Recurrent squamous-cell carcinoma arising in pilonidal sinus tract—Multiple flap reconstructions

Squamous-cell carcinoma arising from a pilonidal sinus tract is an unusual complication of a common condition. Approximately 36 cases of carcinoma related to pilonidal disease have been reported in the literature. Wide excision with tumor-free margins has yielded five-year disease-free states in 55 percent of patients. Recurrence rates have been 44 percent to 50 percent in several large series. Regional (inguinal) nodal metastasis occurs in 14 percent of patients, heralding a dismal prognosis. Radiation and chemotherapy are of minimal palliative value. Reconstruction of these patients has consisted of split-thickness skin grafts or local cutaneous and myocutaneous flaps. Some authors have allowed healing by secondary intention. A case of squamous-cell carcinoma arising in a chronic pilonidal sinus tract is reported. Local recurrence required an extensive resection resulting in a large sacral/perineal defect. A single-stage reconstruction of this defect with multiple muscle and musculocutaneous flaps is described.     

Squamous-cell carcinoma developing within anal lichen planus

AIM: We present a case of squamous-cell carcinoma developing within perianal lichen planus. This is a chronic or recurrent cutaneous and/or mucosal dermatosis affecting less than 1 percent of the population. Neoplastic degeneration of cutaneous lichen planus is rare; only one case of squamous-cell carcinoma developing within perianal lichen planus has been described up until now in the international literature. CASE REPORT: Our case involved a 68-year-old woman with chronic, long-term lichen planus spreading all over the vulva and perianal region and the mucosa of the anal canal, where squamous-cell carcinoma developed within the perianal lichen planus. Treatment consisted of wide, circular excision of the perianal skin and mucosectomy of the anal canal up to as far as 1 cm above the dentate line. Reconstruction was performed by means of two V-Y bilateral subcutaneous flaps. CONCLUSION: Wide excision was performed not only to remove the squamous-cell carcinoma but also the lichen planus to prevent recurrence of metachronous or synchronous squamous-cell carcinoma. Follow-up at one year after surgery showed no local recurrence of either lichen planus or squamous-cell carcinoma, which suggests that surgical removal should be the therapy of choice for long-term, chronic perianal lichen planus that has proved to be resistant to medical therapy.     

Reconstructive perineoplasty in the management of non-healing wounds after anorectal surgery

Non-healing wounds (NHW) following anorectal surgery cause great distress to the patient and may be followed by a retracting scar causing anal deformity and incontinence. The management of NHW is controversial. The aim of this study was to review our experience with reconstructive perineoplasty in the treatment of such condition. From January 1992 to June 2000, we treated 12 patients affected by NHW (4 men and 8 women, mean age 47 years), not responding to conservative treatment. None had Crohn's disease or HIV infection. Pre- and postoperative anal manometry and ultrasound were carried out in 8 patients. All had microspinal anesthesia, mechanical preparation of the intestine, and perineal wound cleansing. Reconstructive perineoplasty was performed by means of local flaps (i. e. cutaneous, fasciocutaneous, myocutaneous). Median follow-up was 13 months (range, 1 to 70). Postoperative complications were as follows: 5 perineal suture dehiscences (1 total, 4 partial), the flap being resutured in one case under local anesthesia; one patient required dilatations for mild anal stricture. No case of gross fecal incontinence, retracting scar or perineal ulcer was observed. Among those patients who had disordered anal continence prior to surgery, all but one improved continence score following perineoplasty from 2.8±2.2 to 1.8±1.2 (mean ± sdm, not significant). Following reconstructive perineoplasty, no significant change was observed in functional and morphologic patterns of the anal sphincters either at manometry or by ultrasound. Reconstructive perineoplasty resulted in a good functional and clinical outcome in most cases and, therefore, may be considered an effective procedure in the managment of NHW. Received: 20 December 2000 / Accepted: 15 February 2001     

