Internal Mammary Artery Perforator (IMAP) Flap for Contralateral Chest Wall Reconstruction

Internal mammary artery perforator (IMAP) flap for chest wall reconstruction

Masaki Takeuchi,MD, Kenji Sasaki,MD and Motohiro Nozaki,MD

INTRODUCTION:Many techniques are available for the reconstruction of defects the chest wall following treatment for breast cancer. The myocutaneous flap, such as latissimus dorsi flap or rectus abdominis flap, is useful option for the large and deep defect. We have used the internal mammary artery perforator (IMAP) flap(1-3) for the reconstruction of the contralateral small to medium sized chest wall defect and obtained good results with minimal donor site morbidity(4).

MATERIALSANDMETHODS:The IMAP flaps were applied in two patients who have unhealed, localized ulcers of the chest wall with exposure of the rib following radical mastectomy(Figure 1). After the lesion was widely excised, the flap was centered over the second or third intercostal space of the contralateral chest wall(Figure 2). The flap was harvested in lateral-to-medial direction, including pectoralis fascia. Once the intercostal perforators of the internal mammary artery were identified in the parasternal region, the vessels and surrounding subcutaneous tissue were dissected to provide additional length and freedom of rotation of the flap. The flap was rotated to from 90-180 degree along the vascular axis the contralateral chest wall defect(Figure 3). The donor site was closed primarily.

RESULTS:All flaps showed stable postoperative blood circulation and survived completely. The chest wall defects could be covered with healthy, well-vascularized tissue on one perforator without deep infection or exposure of ribs(Figure 4).

CONCLUSION: The IMAP flap is a reliable and less invasive option to be considered for the medial, localized chest wall reconstruction.

REFERENCES

1. Yu P, Roblin P, Chevray P. Internal mammary artery perforator (IMAP) flap for tracheostoma. Head Neck 28:723-729, 2006.

２. Neligan PC, Gullane PJ, Vesely M, Murray D. The internal mammary artery perforator flap: new variation on an old theme. Plast Reconstr Surg. 119:891-893, 2007.

３. Vesely MJJ, Murray DJ, Novak CB, Gullane PJ, Neligan PC. The internal mammary artery perforator flap. an anatomical study and a case report. Ann Plast Surg. 58:156-161,2007.

４. KarabulutAB, Kalender V. Internal mammary artery pedicled island flap for the treatment of chest wall radionecrosis.Plast Reconstr Surg. 108:583-584,2001.

Figure 1. A skin ulcer with exposure of rib cartilage appeared on the left medial chest after radical mastectomy.

Figure 2. A right internal mammary artery perforator (IMAP) flap was raised to reconstruct the left medial chest wall defect.

PM: pectoralis major muscle,

P: internal mammary artery perforator

Figure 3. Demonstration of the versatility of the IMAP flap. The flap can be rotated on its perforator pedicle to fill defects at many locations in the medial chest wall.

Figure 4. Appearance one year after surgery.