Internal Mammary Perforator Research Articles

Anatomy of the sternal origin of the pectoralis major: implications for subpectoral augmentation.

The pectoralis major typically is manipulated for implant coverage and pocket design in subpectoral breast augmentation. An understanding of its anatomy can guide successful creation of the implant pocket. The authors evaluated the anatomy of the sternal origin of the pectoralis major to inform surgical planning, help establish a technique for subpectoral augmentation mammaplasty, and identify the most common locations of perforators. The sternal origins of 24 pectoralis major muscles were dissected and examined in 15 female cadavers to determine the structure and width of the pectoralis major sternal origin and its relationship to the locations of internal mammary perforators. The average width of the sternal origin of the pectoralis major was 7.1 mm (range, 3 mm-1.8 cm). This width decreased slightly from the second rib to the second intercostal space and then increased progressively in the caudal direction toward the fifth rib. The sternal origin terminated an average of 5.4 mm (range, 1-16 mm) from the midline, with the greatest distance at the fifth rib and large variability throughout. A row of perforators from the internal mammary artery traversed the subpectoral space an average of 2.7 cm from the midline (range, 1-3.7 cm). The sternal origin of the pectoralis major was thin and highly variable, suggesting that its partial release for implant medialization during subpectoral augmentation is unsafe.

The Retrograde Internal Mammary System

PURPOSE: The deep inferior epigastric perforator (DIEP) flap, due to its ample tissue, reliable vascular anatomy, minimal donor site morbidity, and excellent aesthetic outcomes, is currently the preferred tissue source for autologous tissue breast reconstruction. In most patients the abdominal donor site provides ample volume for an adequate result. However, in select patients with inadequate abdominal tissue, additional volume must be recruited to achieve optimal outcomes. The stacked DIEP, stacked DIEP/GAP, or stacked DIEP/profunda artery perforator (PAP) flap are excellent options for unilateral and bilateral reconstructions respectively. Stacked flaps, however, are limited by the need for recipient vessels. Well-described options include the antegrade internal mammary system, the thoracodorsal system, internal mammary perforators, or branching vessels off of the primary flap pedicle. There are sporadic reports describing the use of the retrograde internal mammary system as recipient vessels for stacked flaps, but consistent use of these vessels has not been described. METHODS: 34 patients underwent stacked autologous tissue breast reconstruction with a total of 96 free flaps. 19 patients underwent unilateral stacked DIEP reconstruction, 1 had unilateral stacked PAP reconstruction, 1 had bilateral stacked DIEP/SGAP reconstruction, and 13 underwent bilateral stacked DIEP/PAP reconstruction. In all cases the antegrade and retrograde internal mammary vessels were used for anastomoses. RESULTS: Of the 34 patients, one patient experienced total loss of a stacked DIEP construct (98% flap survival rate), and 2 patients experienced minor fat necrosis. All other patients achieved satisfactory tissue volume and outcomes, with the stacked flaps averaging a combined 633.2 grams. CONCLUSION: This is the first study reporting the standard use of the retrograde internal mammary system for recipient vessel anastomosis with stacked flaps. The success we have demonstrated with our clinical results suggests that this is a viable and reproducible technique. The antegrade/retrograde internal mammary system has become the default recipient vessel site in our practice, and we believe it is not only a safe and effective option, but that it also decreases surgical time, facilitates ease of inset, and improves overall efficiency of the case with excellent post-surgical results.

Internal Mammary Perforators as Recipient Vessels for Deep Inferior Epigastric Perforator and Muscle-Sparing Free Transverse Rectus Abdominis Musculocutaneous Flap Breast Reconstruction in an Asian Population

The use of internal mammary perforators (IMPs) as recipient vessels in autologous free flap breast reconstruction has many additional benefits compared with the internal mammary or thoracodorsal vessels. Our goals were to analyze the characteristics of these vessels and to evaluate the reliability of using them in an Asian population. Thirty-five consecutive patients were prospectively studied between November 2000 and December 2010. Twelve patients underwent muscle-sparing-2 transverse rectus abdominis musculocutaneous flap, and 23 had deep inferior epigastric perforator flap reconstructions. Internal mammary perforator vessels were used in 29 patients (83%). Most (75%) of the vessels were located in the subcutaneous plane, and 85% were in the second and third intercostal spaces. There were significantly more usable IMP vessels in the immediate than in the delayed reconstructions (P = 0.049). All the flaps in the study were successful despite 1 requiring emergency re-exploration because of venous congestion. Most of the IMP vessels are small; however, they are still reliable and safe for use as recipient vessels in selected Asian patients. Most are located in the subcutaneous plane, which further facilitates dissection and also reduces recipient-site morbidity.