Gluteal and Perianal Hidradenitis Suppurativa

PURPOSE: Hidradenitis suppurativa is a chronic inflammatory disease of the skin and subcutaneous tissue. Extensive gluteal and perianal disease represents a challenge presentation. The aim of this study was to present results of management of extensive hidradenitis suppurativa in gluteal, perineal, and inguinal areas. METHODS: From January 1980 to May 2000, 56 patients underwent treatment of hidradenitis suppurativa in gluteal, perineal, and inguinal areas through wide excision; 52 (93 percent) were male and 36 (64 percent) were white. Mean age was 40 years. We evaluated distribution of disease, associated conditions, use of diverting colostomy, management of operative wounds, time to complete healing, complications, and recurrence. RESULTS: Twenty-one (37.6 percent) and 17 (30.6 percent) patients had gluteal and perineal disease, respectively. Squamous-cell carcinoma and Crohn's disease were observed in one patient each. Wide surgical excision was performed in all. Healing by second intention was the choice in 32 (57.1 percent) patients, and 24 (42.9 percent) patients underwent delayed skin-grafting. Diverting colostomy was used in 23 (41 percent) patients. Mean time for complete healing in the nongrafted group was 10 (range, 7-17) weeks and in the skin graft group was 6 (range, 3-9) weeks. New resection was performed in five (8.9 percent) patients. Partial graft loss rate was 37.5 percent and recurrence was observed in only one (1.8 percent) patient. CONCLUSION: Significant morbidity derives from extensive gluteal and perineal hidradenitis suppurativa caused by the disease extension and large wounds that result from surgical treatment. Wide surgical excision is the treatment of choice and leads to cure. Skin-grafting and healing by second intention lead to effective wound healing.     

The Oblique Rectus Abdominal Myocutaneous Flap for Complex Pelvic Wound Reconstruction

Purpose  The oblique rectus abdominal myocutaneous flap is a seldom used flap design based on perforating vessels exiting the rectus near the umbilicus. Compared to other flaps, the oblique rectus abdominal myocutaneous flap provides increased soft tissue to fill pelvic dead space, with the further advantage of intact skin to close perineal defects. Here we detail the oblique rectus abdominal myocutaneous flap in achieving closure of complex perineal wounds. Methods  A review of indications and outcomes in 16 patients undergoing complex pelvic operations requiring reconstruction with this flap was undertaken. Results  All patients had been previously treated with pelvic irradiation for cancer. Indications for flap reconstruction included abdominal perineal resection for anal/rectal cancer, pelvic sarcoma/sacral resection/exenteration, small bowel/colonic fistula resection, and total proctocolectomy with vaginal reconstruction. Median follow-up was 17 (range, 1–57) months. Complications included epidermal necrosis at the flap tip (n = 2), delayed perineal wound breakdown (n = 1), one abdominal wound infection, one small abdominal dehiscence, and four pelvic abscesses all managed nonoperatively. A single recurrent fistula required operative resection three months postoperatively. There were no cases of complete flap necrosis, vascular failure or persistently draining perineal sinus, and no mortalities related to the flap reconstruction. Conclusions  The treatment of complex pelvic wounds, especially following pelvic radiation, is facilitated by the oblique rectus abdominal myocutaneous flap. This technique provides ample tissue for large pelvic wounds, including skin for perineal defects. Comparing our results to existing literature, the oblique rectus abdominal myocutaneous flap displays a favorable morbidity profile, providing a safe means of delivering well-vascularized tissue to the pelvic cavity and perineal floor. Presented at the Midwestern Surgical Association, Mackinac Island, Michigan, August 6 to 8, 2006 Reprints are not available.     

A strong reconstruction option for tissue loss on hand and wrist due to firearm injury in the Syrian war: Reverse posterior interosseous flap

All of the injuries were the open injuries with bone or tendon structures in the hand and wrist region as a result of the firearm injury (FI) in the Syria. In the study, we assessed the outcomes of the posterior interosseous flap (PIF) on hand and wrist that we used for the Syrian injured people including civilians and soldiers in this War. PIF was applied to 77 patients who composed of 43 female and 34 male that all patients were evaluated for tissue loss resulting from gunshot wounds and injured in the War between 2014 and 2020 years with tissue loss in hand and wrist as a result of FI. The flap survival rate was 100% for all the patients. The dimensions of flaps ranged from 4.1 cm × 2.2 cm to 9cm × 5.4 cm with 0.51 ± 0.12 cm thickness. The mean pedicle length was 6.33 ± 1.08 cm. The surgery for PIF took 68.8 ± 22.1 minutes, while blood loss was 60 ± 24 mL. We observed no palsy conditions including the posterior interosseous nerve. The donor sites were treated by primary intention in the patients. We found the superiority of PIF with the postoperative follow-up comfort, ease of fracture healing, easy and fast, easy-to-apply method and no second additional session requirement in FI patients. We did not detect flap necrosis in any patient or observe a flap-related complication. As a result of the present study, it strongly supports the thesis that PIF is the best option in these cases.     

