Fish skin graft for definitive healing of large hematoma excisional wound of a patient receiving warfarin treatment: a case study

Introduction: A hematoma is a collection of blood underneath a wound that has been sutured closed. It results from poor coagulation of vessels lacerated during the procedure and presents as a tense, sometimes painful expansion underneath the wound. The overlying skin may become necrotic from the intense pressure of the blood collection underneath. Large and old ( >48 hours) hematoma requires surgical intervention to leave large full-thickness tissue defects. Fish skin grafts can potentially be used for wound closure through healing by secondary intention.

Methods: A 70-year-old male patient presents with a large hematoma with necrosis of overlying skin that requires excision in the right leg calf. The patient has a medical history of diabetes and is also receiving warfarin. The hematoma was removed, and the wound bed was prepared using ultrasonic debridement. Skin grafting or primary closure were not feasible options. The fish skin graft was chosen as the skin substitute for definitive wound closure. There was significant undermining, which was filled with intact fish skin grafts, with a larger FSG secured over the top. Negative wound pressure therapy was used as an adjunct for the first three weeks. The patient received 7 applications of fish skin graft.

Results: The complete wound closure was achieved within 17 weeks. The wound bed showed excellent development of granulation tissue day seven post-application; the wound measured 105cm2. The wound decreased to half its size, measuring 50cm2 at week 4 with no more undermining. The patient reported improved pain with the first application.

Discussion: The patient showed rapid and steady healing progress, still maintaining the warfarin treatment. Patients on anticoagulant therapy and those with congenital coagulation defects have the highest risk of developing hematomas. In these patients, small vessels that appear to be no longer bleeding when closing the defect can bleed again after the wound is closed. Fish skin graft helped accelerate healing and manage excess bleeding between debridements.