• Ralf Stroop, Frank Holms, Makoto Nakamura, and Ralph Lehrke.
• Department of Stereotactical Neurosurgery, Barbara-Hospital, Hamm, Germany; Department of Neurosurgery, Academic Hospital Cologne-Merheim, Cologne, Germany. Electronic address: ralf@stroop.de.
• World Neurosurg. 2018 Jan 1; 109: e699-e706.

BackgroundDeep brain stimulation (DBS) indications include movement disorders, psychiatric affections, or epilepsy in which patients risk social isolation heightened by abnormal motions or behavioral patterns. Further stigmatization after DBS surgery from head shaving, visible scarring, or disfigurement from bulky lead insertion points should be avoided.ObjectiveWe present a cosmetically optimized, adapted submammarian approach for DBS neurostimulator implantation that leaves the décolletage untouched.MethodsOver 24 months, 61 patients suffering from Parkinson disease, dystonia, or tremor underwent DBS surgery. The modified, submammarian approach was compared with the conventional infraclavicular approach regarding clinical outcome, complications, and limitations over a 5-year follow-up.ResultsNeurostimulators were implanted in a paraumbilical (n = 20) or infraclavicular position (n = 41; Parkinson disease, n = 27; dystonia, n = 9; tremor, n = 5), the latter using a standard (n = 16), modified juxta-axillary (n = 6), or submammarian approach (n = 19; 18 women, 1 man with significant gynecomastia). After 12 months, there was no significant difference in the infection rate and one event of rebleeding in each group. Overall, operation time was longer (+20 minutes) for the submammarian versus standard, infraclavicular approach, but acceptable. Neurostimulator replacement was, necessary within 5 years due to advanced battery discharge (n = 32). Battery replacement was easily achieved using the submammarian approach (n = 14), again with increased surgical time (+20 minutes), and iatrogenic damage to extensions was avoidable.ConclusionsA submammarian approach might be an alternative for infraclavicular implantation of DBS neurostimulators, particularly in female patients in the context of cosmetically optimized surgery. Patients' self-perception and self-esteem may be strengthened, potentially enabling them to better cope with disease.Copyright © 2017 Elsevier Inc. All rights reserved.

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