Submuscular approach

Reflecting the lateral clavicular head of the pectoralis major muscle creates the lateral submuscular approach. In this case, an initial vertical incision is made along the deltopectoral groove. The dissection is carried down to the snrface of the pectoralis fascia. The lateral border of the pectoralis major clavicnlar head is retracted medially and a subpectoralis major muscle plane of dissection established. 

Gold MR, Peters RW, Johnson JW, Shorofsky SR. Complications associated with pectoral cardioverter-defihriUator implantation comparison of subcutaneous and submuscular approaches. Worldwide Jewel Investigators. JAm Coll Cardiol 1996 28 1278-82. 

The lateral anterior axillary submuscular pectoral approach calls for creation of a dissection plane in the anterior axillary fold (104). A dissection plane is easily established as the pectoralis major is separated at the planes created between the pectoralis major and minor muscles. A skin incision is created inferiorly along the anterolateral axillary fold. It is carried down to the surface of the pectoralis major muscle. Both the pectoralis major and minor muscles are identified and separated and a plane of dissection is created between them. This approach usually requires a separate incision for venous access and tunneling to the axillary fold ineision. The inferolateral margin of the pectoralis major muscle is easily separated from the adjacent subcutaneous tissue for establishing a large plane of dissection. The ICD should be placed as medial as possible with the leads lateral to avoid the risk of CAN abrasion. With the ICD or pacemaker in the pocket, a careful multilayered closure is used. 

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