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To celebrate Pride, we’re elevating stories of strength, truth, and transformation from LGBTQIA+ influencers, activists, and community members, plus highlighting leaders in the field of gender confirmation surgery and hormone replacement therapy.
In the past five years alone, a spectrum of gender confirmation surgery options have become more accessible for patients seeking ways to match their physical being to their true gender. Beyond breast augmentations and mastectomies, vaginoplasties and phalloplasties, procedures like facial feminization and voice modification—offered by more providers than ever before—have made it easier for trans patients to finally feel at ease in their bodies, quelling feelings of gender dysphoria, a term that refers to a chronic state of distress caused by the cognitive dissonance between one’s self and the gender they were assigned at birth. But while there are more options available, that’s not to say that all physical traits that are seen as inherently male or female are so easy to change.
One such feature is the breadth of one’s shoulders. If you conjure up a mental image of the most masculine body you can think of, you probably see a guy with a broad chest and shoulders—a Jason Momoa type. For a transfeminine patient yearning for a more womanly silhouette, this has long been a challenge. “My shoulders are, like, number one on the dysphoria checklist,” wrote a Reddit member in a thread in the r/MtF community. Currently, there’s only a very limited number of providers worldwide known to offer the niche procedure that can address this concern: clavicle cosmetic surgery, or shoulder surgery.
Though the majority of patients seeking this surgery are trans feminine (or, on occasion, cisgender women) looking to narrow the look of the shoulders through clavicle shortening, you’ll occasionally find patients, often cisgender men, hoping for a larger look, interested in the reverse form of the procedure (clavicle lengthening). The results of both procedures can be striking: up to about 20% of the clavicle can be removed, to slim the shoulders without affecting form and function, while approximately 20 millimeters can be added in length to a clavicle—shoulder gains of about 1.5 inches overall.
If you’re seriously concerned with how wide or narrow your shoulders are, these surgical procedures could have an impressively positive impact on your self-esteem. Here, we break down exactly what cosmetic clavicle surgery is, how it works, and what alternative “starter” options are available to those who are not yet ready to commit to a more invasive procedure.
What is clavicle shortening surgery?
First, let’s recap what the clavicle is and where it’s located. Also known as the collarbone, these S-shaped bones are on the front of the chest and connect the sternum (or breastplate, the bone between your upper ribs, between your pectoral muscles) to the scapulas, or shoulder blades. The clavicle basically acts as a support beam for your shoulders, protecting essential nerves and organs while allowing weight to transfer from your arms to the rest of your body.
Collarbone fractures are fairly common—they account for 10% of all fractures—and when a patient needs to get that injury treated, they likely see an orthopedist surgeon, a physician whose specialty includes diagnosis and treatment of musculoskeletal conditions. It may surprise you to learn, then, that the surgeons who perform cosmetic clavicle procedures are plastic surgeons—but it shouldn’t. “Every aesthetic procedure has its origins in reconstructive surgery,” explains Dr. Barry Eppley, a board-certified plastic surgeon in Carmel, Indiana. He has been offering cosmetic clavicle surgery for about six years and is one of only two known American plastic surgeons who perform the procedure. “The leap from reconstructive surgery to aesthetic surgery is the ability to modify the operation and achieve the aesthetic goal,” he says, noting that includes a minimally visible incision.
Cosmetic clavicle surgery is a form of osteotomy—surgery that involves lengthening or shortening a bone. During the procedure, a small incision is made along the collarbone, then the surgeon removes the periosteum, a thin membrane covering the bone, before using a bone saw to cut the clavicle.
If the goal is narrower shoulders, a fraction of the bone is excised, leaving two halves. Their ends are connected and that union is reinforced with supportive metal plates. Once protective tissue is reconnected and the incision is closed, the procedure is repeated on the other side. Though some surgeons use just one plate on either side and suggest they be removed a year post-op, Dr. Eppley is more cautious and double-plates each side, which also allows for faster mobility.
When widening shoulders, Dr. Eppley performs what is known as a sagittal split. He cuts the collarbone at an oblique angle, slides the two halves a brief distance away from each other, and secures them with metal plates.
What is the recovery process like after cosmetic shoulder surgery?
The good news is that recovery is somewhat speedy, especially in the context of clavicle shortening surgery. “The clavicle heals quickly when you’re doing a reductive osteotomy […] it has a huge marrow space, so it has a lot of cells to help heal,” says Dr. Eppley. What can be challenging about recovering from these procedures is your loss of mobility.
Dr. Eppley breaks down his patients’ recovery into three two-week stages. For the first two weeks, which he says is the hardest part of recovery, the patient must keep their elbows as close to their bodies as they can. You can bend your arms at the elbows, but other than that, you shouldn’t move your arms—so you’ll want to have someone you trust on standby to help you during this initial healing phase. “After two weeks, we want you to get your arms out about 30 or 45 degrees [away from your body],” he says. That’s about the time when you can do your hair, and you get adjusted to using your arms with limited range as you heal.
For the last two weeks, you can graduate to moving your arms 90 degrees away from your body and begin returning to your normal activities. More strenuous physical movements will have to wait until about 12 weeks post-op. “Men who are lengthening [their clavicles] have to be a little more careful,” warns Dr. Eppley, as the surgical technique doesn’t lend itself to as smooth a healing process as for a shortening procedure.
What alternatives are there to shoulder lengthening or shoulder shortening surgery?
