Internal mammary artery perforator (IMAP)-based fasciocutaneous flaps have recently gained popularity in sternal wound reconstruction due to their decreased donor site morbidity. However, patients with significant macromastia or who are obese present a challenge when using these flaps due to their anatomy and associated comorbid conditions. Despite the prevalence of this population, there is a relative paucity of data on the use of local fasciocutaneous flaps and techniques to close sternotomy wounds in the obese population with hypertrophic or ptotic breasts. The authors describe a novel technique using simultaneous unilateral breast reduction with a fifth intercostal IMAP-based flap for closure of a median sternotomy wound through a case presentation, an anatomical injection study, and review of the literature. Five fresh female cadavers were used to conduct 8 trials of injection of the IMAP arteries, isolation of the fifth IMAP branch, and elevation of a local flap. The literature was comprehensively reviewed with a total of 33 cases of IMAP flaps for sternal reconstruction being described. The most commonly used perforators with the second and sixth IMAPs. Overall complication rate was reported to be 9.1% (3/33), with 2 cases reporting dehiscence and 1 with flap tip necrosis. No cases reported use of the fifth IMAP or formal breast reduction procedures, which was successfully performed in a 40-year-old diabetic female patient history of multiple left-sided thoracic surgeries and radiation with a chronic sternal wound.