Internal Mammary Artery Perforator Flap Research Articles

Internal Mammary Artery Perforator Flap for Immediate Volume Replacement Following Wide Local Excision of Breast Cancer.

BackgroundBreast-conserving therapy is defined as a breast-conserving wide local excision (WLE) of a mammary tumour combined with postoperative radiotherapy. Immediate restoration of the mammary shape by use of breast reduction techniques (volume displacement) or tissue replacement techniques (volume replacement) is gaining popularity to prevent breast malformation.MethodsTo date, using the internal mammary artery perforator (IMAP) flap has been suggested for immediate volume replacement after WLE, but has never been evaluated in a published study.ResultsWe applied this flap in 12 women (mean age, 56.1 years) after WLE (mean specimen weight, 46.5 g) of the medial aspect of the breast. Over a median follow-up of 35.3 months (standard deviation, 1.2 months), 4 women needed repeated surgery for dog-ear correction of the donor site.ConclusionsIn our experience, the use of an IMAP flap was a reliable technique with good cosmetic outcomes after oncoplastic reconstruction. In this series, donor site revision often proved necessary initially, but we showed that this may easily be prevented.

Application of Tissue Expansion with Perforator Flaps for Reconstruction of Challenging Skin Lesions

One set of perforators can supply its own perforasome as well as the adjacent perforasome. The process of tissue expansion can mimic the effect of surgical delay to include more perforasomes into the perforator flap. By combining the perforasome theory with the technique of tissue expansion, large and various expanded perforator flaps can be achieved. From July 2007 to July 2014, we performed eight different types of expanded perforator flaps in a total of 83 cases: 41 supraclavicular artery perforator flaps, 11 superficial cervical artery perforator flaps, 15 lateral thoracic perforator flaps, 6 internal mammary artery perforator flaps, 6 thoracoabdominal perforator flaps, 2 facial artery perforator flaps, 1 posterior interosseous perforator flap, and 1 ulnar collateral artery perforator flap. During the follow-up period, the survival rate, color, texture, and retraction of the flaps were assessed. The dimensions of the flaps ranged from 8 × 6 to 25 × 25 cm. Minor flap necrosis occurred in 20.5% of the cases, and severe flap necrosis developed in 2.4% of the cases. The donor sites were closed primarily in all but three cases. During the follow-up period (average, 13 months; range, 8-18 months), no flap contracture was observed with a good color and texture match. By combining the concept of perforasome with the technique of tissue expansion, flaps with large dimensions and reliable blood supply can be achieved, allowing a more flexible design to reconstruct various and challenging skin lesions.

Abstract: Principles and Algorithm for the Microsurgical Treatment of Unstable Keloids on the Trunk after Burn Injury

