Six hours after a free anterolateral thigh flap transfer to the lower leg, the flap appears dusky purple and swollen, with capillary refill present and brisk (under 1 second). Pinprick testing shows bright red bleeding. Which management step is most appropriate?

• A Release sutures and explore the pedicle for arterial thrombosis
• B Administer a bolus of heparin and elevate the limb without exploration
• C Apply warm compresses and observe for 24 hours before any intervention
• D Treat as venous outflow obstruction and urgently explore the venous anastomosis ✓

Explanation

Venous congestion presents with a dark blue-purple congested appearance, swelling, rapid brisk capillary refill, and dark blood on pinprick, caused by impaired venous outflow. Arterial insufficiency instead shows pallor, absent or slow capillary refill, and absent bleeding on pinprick. An established free flap crisis must be explored immediately because salvage rates fall steeply after a few hours; observation, warming, or heparin alone wastes the window for re-exploration.

Reference: Bailey and Love's Short Practice of Surgery, 27th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.