Internal Mammary Artery Perforator Flap to Cover Sternotomy Wounds: A Prospective Study: Internal Mammary Artery Perforator Flap to Cover Sternotomy Wounds

Muhammad Bilal; Imran Shahzad; Kamran Khalid; Farrukh Aslam Khalid; Abdul Malik Mujahid; Ahmad Saeed

doi:10.54393/pjhs.v7i6.3950

Authors

Muhammad Bilal Department of Plastic Surgery, Jinnah Burn and Reconstructive Surgery Centre, Allama Iqbal Medical College, Lahore, Pakistan
Imran Shahzad Department of Plastic Surgery, King Edward Medical University, Mayo Hospital, Lahore, Pakistan
Kamran Khalid Department of Plastic Surgery, Jinnah Burn and Reconstructive Surgery Centre, Allama Iqbal Medical College, Lahore, Pakistan
Farrukh Aslam Khalid Department of Plastic Surgery, King Edward Medical University, Mayo Hospital, Lahore, Pakistan
Abdul Malik Mujahid Department of Plastic Surgery, Jinnah Burn and Reconstructive Surgery Centre, Allama Iqbal Medical College, Lahore, Pakistan
Ahmad Saeed Department of Plastic Surgery, Royal Devon and Exeter Hospital, Devon, United Kingdom

DOI:

https://doi.org/10.54393/pjhs.v7i6.3950

Keywords:

Internal Mammary Artery Perforator Flap, Sternotomy Wound, Mediastinal Defect, Conventional Reconstructive Flaps

Abstract

The issue of sternotomy wounds is a continued challenge in cardiac and thoracic vascular surgery, especially in patients who have various comorbidities and are infected. Functional morbidity is linked to traditional muscle flaps that are effective. IMAP flap provides an alternative to other conventional flaps and the internal mammary perforator (IMAP) flap, which maintains muscle functionality while also producing well-vascularized tissue. Objectives: To determine the clinical results of the internal mammary artery perforator flap to reconstruct presternal and mediastinal sternotomy wound defects. Methods: This prospective observational study was conducted during the period of August 2024 and February 2025 at the Department of Plastic Surgery, Jinnah Burn Reconstruction Surgery Centre/Allama Iqbal Medical College. Institutional ethical approval was obtained No.6117/ED/JB&RSC. Results: In this study, the mean age of the cases was 56.4 ± 10.8 years. There were 21 (70%) males and 9 (30%) females enrolled. Complete reconstructive success was achieved in 10 patients, partial success was achieved in 15 patients, and non-healing wounds were found in 5 patients. Recurrent infection was found in 5 patients (16.7%), and mortality associated with sepsis was observed in 4 patients (13.3%). Conclusions: IMAP flap is a secure reconstruction of the defects present on the presternal and mediastinal sternotomy wounds, which has a good healing outcome even in high-risk patients. IMAP flap is a better alternative to the conventional muscle flap for chest wound coverage.

References

De Tymowski C, Provenchère S, Para M, Duval X, Grall N, Sahnoun T et al. Deep Sternal Wound Infection After Cardiac Surgery: A Combination of 2 Distinct Infection Types, Deep Incisional Surgical-Site Infection and Mediastinitis: Results of a Retrospective Study. Surgery. 2025 May; 181: 109255. doi: 10.1016/j.surg.2025.109255.

Banda CH, Wilson E, Malata CM, Narushima M, Ogawa T, Hassanein ZM et al. Clinical Application and Outcomes of Reconstructive Microsurgery in Africa: A Systematic Review and Meta-Analysis. Journal of Plastic, Reconstructive and Aesthetic Surgery. 2022 Jul; 75(7): 2035-48. doi: 10.1016/j.bjps.2022.04.028.

Chen CY, Kuo SM, Tarng YW, Lin KC. Immediate Application of Negative Pressure Wound Therapy Following Lower Extremity Flap Reconstruction in Sixteen Patients. Scientific Reports. 2021 Oct; 11(1): 21158. doi: 10.1038/s41598-021-00369-5.

Wyckman A, Abdelrahman I, Steinvall I, Zdolsek J, Granfeldt H, Sjöberg F et al. Reconstruction of Sternal Defects After Sternotomy with Postoperative Osteomyelitis, Using a Unilateral Pectoralis Major Advancement Muscle Flap. Scientific Reports. 2020 May; 10(1): 8380. doi: 10.1038/s41598-020-65398-y.

Khashkhusha A, Butt S, Abdelghaffar M, Wang W, Rajananthanan A, Roy S et al. Sternal Wound Reconstruction Following Deep Sternal Wound Infection: Past, Present and Future: A Literature Review. Journal of Cardiovascular Development and Disease. 2024 Nov; 11(11): 361. doi: 10.3390/jcdd11110361.