INTRODUCTION: Unstable keloids are one of the most frustrating clinical problems in wound healing and the pathogeneses remains largely unknown.1 To date, little is known in the literature about the microsurgical management of unstable and middle-sized keloids on the trunk, and a clear consensus is lacking.2 Perforator flaps are thin and pliable, have a robust blood supply, potentially release the scar-site tension effectively and may provide an outcome with well-matched color, thickness, and texture.3,4 In this study, we provide a versatile algorithm by using various pedicled and free perforator flaps for the treatment of keloids on the trunk. MATERIALS AND METHODS: Patients with a history of multiple treatments of middle-sized keloids on various regions of the trunk were included. Color Doppler ultrasound (CDU) and multidetector-row computed tomographic angiography (MDCTA) were performed preoperatively. Depending on the location of the keloid, the following flaps were used: superficial circumflex iliac artery perforator (SCIP) flap, internal mammary artery perforator (IMAP) flap, superior epigastric artery perforator (SEAP) flap, anterior intercostal artery perforator (AICAP) flap, deep inferior epigastric artery perforator (DIEP) flap and anterolateral thigh (ALT) flap. RESULTS: Between June 2013 to June 2015, 29 patients (15 male and 14 females) with a mean age of 41 ± 15years were treated. Totally, we performed 5 free SCIP flaps, 2 pedicled SCIP flaps, 8 IMAP flaps, 6 SEAP flaps, 3 AICAP flaps, 4 DIEP flaps and 1 ALT flap. The mean flap size was 83 ± 36cm2 and the mean flap thickness was 14.8 ± 5mm. One partial distal necrosis occurred after a pedicled AICAP reconstruction, which healed conservatively. After a mean follow-up of 5 ± 3months, all surviving flaps showed excellent thickness, texture and color match. Importantly, there was no need for secondary debulking surgery. The donor site healed well after primary closure in all patients. CONCLUSION: We successfully applied various free and pedicled perforator flaps for the treatment of unstable keloids on the trunk. Based on our experience, we provide a useful and reliable algorithm in order to achieve the best possible outcome. No disclosures REFERENCES: 1. Ogawa R, Chin MS. Animal models of keloids and hypertrophic scars. J Burn Care Res 2008;29(6):1016–1017 2. Wang J, Min P, Grassetti L, et al. Preliminary Outcomes of Distal IMAP and SEAP Flaps for the Treatment of Unstable Keloids Subject to Recurrent Inflammation and Infections in the Lower Sternal and Upper Abdominal Areas. J Reconstr Microsurg 2015 3. Hong JP, Choi DH, Suh H, et al. A new plane of elevation: the superficial fascial plane for perforator flap elevation. J Reconstr Microsurg 2014;30(7):491–496 4. Koshima I, Soeda S. Inferior epigastric artery skin flaps without rectus abdominis muscle. Br J Plast Surg 1989;42(6):645–648

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

ObjectiveTo determine the feasibility of using the internal mammary artery perforator (IMAP) flap for superficial and deep sternal wound breakdowns. MethodsThis 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. ResultsAll 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. ConclusionsThe 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.

Preliminary Outcomes of Distal IMAP and SEAP Flaps for the Treatment of Unstable Keloids Subject to Recurrent Inflammation and Infections in the Lower Sternal and Upper Abdominal Areas

We present the clinical application of the sixth internal mammary artery perforator (IMAP) and superior epigastric artery perforator (SEAP) flaps for the treatment of defects resulting from the excision of large lower sternal and upper abdominal keloids. Perforator selection and flap design were based solely on preoperative multidetector-row computed tomographic angiography (MDCTA) of the areas adjacent to the soft tissue defects. Between January 2009 and June 2014, 15 patients with large, unstable keloids subject to recurrent inflammation and infections and with a history of multiple failed treatments underwent surgical excision and early postoperative radiation therapy. The defects were located in the upper abdomen (n = 6) or lower sternum (n = 9). All patients underwent preoperative MDCTA for perforator localization. A total of 15 patients underwent keloid removal followed by IMAP (n = 10) and SEAP (n = 6) flap coverage combined with early postoperative low-dose radiation therapy (350 cGy/5 fractions/5 days or 400 cGy/4 fractions/4 days). Flap sizes ranged from 9 × 5 to 17 × 6 cm. Only one IMAP flap developed a 2 × 2 cm tip necrosis, which was managed with dressing changes. The remaining flaps healed uneventfully with no keloid recurrence at 23.4 months. In all cases, the perforator location determined by preoperative MDCTA was precisely consistent with the intraoperative findings. The sixth IMAP and SEAP flaps combined with early postoperative radiation therapy provided a valid and feasible approach for the surgical treatment of large keloids in the lower sternal and upper abdominal. MDCTA enabled detailed preoperative assessment of the perforators, facilitating both flap design and dissection, and saving operating time. Although longer follow-up is required, these preliminary results are encouraging.