If you’re looking to narrow your shoulders without surgery, your options are very limited. Liposuction in this area isn’t going to deliver the desired result—the only treatment that could help create a slender look is Botox. “I do have patients who are transitioning to a more feminine body, and Botox injections are very effective for shrinking thick necks and shoulders,” says Dr. Jessie Cheung, a board-certified dermatologist with practices in New York City and Chicago. “Depending on the baseline thickness of their shoulders, there can be a dramatic difference—yes, inches!—after a series of injections.” To slim the neck and shoulders using Botox, Dr. Cheung injects the trapezius muscle, a large, kite-shaped muscle that runs from the base of the skull down your spine and extends from shoulder to shoulder (want to feel it in action? Shrug your shoulders—your traps did that).
The effects can be noticed after one month, with results peaking about three months after treatment and lasting past the six-month mark, in some cases. “I want to avoid creating any noticeable shoulder weakness, so I will perform an injection every three to four months until the desired slimming effect is achieved,” she says. “I’m a huge fan of [trapezius] Botox injections—not just for cosmetic purposes but also for patients who suffer from shoulder pain, upper back pain, or bruxism.”
Dr. Brian Dorner, a board-certified plastic surgeon in Dublin, Ohio, who works with transgender patients doesn’t offer this option and sees a downside to the treatment: “The amount of Botox needed would be a relatively large volume, and it would have to be repeated every few months, to maintain the effect,” he points out. If patients were to approach him seeking narrower shoulders, he says, he’d refer them to someone who performs clavicle shortening surgery.
For those who want broader shoulders, “there are three things you can do,” says Dr. Eppley. Clavicle lengthening aside, there are injections. Dr. Eppley specifically calls out autologous fat injections to the deltoid muscle, or the rounded area of the shoulder (think of the area covered by a cap sleeve). “Fat injections can survive in muscle,” he notes but also points out that fat injections can be unpredictable in terms of longevity—and the patient needs fat available to harvest. Dr. Cheung recommends dermal fillers instead. “Fillers are a great option for those who aren’t ready to commit to surgery or are seeking less downtime,” she says. She prefers biostimulatory fillers—such as Bellafill, Radiesse, Sculptra, or Renuva—as the results can last up to five years. “I inject every six to eight weeks, until the desired volume is achieved,” she says. “Dramatic results can be achieved over time, and patient satisfaction is quite high while boosting their body confidence.”
If you’re okay with the idea of surgery but not ready to for a bone saw, you can always go the implant route. “Implants are common for broader shoulders,” says Dr. Dorner. “They can be either standard deltoid implants or a custom implant, which can be fashioned either from a custom molded putty or by CT scan,” he says. “These effectively broaden the shoulders and generally last for decades.” Dr. Eppley adds that deltoid implants can be inserted over or under the muscle—just like breast implants.
Why is cosmetic clavicle surgery so uncommonly performed?
For one thing, clavicle surgery is, perhaps quite obviously, not a casual procedure. As opposed to addressing concerns with Botox injections or implants, the patient seeking treatment has to be seriously committed, have a support system in place, and be prepared for any drawbacks. “I have performed consultations and surgical work for patients who are in the LGBTQIA+ community,” says Dr. Kevin Debiparshad, a board-certified orthopedic surgeon in Henderson, Nevada, who specializes in limb-lengthening procedures. “In general, I feel that these patients are motivated and have good satisfaction with the results of surgery that help them realize the image they are pursuing. Overall, these patients seem to have an improvement in quality of life as successful surgical outcomes are achieved.”
However, that doesn’t mean that Dr. Debiparshad plans to perform this procedure anytime soon. “I believe the ability to shorten or lengthen the clavicle can be done safely, to achieve a cosmetic result,” he says, “but there is very limited peer-reviewed data reporting the outcomes.” His main hesitation is the risk of affecting the function of the clavicle. “In general, if I perform a cosmetic procedure on a patient, I do not want to jeopardize function to achieve the desired cosmetic results.” Immediate risks of clavicle surgery can include sensory nerve damage or a collapsed lung, while “long-term risks include hardware irritation and, most important, the permanent shift of the shoulder girdle,” says Dr. Debiparshad. The muscles where the scapula and clavicle connect to the arm could become weakened and easily fatigued over time, ultimately impeding the shoulder’s ability to move effectively.
As is the case with all aesthetics procedures, it’s important to weigh the benefits against the disadvantages and consult with a highly skilled provider when considering such an intensive procedure. Dr. Debiparshad also recommends physical therapy and muscle rehabilitation after clavicle surgery, to optimize the outcome.
Likely the greatest reason that clavicle surgery is so niche is because no one knows to ask for it. As we mentioned earlier, gender confirmation procedures have increased in accessibility in recent years, largely due to awareness. “In my practice, I rarely, if ever, get a request for clavicle shortening,” says Dr. Dorner. “The fact there are few patients looking for the procedure makes it harder to justify training to add it to my practice.” But just as facial feminization surgery is far more popular and widely available today than it was a decade ago, the tides can turn for clavicle surgery. “As this burgeoning transgender population become more aware of it and the demand increases, I’m sure there’ll be more than four [providers],” says Dr. Eppley, who performs about one cosmetic clavicle procedure a month. “Awareness creates need, which makes availability.”
Is shoulder surgery Worth It?
Anyone who has undergone plastic surgery knows that it can be life changing, especially in the case of gender affirmation. Though Dr. Dorner doesn’t offer clavicle procedures, he does offer rib reshaping and removal, which is often requested by trans patients. “It can be enormously gratifying as they continue their transition and helps them feel more comfortable with their own body image,” he says.
Regarding his own cosmetic clavicle surgery patients, Dr. Eppley has found that all have been satisfied with their outcomes—he credits this, in large part, to setting expectations. Before surgery, he always performs computer imaging, creating the minimal possible result. “I tell patients, ‘Never go into an elective aesthetic procedure hoping you get the best result,’” he says. He finds that those who are satisfied by even the smallest change to their image typically go ahead with the procedure. “It doesn’t surprise me that in my experience, every single patient thinks it was well worth it.”
