Dusky Free Flap Reconstruction

You are the General Surgery CT1 and are asked to see a 45year old lady who underwent a right mastectomy with DIEP flap reconstruction one day ago. The nurse is concerned as the flap looks dusty. How would you approach this.

Example answer introduction

In this scenario, I would be concerned that there is compromise to the flap blood supply and therefore attend immediately.  I would assess this patient using an A-E approach according to the CCRISP algorithm followed by a focused history and examination. I would arrange further investigations to confirm my diagnosis depending on my clinical suspicions and escalate to the general surgery registrar.

Initial Assessment and Simultaneous Resuscitation


On arrival, manage the patient using an A to E approach according to the Advance Life Support algorithm.

  • Airway 

  • Breathing - check oxygen saturations, respiratory rate, listen to chest, assess work of breathing, breathing depth - if concerns  give high flow oxygen 

  • Circulation

    • Pulse, Blood pressure, capillary refill time, mucus membranes, skin turgor, fluid input/output, catheter is septic

    • IV access - large bore and bloods including CRP

    • Give fluid challenge of 250ml crystalloid solution if evidence of shock 

    • If suspecting bleeding, you may need to activate the Major Haemorrhage Protocol

  • Disability - GCS, pupillary response, blood sugar, temperature

  • Exposure - rashes, systemic signs of shock - expose the whole abdomen - there may be clues!!


During this acute phase state remember to provide constant reassessment

During initial assessment I would send bloods for FBC, U&E, LFTs, CRP, Lactate, Amylase, blood glucose, clotting studies, Group and Save and blood and urine cultures if spiking a temperature. 

Focused history​

  • Allergies

  • Medications – VTE prophylaxis, analgesia 

  • Past medical history 

  • Last meal

  • Events leading up to this point 

    • Indication for surgery

    • Review operation notes – any high risk of complication, was the operation difficult

    • Review flap observation chart

Examination and investigations

Examine flap

  • Evaluate the flap colour

  • Capillary refill time

  • Doppler signal 

  • Skin turgor

  • Some may check bleeding on pinprick

If arterial cause of flap ischaemia:

  • Flap is usually pale, cool, has a slow CRT, no bleeding on pinprick and has loss of arterial (triphasic) Doppler signal

If venous cause of ischaemia:

  • Flap is usually warm, congested and bluish in colour, has a brisk CRT, rapidly bleeding of dark blood on skin prick and there will be loss of doppler signal 


FBC, CRP, U&Es, group and save

Example questions to progress the station

Q1 What are the common causes of flap failure?



  • Arterial: technical problem with anastaomsis, spasm, thrombosis due to vessel trauma

  • Venous – kinking of pedicle at site of anastomosis, spasm, thrombus, possible compression due to dressings or haematoma

  • Veperfusion injury secondary to prolonged ischaemic time


  • hypercoagulable state

  • odemea due to excessive fluid administration

Initial management

  • IV fluids to optimise blood pressure

  • Analgesia

  • Keep flap warm e.g. forced air warming blanket e.g. Bair hugger

  • Keep NBM

  • Urgently discuss with on call surgical registrar – the patient will need to urgently attend theatre for exploration 

  • Ensure venous thromboembolism prophylaxis has been prescribed and given


Definite discussion with:

  • Plastic Surgical registrar/consultant

Consider discussion with:

  • Anaesthetics and theatres – exploration is likely required

When recognised early and managed promptly (i.e. within 6 hours) compromised flaps have a 75% salvage rates. 


Definitive management is often surgical with urgent re-exploration to inspect vascular pedicle for compression/kinks, assess patency of anastomosis and  identify whether the is thrombus formation. If so an embolectomy or intra-arterial thrombolysis can be performed.

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