Outcomes of an Early Protocol for Dependent Conditioning in Lower Extremity Microsurgical Free Flaps

Abstract

Background Free tissue transfer is integral to traumatic, oncologic, and diabetic lower limb reconstruction. However, limited data exist on postoperative dependent conditioning or “dangling.” We report our experience utilizing an early pathway for fasciocutaneous flap dangles. Methods Lower extremity microsurgical reconstructions from December 2014 to December 2016 were reviewed. Postoperative pathway included tissue oximetry and Doppler monitoring. On postoperative day 2, dangling started at 5 minutes three times daily with monitoring for flap congestion, signal loss, or persistent oximetry drop. Dangles were increased daily by 5 minutes per dangle to 20 minutes three times daily. Results Twenty-six patients underwent lower extremity reconstruction and completed an early dangling protocol with anterolateral thigh (n = 23, 88.5%) or medial sural artery perforator (MSAP, n = 3, 11.5%) flaps. Average age and body mass index (BMI) were 53.6 years and 28.6, respectively. Infection (n = 16), trauma (n = 13), exposed hardware (n = 12), and malignancy (n = 3) were common etiologies with most wounds below the knee (n = 23). Flaps were primarily taken on one perforator (n = 17) with an end-to-end arterial (n = 18) and two venous (n = 16) anastomoses. With an 8.7-month follow-up, partial and complete flap loss rates were each 3.8% (n = 1). Mean hospital stay was 7.9 days (range: 6–12 days) with 84.6% (n = 22) of patients on ambulatory care with assistance on discharge. Conclusion Lower extremity microsurgical reconstruction can be performed safely and effectively utilizing a standardized postoperative care and dangling pathway. An early, cautious dangle protocol does not increase complications but affords decreased hospital stays and early flap conditioning. In the absence of complicating factors, such as vascular insufficiency, utilizing a defined protocol in these complex patients allows for enhanced, consistent care.

Elastic Wrapping of Lower Extremity Free Flaps during Dangling Improves Microcirculation and Reduces Pain as well as Edema

“…13,14,16 The dangling regimen used in this study can be considered conservative in comparison to much earlier beginning of dependency discussed in the literature. 9,10,17 Based on the results in the literature and our own findings, we will move to a more aggressive dangling regimen supported by elastic wrapping.…”

Assessing the Safety and Efficacy of Regional Anesthesia for Lower Extremity Microvascular Reconstruction: Enhancing Recovery

“…PNC usage along with expedited limb dependency form our growing experience of enhanced recovery in this setting. 11,12 Safety Profile…”

“…Our group has previously described a uniformly adopted protocol to achieve early-expedited limb dependency over a 3-day period postoperatively-allowing for functional ambulation at postoperative day 5. 11 We also prefer fasciocutaneous flapbased reconstruction in the lower extremity-focusing on periscarpal (superthin) and suprafascial flap elevations even in the setting of osteomyelitis, peripheral vascular disease, and diabetic foot wounds. 12…”

Skin grafting the vascular pedicle: a useful technique to avoid microvascular collapse in free tissue transfer for limb salvage

“…An enhanced recovery protocol was utilized for the majority of our patients including the use of regional anesthetic block [9] and an early limb dependency program [10] helped patients dangle early in their postoperative course expediting hospital stay, discharge to rehabilitation facilities, and return toward functional ambulation.…”