AbstractObjective:To report the technique of subpectoral (SP) implantation of the vagus nerve stimulator (VNS) generator.Methods:We retrospectively reviewed and compared demographics and complications from patients receiving either subcutaneous (SQ; n = 107) or SP (n = 138) VNS implants, performed by one surgeon (WKD) between 1999 and 2003. Selection of implant location was made during the preoperative surgeon-patient consultation on the basis of surgeon recommendation and patient preference.Results:The standard VNS generator implantation is performed within a SQ pocket in the left infraclavicular region of the chest. We have modified this technique by placing the generator into a deeper pocket SP, beneath the pectoralis major muscle, while tunneling the electrodes SQ in the usual fashion. The SP group was substantially younger (median age 19 yr) compared with the SQ group (median age 29 yr). At an average follow-up of 52 months for SQ implants and 28.4 months for SP implants, there were 2.9% infections per patient in the SQ group and 2.5% infections per patient in the SP group. There were three cases of excessive generator mobility in the SQ group; no cases occurred in the SP group.Conclusion:The SP implantation technique provides an attractive alternative to SQ VNS implantation. With increased soft tissue coverage, we provide improved cosmesis, increased wound durability to tampering and trauma, and a comparable infection rate with the SQ group.