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Contour Restoration of the Upper Limb Using Solid Silicone
Implants
Darryl James Hodgkinson, M.B., B.S. (Hons), F.R.C.S. (C)(Plast),
F.A.C.S., F.A.C.C.S., Dip. American BoardPlastic Surgery
20 Manning Road, Double Bay, NSW 2028, Australia
Abstract. Augmentation of the upper limb, except for the
pectoralis major using pectoral implants, has been some-what
taboo for plastic surgeons. Deformities of the upperlimb and
muscular deciencies, however, are aesthetically
unattractive or result in unacceptable asymmetries. Thefollowing
implants have been used for reconstruction of theupper limb after
trauma: deltoid, triceps, and biceps. Fol-lowing the dictum that
the implant needs to be placed be-
neath the muscle (i.e., on the humerus for the deltoid andthe
triceps, and underneath the brachialis for the bicepsmuscles),
these implants are deep and act as spacers
aording the establishment of more volume and symmetry.Access
incisions make use of incisions previously placed forthe repair of
previous trauma, fractures of the upper limb,
or the repair of muscle. Most aesthetic surgeons are notfamiliar
with this anatomy, and revision for the morbidanatomy of the upper
limb is important. Familiarity withthe major nerves of the upper
limb is paramount, particu-
larly familiarity with the radial, ulnar, median, and cir-cumex
humeral nerves.
Key words: Deltoid biceps tricepsSolid silicone im-
plantsUpper arm
Used as a spacer, solid silicone implants can help torestore
symmetry or to establish volume and muscleshape. Accurate moulage
preparation and custom-ized silicone implant manufacture are
paramountprerequisites for obtaining a symmetric nal result.The
immediate complications include neuropraxia(Table 1). However, no
long-term sequelae have oc-
curred during follow-up periods up to 14 years forthese upper
limb implants.
The Cause of Upper Limb Contour Irregularity
My experience with upper limb contour irregularity islimited to
cases caused by rupture of the triceps andbiceps muscles and cases
after injury to the axillarynerve that caused degeneration of the
deltoid muscle.After gaining experience in the restoration of
sym-metry in these cases, I have enhanced the volume ofthe triceps
muscle by a similar spacer implant underthe triceps on the humerus
to enhance the circum-ference of the distal and middle third of the
arm ofpatients with an underdeveloped (puny) tricepsmuscle, for a
purely cosmetic bilateral result.
Deltoid Muscle
The deltoid muscle, shown in Fig. 1, is a triangular,bulky
muscle covering the shoulder joint and con-tributing to stability
and movement of the upperlimb, particularly abduction.
Anatomy of the Deltoid Muscle
The bulkiness of the deltoid muscle accounts for therounded
nature of the normal shoulder. The nervesupply is from axillary
nerve C5C6, which passesthrough the quadrilateral space to supply
the under-surface of the deltoid.
Presentation
Patients who present with deltoid degeneration afteraxillary
nerve damage have persistent wasting of that
Correspondence to D. J. Hodgkinson, 20 Manning Road,Double Bay,
NSW 2028, Australia; email: [email protected]
Aesth. Plast. Surg. 30:5358, 2006DOI:
10.1007/s00266-005-0102-4
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muscle. The cause of injury is either a stretch injury ofthe
brachial plexus and disruption of the axillarynerve at the
quadrilateral space or an iatrogenic in-jury during shoulder
operations or fracture reductionand xation of the proximal humerus
[1,4,5]. Theresulting deformity is a attening of the roundedcontour
and obvious asymmetry with exposure of theacromioclavicular joint
and depressions anteriorlyand posteriorly over the proximal
humerus. Func-tionally, the upper limb is weaker mainly
duringabduction of the arm. A scar from previous at-tempted
orthopedic surgical approaches may beanterior or posterior.
Treatment
The initial moulage preparation is accomplishedusing DAS artists
synthetic clay preparation(DASPronto Air-Hardening Clay for
MoulagePreparation: Item Code SC-M322), which hardensquickly and is
easier to manage than the previouslysuggested papier mache moulage
kit. The moulage ismade to simulate the contour of the opposite
side andsent to the implant manufacturer (Spectrum DesignsInc.,
5921-C Matthews Street Goleta, CA 93117,USA Fax: 805-681-4897) with
specications forproduction. A lightly textured, soft, ve
durometerimplant without suture tags is preferred. The
manu-facturing time is approximately 6 weeks.
For surgical insertion of the implant, the patientis positioned
on the operating table with a shoulderroll behind the aected limb.
With the patient un-der general anesthesia, the old scar is used as
anaccess incision and opened down through into thedeltoid, then
from the deltoid onto the glenohu-meral joint and upper humerus.
