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J Reconstr Microsurg
DOI: 10.1055/a-2737-5482
Original Article

Rethinking Dangling: Omission of Inpatient Dangle Protocols Shortens Hospital Stay Without Adverse Effects on Lower Extremity Flap Outcomes

Authors

  • Michael I. Kim 

    1   Keck School of Medicine, University of Southern California, Los Angeles, California, United States
    2   Division of Plastic and Reconstructive Surgery, Keck School of Medicine of USC, Los Angeles, California, United States

  • Katie A. Shen

    1   Keck School of Medicine, University of Southern California, Los Angeles, California, United States

  • Claire Olivas

    1   Keck School of Medicine, University of Southern California, Los Angeles, California, United States

  • Eloise W. Stanton

    2   Division of Plastic and Reconstructive Surgery, Keck School of Medicine of USC, Los Angeles, California, United States

  • Jennifer Yoon

    1   Keck School of Medicine, University of Southern California, Los Angeles, California, United States

  • Jasmine Jin

    1   Keck School of Medicine, University of Southern California, Los Angeles, California, United States

  • Joseph N. Carey

    2   Division of Plastic and Reconstructive Surgery, Keck School of Medicine of USC, Los Angeles, California, United States

  • David A. Daar

    2   Division of Plastic and Reconstructive Surgery, Keck School of Medicine of USC, Los Angeles, California, United States

  • Emma C. Koesters

    2   Division of Plastic and Reconstructive Surgery, Keck School of Medicine of USC, Los Angeles, California, United States
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Abstract

Background

Formal dangling protocols are often used after lower extremity free flap reconstruction to acclimate flaps to gravitational stress. However, their clinical benefit remains uncertain. This study evaluates how the inclusion or omission of structured inpatient dangling affects flap outcomes.

Methods

A retrospective review was conducted of 82 patients who underwent lower extremity free flap reconstruction at a single institution (2015–2024). Patients were grouped based on use of a formal dangling protocol (≥3 consecutive supervised sessions beginning after postoperative day 5) versus no protocol (ad libitum dangling beginning day 3). Outcomes included flap survival, complications, 30-day unplanned reoperation, time to ambulation, and length of stay. Statistical analysis included chi-squared, t-tests, and multivariable regression models.

Results

Fifty-three patients adhered to a dangle protocol; 29 did not follow a protocol. Demographics, comorbidities, flap type, and defect characteristics were similar between groups. Flap survival (96.2% vs. 96.6%, p = 0.94), partial necrosis (9.4% vs. 10.3%, p = 0.89), and reoperation rates (3.4% vs. 7.5%, p = 0.46) were comparable. On multivariable analysis, dangle protocol use was not associated with reduced complication risk (OR = 0.95, p = 0.93) but was associated with a 3.0-day longer median hospital stay (p < 0.01).

Conclusion

The application of a formal dangling protocol did not affect flap survival but was independently associated with prolonged hospitalization. These findings challenge the necessity of structured regimens and support more patient-tailored postoperative strategies that may accelerate recovery without compromising surgical outcomes.

Keywords

lower extremity reconstruction - free flap reconstruction - dangle protocol


Publication History

Received: 10 June 2025

Accepted: 03 November 2025

Accepted Manuscript online:
05 November 2025

Article published online:
26 November 2025

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