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Changing the length of the clavicle to affect the shape of shoulder is the fundamental premise of shoulder widening and narrowing surgery. This is anatomically based on the tubular shape of the bone that largely runs in the horizontal direction between the shoulder and the sternum. While it is not truly horizontal in orientation, rather a somewhat S-shaped bone, the clavicle nonetheless provides lateral support for the position and shape of the shoulder.

As has been well demonstrated in clavicle reduction surgery, when a segment of the bone is removed, it readily collapses inward. (technically inward and downward) But when the clavicle is cut and efforts are made to lengthen it, it is not such an easy movement. Fundamentally losing support is ‘easy’, adding support runs into resistance. Specifically the outer clavicle segment runs into the shoulder joint and pushes up against it. This can be easily seen in a post x-ray where the shoulder joint space is less than normal or compressed in clavicle lengthening surgery. The end of the clavicle pushes onto the acromion process of the scapula. Thus one component of how much clavicle lengthening can be obtained is affected by how much resistance the scapular complex poses to be moved.

The scapula is the large triangular shape bone in the upper back that not only articulates with the clavicle and upper arm bones but also has a lot of muscles that attach to it that help move the shoulder and arm. The muscular attachments are three basic types, intrinsic (all of the rotator cuff muscles) outer extrinsic (biceps, triceps and deltoid muscles) and inner extrinsic. (trapezius, serratus, elevator and rhomboid muscles) When one moves their shoulders backward, somewhat mimicking the ability of the clavicle to be lengthened, this requires muscle contraction as well as flexibility of the surrounding tissues.

While it is not absolutely yet proven that tightness/stiffness of the shoulder blades may pose an intraoperative limitation in clavicle lengthening surgery, I have run into patients where it was very hard to create the desired amount of bone lengthening. The outer mobilized clavicle segment simply ran into great resistance to being moved. (despite even having a vertical support roll placed down the center of the spine to allow their shoulders to passively fall back on the operating table) As a result I recommend patients preoperatively do a shoulder loosening regimen to potentially help their clavicles to be maximally lengthened. 

There are a variety of shoulder stretching exercises that can be preoperatively helpful before clavicle lengthening surgery. These include shoulder rolls (with and without weights), pendulum stretches, cross-body arm swings, and cross-body shoulder stretches.Various yoga poses are also helpful including the child’s pose, raged pose, eagle arm stretch, cow face pose and side lying thoracic rotation. All of these well known shoulder stretches have been designed to help with shoulder stiffness and tightness to alleviate pain and tension. But they are just as valid for preoperative preparation for aesthetic shoulder surgery, particularly clavicle lengthening.

One does not have to do all of them, just pick one or two that you can do at least once daily six weeks before the surgery. The one maneuver that I consider the most helpful and easiest to do is the hands behind the back stretch, specifically clasped hands.  

Any effort to loosen the shoulders is going to be very helpful during surgery with the goal of maximum clavicle lengthening which at a minimum 18 to 20mms but 25mms is more ideal and my intraoperative goal on each side. 

Dr. Barry Eppley

Indianapolis, Indiana

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