Managing bleeding complications in skin surgery

Mr AB, aged 78 years, developed a lentigo maligna (LM) on his left cheek just below the orbital margin. Dermoscopy was typical for LM, with thickened variable peri-follicular pigmentation, some granular pigmentation, and an area of regressive depigmentation. Mr AB has a past history of aortic valve replacement and has been taking warfarin prophylaxis for many years. The tumour was excised with a 6 mm margin and effected a laterally based transposition flap. Warfarin was not ceased either before or after surgery. A small bleed occurred from the wound 2 days postsurgery. Redressing was effected but no other intervention was required. Sutures were removed on day 8. Two days after removal of sutures, Mr AB bumped his left cheek in a stumble and the wound started bleeding again. He developed a haemorrhage under the flap resulting in significant haematoma, flap necrosis, and subsequent ulceration at the site. This required wound toileting and repeated dressings in a prolonged postoperative course. Over time, the wound healed with conservative management.