Revisiting the musculocutaneous external oblique flap as a versatile alternative in large thoracic wall defects

Background The external oblique myocutaneous flap has been previously described for reconstruction of chest-thoracic wall defects smaller than 400–500 cm2. However, it is utilized less often than workhorse flaps such as the omental, pectoralis, rectus abdominis, and latissimus dorsi myocutaneous flaps as many plastic surgeons are not aware that the flap can cover larger areas than previously documented. Case presentation We report a 57-year-old female tobacco user who underwent a resection of a grade 3 breast angiosarcoma resulting in a high left chest wall soft tissue defect approximating 900 cm2. The patient underwent an external oblique myocutaneous pedicle flap reconstruction of the defect, most notably in anticipation of postoperative adjuvant radiation therapy. No gross flap complications and or patient impairment were noted. Thirteen months status post flap reconstruction, the patient underwent an aortic valve replacement requiring re-elevation of the same flap for exposure. The flap demonstrated excellent viability during the procedure and postoperatively. Conclusion The pedicled external oblique myocutaneous flap should be considered when reconstructing larger high chest wall defects when other more common flaps used in chest reconstruction may not be indicated. The external oblique myocutaneous flap is an excellent tool in the armamentarium of any reconstructive surgeon; it is a straightforward and versatile flap that can be safely and reliably used in durable reconstruction of defects of the chest wall and covers defects larger than previously described in the literature.

An unusual differential of neck swelling: left apical hernia

<p class="abstract">Pulmonary herniation is a protrusion of the lung beyond the usual boundaries of the thoracic cavity, which is caused by increased intrathoracic pressures coupled with thoracic wall defects. Most lung hernias are asymptomatic, but when symptomatic they present as a bulging, crepitant mass protruding through the chest wall. A computed tomographic scan is usually diagnostic, and a small subset of patients requires surgery to correct the defect. In my report there is a 49 year old male patient with cystic swelling in the left side of the neck which increases on coughing, along with a small nodular midline swelling which moves on deglutation. Probable diagnosis of thyroid swelling with laryngocele as a differential was made. FNAC of nodular swelling was suggestive of nodular colloid goitre. CECT neck implied solitary thyroid nodule. The patient was taken for surgery to remove the thyroid nodule but surprisingly left apical lung hernia was diagnosed along with the thyroid nodule. Apical lung hernias are more common in males than in females (2:1) and more common on the right side than on left (6:1). However this patient had herniation on the left side which is quite rare. Usually asymptomatic, surgical treatment is rarely warranted unless it undergoes incarceration. Apical lung hernia though a rare entity should be considered in the differential diagnosis of a neck swelling.</p><p class="abstract"> </p>