The Subpectoral Technique for Aesthetic Placement of Pacemakers and Implantable Cardioverter Defibrillators

Sir: It was with great interest that we read the article “Inframammary Cardiac Pacemaker Insertion in Women: An Aesthetic Alternative,” by Dr. Schaverien and colleagues.1 Nowadays, the use of pacemakers and implantable cardioverter defibrillators represents the main antiarrhythmic treatment for a wide range of clinical indications. Even if their size has progressively been reduced in recent years, the superficial placement of these devices usually produces a significant aesthetic discomfort, especially in young women. The subclavian scar is frequently visible and hypertrophic, and swelling is always appreciable in the anterior chest, especially in thin patients with reduced subcutaneous tissue available. Furthermore, the superficial placement can be complicated by skin ulceration and implant exposition, especially when adequate soft-tissue coverage is lacking. The authors1 report a short case series (three cases presented) about pacemaker subglandular placement in young female patients. Nevertheless, the proposed subglandular approach, already described by Ozin and colleagues2 in 2004, was not compared with the subpectoral technique for placement of the device, first reported by Giudici3 in 2001 and subsequently popularized by the same author’s group in 20104 and by our group in 2012.5 Between January of 2001 and December of 2011, in collaboration with the cardiology team, we performed 30 cases of implantable cardioverter defibrillator subpectoral placement or substitution. Seventeen patients underwent primary implantable cardioverter defibrillator placement, while 13 patients required substitution for device exposure or malfunctioning. A 1.5-cm horizontal incision was performed in the subclavian region to allow the leads to reach the subclavian vein. Then, a 4-cm access on the inframammary fold was made, and pectoralis major costal insertions were detached from the ribs to create a subpectoral pocket (Fig. 1). After a full-thickness fenestration on the upper portion of the muscle, the leads were introduced into the pocket using a 32-Fr thoracic catheter and connected to the implant. Care was taken to prevent caudal dislocation of the device using absorbable sutures to approximate the edges of the dissected submuscular pocket. The operation was performed with the patient under sedation and lasted an average time of 54 minutes. Only three minor complications were registered (one wound dehiscence and two caudal dislocations of the device). The photographic follow-up showed no significant differences between preoperative and postoperative images, and all the patients were satisfied with the aesthetic outcome.Fig. 1: Surgical technique. The two dotted lines represent the incisions performed for submuscular placement of the device. The subpectoral pocket is created by detaching pectoralis major costal insertions through a 4-cm access on the inframammary fold. The device is placed under the muscle to reduce its visibility, and the leads are allowed to reach the subclavian vein through a 1.5-cm access in the subclavian region.Our standardized approach allowed us to obtain optimal aesthetic and functional results in primary placements, but also proved to be very useful in secondary cases, when a deeper pocket creation was necessary to reduce visibility or correct exposure of the device. Furthermore, the submuscular placement, when compared with the subglandular technique, demonstrated a lower rate of mammogram obscuration and device dislocation. For all of these reasons, we believe that all plastic surgeons who work in collaboration with cardiology teams should be acquainted with this technique, which should be offered as a first choice to all eligible patients to reduce the visible signs of the procedure and improve the psychological outcomes. DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. No intramural or extramural funding supported any aspect of this work. Paolo Persichetti, M.D., Ph.D. Beniamino Brunetti, M.D. Tiziano Pallara, M.D. Gabriella Cassotta, M.D. Barbara Cagli, M.D. Plastic and Reconstructive Surgery Unit Campus Bio-Medico di Roma University Rome, Italy