Salvage of a free osteocutaneous fibula flap by creating a distal arteriovenous fistula in facial reconstruction

The case of a 25-year-old male with a facial gunshot wound is reported. A free fibula flap was performed for facial reconstruction. At 48h after the operation, a thrombotic event was observed in the anastomosis. A distal arteriovenous (AV) fistula was performed to regulate the blood flow in the flap, and a combination of flaps (forehead flap and internal mammary artery perforator (IMAP) flap) was used for the skin defects. After creating the distal AV fistula, the blood flow was regulated and the free flap salvaged. No bone healing problem was observed in the free fibula flap and there were no complications related to the forehead and IMAP flaps. The fistula was patent at 2 years postoperative. Although all high-resistance flap conditions cannot be corrected with a distal AV fistula, the method presented in this case could be used as a last resort procedure for free flap salvage.

Gemella morbillorum Infection after Acupuncture Therapy.

Gemella morbillorum Infection after Acupuncture Therapy.

Three-Dimensional Printing of Perforator Vascular Anatomy

Sir: The use of three-dimensional printing has increased in recent years with the advent of commercially available three-dimensional printers and lower costs. Computed tomographic data can be obtained rapidly and incorporated into three-dimensional reconstructions visualized in two dimensions. This information can be used to produce a physical object using progressive layering of different polymers or materials with a three-dimensional printer. Production of three-dimensional models allows improved visualization and manipulation of anatomical structures compared with two-dimensional representations. They can be used for surgical planning, implant design, and education.1 Three-dimensional models have also been used for training on patient-specific models to simulate surgical procedures to help understand difficult anatomy, predict complications, and potentially reduce operating time.1–41–41–41–4 We produced a three-dimensional model to facilitate understanding of the regional anatomy of the internal mammary artery. We chose the internal mammary artery perforator system, as its relationship to surrounding ribs is important in the dissection and identification of the dominant perforator while raising the internal mammary artery perforator flap. To create a three-dimensional model of the dominant internal mammary artery perforator, a fresh cadaver was injected with the modified lead oxide technique described previously.5 The cadaver was obtained through the Dalhousie University Donor Program. Plain films and computed tomographic images of the cadaver were obtained and the data were analyzed using Materialise’s Interactive Medical Image Control System program (Materialise, Leuven, Belgium). Using the program, three-dimensional images of the dominant internal mammary artery perforator and surrounding structures were created (Fig. 1).Fig. 1: Three-dimensional reconstructions of the left bony thorax, internal mammary artery, and dominant left internal mammary artery perforator and lateral thoracic artery from cadaveric computed tomographic data using Materialise’s Interactive Medical Imaging Control System. (Left) Anterior-posterior, (center) oblique, and (right) posterior-anterior views (*, second internal mammary artery perforator; •, second rib; , lateral thoracic artery).The reconstruction was printed in three dimensions using a composite powder printing process on a ProJet x60 series printer with a Z-bond 90 infiltrant (3D Systems, Rock Hill, S.C.). This produces a three-dimensional object by successively laying down the infiltrant to build the model slice by slice based on the reconstruction. We report the first use of three-dimensional printing to produce vascular perforator anatomy. The dominant internal mammary artery perforator can be seen branching off of the internal mammary artery, through the second intercostal space and anastomosing with the lateral thoracic artery (Fig. 2).Fig. 2: Anteroposterior (left) and oblique (right) views of a three-dimensional model of the left bony thorax, internal mammary artery, and internal mammary artery perforator (*, second internal mammary artery perforator; •, second rib; , lateral thoracic artery). The lateral thoracic artery was based on cadaveric data and printed using a ProJet x60 series printer with a Z-bond 90 infiltrant (3D Systems, Rock Hill, S.C.).The use of three-dimensional printing to produce physical objects is the next step from three-dimensional reconstructions visualized on two-dimensional screens. It allows rapid manipulation and understanding of an individual’s anatomy by physically holding the object and being able to visualize it in multiple planes. This can be useful for teaching learners, and can be used as a tool to better explain the proposed surgery to patients using their own anatomy. One limitation of the process is the cost associated with production of the model, which can be anywhere from $400 to $1200. Also, due to the minuteness of perforator vessels, some smaller vessels do not endure the printing process due to the resolution limitations of the three-dimensional printer. This can be ameliorated with a larger model, albeit at a higher cost. Also, the materials used to make certain models are delicate, and rough handling can cause perforator branches to crack. However, postprinting processing with materials such as wax can create a durable model that can be used in clinics and teaching sessions. DISCLOSURE The authors have no financial interest in any of the products or devices mentioned in this article. Joshua A. Gillis, B.Sc., M.D. Steven F. Morris, M.D., M.Sc. Division of Plastic Surgery Dalhousie University Halifax, Nova Scotia, Canada

