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The anterior deltopectoral approach is the standard approach for performing the open Latarjet procedure. Through the use of a more medial and vertical skin incision, the scar can be cosmetically covered by the bra strap in women. We call this incision the bra strap incision.

The intention of this study was (1) to elaborate if the bra strap incision is considered beneficial by female patients, (2) to find reproducible landmarks to indicate how the bra strap incision has to be oriented, and (3) to evaluate preliminary clinical results of patients in whom the bra strap incision was used.

To assess the typical course of the bra strap, anatomical landmarks were assessed in 100 consecutive female patients as the distance from the bra strap center to (1) the tip of the coracoid process, (2) the superior end of the anterior axillary fold, and (3) the acromioclavicular joint.

This analysis shows that the bra strap incision appears to be highly welcomed by female patients and does not compromise the clinical outcome, when compared to previously published data. However, even though the typical location of the bra strap can be determined, the large variations in the distances make it more preferable to preoperatively mark the incision for optimal placement.

The study was performed at the Balgrist University Hospital, University of Zurich, Switzerland, after the Ethical Committee Zurich, Switzerland approved the study protocol (Cantonal Ethical Committee Nr.:2017-00891.

We retrospectively reviewed all female patients identified in our comprehensive database who underwent the Latarjet stabilization procedure with the use of a bra strap incision between January 2015 and January 2017. All female patients with a minimum follow-up of 12 months and a completed Constant and Murley Score [12] (CMS) were included for the analysis of the functional results.

In all patients, the bra strap course was marked preoperatively with a permanent marker so that the surgeon could set the bra strap incision intraoperatively. The Latarjet procedure was performed as described in previous studies from our institution [8, 13], according to the technique described by Walch [14], which is a modification of the original technique described by Latarjet [7].

The shoulder function was assessed as the secondary endpoint with the CMS, the relative CMS [15], the subjective shoulder value [15], and the pain level, which was assessed within the CMS on a scale from 15 (no pain) to 1 (worst pain) points. To assess shoulder instability, the anterior apprehension [16] and anterior drawer tests [16] were performed in all 18 patients.

To predict the bra strap course on the skin of a female patient, three mean distances from shoulder anatomical landmarks to the longitudinal center of the bra strap were elaborated as the third outcome parameter. Therefore, we measured these distances in 100 female patients who were seen in our outpatient shoulder clinic between November and December 2017. All patients with no previous shoulder surgeries, no scars at the shoulder region, a cup size between A to D (European size), and who provided a signed consent form were included for the measurement study. For each cup size group (A to D), 20 women were consecutively recruited. The recruitment was stopped when each group reached 20 participants. As patient demographic characteristics, the actual cup size (European size A, B, C, or D), body weight in kilograms, and the body mass index (BMI) in kg/m2 were measured.

The shoulder landmarks were (1) the acromioclavicular joint line, (2) the tip of the coracoid process, and (3) the top of the anterior axillary fold. From these landmarks, the distance to the longitudinal center of the bra strap was measured in millimeters, see Fig. 2. The mean distance of each landmark to the longitudinal bra strap center with its coefficient of variation was evaluated as the tertiary endpoint. In an attempt to improve bra strap position prediction, the associations between distance measurements and demographic information (cup size, body weight, and BMI) were investigated as the secondary outcome parameters using ordinary least square linear regression including a constant in the equation. The P values were Bernoulli-corrected. P values

Distances from the anatomical landmark to the longitudinal center of the bra strap. Distance 1 = center of the acromioclavicular joint to the bra strap center. Distance 2 = tip of the coracoid process to the bra strap center. Distance 3 = top of the anterior axillary fold to the bra strap center

The bra strap incision is not a new incision. It might have been used by many surgeons for many years, but to our knowledge, it has never been published so far. The alteration of the bra strap incision compared to the standard skin incision for the deltopectoral approach is minimal and does not affect the clinical outcome after the Latarjet procedure. In this study, the scar was only used in stabilization procedures (Latarjet) but the coverable skin incision can also be used for surgical procedures on the clavicle, the AC joint, or shoulder joint.

The bra strap incision can only be covered in bras which have a lateral strap, which runs vertically up towards the AC joint. These types of bras are by distant the most used and sold bras worldwide. Nevertheless, there are other types of bras available without straps or with triangular straps which are mounted with each other behind the neck. These types of bras would not allow coverage of the resulting bra strap incision scar.

Leslie et al. described an axillary incision for the deltopectoral approach [10] to gain a cosmetic advantage because the incision can be hidden in the axilla. Even though the axillary skin is easily moveable, the axillary incision is located too inferiorly to be suitable for the open Latarjet procedure as the coracoid process, which has to be addressed and mobilized, lies too superiorly.

The study only included female patients who underwent the open Latarjet procedure. Distal or midshaft clavicular fractures, coracoclavicular ligament reconstruction, tendon transfers like pectoralis major transfers, or shoulder arthroplasty are other interventions in which the bra strap incision might be useful.

The prediction of the bra strap course would be helpful for surgeons who want to meet the aesthetic demands of female patients. The elaborated mean distances from the three well palpable and visible shoulder anatomical landmarks to the longitudinal center of the bra strap allow an estimation of the general course of the bra strap. The tip of the coracoid process is within a mean lateral distance of 15 mm closer to the bra strap center than the more laterally placed acromioclavicular joint and axillary fold with a mean lateral distance of 28 and 30 mm, respectively.

Nevertheless, the mean distances showed high variability, which makes a reliable prediction of the bra strap course and therefore makes the drawing of the coverable bra strap incision difficult. Therefore, preoperative marking of the bra strap courses is still necessary if the surgeon desires to achieve the bra strap incision with its resulting scar.

There are two major limitations of the study. First, to confirm the safety of the altered incision technique, more patients would have been needed and should have been compared to a control group. Nevertheless, the clinical results from this study are almost identical with prior data with the use of an oblique incision [8, 17]. Second, thoracic landmarks were not evaluated because the main part of the thorax was covered by draping during shoulder surgery. With a change of shoulder draping technique toward a more medially exposed operating field, the thoracic landmarks might be visible and used for additional orientation of the bra strap skin incision for the deltopectoral approach. Therefore, the measurement of distances from the deltopectoral skin incision to medial thoracic landmarks might be of interest but was not addressed in this study.

The bra strap incision for the open Latarjet procedure was welcomed by all patients included in this survey. The change of the incision orientation did not compromise technical feasibility and clinical results. Optimally, the skin incision is preoperatively marked in agreement with the patient. If this is not possible, the mean distances from the bra strap center to the acromioclavicular joint, the tip of the coracoid process, and the top of the anterior axillary fold lie approximately 28 mm, 15 mm, and 30 mm lateral to the bra strap center, respectively.

Nevertheless, the variability of these mean distances is too high to reliably predict the bra strap course, which makes preoperative marking of the bra strap course more favorable for the optimal coverable incision placement.

The datasets generated and/or analyzed during the current study are available in the REDCap system of the Balgrist University Hospital repository. The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

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