A 64-year-old man undergoes Mohs micrographic surgery (MMS) with a local flap reconstruction for a 1.8 cm basal cell carcinoma on the cheek. The procedure is completed without complications, and the patient is discharged with postoperative wound care instructions.

Twelve hours later, he returns to the clinic with increasing pain, significant swelling, and firm purple discoloration at the surgical site. He denies systemic symptoms such as fever or chills. Examination reveals a tense, expanding hematoma beneath the flap with increasing firmness and ecchymosis.

What is the most appropriate next step in management?

A. Apply firm pressure and observe for 24 hours

B. Needle aspiration of the hematoma

C. Remove sutures, evacuate the hematoma, and assess flap viability

D. Initiate empiric antibiotics and schedule follow-up in 24 hours

E. Administer IV heparin to prevent further clot expansion

Rationale:

This question tests the recognition and management of a postoperative hematoma in dermatologic surgery, particularly after flap reconstruction. Postoperative bleeding typically present within 24 hours. Hematomas are a localized collection of blood and early-stage hematomas present with pain, swelling, and ecchymosis. Treatment options vary based on the stage of the hematoma: early, gelatinous, organized, and liquefaction. 

Correct Answer: C. Remove sutures, evacuate the hematoma, and assess flap viability

Immediate intervention is required to prevent flap necrosis. Removing sutures allows direct evacuation of the hematoma and assessment of perfusion. Hemostasis should be re-established using electrocautery or hemostatic agents.

Incorrect answer choices:

A. Applying firm pressure and observing for 24 hours is reasonable for small bleeding surgical sites. However, hematomas under flaps require immediate evacuation to prevent necrosis. In this scenario, observation risks worsening tissue ischemia and flap failure.

B. Needle aspiration of the hematoma is typically ineffective for a large, expanding hematoma under a flap. Incomplete evacuation leads to continued vascular compromise and likely continued bleeding. 

D. Initiating empiric antibiotics is reasonable as hematomas can serve as a nidus for infection. However, in this scenario, the patient has an expanding hematoma shortly after surgery, and the first immediate option is to evaculate the hematoma and achieve hemostasis.

E. Administering IV heparin to prevent further clot expansion would worsen bleeding. Hematomas in this setting are due to local surgical bleeding, not thrombosis.

Additional reading at Procedural Dermatology Chapter 24: Surgical Complications and Their Management