Pharyngotracheal fistula closure using the internal mammary artery perforator island flap

Salvage laryngectomy following organ preservation therapy is a frequent condition that exposes patients to pharyngocutaneous and pharyngotracheal fistulas. Definitive treatment frequently requires well vascularized tissue harvested from the chest. To limit tracheostoma obstruction, a thin and pliable flap is preferable. The internal mammary artery perforator (IMAP) island flap fulfills these criteria, but it is not well known and is not commonly used by head and neck surgeons. In this article, based on our experience, we describe our surgical technique and the strengths and weaknesses of this flap. Retrospective cohort study and systematic review of the literature. An IMAP flap was performed on 12 patients to repair postoperative fistulas, located in the lower neck close to the tracheal stoma or involving the posterior tracheal wall, from March 2009 to December 2012. The medical records of each of patient were retrospectively analyzed. A breach of the pleura occurred in one patient. It was diagnosed and treated perioperatively. One patient had a total flap necrosis and required a reoperation. The postoperative course was uneventful in 11 patients (92%). All donor sites were closed primarily without any wound-healing problems. The IMAP flap is reliable. Its advantages make it a convenient flap to repair peritracheostomal defects and fistulas. The harvesting technique is not very demanding but requires training.

Suprafascial pre‐expansion of perforator flaps and the effect of pre‐expansion on perforator artery diameter

This study addresses the "pre-expanded perforator flap concept" by demonstrating a case series of relevant reconstructive procedures and evaluate the perforator vessel diameter changes that happen during the pre-expansion procedure. Fourteen patients were treated with 15 flaps. One patient was treated with two pre-expanded internal mammary artery perforator flaps. In other cases, thoracodorsal, circumflex scapular, lumbar, intercostal, lateral circumflex femoral, and deep inferior epigastric artery perforator flaps were used. Technical details and rate of complications were noted. Evaluations of the flap pedicles were done both by hand held Doppler and by color Doppler ultrasound (CDU). Flaps successfully served to resurface and release thick and rigid broad scar tissues and contractures in 11 of relevant 12 patients (in one patient with 50% flap loss, adequate contracture release could only be obtained with addition of a secondary split thickness skin graft to the residual flap) and provided a good source of tissue for anterior neck reconstruction of one patient and penis reconstruction of another patient. In six patients, perforator artery diameters were measured by CDU both before and after the expansion process and a significant increase secondary to the pre-expansion procedure was detected (Pre-expansion mean: 0.48 ± 0.08 mm; post-expansion mean: 0.65 ± 0.10 mm; P < 0.05). Flaps as large as 30 × 20 cm were harvested. Totally three partial flap necroses were experienced in 15 flap procedures. Suprafascial pre-expansion of the perforator flaps seems to provide a solution to achieve broader and thinner perforator flaps with larger perforator arteries.

Reconstruction of the face and neck with different types of pre-expanded anterior chest flaps: A comprehensive strategy for multiple techniques

