The IMAP Flap: A Natural Evolution

An improved understanding of vascular anatomy has led to the description of new flaps and affords a greater choice in reconstructive options. Flaps that were formerly workhorses have in some cases been relegated to second line or have been dropped completely from the armamentarium. The deltopectoral (DP) flap was introduced by Bakamjian in 1965 and was quickly adopted by surgeons all over the world as an excellent option in head and neck reconstruction. The unsightly donor defect, as well as the advent of more sophisticated flaps, has led to a decline in its use. However, the DP flap is, in many ways, still a very attractive option.

This paper described early experience with the internal mammary artery perforator (IMAP) flap. To date, it has been used for neck resurfacing, as well as for pharyngo-esophageal reconstruction. The flap is based on one or multiple perforator vessels from the internal mammary artery. Mobilization of the flap involves resection of the intervening costal cartilage(s) in order to expose the internal mammary. This vessel is divided distally and mobilized. The flap can be pedicled up into the neck. It can also be used as a free flap, which further increases its potential applications. Unlike the DP flap, the IMAP flap donor site can be closed directly and, as with all perforator flaps, the skin paddle can be placed over the perforating vessels in such a way as to optimize both flap tissue and donor site. Clinical applications as well as harvest techniques were described.