Download PDF
J Reconstr Microsurg
DOI: 10.1055/a-2508-6558
Original Article

Early Initiation of Dangle Protocol in Lower Extremity Free Flap Microsurgery

Shannon Su
1   Emory University School of Medicine, Atlanta, Georgia
,
Ambika Menon
2   Division of Plastic Surgery, Emory University, Atlanta, Georgia
,
Carolyn Taillon
2   Division of Plastic Surgery, Emory University, Atlanta, Georgia
,
Omar Saad
1   Emory University School of Medicine, Atlanta, Georgia
,
Tyler Merceron
2   Division of Plastic Surgery, Emory University, Atlanta, Georgia
,
Paul Ghareeb
1   Emory University School of Medicine, Atlanta, Georgia
2   Division of Plastic Surgery, Emory University, Atlanta, Georgia
› Author Affiliations
› Further Information
Also available at
    Permissions and Reprints

Abstract

Background Defects of the lower extremity often require free tissue transfer to provide adequate soft tissue reconstruction. Patients typically undergo a postoperative dangle protocol to condition the flap to withstand the increase in venous pressure. The purpose of this study was to evaluate the safety and postoperative length of stay after early initiation of dangle.

Methods A retrospective review of patients undergoing lower extremity free tissue transfer reconstruction at the Grady Memorial Hospital from 2012 to 2022 was conducted. Patient demographics, surgical characteristics, and outcomes were analyzed. Patients were categorized into two groups: early (within 5 days after surgery) and late dangle (day 6 or greater). Univariate and multivariate statistical analyses were performed, with significance determined to be p < 0.05.

Results A total of 83 of 99 available patients met inclusion criteria; 22 patients underwent early and 61 late dangle. Free flap survival was 90.9% in the early and 90.2% in the late group. The mean postoperative length of stay in the early and late groups were 12.3 and 18.8 days, respectively (p = 0.0018). There was no difference in the number of patients who had wound healing complications, flap failure, and a need for amputation in each group.

Conclusion Our results demonstrate that initiation of an early dangle protocol does not affect surgical outcome and leads to a reduction in postoperative length of stay. These results can be used to inform evidence-based recommendations for flap management in lower extremity reconstruction.

Keywords

dangle protocol - free flap - outcomes


Publication History

Received: 31 May 2024

Accepted: 23 December 2024

Accepted Manuscript online:
30 December 2024

Article published online:
28 January 2025

© 2025. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Pu LLQ. Free flaps in lower extremity reconstruction. Clin Plast Surg 2021; 48 (02) 201-214
    CrossrefPubMedSearch in Google Scholar
  • 2 Soteropulos CE, Chen JT, Poore SO, Garland CB. Postoperative management of lower extremity free tissue transfer: a systematic review. J Reconstr Microsurg 2019; 35 (01) 1-7
    Thieme ConnectPubMedSearch in Google Scholar
  • 3 Sakurai H, Yamaki T, Takeuchi M, Soejima K, Kono T, Nozaki M. Hemodynamic alterations in the transferred tissue to lower extremities. Microsurgery 2009; 29 (02) 101-106
    CrossrefPubMedSearch in Google Scholar
  • 4 Rohde C, Howell BW, Buncke GM. et al. A recommended protocol for the immediate postoperative care of lower extremity free-flap reconstructions. J Reconstr Microsurg 2009; 25 (01) 15-19
    Thieme ConnectPubMedSearch in Google Scholar
  • 5 Xipoleas G, Levine E, Silver L, Koch RM, Taub PJ. A survey of microvascular protocols for lower extremity free tissue transfer II: postoperative care. Ann Plast Surg 2008; 61 (03) 280-284
    CrossrefPubMedSearch in Google Scholar
  • 6 Trull B, Zhang Z, Boyd K, Allen M, Zhang J. Canadian postoperative dependency protocols following lower limb microvascular reconstruction: a national survey and literature review. Plast Surg (Oakv) 2021; 29 (02) 122-127
    CrossrefPubMedSearch in Google Scholar
  • 7 Orseck MJ, Smith CR, Kirby S, Trujillo M. Early ambulation after microsurgical reconstruction of the lower extremity. Ann Plast Surg 2018; 80 (06) S362-S364
    CrossrefPubMedSearch in Google Scholar
  • 8 Jokuszies A, Neubert N, Herold C, Vogt PM. Early start of the dangling procedure in lower extremity free flap reconstruction does not affect the clinical outcome. J Reconstr Microsurg 2013; 29 (01) 27-32
    PubMedSearch in Google Scholar
  • 9 Neubert N, Vogt PM, May M. et al. Does an early and aggressive combined wrapping and dangling procedure affect the clinical outcome of lower extremity free flaps? A randomized controlled prospective study using microdialysis monitoring. J Reconstr Microsurg 2016; 32 (04) 262-270
    PubMedSearch in Google Scholar
  • 10 Seth AK, Diamond S, Iorio ML. Outcomes of an early protocol for dependent conditioning in lower extremity microsurgical free flaps. J Reconstr Microsurg 2017; 33 (09) 670-678
    Thieme ConnectPubMedSearch in Google Scholar
  • 11 Krijgh DD, Teunis T, Schellekens PPA. et al. Is dangling of the lower leg after a free flap reconstruction necessary? Study protocol for a large multicenter randomized controlled study. Trials 2019; 20 (01) 558
    CrossrefPubMedSearch in Google Scholar
  • 12 Dornseifer U, Kleeberger C, Kargl L. et al. Perfusion controlled mobilization after lower extremity free flaps-pushing the limits of time and intensity. J Reconstr Microsurg 2017; 33 (03) 179-185
    PubMedSearch in Google Scholar
  • 13 Krijgh DD, van Straeten MME, Mureau MAM. et al. Postoperative care in microvascular free flap reconstruction of the lower extremity: a systematic review. Orthoplastic Surg 2020; 1–2: 21-26
    CrossrefPubMedSearch in Google Scholar
  • 14 Donato D, Veith J, Holoyda K. et al. Associations of discharge destination and length of stay in lower extremity free flap reconstruction. J Plast Surg Hand Surg 2023; 57 (1-6): 279-284
    CrossrefPubMedSearch in Google Scholar
  • 15 Hospital Adjusted Expenses per Inpatient Day. The Henry J Kaiser Family Foundation; 2021
    Search in Google Scholar
  • 16 Salomon B, Dasa V, Krause PC, Hall L, Chapple AG. Hospital length of stay is associated with increased likelihood for venous thromboembolism after total joint arthroplasty. Arthroplast Today 2021; 8: 254-257.e1
    CrossrefPubMedSearch in Google Scholar
  • 17 Kuriakose JP, Wu W, Weng W, Kamdar N, Burney RE. Association of prophylaxis and length of stay with venous thromboembolism in abdominopelvic surgery. J Surg Res 2023; 282: 198-209
    CrossrefPubMedSearch in Google Scholar