Postoperative empyema associated with a bronchopleural fistula often becomes chronic and intractable, requiring a two-step management approach consisting of initial infection control by open-window thoracostomy, followed by obliteration of the thoracic cavity using tissue transfer techniques. Several studies have reported the use of free myocutaneous flap transfer for treating empyema; however, there are limited reports on free perforator flap transfer to the upper thoracic cavity using the internal mammary vessels as the recipient. We present a case of a 76-year-old man with lung cancer who underwent a right upper lobectomy, but postoperatively developed pulmonary apex empyema and underwent thoracostomy. The vessels perfusing the adjacent muscles had already been transected during the first and subsequent operations. Therefore, we performed free anterolateral thigh flap transfer using the internal mammary vessels as the recipient, successfully treating the empyema. While local pedicled flaps, such as the pectoralis major myocutaneous or latissimus dorsi flaps, are typically the first options for upper thoracic reconstruction, in complex cases following multiple thoracotomies or thoracostomies, where the vessels perfusing the adjacent muscles have been transected or sacrificed and are no longer viable, free tissue transfer is a viable option. Free anterolateral thigh flap transfer is a useful option in such cases.
