Cosmetic aspects of device implantation

Published:August 22, 2018DOI:
      The cosmetic aspects of device implantation imply achieving an aesthetically pleasing surgical result. It involves concealing the cardiac implantable electronic device, avoiding unsightly scars, device bulges, and protrusion (Figure 1). Cosmetic device implantation is indicated for the extremely thin patient at risk of erosion and the young patient concerned with body image. These techniques are also important in the pediatric population, patients with burn injury, and patients after mastectomy. For years, various techniques have been developed to conceal and protect the device (Table 1). These techniques are more complex but can be performed by an experienced implanting physician. A thorough knowledge of the superficial and deep regional anatomy is essential. The techniques have the potential complications of lead dislodgment, hematoma, and infection. The procedures can be performed with local anesthesia and conscious sedation, but general anesthesia is frequently necessary for patient comfort. This review outlines the various procedures designed to produce a clinically satisfactory cosmetic device implantation.
      Figure thumbnail gr1
      Figure 1Elderly female patient with a pacemaker with a poor cosmetic result.
      Table 1Techniques that conceal CIED
      Technique Cosmetic result Comment
      Subcutaneous pocket: inframammary fold Two incisional scars Requires tunneling techniques
      Subcutaneous pocket: mid-axilla One incisional scar, optimal cosmetic result. CIED concealed in the axilla Requires a pacemaker or small device
      Submuscular pocket: anterior pectoralis major One incisional scar CIED well concealed
      Submuscular pocket: lateral subpectoral at the deltopectoral groove One incisional scar Anterior visible scar, lateral device migration into the shoulder
      Submuscular pocket: anterior axillary subpectoral at the anterior axillary fold One incisional scar, optimal cosmetic result, no visible scar or device Discomfort from potential lateral device migration into the axilla
      Submuscular pocket: anterior axillary fold and inframammary fold Two incisional scars, optimal cosmetic result, no visible scar or device Requires tunneling techniques
      CIED = cardiac implantable electronic device.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Heart Rhythm
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Belott P.H.
        • Bucko D.
        Inframammary pulse generator placement for maximizing optimal cosmetic effect.
        Pacing Clin Electrophysiol. 1983; 6: 1241-1244
        • Roelke M.
        • Jackson G.
        • Hawthorne J.W.
        Submammary pacemaker implantation: a tunneling technique.
        Pacing Clin Electrophysiol. 1994; 17: 1793-1796
        • Shefer A.
        • Lewis S.B.
        • Gang E.S.
        The retropectoral axillary permanent pacemaker: description of a technique for percutaneous implantation of an invisible device.
        Pacing Clin Electrophysiol. 1996; 16: 1646-1651
        • Achland R.
        DVD 1: the upper extremity (No. 1).
        in: Achland R. Achland’s DVD Atlas of Human Anatomy. DVD Edition. Lippincott, Williams and Wilkins, Philadelphia: PA2010
        • Belott P.H.
        • Reynolds D.W.
        Permanent pacemaker and implantable cardioverter-defibrillator implantation.
        in: Ellenbogen K.A. Kay G.N. Lau C. Wilkoff B.L. Clinical Cardiac Pacing, Defibrillation, and Resynchronization Therapy. Elsevier, Philadelphia, PA2011: 503
        • Costeas X.
        • Strembelas P.
        • Markou D.
        • Stefanadis C.
        • Toutouzas P.
        Subpectoral cardioverter-defibrillator implantation using a lateral approach.
        J Interv Card Electrophysiol. 2000; 11: 611-619
        • Babuty D.
        • Mirza A.
        • Clementy N.
        • Pierre B.
        • Lallemand B.
        • Lemoine E.
        • Neville P.
        Left retropectoral axillary implantation of defibrillators in young women.
        Ann Thorac Surg. 2012; 93: 331-333
        • Al-Bataineh M.
        • Sajadi S.
        • Fontaine J.
        • Kutalek S.
        Axillary subpectoral approach for pacemaker or defibrillator implantation in patients with ipsilateral prepectoral infection limited venous access.
        J Interv Card Electrophysiol. 2010; 27: 137-142
        • Giudici M.
        • Meierbachtol C.
        • Paul D.
        • Krupa R.
        • Vazquez L.
        • Barold S.
        Submammary device implantation in women: a step-by-step approach.
        J Cardiovasc Electrophysiol. 2013; 24: 476-479
        • Genesis Health System
        Submammary device implant for irregular heart beat.
        (Published December 22, 2010. Accessed March 13, 2018)
        • Noro M.
        • Zhu X.
        • Takagi T.
        • et al.
        Left axillary pacemaker generator implantation with direct puncture of the left axillary vein.
        Pacing Clin Electrophysiol. 2015; 38: 35-41