The pocket then isbluntly dissected anteriorly, laterally, and
posteri-orly to accept the implant (Fig. 2). Posteriorly,
thedissection is limited by the axillary nerve andaccompanying
vessels (posterior circumex humeralvessels), but because these have
been damagedpreviously, they can be elevated and stretched toaccept
the implant posteriorly without fear of fur-ther damage.Once
inserted, the soft textured implant may re-
quire some judicious trimming to prevent buckling ora dead space
around the humerus. The soft implantwill bend and contour around
the curved surface ofthe humerus. The deltoid remnant then can be
closed.No drains are used. The results have been stable up to5
years postoperatively with maintenance of theshoulder contour
(Figs. 3 and 4).
Triceps Muscle
Tears of the triceps muscle often are seen in high-impact
injuries, usually forced extensions, or inbody builders because of
extreme heavy weightlifting.
Anatomy of the Triceps Muscle (Fig. 5)
The triceps has three heads: long, lateral, andmedial. The long
head arises from the scapula,whereas the lateral head originates
from theproximal humerus and covers the medial head(deep) arising
from the shaft of the humerus. Themedial head is most often the
site of rupture, and
Fig. 2. Intraoperative views of a customized solid
siliconeimplant placed on the humerus beneath the
degenerateddeltoid.
Fig. 1. The deltoid muscle gives bulk and convex contourto the
shoulder.
54 Contour Restoration of the Upper Limb
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in acute trauma, the accompanying hematomamasks the nature and
extent of the medial rupture[7]. Most cases go untreated, and the
result is adeciency in the bulk of the muscle, causingasymmetry in
relation to the normal, unaectedside. The triceps is supplied by
the radial nerveC5C8 and passes across the upper humerus alongthe
radial groove between the lateral and medialhead of the muscle.
Surgical Treatment
A preparation moulage of the deformity is made tocorrect the
asymmetry of the upper arm. After itscustomized manufacture, the
implant is inserted withthe patient lying prone, arms extended.
With thepatient under general anesthesia, a transverse incisionis
made parallel to an upper posterior elbow crease(Fig. 6). The
incision is 5 cm long and exposes thetriceps tendon as it inserts
into the olecranon process
of the ulna. Once exposed, the lateral muscle bersare separated
and split from the tendon to expose thesubtriceps. The medial
(deep) muscle then is strippedfrom the humerus. Care must be taken
not to damagethe radial nerve, which means resisting the
tempta-tion to make this space too far proximally up thearm. The
dissection plane is established with care notto dissect too much
medially to avoid traction dam-age to the distal radial nerve. The
5 Durometer cus-tomized silicone implant is inserted into the
pocket,and the incision is closed in layers. In nontraumaticcases,
a modied calf implant of appropriate size hasbeen used to bulk up
the medial head of the triceps,and both arms then are subjected to
surgery at thesame time (Fig. 6).Patients request triceps
augmentation because of
distal arm puniness that embarrasses them whenwearing a T-shirt
viewed from behind. They arepleased with the greater circumference
of the upperarm achieved by the implant (Figs. 7 and 8).
Afterinsertion of the solid implant, extra bulk is deliveredfrom
behind the muscle, increasing the girth of thedistal arm
approximately 2 cm by displacement of themedial head of the triceps
muscle.
Fig. 3. Asymmetry and convexity of the left shoulder sec-ondary
to axillary nerve injury and deltoid muscle degen-eration.
Fig. 4. Postoperative view of the shoulders after insertionof a
customized solid silicone implant on the humerus toreestablish
contour.
Fig. 5. Triceps muscle with three heads giving volume tothe
posterior upper arm.
D. J. Hodgkinson 55
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Discussion
Although rare, the established deformity of themedial head of
the triceps rupture causes a girthdiscrepancy and visual deciency
that cannot beovercome by exercises and weight lifting. The
solidimplant insertion requires the surgeon to be cogni-zant of the
anatomic position of the radial nerve.Postoperatively, one patient
experienced bilateralwrist drop, which was temporary, and returned
to fullfunction in 6 weeks. Results have been stable up to
7years.
Biceps Muscle
Anatomy of the Biceps Muscle
The biceps muscle, shown in Fig. 9, has two origins.The short
head from the coronoid process arises with
the coracobrachialis, and the long head arises from along,
narrow tendon from the supraglenoid tubercleat the apex of the
glenoid cavity. This long tendon,more prone to rupture in later
years, is associatedwith rotator cu injuries to the shoulder,
whereasrupture of the distal biceps is more likely duringforced
extension or during excessive curling of heavyweights by body
builders [6]. The nerve supply to themuscle is from the
musculocutaneous nerve C5C6,which runs between the brachialis and
biceps muscles.If prior exploration and repair of the distal
musclehave taken place, an anterior incision will give accessfor
insertion of a customized soft 5 durometer spacerimplant.
