the use of implantable cardioverter - defibrillators ( icds ) is important for preventing sudden cardiac arrest in patients at high risk of fatal ventricular arrhythmias.1 ) in the past decades , cardiologists paid attention primarily to medical problems and prolongation of the life expectancy of patients with heart failure . recently , the quality of life as well as survival of such patients has been emphasized . therefore , the demand for subpectoral implantation of cardiac implantable electronic devices ( cieds ) is increasing in young female patients concerned about their body image . we report a case of combined subpectoral implantation of icd and augmentation mammoplasty via the axillary approach in a young female patient with dilated cardiomyopathy and small breasts . a 20-year - old female patient presented to the emergency department because of dyspnea and chest discomfort . transthoracic echocardiogram revealed an enlarged left ventricular dimension and severe global hypokinesia of the left ventricle ( ejection fraction , 20% ; fig . 1 ) . cardiac magnetic resonance images showed severely decreased left ventricular function and ill - defined delayed enhancement in the septum , both compatible with dilated cardiomyopathy . after 9 months of optimal medical treatment including perindopril , furosemide and spironolactone , cardiac function had not improved . the patient still complained of dyspnea on exertion of new york heart association functional class ii . non - sustained monomorphic ventricular tachycardia was detected on 24 h electrocardiogram monitoring ( fig . we proposed two options for icd implantation : subcutaneous or subpectoral implantation via the axillary incision . the patient preferred the latter option , and also requested augmentation mammoplasty for her small breasts . after consulting the plastic surgeon , we performed a combined subpectoral icd implantation and augmentation mammoplasty procedure via the axillary incision . before augmentation mammoplasty , the volumes of right and left breasts were 46 and 56 ml , respectively , as measured anthropometrically . under general anesthesia , skin incisions were performed on both axillary creases , and the plane between the pectoralis major muscle and the rib cage were dissected under endoscopic guidance . two 185 g form - stable gel breast implants ( natrelle ; allergan , irvine , ca , usa ) were implanted into the subpectoral plane of both breasts . because the patient 's blood pressure decreased in the sitting position , norepinephrine was infused intravenously to maintain mean arterial blood pressure above 80 mmhg . after bilateral breast augmentation by the plastic surgery team , the left axillary vein was punctured via the seldinger technique . a defibrillating ventricular lead ( durata 7120q-58 cm ; screw type , st . jude medical , valley view court sylmar , ca , usa ) was inserted into the right ventricle via the 9 fr guiding sheath and was stably anchored at the right ventricular apex . an atrial lead ( tendril sts 2088tc-52 cm ; screw type , st jude medical ) the ventricular and atrial leads were connected to the icd generator ( ellipse dr , st jude medical ) . the icd generator was implanted into the subpectoral plane immediately above the left breast implant . , volumes of the right and left breasts were 163 and 169 ml , respectively ( fig . we present herein a successful case of combined subpectoral icd implantation and augmentation mammoplasty via axillary incisions in a young female patient who was dissatisfied with her body image . cieds have shown to improve survival and symptoms of patients with heart disease , and their use has been increasing.1)2)3 ) the use of icd implantation in young patients due to congenital heart disease , cardiomyopathy , and genetic disorders , such as a long qt syndrome , has also increased.4 ) currently , quality of life as well as survival is important . as the number of young patients who require cied has increased , physicians should be concerned regarding not only patients ' medical problems but also esthetic aspects and psychological fitness . in particular , young or female patients are more concerned about their body image and psychosocial distress associated with shock or sudden death rather than older or male patients.5)6 ) despite the reduction in the size of cieds in the last few decades , routine subcutaneous device implantation in the pectoral area still results in a visible scar and protrusion . furthermore , protrusion at the anterior chest causes awareness of the device and discomfort with daily activities when using purse straps , bra straps , or seat belts . recently , in the united states , the application of subpectoral cied implantation has increased in young female patients having cosmetic concerns.7)8 ) although there are several methods for cosmetic cied implantation , no nomenclature for these methods has been suggested . we suggest a nomenclature for cosmetic cied implantation based on a combination of three components : incision for lead insertion , incision for generator insertion , and layer of generator implantation . in previous studies9)10 ) and real - world practice , four types of cosmetic cied implantation have been reported : axillary - axillary - subpectoral , axillary - inframammary - submammary , infraclavicular - axillary - subpectoral , and infraclavicular - inframammary - submammary implantation ( fig . 6 ) . the submammary layer lies beneath the mammary glandular tissue and above the pectoralis major muscle . in the present case , we used axillary - axillary - subpectoral implantation . implantation is superior at it results in minimal and invisible scarring . complications of subpectoral or submammary cied implantation are not higher than that of those implanted subcutaneously . obeyesekere et al.10 ) reported 20 cases of submammary icd implantation , and did not note complications related to the implantation site , such as infection and device migration . during a follow - up of 5 years , the incidence of appropriate and inappropriate shock due to the icd was similar to that reported in other studies . the overall risk of any pocket - related complications was not different between the two groups , and lead complications occurred more frequently in the subcutaneous group.11 ) patients ' satisfaction and acceptance rates were higher in the submammary or subpectoral group than subcutaneous group.7)9 ) a generator is implanted between the pectoralis major muscle and the rib cage via an axillary incision . although the device is implanted subpectorally or submammarily , esthetic concerns remain in female patients with low body weight and small breasts . a combined subpectoral icd implantation and breast augmentation surgery has been reported.12 ) breast augmentation helps conceal the remaining protuberant chest due to the device . a combined subpectoral cied implantation and augmentation mammoplasty procedure is feasible , because the layer of cied implantation is identical to that of breast implantation . this combined procedure is usually performed by cooperation between a cardiac electrophysiologist and a plastic surgeon under general anesthesia . therefore , multidisciplinary care by a cardiac electrophysiologist , a plastic surgeon , and an anesthesiologist is important for combined surgery . in particular , vital signs and heart function monitoring during the operation are essential in patients with heart failure . generator change , icd removal or repositioning from the subpectoral to subcutaneous area also requires general anesthesia . as mentioned above , the complication rates of cied implantation in the subpectoral area and other areas are similar . indeed , in some case series , subpectoral cied implantations not combined with breast augmentation via an axillary approach were performed successfully.13 ) however , later procedures should be carefully managed , because the icd generator and breast implant were implanted in the same subpectoral layer . cases of combined subpectoral icd implantation and augmentation mammoplasty in asians have not been reported previously . combined subpectoral icd implantation and augmentation mammoplasty via the axillary incision is feasible in young female patients with icd indications and small breasts .
subcutaneous implantation of a cardiac implantable electronic device is the standard method . 
 occasionally , subpectoral cardiac implantable electronic device ( cied ) implantation via axillary incisions is performed in young female patients for cosmetic purposes . because subpectoral cied implantation and augmentation mammoplasty involve the same layer , it is feasible to perform both procedures simultaneously . 
 we report a case of combined subpectoral implantation of an implantable cardioverter - defibrillator and augmentation mammoplasty via the axillary approach in a young female patient with dilated cardiomyopathy and small breasts .