Microvascular Modifications to Optimize the Transverse Upper Gracilis Flap for Breast Reconstruction

The free transverse upper gracilis flap is well described for breast reconstruction and is the authors' second choice. Medial thigh soft tissue creates a durable, pliable, aesthetic breast; however, it has been criticized for modest volume and short pedicle. This demands frequent use of bilateral flaps for unilateral reconstructions, sacrifice of thoracodorsal vessels, and/or use of vein grafts. The authors have overcome these issues by modifying their microvascular techniques. The authors describe several maneuvers that they have introduced, including excision and replacement of costal cartilage, using nontraditional internal mammary arterial anastomoses, and using adductor branches for flap-to-flap anastomoses to allow double flap reconstructions. The authors describe their case series of 30 transverse upper gracilis flaps to reconstruct 20 breasts in 18 patients. All flaps have survived. Seventy-five percent of the reconstructions were unilateral, although of these, 67 percent used two flaps to reconstruct one breast. The mean reconstructed breast was 360.9 g. Of 10 breasts reconstructed with double flaps, six used available adductor branches, whereas the others used internal mammary perforators, end-to-side anastomoses, or retrograde arterial flow. To complement this clinical approach, an anatomical study of the branching patterns from the gracilis pedicle has been carried out on 33 cadaveric specimens. The authors' study has allowed a new classification system to be defined and demonstrates suitable branching patterns to allow flap-to-flap anastomoses in 75 percent of patients; in those 25 percent where this is not possible, alternative strategies for double flaps can be sought and have been used successfully in our clinical series. Therapeutic, IV.

Can Previous Diagnostic Examinations Prevent Preoperative Angiographic Assessment of the Internal Mammary Perforators for (Micro)Surgical Use?

Preoperative assessment of the internal mammary artery perforating (IMAP) branches enhances IMAP-based reconstructive procedures. Conventionally, color-flow Doppler, selective catheter arteriography, or CT angiography is used for such assessment. We studied how often these examinations may be rendered superfluous by assessment of previously performed diagnostic examinations. A radiologist and a plastic surgeon jointly assessed whether information on the dominant IMAP could sufficiently be obtained from the thoracic CT scans of 12 head and neck cancer patients and 12 breast cancer patients, and from the mammary MRI of 12 breast cancer patients. Secondly, we retrospectively assessed in how many of the 10 patients who underwent an IMAP-flap head and neck reconstruction, and in how many of the 10 women who consecutively underwent a deep inferior epigastric perforator (DIEP) flap mammary reconstruction such previous diagnostic examinations were available and informative regarding the level of the dominant perforator. All 24 CT scans and 11 of the 12 MRI scans sufficiently allowed assessment of the level of the dominant IMAP. Previous information had already been available in all 10 DIEP flap patients and 6 of the 10 IMAP-flap patients. The distribution of IMAP dominance over the intercostal levels on the scans differed from that found by cadaveric or intraoperative assessment. Previously performed diagnostic CT scans and MRI scans that included the parasternal region usually allow sufficient preoperative assessment of the internal mammary perforators for reconstructive procedures. We advocate re-assessment of such previous examinations before ordering additional angiography. Additionally, we suggest to include the parasternal region in diagnostic scans.

Short Transfer of Free Flaps for Breast Reconstruction Using Internal Mammary Artery Perforators as Recipient Vessels: A Prospective Consecutive Case Series

Introduction: The use of internal mammary perforators (IMP) as recipient vessels for flaps in breast reconstruction has previously been described. We present their utility and limitations as a first choice recipient vessels in a consecutive prospective case series.