Surgical Technique
I prefer to place a spacer implant on the humerus bysplitting
the brachialis muscle and dissecting a sub-periosteal,
subbrachialis muscle pocket (Fig. 10) largeenough to accept the
customized or modied calfimplant. The anterior scarring can limit
the amountof projection achieved. Paradoxically, the biceps
Fig. 8. After triceps implant. Note the convexity of
theposterior arm with a fuller drop to the triceps muscle.
Fig. 7. Before triceps implant in the puny arm.
Fig. 6. Modied solid silicone calf implant insertedthrough the
posterior elbow incision onto the humerus aftersplitting of the
deep head of the triceps.
56 Contour Restoration of the Upper Limb
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muscle has a large projection and cannot be simu-lated
adequately by a contoured nondynamic solidimplant. However,
improvement in symmetry at restand an increase in distal arm girth
are achievable withthis subbrachialis implant (Figs. 11 and
12).
Results
The patients in this study were a small select group of11. At
this writing after 15 years of follow-upevaluation, 13 implants
remain in place with no long-term complications. Two triceps
implants have beenremoved because of discomfort from pressure on
acutaneous branch of the radial nerve (Table 1).Capsular
contracture, if it occurs, is deep under theintact or degenerated
muscle and not clinically sig-nicant. No extrusions have taken
place.
Discussion
Solid silicone spacer implants have been used suc-cessfully in
body contour surgery for a variety ofmusculoskeletal deciencies. In
the chest, they have
an established role in pectus excavatum and Polandssyndrome [3].
In the lower limb, buttock implantshave been used for posttraumatic
wasting of thegluteus maximus muscle, and calf implants have
beenused for post-poliomyelitic lower limb wasting. Theknowledge
gained from the surgical approach tothese muscles and the
submuscular insertion can betransferred for augmentation of
nonpathologic de-cient muscles. Hence, pectoral, buttock, and
calfimplants are prefabricated in various sizes and shapesby a
variety of manufacturers to be inserted forpurely aesthetic
reasons. Most often a moulage andcustomized implant are needed for
muscle tears,which usually are asymmetric, with manufacturemade to
a soft, textured silicone specication. Theimportance of moulage
preparation in the planningstage is stressed. The plastic surgeons
knowledge ofupper limb anatomy likely will not be current. In
thatcase, the surgeon will need to review with cadaverspecimens and
referral to classic textbooks such asHenrys Extensile Exposure [2].
Anatomy texts alsowill be helpful.Long-term tolerance of these
spacer implants with
maintenance of symmetry justies reopening old
Fig. 9. The biceps muscle constitutes the main bulk of
theanterior upper arm. Fig. 10. Intraoperative view of the solid
silicone implant
beneath the brachialis muscle on the humerus to restorebulk to
the upper anterior arm.
D. J. Hodgkinson 57
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incisions to reestablish the contour of the upper
limb.Augmentation of the upper arm with implants forpurely
aesthetic improvement may be a future direc-tion in body contour
surgery.
References
1. Friedman AH, Urbaniak JA, Goldner RD: Repair ofisolated
axillary nerve lesions after infraclavicular bra-chial plexus
injuries: Case reports. Neurosurgery27:403407, 1990
2. Henry AK: Extensile exposure 3. rd ed. Churchill
Liv-ingstone, Edinburgh, 1973
3. Hodgkinson DJ: Chest wall Implants: Their use forpectus
excavatum, pectoralis muscle tears, Polandssyndrome, and muscular
insuciency. Aesth Plast Surg21:715, 1999
4. Loomer R, Graham B: Anatomy of the axillary nerveand its
relation to inferior capsular shift. Clin Orthop243:100105,
1989
5. McIlveen SJ, Duralde XA, Alessandro DF, Bigliani LU:Isolated
nerve injuries about the shoulder. Clin Orthop306:5463, 1994
6. Ramsey ML: Distal biceps tendon injuries: Diagnosisand
management. J Am Acad Orthop Surg 7:199207,1999
7. Van Riet RP, Morrey BF, Ho E, ODriscoll SW: Sur-gical
treatment of distal triceps ruptures. J Bone JointSurg Am
85:19611967, 2003
Table 1. Complications arising from upper limb solid sili-cone
implants
Upper limb solid silicone implants. 19912004No. of implants
15Seroma 0Hematoma 0Extrusion 0Infection 0Nerve weaknesstransient
2Pain requiring removal 2
Fig. 11. Deciency of the biceps bulk distally, above thecubital
fossa, after distal muscle rupture and attemptedorthopedic
repair.
Fig. 12. Bulk of the upper arm restored in a body builderafter
insertion of a solid silicone implant.
58 Contour Restoration of the Upper Limb