For large defects or deformities of the face and neck, the anterior chest area appears to be an excellent donor site that provides well-matched skin colour and texture. Many flap techniques based on the anterior chest area have been reported; however, there are few reports that focus on a treatment strategy for these different flap techniques. A retrospective study was performed to propose a treatment algorithm. A total of 69 cases were reviewed from May 2005 to July 2011, in which different types of anterior chest flaps were performed for face and neck reconstruction. The reconstructive procedures, the defect characteristics and the complications were collected and analysed. Thirty-three pedicled thoracic branch of the supraclavicular artery flaps (the pedicled TBSA flap), 11 pedicled internal mammary artery perforator flaps (the pedicled IMAP flap), 8 free internal mammary artery perforator flaps (the free IMAP flap), 4 supercharged TBSA flaps, 17 prefabricated flaps and 3 supercharged prefabricated flaps were performed. The applications of six types of pre-expanded anterior chest flaps were described in an algorithmic approach. A treatment strategy for face and neck reconstruction using six anterior chest flap techniques is proposed. It recommended a personalised flap planning according to the characteristics of deformities/defects and the regionally dominant vessels of the anterior chest area.

Clinical Application of the Internal Mammary Artery Perforator Flap in Head and Neck Reconstruction

The skin texture of the internal mammary artery perforator flap closely resembles that in the face and neck, making it the perfect source of tissue for head and neck reconstruction. In this article, the authors describe their experience in recent application of this flap in head and neck reconstruction and evaluate its pros and cons. A total of 15 patients (three women and 12 men) with a mean age of 58.6 years received an internal mammary artery perforator flap for head and neck defect repair from April of 2007 to August of 2011. There were 11 internal mammary artery perforator pedicle flaps and four internal mammary artery perforator free flaps. Flap size ranged from 5 × 3 cm to 15 × 8 cm, pedicle length ranged from 3 to 6 cm, and 14 of 15 flaps (93.3 percent) had a sizable perforator identified during dissection. In the female patient who had no sizable perforator, the originally intended free flap was transformed to a platysma myocutaneous flap, which served as a backup procedure, extending from the same surgical incision. All of the transfers were successful. The donor sites were closed primarily in all patients except one, who received a split-thickness skin graft for a 15 × 8-cm donor defect. With excellent skin color and tissue texture matching and minimal donor-site morbidity, the internal mammary artery perforator flap is emerging as a potential alternative reconstructive tool for the head and neck region.

Rib-Sparing and Internal Mammary Artery–Preserving Microsurgical Breast Reconstruction with the Free DIEP Flap

Using an internal mammary artery as the recipient vessel in a free flap autologous breast reconstruction is common practice, but this vessel is often sacrificed for end-to-end anastomosis and is typically assessed by removing a costal cartilage segment. The authors studied the reliability of the end-to-side arterial anastomosis using a rib-sparing approach by comparing it with end-to-end anastomosis. The authors analyzed 100 consecutive medical records of patients who underwent autologous breast reconstruction with a free deep inferior epigastric artery perforator flap in which the internal mammary vessels were assessed using a rib-sparing technique. The study compared the complications between the two groups of end-to-side arterial anastomosis (50 cases) and end-to-end arterial anastomosis (50 cases). Exposure of the internal mammary artery using a rib-sparing technique was performed successfully in all 100 flaps. The second and third intercostal spaces were used in 46 and 54 cases, respectively. The mean width of the used intercostal space was 18.3 ± 2.4 mm in the end-to-side group and 18.3 ± 2.9 mm in the end-to-end group (p = 0.923). All flaps survived without partial or total necrosis. One case of venous insufficiency that required exploration occurred in the end-to-side group; the flap was totally saved with venous revision. There was no significant statistical difference between the end-to-side and end-to-end groups in all other variables, including mean flap ischemic time (p = 0.431) and fat necrosis (p = 0.339). The rib-sparing and internal mammary artery-preserving free deep inferior epigastric artery perforator flap transfer is an efficient and safe technique for microsurgical breast reconstruction.

