The internal mammary artery gives off intercostal perforators through the second and third intercostal spaces into the breast tissue and overlying skin. These perforators are the basis of the internal mammary artery perforator (IMAP) flap and are used as recipient vessels for anastomosis in free flap breast reconstruction when the thoracodorsal vessels have been sacrificed by previous axillary surgery.
| Origin | Internal thoracic (internal mammary) artery |
|---|---|
| Course | Pass forward through the upper intercostal spaces, mainly the second and third, close to the sternal border, to supply the pectoralis major, overlying skin and medial breast |
The perforators of the second and third intercostal spaces, the second usually being the largest, are a major supply to the medial breast skin, so preserving them during mastectomy improves the survival of the medial skin flap. They are the pedicle of the internal mammary artery perforator (IMAP) flap. The internal mammary vessels themselves, usually exposed at the second or third intercostal space after removing a short segment of costal cartilage, are the commonest recipient vessels for DIEP free flap breast reconstruction, and a large perforator can sometimes be used instead to avoid removing cartilage. CT angiography maps these vessels before surgery.
The internal mammary artery and vein, reached by removing a short segment of costal cartilage, are the standard recipient vessels for DIEP flap anastomosis in breast reconstruction.
Division of the upper internal mammary perforators during mastectomy can devascularise the medial skin flap, causing necrosis and wound breakdown along the medial scar.
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