Case Report
Internal Mammary Artery Perforator Flap for Coverage of Wounds in the Forearm
Diego Colín Vega*, Anabel Villanueva Martínez, Esteban Limón Hernández, Julio Palacios Juárez and Rodolfo L Ríos Lara y López
Corresponding Author: Dr. Diego Colín Vega, Department of Plastic and Reconstructive Surgery, Hospital General de México, Dr. Balmis 148, Colonia Doctores, Mexico City, Mexico
Received: August 27, 2019; Accepted: October 01, 2019; Published: November 14, 2019;
Citation: Vega DC, Martínez AV, Hernández EL, Juárez JP & Lara y López RLR. (2019) Internal Mammary Artery Perforator Flap for Coverage of Wounds in the Forearm. J Infect Dis Res, 2(2): 57-59.
Copyrights: ©2019 Vega DC, Martínez AV, Hernández EL, Juárez JP & Lara y López RLR. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
 

Introduction: In severe upper limb injuries, which leave extensive and deep wounds with significant damage to vascular and nervous structures and bone exposure, surgical options are often limited. In these cases, when patients present severe vascular damage, comorbidities or they are in a center that does not count with the conditions for a microsurgical reconstruction; the internal mammary artery perforator flap is a great option for coverage.

In this work we describe the use of the Internal Mammary Artery Perforator (IMAP) flap for coverage of a wound in the forearm in a non candidate patient for reconstruction with microsurgical flaps.

Discussion: The internal mammary artery perforating flap is a widely known flap in its vascular anatomy, technically simple, safe, versatile, with a good arc of rotation and with low morbidity.

Conclusion: Due to all the virtues that this flap offers and its low morbidity it is an excellent option to cover not only local and regional wounds, but also distant wounds as in the case described, interpolating it to the upper extremities with excellent results.

 

Keywords: Internal mammary artery, Flap, Perforator

INTRODUCTION

There are patients who suffer trauma to the upper limb, leaving extensive and deep wounds that not only leave soft tissues (muscles, tendons, blood vessels and nerves) exposed, but also the bone; having, therefore, to cover these areas with quality tissue, well vascularized, wide and with plentiful thickness. Although most of the time this type of lesions can be ideally covered with free flaps, in certain cases, due to the presence of a major lesion and loss of the main arteries of the affected limb, free flaps cannot be performed and other option should be consider [1].

The internal mammary artery perforator flap is a good option for these cases given its well known anatomy, technical ease to perform, due to the size and thickness of the tissue that can be interpolated and its low morbidity [2]. This flap is a modification of the medially based deltopectoral flap which was described in 1965. It is a very versatile fasciocutaneous flap, of good thickness, easily foldable, with a large arc of rotation and with low morbidity since the donor area can be primarily closed. It is based on perforating arteries of the internal mammary artery and its main use is described for reconstruction of the head and neck [3,4].

Different clinical applications exist for the IMAP flaps. The flaps based on IMAP 1 or 2 may be rotated cranially for tracheostoma or anterior neck reconstruction. The flaps based on IMAP 4 or 5 supplying the skin of the inframammary fold could be used for reconstruction of the contralateral thoracic wall, breast or thoracic limb. The harvest site of IMAP 1 and 2 can be closed directly if the width of the flap is less than 6 cm. The IMAP 4 and 5 harvest site could be closed via a reduction mammaplasty technique, thus minimising donor-site morbidity [5].

In this work we describe the use of this versatile flap for coverage of the forearm in a patient who suffer an extensive and deep wound secondary to an exposed fracture of the left forearm with extensive soft tissue loss and that was non candidate for reconstruction with microsurgical flaps.

TECHNIQUE

With the patient in a decubitus position, the flap is marked at the level of the 4th or 5th intercostal space, once de perforator was identified with the help of a Doppler, the flap is drawn transversely. The medial limit was the sternum (midline), the length was just at the anterior axillary line and the width was based on the coverage required (8 cm to obtain a primarily closure of the defect) (Figure 1). The superior and inferior incisions were first made down to the pectoralis fascia and subfascial dissection was carried out from lateral to medial using monopolar diathermy, until 4-5 cm from the sternal border. At this point, dissection was performed using tenotomy scissors until the perforator vessels were identified. After that, the flap onset in the forearm was made (Figure 2) and an on layer primarily closure of the donor defect was done after undermining and a suction drain placement [6].

DISCUSSION

Different clinical applications exist for the IMAP flaps. The flaps based on IMAP 1 or 2 may be rotated cranially for tracheostoma or anterior neck reconstruction. The flaps based on IMAP 4 or 5 supplying the skin of the inframammary fold could be used for reconstruction of the contralateral thoracic wall, breast or thoracic limb.

The internal mammary artery perforating flap is a widely known flap in its vascular anatomy, technically simple, safe, versatile, with a good arc of rotation and with low morbidity.

For all these features this flap is a great option for the coverage of wounds in patients that are not candidates for microsurgical flaps.

CONCLUSION

Due to all the virtues that this flap offers and its low morbidity it is an excellent option to cover not only local and regional wounds, but also distant wounds as in the case described, interpolating it to the upper extremities with excellent results.

1.       Gillis JA, Prasad V, Morris SF (2011) Three-dimensional analysis of the internal mammary artery perforator flap. Plast Reconstr Surg 128: 419e.

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

3.       Yu BT, Hsieh CH, Feng GM, Jeng SF (2013) Clinical application of the internal mammary artery perforator flap in head and neck reconstruction. Plast Reconstr Surg 131: 520e.

4.       Hanasono MM, Butler CE (2009) Three- and four-dimensional arterial and venous perforasomes of the internal mammary artery perforator flap. Plast Reconstr Surg 2009: 1770-1771.

5.       Schmidt M, Aszmann OC, Beck H, Frey M (2010) The anatomic basis of the internal mammary artery perforator flap: A cadaver study. J Plast Reconstr Aesthet Surg 63: 191-196.

6.       Iyer NG, Clark JR, Ashford BG (2009) Internal mammary artery perforator flap for head and neck reconstruction. ANZ J Surg 79: 799-803.