Breast reconstruction using internal mammary artery perforator (IMAP) flap

Post mastectomy reconstruction using the internal mammary artery perforator (!MAP) flap, previously called breast-sharing technique, is an appealing procedure because it utilizes the tissue to be excised during reduction of the residual breast to achieve symmetry. Literature mentioned that this tissue is supplied by the lower !MAPs with no further details. The aim of this study was tore-explore the old theme of breast-sharing by describing the !MAPs included in the pedicle of this breast-derived flap via using color Duplex ultrasound preoperatively, thus re-introducing the flap under a name relating to its exact vascular supply, that is, !MAP flap. Six breasts of six patients presented for post mastectomy reconstruction were preoperatively screened via color duplex, and were operated on. Three cases (50 %) underwent completely successful !MAP flap breast reconstruction, two (66. 7 %) experienced partial flap loss, and one patient (16. 7 %) had total flap necrosis. We see the !MAP flap deserves to be within the repertoire of the plastic surgeon to be prudently employed in the properly selected patients.

Reconstruction of the (Crico)trachea for malignancy in the virgin and irradiated neck

Reconstruction of the trachea following resection for malignancy is challenging. We present our experience over a 5-year period, and a reconstruction algorithm with particular emphasis on minimising complications associated with radiotherapy. A maximum of six tracheal rings can be resected and anastomosed primarily with acceptable tension. A more conservative approach is required in an irradiated trachea. For a limited defect localised anteriorly or laterally, a tracheal flap can be fashioned. As for more eccentric defects, an option is to convert the defect into an asymmetrical segmental defect, and to primarily anastomose the trachea with rotation of the distal stump. Our workhorse loco-regional flaps for patch reconstruction or suture line reinforcement include the sternocleidomastoid, internal mammary artery perforator and pectoralis major myocutaneous flaps. For extensive defects, a radial forearm free flap (RFFF) with rib cartilage struts for rigidity provides a good solution. Fifteen patients (M:F=4:11, median age 69 years) were identified. Six cases were locally aggressive papillary thyroid cancer. Mean follow-up was 17 months. Five and two patients had had radiotherapy prior to and following tracheal resection, respectively. Nine patients were extubated at the end of surgery, two were successfully decannulated from their T tube subsequently, and one from his tracheostomy. The two surgical complications included a partial RFFF dehiscence causing minor air leak, and major haemorrhage that warranted urgent operation and pectoralis major flap reconstruction. Reconstruction of the trachea requires individualised techniques suited to the patient's body habitus, co-morbidity, previous treatment and the configuration of the defect.

Dual perforator propeller internal mammary artery perforator (IMAP) flap for soft-tissue defect of the contralateral clavicular area

The internal mammary artery perforator (IMAP) flap represents the evolution from axially pedicled flaps (deltopectoral flap) to perforator flaps. Both flaps are typically used for neck and tracheostoma reconstruction in male patients. We present the case of a 68-year-old obese female patient with a right upper thoracic radionecrosis secondary to breast irradiation. Soft-tissue defect measured 12×18 cm. She also complained of left breast hypertrophy. Following radical debridement, a left IMAP flap extending from midline to the anterior axillary fold was raised, based on the second and fourth IMAP vessels. The flap was rotated 180° on its second and fourth perforators to cover the defect and the left breast was reshaped. The flap survived entirely and wound healing was uneventful. Ptosis and breast hypertrophy were corrected at the same time. The IMAP flap can be harvested all the way to the anterior axillary fold and used as a large propeller flap, which makes this flap suitable for contralateral thoracic reconstructions, even in female patients.

A novel salvage approach for pedicle axial flap—free‐ization of pedicle internal mammary artery perforator flap

A pedicle flap with distal segment compromise is classically managed by allowing tissue demarcation, debridement of non-viable tissue, and local tissue manipulation to achieve wound closure. When aggressive debridement leaves insufficient tissue for defect coverage, the original flap is often discarded. We present a case of distal necrosis of a pedicle internal mammary artery perforator flap for cheek reconstruction. The flap, which was rendered too small after debridement for defect coverage in its pedicle form, was converted to a free flap. The technical details of such conversion and potential feasibility of applying this conversion to other compromised pedicle flaps are discussed. We hypothesized that the principle of "free-ization" can be applied effectively for salvage of other failing pedicle flaps with axial blood supply.

