61-year-old woman underwent Mohs excision of left forehead basal cell carcinoma on 7/11/2017. Patient developed bleeding and pain post-op day 1. A subsequent polymicrobial wound infection was treated with antibiotics. Post-op hematoma is the likely contributing factor to skin flap necrosis. All ischemic tissue has self-debrided without surgical intervention. Patient is seeking reconstructive options.
The case represents a simple rotation flap ischemia due to hematoma. The rotation flap is sufficiently wide based on a random blood supply. However, a hematoma can be an independent variable for flap ischemia. Specific reasons are not known, but have been hypothesized. These reasons include potential hypercoagulability of the dermal blood supply above the hematoma, increased tension on the flap due to the hydrostatic pressure of hematoma, or possibly other factors causing vascular compromise. Treatment of hematoma underneath a random flap requires immediate evacuation of hematoma. Myocutaneous flaps are much less vulnerable to ischemia due to a deep hematoma.