For men who seek wider shoulders beyond that of exercise there are three surgical options. The medial bone-based approach is clavicle lengthening while the lateral soft tissue methods include deltoids implants and deltoid fat injections. Each of these shoulder widening methods has their advantages and disadvantages and no method is perfect.
The lateral soft tissue augmentation methods offer a much shorter recovery and their effectiveness is based on enhancing the shape of the shoulder deltoid muscle.The debate between implant vs fat for muscular enhancement is a classic one that exists all over the body. But for those patients that choose deltoid implants, there are two locations in which the implant can be placed. It is either under the muscle (submuscular) or on top of it. (subfascial) Both of these pocket locations have their advocates and both locations can be effective.
In subfascial deltoid implant placement I find that a superior incision just lateral to the acromioclavicular joint in a skin crease seen when raising the arm is the most effective approach. It is critically important that the implant be positioned high enough that there is not a large stepoff from the transition of the top of the shoulder to the side. When the pocket is created superiorly it is far easier to control the inferior extent of the pocket. The incision is fairly small and it heals well so adverse scarring is not a concern.
When making a subfascial pocket on top of the muscle it is important to remember that anatomically it is not a gliding muscle. (like the biceps muscle for example) Thus the fascia will be very adherent and does not easily detach from the muscle. I find that taking facelift scissors to develop the pocket (separate the fascia from the muscle) is the most effective way to do so. After which a flat elevator can be used to ensure that all fascial bands are released and the entire pocket is uniformly elevated.
There are no, as of yet, standard deltoid implants, I have them custom made based on preoperative patient measurements. But having done enough of them at this point there are some ‘standard’ models on existing design files. They are ultrasoft soft solid silicone material.
The deltoid implant is inserted in a rolled shape and unrolled once inside the pocket. The top portion of the implant should be at the same level on both sides. A drain is placed and exited through the skin as low as possible. The fascia is then closed over the implant as well as the skin. The incisions are taped and the upper arm is ace wrapped
Drains are kept in for 2 or 3 days. Some patients will experience small fluid collections after the drains are remove that will need to be aspirated, usually once, with a percutaneous needle using local anesthesia. One can expect varying amounts of bruising due to the release of the fascia from the muscle. This will take up to three weeks gayer surgery two fully clear. Because of the soreness of the muscle from the surgery I don’t have to give the patient any specific physical restrictions. Their comfort level will determine their tolerated physical activities. Most patients can return to exercise one month after the surgery.
Dr. Barry Eppley