The IMAP flap for pharygoesophageal reconstruction following stricture release

Small-medium pharyngo-oesophageal or peri-tracheostoma defects represent a difficult reconstructive problem. Previous solutions included locoregional options such as the deltopectoral flap, or microvascular free tissue transfer. The authors present a novel application of the internal mammary artery perforator (IMAP) flap for reconstructing such defects. The IMAP flap may be mapped using pre-operative Doppler or CTA, and is raised on a single perforator. The relatively quick and simple flap raise provides robust fasciocutaneous tissue, may be tunneled subcutaneously to reach the neck and yields an inconspicuous donor site. The authors provide several cases demonstrating applications of the IMAP flap for reconstructing small-medium sized defects following release of annular pharyngoesophageal stricture, and studies documenting post-operative swallow. Overall, the pedicled IMAP fasciocutaneous flap is a useful technique to provide excellent composite tissue to reconstruct defects resulting from release of annular pharyngeal strictures. It is technically simple, and yields an inconspicuous anterior chest donor site.

Three-Dimensional Analysis of the Internal Mammary Artery Perforator Flap

The internal mammary artery perforator flap is a versatile flap used for reconstruction of the head and neck. Using dissection, angiograms, and three-dimensional reconstruction, the authors describe the vascular anatomy of the internal mammary perforator arteries, including their course, diameter, location of perforation, and relationship to other tissues (e.g., bone, muscle, and skin). Fourteen fresh cadavers were injected with either latex or a lead oxide/gelatin mixture and dissected to show the anatomy of the internal mammary artery perforators. Plain film and computed tomographic angiograms were obtained and analyzed on the lead oxide-injected cadavers. The computed tomographic angiography Digital Imaging and Communications in Medicine images were imported into Materialise's Interactive Medical Imaging Control System software to produce three-dimensional reconstructions of the internal mammary artery perforator anatomy. The second internal mammary artery perforator was the dominant perforator in 10 of the 14 cadavers. The mean emerging diameter of the dominant second perforator was 1.0±0.4 mm, with a mean superficial length of 51.8±16.1 mm on the latex-injected and lead oxide-injected cadaver angiograms. The mean distance from the sternal margin to the point of emergence from the internal mammary artery was 7±1.4 mm. The three-dimensional reconstructions demonstrated anastomoses between the dominant perforator and the lateral thoracic artery. The vascular anatomy of the internal mammary artery perforators was documented using cadaveric dissections, angiograms, and computed tomographic angiograms analyzed with Materialise's Interactive Medical Imaging Control System. The diameter, point of perforation, course, and relationship to surrounding anatomical structures has been shown using a vascular injection technique and three-dimensional reconstructions.

Utility of IMAP Flap in Hypopharyngeal Reconstruction

Objective: 1) Describe a novel use of the internal mammary artery perforator (IMAP) fasciocutaneous rotation flap for hypopharyngeal reconstruction. Method: Case series at university-based tertiary care hospitals. We report 2 cases using the IMAP flap for hypopharyngeal reconstruction. We describe flap elevation and inset and the clinical course of the patients. Outcome measures were flap viability, pharyngocutaneous salivary fistula, and postoperative swallow function. Results: Case 1 was a 59 year-old male who underwent organ sparing protocol 5 years prior. He underwent laryngectomy for nonfunctioning larynx. Case 2 was a 58-year-old male with T4 squamous cell carcinoma of the larynx with pyriform sinus involvement. We performed a single flap in both cases. Each flap was based on the dominant internal mammary artery perforator vessels at the second and third intercostal spaces. There were no full or partial flap deaths. Both patients developed minor salivary fistulae that healed with conservative, nonoperative management. Both patients tolerated an oral diet within 5 weeks postoperatively. Conclusion: The IMAP flap is ideally suited for hypopharyngeal reconstruction and should be included in the armamentarium of reconstruction options. It is easy to harvest, thin, and pliable, and the arc of rotation allows for tension-free hypopharyngeal reconstruction. Salivary fistulas may occur.