I truly believe that one needs to perform the incision more laterally in patients with breast implants or large breasts. In these cases, I will position the patient with the arm over the head. As you can see in the pictures, the incision cannot be infra-mammary, it needs to be more lateral. One should always target the center of the incision to be in line with the mid portion of the sternum. In other words, it should be directly across from this point of reference. ((( OF NOTE, the external landmark that mostly correlates with the location of the mitral valve is the mid portion of the sternum ))). BTW, I also use this incision with the arm placed over the head in patients that have an elevated right hemi- diaphragm. It will allow me a more direct vision of the mitral valve. The entry site for the atrial lift post will be located at the infra-mammary fold or will be very medially. If placed medially, the post will graze the right lateral aspect of the sternum. Care needs to be taken to avoid injury to the IMA.
PICTURE 4 shows the atrial lift post placed in the region of the infra-mammary fold.
PICTURE 5 & 6 show the post placed immediately lateral to the sternum.
In patients requiring a mini AVR, the implants will usually be below the incision.