Facial arteriovenous malformation managed with ablative surgery and dual rotational flap reconstruction

A 34-year-old man had previously had partial resection of a left facial hemangioma or arteriovenous malformation which included partial mandibulectomy and external carotid arterial ligation for treatment of recurrent bleeding. Because of recurrent intraoral bleeding with aspiration and profound anemia and angiographic analysis showing large tortuous abnormal vessels feeding the lesion from the cranial base, the patient had tracheostomy for airway control, radical left facial resection, completion hemimandibulectomy, and subtotal maxillectomy. He required 20 units of blood components intraoperatively. Oral reconstruction was done with a pedicled pectoralis major myocutaneous flap, and left facial reconstruction was done with a rotational transaxillary latissimus dorsi myocutaneous flap supplemented with skin grafts as appropriate for coverage of the rotated muscles. Postoperatively, the patient has had no further oral bleeding. This case illustrates the multiple difficulties involved in the surgical management of a high-flow arteriovenous malformation.