Case 11 2026: Dual Internal Mammary Artery Perforator Propeller Flap for Anterior Chest Wall Reconstruction

Nelson Ramirez Lozano; Alejandro Angelillis Osorio

Journal of Plastic, Breast & Reconstructive Surgery·Peer-reviewed, open-access surgical case reportsPeer-reviewed · Open access

Case 11 2026: Dual Internal Mammary Artery Perforator Propeller Flap for Anterior Chest Wall Reconstruction · JPBRS

Case report

Case 11 2026: Dual Internal Mammary Artery Perforator Propeller Flap for Anterior Chest Wall Reconstruction

Nelson Ramirez Lozano¹, Alejandro Angelillis Osorio¹

¹Hospital de Santa Sofía Manizales, Colombia

Published April 15, 2026359 views3 min read

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Abstract

Reconstruction of anterior chest wall defects following skin cancer resection represents a significant surgical challenge. We report a successful case utilizing a propeller flap based on two perforators of the internal mammary artery for reconstruction, achieving stable soft tissue coverage without generating additional donor-site deformity. Patient medical history A male patient in his sixth decade of life was referred with an anterior chest wall defect measuring approximately 8 × 12 cm in diameter, resulting from resection of a squamous cell carcinoma via Mohs micrographic surgery. A propeller flap was designed, two perforators were identified intraoperatively, microsurgical dissection was performed, and flap rotation was executed. Before and After Patient examination Anterior chest wall defect measuring approximately 8 × 12 cm in diameter with imminent risk of osseous exposure. Pre-operative considerations The reconstructive goals were defined as follows: Provision of durable and stable soft tissue coverage Avoidance of additional donor-site morbidity Prevention of secondary deformity at the donor site 1 Flap Dissection The flap design was planned in this configuration for two reasons: 1) alignment with the anatomical axis of the internal mammary artery perforators; and 2) donor site closure oriented to prevent additional contour deformity. 2 Perforator Selection Perforators were selected based on: 1) palpable Doppler-confirmed pulse; and 2) proximity to the pivot point to allow adequate arc of rotation. 3 Isolated Perforators Following meticulous dissection of the selected perforators, complete flap rotati

Key learning points

Pearls

Meticulous microvascular dissection of the perforator vessels is of paramount importance in this type of flap, particularly when the design relies on a dual-pedicle configuration.

Pitfalls

Careful intraoperative assessment must always be performed to ensure the absence of perforator kinking, which may critically impair vascular inflow and compromise flap viability.

Alejandro Angelillis Osorio. Surgical Assistant, Oncologos de Occidente, Manizales, Colombia.

Patient history

A male patient in his sixth decade of life was referred with an anterior chest wall defect measuring approximately 8 × 12 cm in diameter, resulting from resection of a squamous cell carcinoma via Mohs micrographic surgery. A propeller flap was designed, two perforators were identified intraoperatively, microsurgical dissection was performed, and flap rotation was executed.

Examination

Anterior chest wall defect measuring approximately 8 × 12 cm in diameter with imminent risk of osseous exposure.

Pre-operative considerations

The reconstructive goals were defined as follows:

Provision of durable and stable soft tissue coverage
Avoidance of additional donor-site morbidity
Prevention of secondary deformity at the donor site

Step 1 — Flap Dissection

The flap design was planned in this configuration for two reasons: 1) alignment with the anatomical axis of the internal mammary artery perforators; and 2) donor site closure oriented to prevent additional contour deformity.

References

Internal mammary artery perforator (IMAP) flaps Ellis, Marco F. Operative Techniques in Otolaryngology-Head and Neck Surgery, Volume 30, Issue 2, 96 – 100
Takeuchi M, Sakurai H. Internal mammary artery perforator flap for reconstruction of the chest wall. J Plast Surg Hand Surg. 2013 Sep;47(4):328-30. doi: 10.3109/2000656X.2012.718893. Epub 2013 Jul 15. PMID: 23848424.
Rüegg EM, Lantieri L, Marchac A. Dual perforator propeller internal mammary artery perforator (IMAP) flap for soft-tissue defect of the contralateral clavicular area. J Plast Reconstr Aesthet Surg. 2012 Oct;65(10):1414-7. doi: 10.1016/j.bjps.2012.03.009. Epub 2012 Apr 13. PMID: 22503312.

How to cite this article

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Case 11 2026: Dual Internal Mammary Artery Perforator Propeller Flap for Anterior Chest Wall Reconstruction

Abstract

Key learning points

Patient history

Examination

Pre-operative considerations

Step 1 — Flap Dissection

References

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Step 2 — 2

Step 3 — 3

Step 4 — 4

Post-operative plan

Pearls

Pitfalls