The internal mammary artery perforator flap and its subtypes in the reconstruction of median sternotomy wounds

Abstract

Objective: To determine the feasibility of using the internal mammary artery perforator (IMAP) flap for superficial and deep sternal wound breakdowns.

Methods: This was a retrospective case review of 9 patients with sternal wound dehiscence over an 18-month period between 2013 and 2015. Seven of the 9 patients received a single IMAP flap to cover full-length sternal wounds, including 4 with a fasciocutaneous flap and 3 with a musculocutaneous flap.

Results: All of the patients were male, with a mean age of 68 years. The mean number of perforators was 1.3, with a mean perforator diameter of 1.5 mm. In all cases, the torsion angle was 80 degrees, with a translational pedicle movement of 1 to 2 cm. There were no instances of total flap failure and only 2 cases of partial flap necrosis, which were managed conservatively. One flap, performed when both internal mammary arteries had been harvested previously, showed complete survival.

Conclusions: The IMAP flap has an advantage in its the ability to reconstruct the entire length of a sternotomy wound from the suprasternal notch to the xiphisternum with relatively minimal dissection and morbidity compared with more conventional flaps such as pectoralis major, rectus, and omental flaps. Nevertheless, caveats for its use remain, such as in patients with vasopressor therapy and the resulting subclavicular scar, which is unaesthetic in women. Overall, the IMAP flap is an attractive reconstructive tool specifically in stable male patients with noninfected sternotomy wound dehiscence with a defect width of up to 7 cm. In this patient subset, it is the ideal first-line reconstructive tool.

Keywords: internal mammary artery perforator flap; median sternotomy wound.