The most recent refinement in flap reconstruction has been the advent of perforator-based flaps. The term “perforator flap” was first introduced by Koshima in 1989 for paraumbilical flaps harvested as free flaps . However, pedicled perforator flaps for head and neck reconstruction have rarely been an option owing to the lack of perforator flaps in this region. The deltopectoral flap, first described in the 1960s by Bakamjian, fulfills much of the properties fundamental to perforator flaps . A variation of the classic deltopectoral flap is the IMAP flap. A significant advantage of this flap is that primary closure of the donor defect is possible with no issues related to flap viability. There are a few case reports describing the use of this flap in the closure of circumferential pharyngeal defects and for tracheostome and anterior neck reconstruction. To our knowledge, this is the first report describing this particular use of the flap.
This flap is particularly helpful in patients where local options are best avoided due to prior radiotherapy. A thin and pliable fasciocutaneous flap, it is well suited to anterior neck defects, especially suited for tracheostomy reconstruction where bulky muscle from pectoralis major or latissimus dorsi flaps may obstruct the tracheostome. In addition to this, it may avoid the need for complex and prolonged free-flap reconstruction in selected patients.
IMAP flap is based on a single IMAP vessel as an island and hence, it is more maneuverable due to an increased arc of rotation. The added benefit of primary closure of the donor site enables this flap to be used in situations where a deltopectoral flap would not be used due to the additional morbidity of a skin graft. Anatomical studies have shown that the IMAP vessels are located 13 to 14 mm (mean) from the lateral border of the sternum. Although perforators are usually present in the first five intercostal spaces, the second IMAP is the most constant and reliable , though in our case it was the first perforator that was dominant. Mean arterial diameter ranges from 0.85 mm as seen in cadaveric dissections to 1–1.5 mm in live dissections . Preoperative handheld Doppler devices can usually confirm the presence of these vessels, although it tends to be less reliable in predicting the course or size of these vessels.
In our case, the patient had persistent intractable TEP site leak not responding to conservative management which finally settled with this flap cover, which was relatively very easy to harvest, less time consuming, robust flap with minimal donor site morbidity. It therefore cannot be over-emphasized that with a problem so commonly occurring with the use of voice prosthesis, a simple solution like this for recalcitrant cases should be more often sought after rather than resorting to other complex forms of reconstruction.