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Background: In females seeking shoulder narrowing reshaping surgery there are three factors that must be considered during the procedure. The location and extent of the incisional access, how much length of the clavicle can be removed and how are the two bone ends going to be securely put back together. Much discussion has been previously done on the amount of clavicle bone removal and the plate and screw fixation methods used. Much less has been said about the incision which in an aesthetic operation always has great relevance.

Most clavicle procedures from an orthopedic perspective is done through long incisions placed on the anterior surface of the bone. This provides the most direct access even if it produces the most visible scar. While this is acceptable in traumatic clavicle fractures it is not for an aesthetic shoulder procedure such as clavicle reductions. For this reason the incision is moved onto a more superior position behind the clavicle in the supraclavicular fossa at its inner third. This concave soft tissue lower neck area has thinner skin in a less visible location. 

Due to the concept of the ‘mobile window’ the incision can be slide forward to fully visualize the bone in a 360 degree fashion. It can also be slide from side to side to reach beyond the length of bone seen through the incision. Once the operation is complete the incision slides back over the clavicle back into the less visible supraclavicular fossa. But there are some technical maneuvers in making and closing the incision that contribute to the best scar result possible.

Case Study: This female desired a shoulder narrowing surgery for a more feminine upper torso appearance. She was tall at 5’ 10” and had very prominent clavicles with a strong s-shaped curve to them with a clavicle length of 17cms.

At 7 cms from the sternal notch the inner end of planned supraclavicular incision was marked. A length of 3.5cms was then marked laterally from this point. In front of the marked incision a 3cm length of bone removal was made on the skin. The incision could barely been seen over the top of the clavicles.

Under general anesthesia the incisions were made and the skin slide forward over top of the bone. Then 3cms of bone length was removed, double plate fixation applied and the skin incisions closed. By comparing the length of the incisions vs that of the bone removed, their lengths were not that different.

The immediate results of the shoulder narrowing surgery could be seen on the operative table.

One of the surgical goals in shoulder narrowing surgery is to keep the incision as small as possible. This is aided by placing the incision behind where the bone is to be removed in a concave skin location rather than a convex one right over the clavicle. The incision is mobile and does permit a remarkable amount of work to be done underneath it. But the edges of the skin incision are exposed to a lot of trauma (stretching) during the surgery so they look a little ‘beat up’ after the bone work is done. Fortunately the thinner skin of the supraclaviclar fossa heals well and such trauma rarely results in a hypertrophic scar. But during the closure it is very important to close back all of the soft tissue layers that have been released to access the bone. This includes the periosteum, muscle, fascia and dermis. This takes the tension off of the healing skin edges, prevents a contour deformity, and allows it to fall back into the fossa where it started.

Case Highlights:

1) The incisional location in shoulder narrowing surgery is in the supraclavicular fossa above and behind the inner third of the clavicle.

2) The length of the supraclavicular skin incision should not be much longer than the length of the bone that is to be removed. 

3) Reapproximating the deeper soft tissues over the clavicle is necessary for plate coverage and a tension-free skin closure. 

Dr. Barry Eppley

Indianapolis, Indiana

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