A Clinical Anatomic Study of Internal Mammary Perforators as Recipient Vessels for Breast Reconstruction

BackgroundPartially resecting ribs of the recipient site to facilitate easy anastomosis of the internal mammary vessels to free flaps during breast reconstruction can cause chest wall pain or deformities. To avoid this, the intercostal perforating branches of the internal mammary vessels can be used for anastomosis. The purpose of this study was to investigate the location and size of the internal mammary perforator vessels based on clinical intraoperative findings and to determine their reliability as recipient vessels for breast reconstruction with microsurgical free tissue transfer.MethodsTwelve patients were preoperatively screened for the presence of internal mammary perforators using Doppler tracing. After modified radical mastectomy was performed by a general surgeon, the location and size of the internal mammary perforator vessels were microscopically investigated. The external diameter was examined using a vessel-measuring gauge from a mechanical coupling device, and the distance from the mid-sternal line to the perforator was also measured.ResultsThe largest arterial perforator averaged 1.5 mm, and the largest venous perforator averaged 2.2 mm. Perforators emerging from the second intercostal space had the largest average external diameter; the second intercostal space also had the largest number of perforators arising from it. The average distance from the mid-sternal line to the perforator was 20.2 mm.ConclusionsInternal mammary perforators presented consistent and reliable anatomy in this study. Based on these results, the internal mammary perforators appear to have a suitable diameter for microvascular anastomosis and should be considered as an alternative recipient vessel to the internal mammary vessel.

Contralateral Direction of the Internal Mammary Perforator Flap

Contralateral Direction of the Internal Mammary Perforator Flap

Use of the deltoid branch-based clavicular head of pectoralis major muscle flap in isolated sternoclavicular infections

The pectoralis major (PM) flap is the workhorse flap for acute, sub-acute and chronic sternoclavicular infections (SCIs). Attempts at using only the clavicular head of the pectoralis major muscle (CPM), based on internal mammary perforators or the thoracoacromial artery, have been reported. We describe the harvest of a deltoid branch-based flap (CPM-DTA) and examine its use in managing a series of isolated, acute and sub-acute sternoclavicular infections. From 2007 to 2012, 28 subjects with SCI underwent PM flaps at our institution. Six were excluded for extensive chest wall involvement, and four were excluded from chronic osteomyelitis (5 months of infection or greater). Of the remaining 18 patients with isolated SCI, 12 underwent traditional PM flaps (Group-A), while six underwent CPM-DTA (Group-B). Features studied include age, gender, co-morbidities, culture, need for intra-operative extension of the sternoclavicular incision, postoperative complications, wound healing, time from infection onset to debridement, length of hospital stay, postoperative chest wall contour deformity and follow-up. Infections resolved and wounds healed in all patients following a single reconstructive procedure. Intra-operative need for extended incisions and postoperative ipsilateral anterior chest wall contour deformity are noted in all Group-A subjects but in no Group-B subjects. In patients with isolated, acute and sub-acute SCI, the CPM-DTA flap achieves effective wound closure while avoiding large sternal incisions and the morbidity associated with standard PM muscle harvest. Harvesting the CPM-DTA flap preserves the sternocostal head of the pectoralis major muscle and its thoracoacromial pedicle. This preserves the muscle for future flap use if necessary.

Escolha do vaso receptor em reconstrução de mama microcirúrgica

INTRODUCAO: A transferencia microvascular de tecido autogeno se tornou o padrao de referencia para a reconstrucao da mama. Como em qualquer reconstrucao com tecido livre, a escolha do vaso receptor e fundamental para o planejamento adequado na reconstrucao mamaria. O objetivo do presente estudo e determinar quais dentre os vasos receptores disponiveis (a arteria mamaria interna e seus vasos perfurantes ou os vasos circunflexos escapulares) sao mais adequados para a reconstrucao microvascular da mama. METODO: Foi realizada analise retrospectiva de 117 pacientes consecutivas submetidas a reconstrucao da mama microvascular, entre janeiro de 2005 e dezembro de 2007. Foi estabelecido um algoritmo que pode ser aplicado para a selecao do vaso receptor com base em alguns parâmetros, como disseccao axilar, tempo da reconstrucao (imediata ou tardia) e presenca de radioterapia pre-operatoria. Foram avaliadas as complicacoes relacionadas ao retalho, a taxa de conversao e os resultados clinicos. RESULTADOS: A arteria mamaria interna e seus vasos perfurantes e os vasos circunflexos escapulares sao adequados para a reconstrucao da mama, com taxas semelhantes de complicacoes e de viabilidade. Observou-se, tambem, maior risco de perda do retalho com o uso do retalho da arteria epigastrica inferior superficial em comparacao ao retalho da arteria epigastrica inferior profunda ou retalho musculocutâneo abdominal transverso de musculo reto do abdome com preservacao do musculo. CONCLUSOES: A reconstrucao mamaria microcirurgica e um metodo seguro e confiavel, com alta viabilidade do retalho e baixas taxas de complicacao.