Myocutaneous flaps and proctocolectomy in severe perianal Crohn’s disease—a single stage procedure

Background Complex perianal wounds can be extremely difficult to treat and primary closure of these defects can be a challenge even for experienced surgeons. So far, myocutaneous flaps for wound closure after removal of malignant tumors are a well-accepted option, but there are only a few reports focusing on the primary closure of the perineal wound after proctocolectomy for Crohn’s disease. We describe our experience with wide excision of the diseased perineum using a combined abdominoperineal two-team approach. Materials and methods We performed proctocolectomy with permanent ileostomy in five patients with longstanding extensive Crohn’s disease. All five patients had fistulizing perineal Crohn’s disease combined with Crohn’s colitis. Each patient received at least one flap for primary wound closure, either a rectus abdominis myocutaneous flap or a gracilis flap. Results Indication for surgical intervention included anal or bowel stenosis, septic condition, fecal incontinence, or a combination of these features. One patient had a simultaneous adenocarcinoma of the sigmoid colon. Five patients underwent a total of seven flaps. Three months after surgery, complete healing was achieved in all patients; one patient suffered recurrence in the region of his right thigh. Mean follow up was 19.6 months (range—12–43 months). Conclusions Myocutaneous flaps are a promising therapeutic option in patients with chronic perianal disease. With the transposition of well-vascularized tissue into the perineal defect, complete healing and control of sepsis can be achieved in the majority of patients.     

Skin and soft tissue infections in injection drug users

Skin and soft tissue infections are the most common cause for hospital admission of injection drug users. Cutaneous and subcutaneous abscesses are the most frequent type of SSTI and occur most commonly when drug users are no longer able to inject intravenously and resort to injection directly into skin or muscle. Abscesses may be difficult to differentiate from uncomplicated cellulitis or may be confused with pseudoaneurysms, hematoma, phlegmon, or thrombosed vein. Special studies, including ultrasonography; CT scans, and MR imaging; or careful incision and inspection may be necessary to clarify the extent of infection and the presence of abscess. These procedures may also help differentiate a subcutaneous abscess from a vascular structure. Uncomplicated cellulitis most commonly responds to antibiotic therapy directed toward Staphylococcus aureus and Streptococcus spp. In several recent studies, cutaneous and subcutaneous abscesses have been found to be caused by polymicrobial infections and to include anaerobic organisms as well as aerobic gram-positive cocci in a little more than 50% of cases. Complete, often repeated, incision and drainage is a prerequisite for successful outcome in these cases. Complications of SSTI are many and are potentially life threatening. They include direct extension of subcutaneous abscess into vital areas or structures, necrotizing fasciitis and myositis, bacteremia, and sepsis. An outbreak of a highly lethal SSTI that recently occurred in Scotland, Ireland, and England seems to have resulted from infection with Clostridia spp, including C. novyi and C. perfringens. A rare but well-documented SSTI in injection drug users is pyomyositis, an abscess-forming infection of skeletal muscle. More than 20 cases have been reported in temperate climates to date. Although not life-threatening, chronic cutaneous venous ulcers of the lower extremities are common and debilitating, requiring long-term multidisciplinary care for successful healing.     

Multi-limb necrotizing fasciitis in a patient with rectal cancer

Necrotizing fasciitis is a devastating soft tissue infection affecting fascias and subcutaneous soft tissues. Literature reviews have identified several related risk factors, including malignancy, alcoholism, malnutrition, diabetes, male gender and old age. There are only scanty case reports in the literature describing its rare association with colorectal malignancy. All published cases are attributed to bowel perforation resulting in necrotizing fasciitis over the perineal region. Isolated upper or lower limb diseases are rarely identified. Simultaneous upper and lower limb infection in colorectal cancer patients has never been described in the literature. We report an unusual case of multi-limb necrotizing fasciitis in a patient with underlying non-perforated rectal carcinoma.     

