis
• There are several different treatment
techniques, which differ in the type and size of
incisions, the type of cannula and curette
used, and the aggressiveness of the procedure.

Axilla
Liposuction
• At first, a starch-iodine test helps
identify the area of excessive
sweating.
• After the test, the site is marked,
and the axillary vault is prepped.
• Multiple access incisions are
made in the periphery of targeted
area and sometime inside the
axilla.

Axilla
Liposuction
• The axillary area is anesthetized with
50–200 mL of syringe-administered
tumescent anesthesia, depending on the
size of the target area.
• Like the neck, I use the spinal needle
and increase the concentration of
lidocaine and adrenaline.
Injection anesthetic solution by spinal needle

Axilla Liposuction
• While waiting for the anesthesia to reach its
maximum effect, I massage the area with ultrasound
• Once the skin is visibly blanched, I use the
powered 2mm- spatula with one hole directed away
from the dermis without suction (tunneling).
• Recently, I used monopolar radiofrequency and
fractional radiofrequency.

Axilla
Liposuction
• I use a powered 3 mm multiholes
cannula to debulk fatty tissue.
• After debulking, I switch to a 2mm
spatula with one hole directed
against the dermis.
• Followed by a 2mm Toledo fork to
scrape away the eccrine glands using
back-and-forth motion in a crisscross
pattern.
Awake Patient

Axilla
Liposuction
• Endpoints are reached when a complete
elevation of the skin from subcutaneous fat,
lividity of the skin, and no fat adhering to the
dermis.
• Incisions are left open for drainage.
• Performing large “windshield wiper” motions
with the cannula should be avoided to
circumvent disrupting the integral vasculature
connecting the dermis and subcutis.
• A compression bandage for 24 hours or a
figure-of-eight dressing for ten days is applied.
SURGICAL END POINT
First Post-operative Visit

THE END
• This chapter, a unique educational manual, is dedicated to dermatologists
and cosmetic surgeons who want to excel in delivering the best care and
liposuction results to their patients with the most innovative techniques
and latest technology in a safe outcome-driven manner.
• I have assembled my experience and global experts to inform you how
liposuction is done in a simplified, efficient, and reproducible manner.
• Liposuction is more of an art than a surgical procedure.
• It entails a practical application of scientific knowledge with precision and
craftsmanship and is a skill attained with clinical experience.
• It brings as much contentment and joy to the person undergoing it as to
the surgeon practicing.

From Adding (1997) to Removing Fat (2022):
Evidence Based Practice
By
Prof. Osama B. Moawad, M.Sc. M.D.

Arms and Axilla Liposuction.pptx

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