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.

Superficial inferior epigastric artery (SIEA) free flap using perforator vessels as a recipient site: clinical implications in autologous breast reconstruction

Background Breast reconstruction with autogenous tissue is a well-established technique, but there are some limitations related to donor-site morbidity. Among available techniques, the superficial inferior epigastric artery (SIEA) flap is the least invasive procedure because it does not require harvesting or incision of the rectus muscle or the abdominal fascia. Besides adequate flap choice, the proper selection of the recipient vessels is an important factor. Thus, the internal mammary perforator branches (IMPBs) have been an attractive option regarding recipient pedicle morbidity. Methods The investigators reported the use of the free SIEA flap with the IMPBs as a recipient site to reconstruct radical mastectomy. Results Five patients with invasive ductal carcinoma underwent modified radical mastectomy and reconstruction. The IMPBs were selected as the recipient site and a free SIEA flap was used. The donor defect was closed directly without synthetic mesh. Satisfactory breast shape was achieved, and no complications were observed. Conclusions For selected patients, the SIEA flap and IMPBs may constitute a new alternative for immediate breast reconstruction, because of the possibility of large tissue transfer with minimal donor and recipient area morbidity. The SIEA pedicle size and the quality of IMPB vessels should be carefully evaluated.

Intraoperative Modification of Pitanguy Technique of Reduction Mammaplasty for Elevation of the Nipple–Areola Complex in Case of Severe Breast Ptosis

The Pitanguy method of reduction mammaplasty has been shown to be an anatomically safe technique in the management of the ptotic breast. However, the technique, as first described, cannot be applied in gigantomastia or severe breast ptosis cases or cases of dense parenchyma of the breast. The senior surgeon suggested an intraoperative modification of the Pitanguy method of reduction mammaplasty to make it applicable for such cases. A retrospective study of 122 patients with severe breast ptosis (70), gigantomastia (45), or dense breast parenchyma (7) who underwent a modification of the Pitanguy method was performed. The current procedure involves all the operating steps of the superior pedicle technique as described by Pitanguy, from the marking technique to the keel resection of the breast. If the nipple-areola complex is elevated inadequately, the surgeon can use the senior surgeon's modification to elevate the complex to the desired height. This modification consists of dissecting the upper pole of the breast vertically to the fascia of the pectoralis major muscle and laterally to the nipple-areola complex. The medial flap is then advanced superiorly, rotated 90°, and sutured to point A, while the lateral flap is placed below the medial one. This maneuver maximizes elevation of the nipple-areola complex to the desired height. The mean change in nipple position was 14cm (range=10-16cm). The mean weight reduction of each breast was 900g (range=700-1300g). The follow-up included 119 patients and the follow-up period ranged from 1 to 3years (mean follow-up=2years). Three patients were operated on less than 3months ago and were not involved in this study. All patients gained natural shaped breasts and they were pleased with the results. Serious complications, including flap necrosis, were avoided since caution was used to preserve the internal mammary perforators while performing this method. This technique provides a versatile, well-vascularized pedicle that allows elevation of the nipple-areola complex at the desired height in cases of severe breast ptosis, gigantomastia, or dense breast parenchyma.

