PMC6968665_01
Patient underwent tracheostomy, segmental mandible resection, left selective neck dissection, and reconstruction with left fibula free flap (FFF). His past-medical history was relevant for mechanical bi-leaflet mitral valve replacement 4 years prior for which he was on warfarin (6 mg PO daily). (A) Intraoperative resection. (B) Mandible reconstruction with two segments FFF and reconstruction plate.
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The surgical procedure was uneventful, and patient did not have any unusual intraoperative bleeding (Figure 1).
(A) Postoperative day 3, patient started progressive bleeding in the FFF donor site reaching an output of ~100 mL/h of blood. (B) Six months after discharge. Donor site of FFF is fully healed.
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The following day, patient started progressive bleeding in the donor site of the FFF (through the skin graft and through the adjacent drain) that became bloody and with an output of ~100 mL/h (Figure 2). Patient was followed closely in our outpatient clinic until an appropriate healing on his FFF donor site was achieved (Figure 2). After these two life-threatening bleeding events, the patient returned to his baseline condition and completed his radiation treatment following the tumor board's recommendation (Figures 2 and 4).
(A) Thirty days after his operation, patient consulted our emergency room complaining of progressive facial edema and difficulty swallowing. His INR on presentation was 2.49. (B-C) A CT scan of the neck with IV contrast was performed which showed a 9.1 cm hematoma lateral to the left mandible with an internal focus of hyperdensity concerning for active hemorrhage. (D-E) The angiogram demonstrated no evidence of active bleeding or suggestions of any potential bleeding site.
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The swelling continued to worsen so he consulted our emergency room complaining of difficulty swallowing (Figure 3). A repeated CT scan showed larger hematoma and extensive edema of airway mucosa (Figure 3). The angiogram demonstrated no evidence of active bleeding or suggestions of any potential bleeding site (Figure 3).
(A-B) Follow-up in outpatient clinic 30 days after the second bleeding event. Patient has minimal facial edema, no local pain and normal mouth opening. Tracheostomy cannula was removed, and the opening is healing satisfactorily. (C-D) Six months after last surgery. The patient fully recovered from these two bleeding events, completed his radiation therapy and returned to his normal activities.
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After these two life-threatening bleeding events, the patient returned to his baseline condition and completed his radiation treatment following the tumor board's recommendation (Figures 2 and 4).