Q.  Summertime is the season I dread as short sleeve tops are again back in my closet.  The skin in my triceps area flaps back and forth as I move my arms.  Is there anything short of surgery that can improve the loose skin of my upper arms?

A. You are describing what is called a bat-wing deformity or as some have recently called it, the angel wing deformity.  It is basically excess skin (and usually excess fat), located on the back side of the upper arm.  It is often, but not always, associated with significant weight loss.  After losing a significant amount of weight, the fat of the upper arm decreases but the skin does not tighten up.  Unfortunately, there is nothing nonsurgical that shows any promise of decreasing the fat and tightening the skin.  The only option that consistently gives a worthwhile result is to perform a brachioplasty (surgical removal of the excess skin and fat).

It is typically performed at an outpatient surgical center and is done under general anesthesia.  Depending on the amount of loose skin and excess fat, the procedure can take anywhere from 3-5 hours to complete.  An overnight stay is often recommended to observe the patient the first night following surgery.  The incision is located on the inside of the upper arm, and typically runs from the inner part of the elbow all the way to the armpit.  Liposuction is sometimes performed simultaneously in order to further reduce the size of the upper arm.  Usually a drain is place under the skin of each arm and is left in place for about a week.  The arm is kept wrapped for 3-4 weeks, but the wrap is removed 2 times daily to allow bathing and to re-apply for comfort.  Due to swelling the final results take about 6 months to see.  Often the scar takes up to a year or more to fade and will never disappear.  The surgery will improve the laxity of the upper arm but will not make it look perfect and often there is still some residual excess skin that remains after the surgery.

Q.  I underwent some plastic surgery on my face about 6 months ago.  My plastic surgeon and I feel that I need a little touch up on an area that I am not happy with.  He said that I would have to pay for the procedure, although he was willing to discount the fees a bit.  Is it acceptable to charge a patient for a touch up surgery?  I would not have needed another surgery if the first one had been done correctly.  

A. This is a very tricky area in plastic surgery.  In a perfect world, you are correct; there would be no additional fee for a touch up surgery.  However, the cost of going to an operating room, giving anesthesia, and doing the surgery is very expensive.  Most surgeons are not able to absorb that kind of cost.

There are typically three fees associated with surgery: anesthesia fee, operating room fee (for equipment, personnel, and supplies), and the surgeons fee.  Sometimes there can also be an implant fee if they are used in surgery and need to be replaced.  Usually, the only fee the surgeon can control and adjust is his professional fee.  You can discuss this with your surgeon to see if his fee can be discounted.  That being said, there are many reasons why someone might need to have a touch up procedure.  Often times it is due to factors that are outside the control of the surgeon, like scarring or infection or bleeding issues, and in that case a surgeon may not feel discounting the fee is warranted.  Possible additional cost that might be incurred on the back end of a surgical procedure is something that should be discussed before an elective surgery.

William Byron Barber II, M.D.

has been practicing plastic surgery in Greensboro for 20 years and is certified by the American Board of Plastic Surgery.  He is Chief of Plastic Surgery for Moses Cone Health System, and is an active member of numerous local, regional and national plastic surgery associations.

Visit his website at: www.BarberPlasticSurgery.com or e-mail him at: AskDrBarber@BarberPlasticSurgery.com