Fallah N, Rasouli M, Amini MR. The Current and Advanced Therapeutic Modalities for Wound Healing Management. Journal of Diabetes and Metabolic Disorders. 2021 Dec; 20(2): 1883-99. doi: 10.1007/s40200-021-00868-2.

Bertheuil N, Leclere FM, Bekara F, Watier E, Flecher E, Duisit J. Superior Epigastric Artery Perforator Flap for Reconstruction of Deep Sternal Wound Infection. Microsurgery. 2021 Jul; 41(5): 405-11. doi: 10.1002/micr.30743.

Angrigiani C, Rancati A, Nahabedian MY, Spinelli E, Breppe P, Rancati A. Perforator-Based Cross-Midline Flaps of the Trunk: A Paradigm Shift in Flap Design. Plastic and Reconstructive Surgery. 2023 Dec; 152(6): 1333-48. doi: 10.1097/PRS.0000000000010567.

Charboub S, El Kamch H, Laabarta H, Hafidi J, Gharib N, Abbassi A et al. Perforator Flaps in Reconstructive Surgery: Report of Our Service's Experience. South Asia Research Journal of Surgery. 2025; 6(4): 76-84. doi: 10.36346/sarjs.2025.v06i04.003.

Marsden N, Shukla L, Grinsell D. Case Report: Revisiting the Internal Mammary Artery Perforator Flap: Salvage Option for Circumferential Pharyngo-Esophageal Defects. Frontiers in Surgery. 2021 Mar; 8: 638345. doi: 10.3389/fsurg.2021.638345.

Lupon E, Njessi P, Camuzard O, Chaput B, Gandolfi S. Preserving Function in Sternal Reconstruction: Complementary Roles of Pectoralis Major and Internal Mammary Artery Perforator Flaps. Annals of Plastic Surgery. 2025 Nov: 10-97. doi: 10.1097/SAP.0000000000004618.

Finelle L, Meresse T, Chaput B, Lupon E, Gandolfi S. Reconstruction of the Anterior Chest Wall Using the Internal Mammary Artery Perforator Flap (IMAP): About A Series of 23 Cases. In Annales de Chirurgie. Plastique Esthétique. 2024 Jul; 69(4): 286-293. doi: 10.1016/j.anplas.2024.05.003.

Oyuntogos A, Njessi P, Camuzard O, Lupon E. The Internal Mammary Artery Perforator Flap as a Reliable Option for Thoracic Osteoradionecrosis Reconstruction: A Case Report. International Journal of Surgery Case Reports. 2026: 10-97. doi: 10.1097/RC9.0000000000000496.

Horvath B, Kloesel B, Todd MM, Cole DJ, Prielipp RC. The Evolution, Current Value, and Future of the American Society of Anesthesiologists Physical Status Classification System. Anesthesiology. 2021 Oct; 135(5): 904-19. doi: 10.1097/ALN.0000000000003947.

Sharbel D, Lin C, Topf MC, Mannion K. The Internal Mammary Artery Perforator Flap in Pharyngoesophageal, Cervical Tracheal, and Cutaneous Neck Reconstruction. Head and Neck. 2024 Jul; 46(7): 1835-40. doi: 10.1002/hed.27769.

Scarabosio A, Tel A, Contessi Negrini F, Albanese R, Robiony M, Parodi P. The Shark Flap: A Modified Internal Mammary Artery Perforator Flap for Composite Defects in Head and Neck Reconstruction. Case Reports in Plastic Surgery and Hand Surgery. 2023 Dec; 10(1): 2178924. doi: 10.1080/23320885.2023.2178924.

Hom DB and Ostrander BT. Reducing Risks for Local Skin Flap Failure. Facial Plastic Surgery Clinics. 2023 May; 31(2) :275-87. doi: 10.1016/j.fsc.2023.01.006.

Facial Plastic Surgery Clinics. 2023 May.

Pirozzi N, Rocco N, Nava MB, Dória MT, Weigert CV, de Andrade Urban C. Internal Mammary Artery Perforator-Based Plug Flap. International Journal of Surgery Case Reports. 2024 Dec; 125: 110567. doi: 10.1016/j.ijscr.2024.110567.

Gonzalez-Martinez CA, Castro-Govea Y, Tellez-Rodriguez BJ, Palomo-Barbosa KV, Rico-Padilla MA, Vidal-Torres O et al. Safe and Time-Saving Method for Pharyngeal Reconstruction Using an Internal Mammary Artery Perforator Flap. Archives of Plastic Surgery. 2026 Feb; 53(03): 241-246. doi: 10.1055/a-2780-1488.

Shimbo K, Kawamoto H, Koshima I. Muscle/Musculocutaneous Versus Fasciocutaneous Free Flap Reconstruction in the Lower Extremity: A Systematic Review And Meta‐Analysis. Microsurgery. 2022 Nov; 42(8): 835-47. doi: 10.1002/micr.30961.