Internal Mammary Artery Perforators for the Salvage of a Superficially Dominant Free Flap Breast Reconstruction

Sir: The deep inferior epigastric perforator (DIEP) flap is becoming widely popular for autologous breast reconstruction because preservation of the rectus abdominis musculature can lead to less abdominal wall morbidity and postoperative pain. Alternatively, a muscle-sparing free transverse rectus abdominis musculocutaneous flap offers many similar advantages. In both cases, deep inferior epigastric vessels are usually anastomosed to the recipient internal mammary vessels in the third intercostal space. However, perforating vessels from the internal mammary circulation have also proven to be reliable recipients for anastomosis.1,2 Using the internal mammary perforators primarily obviates the need for partial rib resection and allows the internal mammary vessels to be preserved for potential future use as coronary revascularization grafts. To our knowledge, use of internal mammary perforators for salvage of a congested flap with patent internal mammary anastomoses has not been previously described. In a recent case of a bilateral free flap breast reconstruction, we noted mild congestion in half of the flap, shortly after dividing the superficial inferior epigastric vein (SIEV). The congestion improved slightly with time while the flap remained connected to the deep circulation, and the decision was made to complete the procedure as a muscle-sparing free transverse rectus abdominis musculocutaneous flap with one arterial anastomosis from the deep inferior epigastric artery to the internal mammary artery, and two venous anastomoses from the inferior epigastric venae comitantes to the two internal mammary veins that were present. The other half of the flap had a normal appearance, and a DIEP flap was performed to reconstruct the left breast. However, the right breast flap appeared mildly congested at the completion of the operation, initially improved, and then worsened over the first postoperative day, necessitating operative exploration. At the time of exploration, all arterial and venous anastomoses were found to be widely patent but, once the SIEV was opened, a continuous jet of venous flow was seen, indicating venous congestion despite the two venous anastomoses (Fig. 1). We augmented the venous outflow by coupling a saphenous vein graft between the SIEV and a perforating vein of the internal mammary circulation in the second intercostal space that had been left intact during the mastectomy (Fig. 2). After placement of the interposition graft, the abnormal tissue turgor and congested color of the flap improved immediately and remained normal throughout the postoperative course.Fig. 1.: A continuous jet of venous blood from the SIEV after venotomy in preparation for salvage vein grafting.Fig. 2.: A saphenous vein graft interposed between the SIEV of the flap and a perforating vein of the internal mammary circulation.This case demonstrates the importance of preserving alternative vessels in cases of microvascular breast reconstruction. It also shows that a superficially dominant hemiflap can become congested, even when harvested as a non-DIEP flap with most of the normal deep circulation preserved. The senior author has previously reported a technique for venous augmentation in a DIEP flap by draining the SIEV to one of the venae comitantes.3 Other options for venous augmentation include an interposition vein graft from the SIEV, superficial circumflex iliac vein, or contralateral pedicle to the cephalic vein4 or to recipient thoracodorsal, lateral thoracic, or intercostal veins.5 Internal mammary perforators should be added to the list of venous augmentation recipient vessels. We recommend routine dissection and preservation of the superficial inferior epigastric vessels during flap harvest, and close communication with the breast surgeons to preserve any sizable internal mammary perforators found during the mastectomy. No additional recipient vessel dissection is necessary. If these vessels had not been preserved in this case, salvage of the congested flap would have been more technically difficult. DISCLOSURE No financial support or benefits have been received by any of the authors, by any member of their immediate families, or by any individual or entity with whom or with which the authors have a relationship from any commercial source that is related directly or indirectly to the scientific work reported in this article. Brian D. Cohen, M.D. Nicholas Vendemia, M.D. Division of Plastic and Reconstructive Surgery New York-Presbyterian Hospital New York, N.Y. Jason A. Spector, M.D. Division of Plastic and Reconstructive Surgery Weill-Cornell Medical Center/New York-Presbyterian Hospital New York, N.Y. Christine H. Rohde, M.D. Division of Plastic and Reconstructive Surgery Columbia University Medical Center/New York-Presbyterian Hospital New York, N.Y.

