■ Before the operation, the areas of surplus skin are marked with the patient standing with his/her arms slightly abducted and bent at the elbow joint to 70°. Optimum preoperative marking is extremely important for brachioplasty. The surgeon must take his/her time and position the incision in such a way that it cannot be seen either from the front or the back when the patient's upper arm is hanging down. In order to do this the surgeon holds the surplus skin together between the thumb and p o a r
index finger of his/her left hand and marks the outer resection border with a pen. In general, markings are made for the upper longitudinal incision about two finger widths above the sulcus bicipitalis medialis. The exact course of the lower incision is only defined during the operation. To achieve a symmetrical result, however, the incision is marked approximately before the operation.
If appropriate, the spindlelike resection in the axilla can be extended in an axillary direction by Z-plasty or a vertical ellipse.
In all aesthetic resections of cutaneous/fatty flaps in the head, neck, or body the final resection is carried out in stages in order to ensure that neither too much nor too little is removed, as in both these cases the result would be unsatisfactory. The skill of the aesthetic surgeon is to have a feeling for the tissue, to be able to think in three dimensions, and to be able to fulfill the patient's wishes with a rigorous explanation of the procedure. An aesthetic surgeon can only be successful in the long term if he or she does this.
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