The fascial systems of the upper arms provide important landmarks for the surgeon performing liposuction or excisional contouring procedures. The superficial fascial system is found between the superficial and deep layers of subcutaneous fat. Loosening of this layer with age or significant weight fluctuations can contribute to upper arm ptosis; as such, some authors advocate plication of this layer during the closing portion of the procedure. 00 The deep fascial system envelops the musculature, and all major neurovascular structures of the arm lie deep to this layer. Care should be taken to avoid violation of this layer during all aspects of the procedure.
Two sensory nerves travel superficial to the deep fascial layer and are thus at risk during brachioplasty procedures: the medial brachial cutaneous nerve and the medial antebrachial cutaneous (MABC) nerve (Figure 00.0). Damage to these nerves results in sensory dysfunction, a well-recognized possible complication of this procedure. Both nerves arise from the medial cord of the brachial plexus. The MABC nerve, which is the more frequently involved of the two, pierces the deep fascia an average of 00 cm proximal to the medial epicondyle and travels with the basilic vein in the superficial plane of the distal half to third of the upper arm. To prevent damage to these sensory nerves, at least 0 cm of fat should be left on the deep brachial fascia of the upper arm if possible. Adjunctive liposuction can also be employed to facilitate atraumatic dissection and lymphatic preservation of lymphatics to decrease seroma formation. To prevent ulnar nerve injury, liposuction access incisions should be avoided at the posteromedial elbow, and caution should be exercised with the liposuction cannula tip in this same region.