Elsevier

World Neurosurgery

Volume 109, January 2018, Pages e699-e706
World Neurosurgery

Original Article
A Submammarian Approach for Cosmetically Improved Implantation of Deep Brain Stimulation Generators

https://doi.org/10.1016/j.wneu.2017.10.057Get rights and content

Background

Deep 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.

Objective

We present a cosmetically optimized, adapted submammarian approach for DBS neurostimulator implantation that leaves the décolletage untouched.

Methods

Over 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.

Results

Neurostimulators 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.

Conclusions

A 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.

Introduction

Deep brain stimulation (DBS) was introduced in 1987, and the surgical procedure is now routine after implantation of more than 100,000 patients worldwide.1, 2 Movement disorders are the most frequent indications for DBS, including idiopathic Parkinson disease (PD), with refractory severe motor fluctuations even under optimized antiparkinsonian drugs3 (most effective cerebral targets are the subthalamic nucleus, globus pallidus internus or, for tremor-dominant PD, the ventrointermediate nucleus4, 5), primary dystonia (usually generalized or focal, juvenile or adult, commonly targeting the globus pallidus internus6), or tremor (e.g., essential tremor, Holmes tremor, encephalitis disseminata or PD, targeting the ventrointermediate nucleus7). Potential new indications8 include mental disorders (e.g., depression, obsessive–compulsive disorders,9 Tourette syndrome,10 anxiety disorders11), dependency,12 pain,13 intractable forms of epilepsy,14 and even Alzheimer disease.15

Common to all of these indications is the fact that patients have suffered severely for a long period of time and run the risk of sustained social isolation boosted by striking, accentuated motions, or behavioral patterns.16 One of the expectations for DBS is that in addition to improvements in motor symptoms and mental disability, there may also be a significant reduction in psychological strain and renewed hope for social reintegration.17 Therefore, it is crucial that DBS surgery will cause as little scarring as possible and not adversely affect a patient's appearance.18 A body that is perceived to be mostly physically intact supports patients' self-esteem and enables them to cope more easily with their disease.19

Therefore, our surgical strategy for DBS surgery has been optimized to consider the cosmetic appearance of DBS. Although newer neurostimulators are smaller in size, they remain inherently bulky and may cause a significant bulge under the skin. Thus, positioning is important. Standard locations for the implantation of a 2-channel DBS pulse generator are typically a one-sided subcutaneous/epifascial infraclavicular position or the abdominal paraumbilical position. Via the use of a standardized surgical technique, generator implantation is either performed immediately after electrode insertion or, after a period of temporary electrode externalization for evaluation procedures, within a few days.20, 21 Less often, a bilateral single-channel generator will be implanted, for example, if the implantation of a second electrode or even of a second pair of electrodes is necessary during the course of the disease (e.g., if tremor reduction in subthalamic nucleus-stimulated PD is insufficient). In rare cases, implantation of 2 less bulky single-channel generators might be considered.22

The lifespan of the neurostimulator must also be considered. The overall lifetime of nonrechargeable neurostimulators is limited because of their falling battery capacity. Even for rechargeable devices (Activa RC [Medtronic, Inc., Minneapolis, Minnesota, USA], Vercise [Boston Scientific, Marlborough, Massachusetts, USA], Brio [St. Jude Medical, St. Paul, Minnesota, USA]), lifespan may be restricted to a predefined period. The endurance of nonrechargeable generators depends on the impulse duration, frequency, and voltage used for stimulation, as well as the electrode impedances. In dystonia or psychiatric disorders, in which greater stimulation voltages are usually required and in which DBS surgery often will be performed in younger patients, frequent surgical exchange of generators may be necessary, which has an impact when planning the implantation site for the neurostimulator.

The paramedian abdominal position may be favored for very slender patients, in whom infraclavicular implantation would project too much and be cosmetically displeasing; however, discomfort can occur if the generator comes into contact with the iliac crest or the rip bow while stooping or sitting down. An abdominal generator position also may be favored because a long distance to the cranial lead insertion point may restrict potential infection and prevent the infection travelling to the leads if it occurs at the generator pouch.23 Infraclavicular aggregate implantation is advantageous in terms of maintaining free moving space. However, an infraclavicular approach to implantation of a DBS pulse generator risks extension into the décolletage, designated a “no-go” area (as in breast surgery) as it can be uncomfortable, is associated with a risk of scarring keloids (Figure 1), and may even be a reason for a female patient to refuse DBS surgery. Therefore, we describe a new approach using an infraclavicular position via a submammarian approach, allowing cosmetically improved implantation of a DBS neurostimulator (Figure 2).24, 25 Cosmetically advantageous submammarian approaches have already been described previously for the implantation of cardiac pacemakers, implantable cardioverter defibrillators, and spinal cord stimulators, providing high patient acceptance and long-term satisfaction, with few complications.26, 27, 28

Section snippets

Patient Enrollment

Over 24 months, 61 patients suffering from movement disorders such as PD, dystonia, or different tremor entities underwent DBS surgery at the Department of Stereotactical Neurosurgery at the St. Barbara-Hospital in Hamm, Germany. Neurostimulators were implanted in accordance with patient preference and based on informed consent, in a paraumbilical or infraclavicular position using one of three approaches: the conventional infraclavicular approach, a modified juxta-axillary access for an

Results

Of the 61 patients who underwent DBS surgery, the generator was placed in an infraclavicular position in 41 patients (27 female, 14 male; aged 40–84 years, median 61 years) via either a standard infraclavicular approach (n = 16; aged 46–70 years, median 59.5 years; 7 female, 9 male patients), a modified juxta-axillary access (n = 6; 2 female, 4 male patients), or a submammarian approach (n = 19; aged 40–84 years, median 62 years; 18 women, 1 male with significant gynecomastia). Indications for

Discussion

To improve the cosmetic overall outcome of patients undergoing DBS surgery, we compared submammarian, juxta-axillary, and conventional infraclavicular approaches for the neurostimulator implantation, resulting in great acceptance of the submammarian or juxta-axillary techniques. Implantation of the generator using the described submammarian technique does not result in any visible scars, whereas less-visible scars were achieved with the use of the juxta-axillary access. Patients felt

Acknowledgments

The authors thank Jens Volkmann for their discussion and valuable input.

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    Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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