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Nelson Ramirez Lozano, Alejandro Angelillis Osorio. Case 11 2026: Dual Internal Mammary Artery Perforator Propeller Flap for Anterior Chest Wall Reconstruction. Journal of Plastic, Breast & Reconstructive Surgery. 2026.
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Nelson Ramirez Lozano1, Alejandro Angelillis Osorio1
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
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.
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.
BeforeAfterA 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.
Anterior
chest wall defect measuring approximately 8 × 12 cm in diameter with imminent
risk of osseous exposure.
The
reconstructive goals were defined as follows:
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.
Perforators
were selected based on: 1) palpable Doppler-confirmed pulse; and 2) proximity
to the pivot point to allow adequate arc of rotation.
Following
meticulous dissection of the selected perforators, complete flap rotation was
achieved without vascular kinking or compromise of pedicle perfusion.
The flap
was inset into the defect, adequate perfusion was confirmed clinically, and
primary closure of the donor site was performed.
The patient
was admitted for approximately one week of inpatient monitoring, during which
flap perfusion was assessed serially and potential complications threatening
flap viability — including hematoma formation — were actively excluded. The
patient was instructed to maintain the supine decubitus position during sleep,
and early mobilization of the upper extremities was initiated. Once wound
healing was confirmed, initiation of adjuvant radiotherapy was to proceed as
indicated per the multidisciplinary oncological treatment plan.
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.
Careful
intraoperative assessment must always be performed to ensure the absence of
perforator kinking, which may critically impair vascular inflow and compromise
flap viability.
