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: dr.hodgkinson@bigpond.com

Aesth. Plast. Surg. 30:5358, 2006DOI: 10.1007/s00266-005-0102-4

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

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

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

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

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