The internal mammary artery perforator flap as a reliable option for thoracic osteoradionecrosis reconstruction: a case report

Introduction and importance: One of the common late complications following radiotherapy is radionecrosis of the surrounding tissue, which can progress to infection, chronic wound, or even sepsis. Surgical reconstruction remains the standard treatment for this condition, as conservative management is ineffective once necrosis and bone exposure occur. We report a case of pedicled internal mammary artery perforator (IMAP) flap to cover a defect of right supraclavicular and clavicular defect created by cutaneous and osteoradionecrosis. Case presentation: 24 years after mastectomy and radiotherapy for right breast carcinoma, lesion with moderate hypermetabolic activity was found on PET CT. After inconclusive biopsy findings, the sternocostoclavicular joint lesion was fully resected. The wound was closed directly, and final histopathology confirmed no evidence of tumor proliferation. Postoperative complication of delayed wound healing, and local infection occurred requiring daily wound care for 7 months. Surgical reconstruction with IMAP flap was performed, followed by complete recovery of chronic clavicular wound and no reduced mobility of upper extremities. Clinical discussion: This case illustrates the reconstructive challenges posed by late radiation-induced tissue injury and highlights the perforator flap's role as an anatomically favorable option when prior surgeries, fibrosis, or vascular compromise limit conventional alternatives. Conclusion: The successful outcome demonstrates that the pedicled IMAP flap provided durable, functional coverage for complex post-radiation cervicothoracic defects in patients with few viable reconstructive options. This case underscores its utility in managing delayed osteoradionecrosis with chronic wound.