National Postoperative Practices in Lower Extremity Free Flap Reconstruction

Abstract

Background Free tissue transfer is an important tool for lower extremity reconstruction but is prone to complications associated with dependency. There is significant national variance in postoperative management, particularly in the initiation and progression of dependency via “dangle protocols,” which can impact bed rest duration, cost, return to work, and rehabilitation. This study characterizes the current landscape of dangle protocols at high-volume microsurgery centers in the United States.

Methods Microsurgery fellowship programs were identified through the American Council of Educators in Plastic Surgery web site. Program directors identified the highest-volume lower extremity free flap surgeon at each institution, who received an anonymous survey assessing practice type, indications for lower extremity free flap reconstruction, postoperative care, and Dangle protocol elements.

Results Thirty-one fellowship programs were identified; 11 responses were collected (34.5% response rate). Factors influencing dangle protocols included recipient site above the knee (67%), number of venous anastomoses (33%), and flap size (33%). About 83% included a bed rest period (range 0–5 days). Dependency was initiated most commonly between postoperative days 3 and 5, with considerable variation in duration, frequency, and progression. Two-thirds did not restrict weight-bearing for soft tissue defects; one-third limited weight-bearing for 2 weeks. Length of stay ranged from 2 days to 1.5 weeks.

Conclusion Significant variance exists in lower extremity free flap protocols nationally, spanning preoperative evaluation, dangle protocols, and postoperative care. These differences may meaningfully affect patient quality of life, cost of care, and return to work. Identifying patterns in protocols and associated complications, and defining standards could inform and improve clinical practice.