The concept of shoulder reduction by removing a segment of the clavicle bone is fairly straightforward. A length of the bone is removed and the outer shoulder width follows inward. Executing it, however, is not quite that simple. As an aesthetic operation the location of the scar and its length become an important element of the operation.
Unlike its very distant cousin, clavicle fracture repair, clavicle reduction incisions mist be much smaller and located neither on top or in front of the bone. Rather they are placed slightly behind in an area between the inner shoulder and the neck known as the supraclavicular fossa or triangle. This area is bounded medially by the sternocleidomastoid muscle, inferiorly by the middle third of the clavicle and laterally by the anterior margin of the trapezius muscle. This fossa has a concave shape so placing the incision in this area is an opportunity to ‘hide’ it. Placing the incision at the lower and inner aspect of the fossa, usually 6 to 7cm from the sternal notch midline, provides the best location for it.
The length of this supraclavicular fossa incision is usually 3.5 to 4cms in length. The flexibility of the skin and underlying tissues allows it to be pulled over the bone to do the procedure under direct vision. It is necessary to widely undermine on each side of the bone to apply the plate and screw fixation. This becomes especially necessary when the bone segment is removed to get the plate used to lie completely flat on the remaining bone segments.
The key to safely drilling the screw holes along the length of the plate, particularly the longer superior plate, is to use a drill guide. This keeps the surrounding skin protected as the drill guide will push up against the skin in the more inner and outer screw holes of the plate.
With the reapposition of deeper tissue layers back over the plated reduced clavicle and with a subcutaneous skin closure, the incision is remarkably small given what has occurred underneath it.
Dr. Barry Eppley