Shoulder Narrowing & Widening Surgery
Shoulder Narrowing & Widening Surgery
The desire for more narrow shoulders is for those patients who seek a more feminized appearance to their upper torso. This is typically requested in the transgender male to female or the cis-female patient. In my experience such requests are equally split between these two patient groups. Shoulder feminization is achieved by removing a segment of bone from the clavicles which allows the bideltoid distance to decrease. This occurs because anatomically the clavicle is the lone horizontal bone of the body and the only structure that keeps the shoulders away from the sternum.
While removal of a segment of the clavicle is a straightforward concept, adapting it for an aesthetic operation with acceptable scarring and low risks requires numerous surgical technique modifications from traditional clavicle surgery used in the treatment of fractures. Where to place the incision, how much bone to remove and the method to hold the shortened clavicle in place as it heals are the three important steps in aesthetic shoulder width reduction surgery.
The placement of the incision is directly above the best location to remove the segment of clavicle bone which is at its inner third. This is the thickest part of the clavicle by cross-sectional diameter and is also the most stable being closest to the sternum. The small skin incision is placed, not over the bone, but up above in the supraclavicular fossa which provides for the most favorable scar healing. The segment of bone removed is typically in the range of 2.0 to 3cms per side. Short rigid plate and screw fixation of the shortened clavicle is used for stabilizing the two bone ends. This results in a bideltoid width reduction of 5 to 6 cms which creates a a more narrow and slightly rounded shoulder appearance. This has also been shown to result in uncomplicated bone healing and no adverse effects on shoulder function.
One of the most common questions about shoulder reduction surgery is in the amount of bone that can be removed and what effect it creates. The visible change in shoulder width occurs as a result of both horizontal bone length reduction as well as some forward rotation of the shoulders. The rounding effect of the shoulders comes from the anterior rotation which appears to be relatively minor as it relates to perceived width reduction.The typical amount of clavicle bone removed is between 2 to 3 cms based on patient body size and natural shoulder width.The question of how much bone can be safely removed is based on its effect on bone healing and postoperative shoulder function. Extrapolating from the orthopedic surgery experience in clavicle fractures, bone shortening in the 2.5cm+ range is not associated with abnormal scapulohumeral kinematics. This indicates that no negative shoulder functions should occur in elective clavicle length reductions in the range of 2 to 3cms. What would happen beyond 3cms of clavicle length loss in a bilateral procedure has unknown effects for shoulder function.
Recovery from shoulder width reduction surgery is unique and should be differentiated from clavicle fracture repair. Because it has no associated soft tissue trauma like which occurs in clavicle fractures and is a very isolated procedure to just one small section of the bone, it is associated with less discomfort after surgery. However because it involves two shoulders (unlike clavicle fractures) it has some greater early functional limitations. Arm motion is restricted to the first few weeks after surgery to keeping the elbows close to the body. Thereafter a gradual progression of range of arm motion is done until 6 weeks after surgery when raising the arms above one’s shoulders can be permitted. Any strenuous physical activities should not be done until two to three months after the surgery.
Widening of the shoulders in a male can be done by several different surgical techniques. Unlike shoulder narrowing, in which there is only one way possible to do so, shoulder widening has three options which are performed at two very different tissue locations. Deltoid implants can be placed at the subfascial location, fat injections can be done into the muscle and subcutaneous tissues and the bony length of the clavicles can be increased.
Each shoulder augmentation method has their own advantages and disadvantages. Muscle augmentation by either fat injection or the placement of subfascial deltoid implants provides a direct augmentation effect whose width increase depends on how much fat survives or the thickness of the implant. These two shoulder augmentation methods provide a fairly limited recovery period but have the known associated disadvantages of implant-related risks and the unpredictability of fat graft survival.
As the clavicles can be shortened for shoulder narrowing they can also be expanded by a similar osteotomy location. The difference is that a bone graft will be needed whose length is directly responsible for the amount of shoulder width increase. Clavicle lengthening osteotomies are more invasive and have a much longer recovery period than any of the other two shoulder augmentation methods. But they offer a potentially more profound shoulder augmentation effect as the shape of the clavicles creates both a widening and slight roll pull back of the shoulders look. They also may have appeal for those patients who seek the ultimate natural approach to their shoulder augmentation. While appealing, it is important to note that to date there is very limited clinical experience with this type of aesthetic shoulder augmentation surgery.
One very important difference between clavicle shortening vs clavicle lengthening is the need for a bone graft. Given the risk of bony non-union in an elective bilateral procedure, an autologous bone graft needs to be done of which the best shape and length comes from the fibular leg bone. This can be harvested from one leg without any functional loss but adds another component to the prolonged recovery process. Suffice it to say that shoulder augmentation by bilateral clavicle lengthening is reserved for the most motivated patient.