Reconstruction of the perineum following anorectal cancer excision

Purpose  Most patients with anal cancer receive chemoradiotherapy as first-line treatment. Persistent/recurrent tumours will subsequently require an abdomino-perineal resection (APR). A proportion of the 20,000 new cases of rectal carcinoma diagnosed in the UK each year receive neo-adjuvant chemoradiation and then an APR. Healing of the irradiated perineal bed is compromised, resulting in high morbidity. Reconstruction of the perineam with well-vasularised tissue is thought to enhance healing. This study investigates a series of 18 patients who underwent APR for anorectal cancer with flap reconstruction of their perineum. Materials and methods  A retrospective analysis of all anorectal cancers requiring an APR and flap reconstruction was performed. Casenotes were reviewed and documentation made of risk factors putting them at increased risk of wound complications. Length of stay, morbidity and outcome variables including primary flap healing were recorded. Results  Between November 2000 and October 2007, 18 cases were performed (M/F = 7:11), six for anal cancer and 12 for low rectal tumours. Pre-operative treatment was chemoradiotherapy in 14 (78%), radiotherapy alone in two (11%) and none in two (11%). Perineal reconstruction consisted of 14 vertical rectus abdominis myocutaneous flaps, three free latissimus dorsi flap and one transverse rectus abdominis myocutaneous flap. Mean hospital stay was 21.8 days (10–54 days). Complete healing was noted in 16 cases with the remaining two continuing to improve under current follow-up. There were no flap losses. Conclusions  Despite most patients being treated with pre-operative radiotherapy, we have had significant success in obtaining primary healing of the perineal defect after APR.     

Dermatologic manifestations of infections in immunocompromised patients

Thirty-one immunocompromised patients (22 renal allograft recipients, 5 patients receiving chronic corticosteroid therapy, and 4 patients undergoing chemotherapy for acute leukemia) with significant dermatologic infection, excluding typical cellulitis and herpesvirus infections, were retrospectively identified over a 12-year period. Of these 31 patients, 15 (48%) had infection restricted to their skin, 6 (19%) appeared to have primary cutaneous infection that spread hematogenously to other parts of the body, 2 (6%) had infections of adjoining nasal tissue that spread to contiguous skin, and 8 (26%) appeared to have disseminated systemic infection that spread to the skin. In six of the eight patients with apparent secondary skin involvement, the development of the cutaneous lesion was the first clinical indication of disseminated infection. Eleven immunocompromised patients (35%) with bacterial infection of the skin or subcutaneous tissue were identified. These patients could be divided into three categories: leukemic patients with bacteremic gram-negative infection metastasizing to the skin (3 cases), renal transplant recipients with recurrent staphylococcal infection on and around the elbow ("transplant elbow") or streptococcal sepsis from a site of cellulitis (5 cases), and immunocompromised patients with opportunistic bacterial infection due to Nocardia asteroides or atypical mycobacteria (3 cases). Seventeen immunocompromised patients (55%) with fungal infection of the skin or subcutaneous tissue were identified. These included 12 patients with opportunistic fungal infection (Cryptococcus neoformans, 4 cases; Aspergillus species, 3 cases; Paecilomyces, 2 cases; Rhizopus species, 2 cases; and Candida tropicalis, 1 case) and 5 patients with extensive, confluent cutaneous dermatophyte infections. One patient with protothecosis and two patients with extensive papillomavirus infection were identified. Of these latter two cases, one had his immunosuppression discontinued, with clearing of his extensive warts; the other had confluent warts of the face and neck that subsequently underwent malignant degeneration to squamous cell carcinoma while chronic immunosuppressive therapy was continued.(ABSTRACT TRUNCATED AT 400 WORDS)     

Anterolateral thigh free flaps with T-shaped pedicles and multiple venous anastomosis for extremity reconstruction

The anterolateral thigh free flap is one of the most preferred options for reconstructing soft tissues of the extremities and vascular anastomosis is one of the most important factors for flaps survival. T-anastomosis and double venous anastomosis have been widely used for increasing flap survival. This report shows both application of T-shape pedicle and multiple venous anastomosis to each 43 cases for extremity reconstruction that have not been described so far in the literature and it showed the necessity of multiple anastomosis. The locations of the lesions were 8 upper extremities (4 hands, 3 forearms, and 1 upper arm) and 35 lower extremities (5 forefeet, 6 dorsal feet, 4 plantar feet, 11 ankles, and 9 lower legs). We applied T-shaped arterial pedicle to limited anatomical area that had 2 or more major arterial communication sites to overcome the obstruction by reverse flow from communication vessels when 1 of the 2 anastomosis was obstructed. We classified multiple venous anastomosis according to flow direction and the vascular connections between the superficial and deep veins. In result, 37 cases survived completely but 2 flaps developed severe necrosis (>50%) because of infection and hematoma and 4 flaps developed partial necrosis due to wound infection. In conclusion, T-shaped pedicle and multiple venous anastomosis is a method to improve free flap survival and useful in cases where sacrificing a dominant vessel is inevitable or those in which only 1 vessel remains.     

