On the second postoperative day following free radial forearm flap reconstruction of the tongue, the flap appears dark purple and swollen, with brisk dark bleeding on pinprick testing. What is the most likely diagnosis and immediate management?

• A Arterial thrombosis; urgent return to theatre for exploration
• B Partial flap necrosis; conservative management with heparin infusion
• C Expected postoperative bruising; observation with elevation of the head
• D Venous thrombosis; urgent return to theatre for exploration ✓

Explanation

Venous congestion presents as a dark, dusky or purple swollen flap with rapid dark bleeding from pinprick, because blood enters through the artery but cannot drain. Arterial insufficiency instead gives a pale, cool, flat flap with absent or scant bright bleeding. Venous compromise causes irreversible flap loss within hours, so immediate surgical exploration with re-anastomosis is mandatory rather than observation.

Reference: Sabiston Textbook of Surgery, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.