When Needs Must - Reconstruction Following Salvage Mastectomy Using a Contralateral IMAP Propeller Flap

We present a case of soft tissue reconstruction following salvage mastectomy using a contralateral internal mammary artery perforator (IMAP) flap.

A 61-year old woman required a salvage mastectomy for an enlarging fungating left breast ductal carcinoma no longer responding to primary endocrine therapy. Due to extreme anxiety, she could only be persuaded to accept a single operation for mastectomy and soft tissue reconstruction, with a single overnight hospital stay. The primary options of latissimus dorsi flap, skin grafting, vacuum-assisted therapy, tissue expansion, and staged surgery were all considered and discounted at the patient’s request.

With the patient remaining in a supine position throughout surgery, the left mastectomy with skin excision was performed. Planning in reverse, a fasciocutaneous flap from the contralateral breast based on the right 2^nd internal mammary artery perforator was designed. The flap was raised in the mastectomy plane, isolated on the perforator, and transposed into the defect in a propeller fashion. The sternal skin bridge was excised to avoid tunnelling the flap. The donor site closed directly, no drains were used. As planned, the patient was discharged home on post-operative day 1, with only 1 dressing change required in clinic at 2 weeks.

Excision margins were clear of tumor, and both the flap and donor site healed without complication. The patient is happy and remains free of local recurrence at 4 months.

 

A derivation from the original description of the mammary artery pectoral flap by Joseph in 1931, the IMAP anatomy and angiosome were described by Veseley et al in 2007¹. Commonly used in head and neck reconstruction, the 2nd intercostal perforator is usually the largest, although the 3rd and 4th perforators can also be considered for supplying the flap. The skin paddle can be safely designed in a transverse, oblique or vertical orientation.  

Conclusion

The contralateral IMAP propeller flap is a useful alternative in cases of salvage mastectomy where standard reconstructive options are not feasible or suitable. Donor site morbidity and impact on the patient are minimal, and it is a robust and straightforward soft tissue reconstruction.