Management of two major postoperative bleeding complications after mandible reconstruction with fibula free flap in a patient under chronic warfarin treatment

Figures

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  Figure 1.. 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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  Figure 2.. (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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  Figure 3.. (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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  Figure 4.. (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.