Human acellular dermal matrix for pelvic floor reconstruction after cylindrical abdominoperineal resection

An alternative treatment for low rectal cancer is the extended posterior perineal approach with reconstruction of the pelvic floor (cylindrical technique). Pelvic floor defects often require flap reconstruction using gracilis flaps, vertical rectus abdominis myocutaneous flaps or local fasciocutaneous flap. In this article, the complicated pelvic floor defect was reconstructed with human acellular dermal matrix. Despite a large resection and previous irradiation therapy, the wound healed without complications.     

What is the relationship between perineal descent and anal mucosal electrosensitivity?

PURPOSE: Perineal descent is found in many patients with anorectal disorders. There is now substantial evidence against perineal descent causing damage to the motor axons in the pudendal nerves, but the sensory sequelae of perineal descent have been neglected. The purpose of this study was to establish the relationship between perineal descent and anal sensation. METHODS: Perineal position was determined in relation to the bony pelvis by means of defecating proctography. Anal mucosal electrosensitivity was determined by using a constant current generator. RESULTS: This study demonstrated significant correlations between perineal position at rest and sensitivity in each third of the anal canal in the study group overall. In women studied alone, there were significant correlations between perineal position at rest and at squeeze and anal mucosal electrosensitivity in each third of the anal canal. CONCLUSIONS: We propose that perineal descent traumatizes the pudendal nerves, damaging the large diameter sensory axons. This may be a precursor of motor axon damage or may correlate with the global pelvic sensory loss found in patients with perineal descent and fecal incontinence.Read at the meeting of the International Society of University Colon and Rectal Surgeons XVth Biennial Congress, Singapore, July 2 to 6, 1994.Mr. A. S. Gee is supported by the Wellcome Trust, London, United Kingdom.     

Muscle Flaps and Their Role in Limb Salvage

Muscle flaps have proved to be a valuable and versatile tool in the surgical treatment of the severely compromised lower extremity. Utilized as both local pedicle flaps and free tissue transfers, muscles have been successfully employed to cover complex wounds, manage osteomyelitis, salvage infected vascular grafts, treat recalcitrant venous stasis ulcers, preserve amputation levels, and restore motion following compartment syndrome. Free flap pedicles have also been used in a flow-through fashion to create a distal arterial bypass. This article explores the multipurpose role of muscle flaps in limb salvage surgery and their beneficial physiologic characteristics in hostile wound environments.     

The value of the rectus abdominis myocutaneous flap in the treatment of complex perineal fistula

Complex perineal fistula and persistent perineal sinus are difficult to treat. We describe our experience with wide excision of the diseased perineum using a combined abdominoperineal approach. Ten patients were reconstructed by a rectus abdominis myocutaneous flap (n=7), rectus abdominis muscle flap (n=2), and omental graft (n=1). Primary healing was achieved in all cases. A median follow-up of 18 months (range 6–54 months) has shown no recurrence of perineal disease or associated abdominal incisional hernia. There were no perioperative deaths. We propose that the rectus abdominis myocutaneous flap is indicated if large amounts of perineal skin has to be sacrificed. When less skin is removed a repair with greater omentum or rectus muscle alone is adequate. The abdominoperineal approach together with filling the residual pelvic cavity with well-vascularized tissue allows definitive treatment to be carried out in one stage.Based on an oral presentation at the Tripartite Meeting, Birmingham, United Kingdom, June 19–22, 1989.     

Mycobacterium marinum infections in transplant recipients: case report and review of the literature

Abstract: Infections due to Mycobacterium marinum are rarely encountered following organ and tissue transplantation. Herein, we report a case of M. marinum infection in a kidney and pancreas transplant recipient who manifested clinically with multiple locally spreading sporotrichoid‐like cutaneous nodules in his left forearm. In order to provide a general overview of post‐transplant M. marinum infections, we reviewed and summarized all previously reported cases of this infection that occurred after transplantation. Including our index case, all 6 cases presented with multiple cutaneous and subcutaneous nodules that had spread locally in the involved extremity. One patient had lesions located in non‐contiguous body sites suggesting either systemic dissemination or multiple sites of inoculation. In all but 1 patient, the cutaneous nodules appeared in an ascending pattern and following exposure to fish tanks or after contact with the marine environment. The diagnosis of M. marinum infection was suspected on clinical grounds and confirmed by mycobacterial culture. Treatment consisted of at least 2 active antibiotics (such as rifamycins, ethambutol, tetracyclines, or macrolides) for 4–9 months, resulting in clinical cure or improvement. Relapse was observed in 1 patient despite completing 6 months of antibiotic therapy. One patient had surgical excision of the lesions. In conclusion, M. marinum should be considered as the cause of cutaneous and subcutaneous nodules in transplant recipients, particularly in the context of fish tank or marine exposure. Compared with the immunocompetent hosts, M. marinum infection may have a more aggressive clinical course after transplantation, and may require a longer duration of antibiotic treatment. Early diagnosis and treatment may prevent local spread and potential systemic dissemination.     