Internal Mammary Perforator Recipient Vessels for Breast Reconstruction Using Free TRAM, DIEP, and SIEA Flaps

Internal Mammary Perforator Recipient Vessels for Breast Reconstruction Using Free TRAM, DIEP, and SIEA Flaps

Internal Mammary Perforator Recipient Vessels for Breast Reconstruction Using Free TRAM, DIEP, and SIEA Flaps

Use of internal mammary perforator recipient vessels may decrease recipient-site morbidity in free flap breast reconstruction. However, it is not known whether they are as reliable as the internal mammary vessels or whether their use would result in increased recipient-site complications. A retrospective study of all 686 lower abdominal free flap breast reconstructions performed during a 4-year period at the authors' institution identified 38 cases in which internal mammary perforator vessels were used. A subset of 114 of the 686 cases was studied in which patients were treated by a single surgeon, internal mammary perforator vessel use was attempted, and vessel measurements were taken intraoperatively. Internal mammary perforator recipient vessels were used in 27 percent of cases attempted, 94 percent of which were located at the second or third intercostal space. Internal mammary perforator arteries were significantly smaller in diameter (1.9 mm) than internal mammary arteries (2.6 mm) (p < 0.0001). Despite this, the incidences of flap loss, fat necrosis, and mastectomy skin flap necrosis were not significantly different between the internal mammary and internal mammary perforator vessel groups. The internal mammary and internal mammary perforator veins were similar in diameter. To the authors' knowledge, this is the largest published series of internal mammary perforator vessels used as free flap recipient vessels. In selected cases, internal mammary perforator vessels can be used without increasing the risk of flap loss, fat necrosis, or mastectomy skin flap necrosis, and are equally reliable and require less invasive surgical dissection than internal mammary vessels. The use of internal mammary perforator vessels may safely minimize recipient-site morbidity.

Extended Approach in Head and Neck Tumors

Surgical treatment of many tumors of the head and neck require extended approaches. Many cervicotomies have been described in the treatment of head and neck and cervical tumors; careful thought must be made by a surgeon when surgical treatment is planned for an extended tumor.Our purpose is to show the versatility of the modified Schobinger incision. Between 2003 and 2005, 18 patients were operated on at our plastic surgery department; all presented extended cervical tumors of various origins.In all 18 patients, a Schobinger incision as modified by Yoel and Linares was used. The principal modification described by these authors consisted in the extension of the vertical line of incision below the subclavicular area to the nipple-areola complex. Partial necrosis occurred in two (11%) patients; one (1.8%) patient developed a pharyngocervical fistula; in all cases, healing occurred spontaneously. The benefits of this incision are as follows: 1) an unobstructed vision of anatomic landmarks and the more distal surgical elements; 2) increased blood supply for the flap by means of recruitment of new arterial vessels from the first, second, third, and fourth internal mammary perforators; 4) should flap necrosis occur, it will not compromise the coverage of the great vessels of the neck; 5) the flap's excessive mobility permits it to be used in facial areas, thus facilitating their reconstruction. Other advantages of this incision are that it permits access to different areas of the surgical field, that it allows protection of vital anatomic structures in both the pre- and postoperative periods, and that it results in an inconspicuous and aesthetically acceptable final scar.

The Value of the Internal Mammary Perforator Branches as a New Perforator Flap

Annals of Plastic Surgery: June 2007 - Volume 58 - Issue 6 - p 706-707 doi: 10.1097/01.sap.0000264835.90517.0b

The Internal Mammary Artery Perforator Flap

The anatomic basis for the internal artery mammary perforator (IMAP) flap is described in this cadaveric study, together with a clinical case report. The IMAP flap is based on a single or double perforator of the internal mammary artery that is included in the pedicle for added length. It provides a very useful source of local tissue with skin of good texture and color for head and neck reconstruction and, being muscle free, is thin. With preservation of the anterior cutaneous branch of the intercostal nerve, the flap has the potential to be sensate. A large area can be covered, particularly if bilateral flaps are raised. The donor site can be closed directly. In selected patients, it offers an excellent option for use in head and neck reconstruction and should be considered as an alternative to the deltopectoral and pectoralis major flaps.

Internal Mammary Perforator Recipient Vessels in Breast Reconstruction Using Free TRAM, DIEP, and SIEA Flaps

Internal Mammary Perforator Recipient Vessels in Breast Reconstruction Using Free TRAM, DIEP, and SIEA Flaps