The simultaneous combination of implants and tram flaps for an aesthetically pleasing breast

In Taiwan, there have quite often been incidences when patients have had more abundant abdominal tissue to make a TRAM flap with a volume larger than the contralateral breast. In these situations, we usually recommend performing contralateral augmentation mammoplasty with a saline implant while undergoing TRAM flap reconstruction. From February 1997 to Mar 2001, 250 breast cancer patients underwent immediate pedicled TRAM flap reconstructions at Kaohsiung Medical University Hospital. Of these, 10 cases not only had TRAM flaps, but also simultaneous insertion of a prosthesis into the contralateral/bilateral breast to form a more pleasing breast mound. These were all saline implants. Each patient was young (aged 31-51 years) and had small to medium sized breasts. During the procedure, the implants were placed in a submuscular pocket formed by the pectoralis major muscle. There were no significant complications or failures. All breasts have remained soft and natural-looking during the follow-up period. Nine of 10 patients appreciated this procedure, and 8 of them would agree to convince other patients of the benefits of this operation. Using pedicled TRAM flaps and saline breast implants can achieve immediate breast reconstruction without the need for prolonged tissue expansion or an obvious back scar. Aesthetic results are excellent and the immediate use of an implant does not appear to pose a risk to the success of the pedicle transfer. It is a good alternative for breast cancer patients with previous hypoplasia of the breasts to achieve simultaneous therapeutic and cosmetic results.     

Management of the perineal wound after rectal excision for neoplastic disease: A controlled clinical trial

Summary Two methods of management of the perineal wound after rectal excision for neoplastic disease were compared in a prospective randomized clinical trial in 65 patients. Twenty-eight patients (Group A) were treated by partial closure of the perineal wound and cigarette drainage of the pelvic space, according to the method proposed by Gabriel. Thirty-seven patients (Group B) were treated by complete suture of the perineal wound and suction drainage of the pelvic space according to the method proposed by Altemeier. Immediate and late results were better in patients in Group B. They achieved healingper primam in 62.85 per cent of cases and had significantly shorter hospital stays than patients in Group A. Three months postoperatively, 91.42 per cent of patients in Group B and 59.25 per cent of those in Group A had complete healing of the perineal wounds, with a statistically significant difference (χ² with Yates correction =7.27, P<0.01). The development in 10 patients of Group B of perineal abscesses or hematomas necessitated reopening of the perineal wounds: however, the postoperative courses were similar to those of patients in Group A. It is concluded that healing by primary intention with use of the method described herein is the treatment of choice for managing the perineal wounds in patients undergoing rectal excision for neoplastic disease.     

Subpectoral Cardioverter-Defibrillator Implantation Using a Lateral Approach

Introduction: Third-generation cardioverter-defibrillators have revolutionized management of ventricular tachyarrhythmias. Implantation can be performed in the electro-physiology laboratory, with minimal morbidity. Generator size has shrunk to the point that subcutaneous implantation is feasible and safe, even under local anesthesia. The prepectoral technique, however, is associated with increased mechanical stress to the subcutaneous tissue and can predispose to device erosion or infection. These complications may be avoided by submuscular placement. Among subpectoral techniques, the lateral approach offers unrestricted ability to deploy patches or array electrodes, should the need arise, and may represent the optimal implant technique under some circumstances. Methods: We studied 29 male patients, aged 29–78 years, who presented with syncope or sustained ventricular tachycardia, and underwent subpectoral defibrillator implantation under general anesthesia or conscious sedation. All devices were third-generation active can systems with biphasic shock capability. Six dual-chamber defibrillators were used. Results: Subpectoral implantation was successful in all cases, with an estimated blood loss of 28±17[emsp4 ]mL and no immediate complications. Except for one patient who developed twiddler's syndrome and ultimately required revision to a subcutaneous pocket, the implant site was tolerated well, and no limitation in the range of motion of the upper limb was observed during 20 months of follow-up. Conclusions: Subpectoral implantation using a lateral approach is technically straightforward and can be applied globally, with modest additional resource and equipment requirements. Familiarity with this approach can maximize the likelihood of successful defibrillator implantation in the electrophysiology laboratory.