Early Start of the Dangling Procedure in Lower Extremity Free Flap Reconstruction does not Affect the Clinical Outcome

Abstract

Flap loss due to postoperative flap edema and thrombosis of the anastomosis remains the predominant concern of reconstructive microsurgeons. Due to the lack of scientific evidence, there is no unanimous opinion on when to mobilize a reconstructed lower extremity, reflecting the uncertainty of plastic surgeons regarding the effect of the dangling procedure on flap microcirculation.

Patients and Methods In this randomized controlled clinical trial, we included 31 patients undergoing free flap transfer to the lower extremity.

The patients were randomly divided into two groups. Cohort I consisted of 15 patients starting the dangling procedure at day 7, and cohort II consisted of 16 patients in which an early aggressive postoperative dependency started at day 3.

Wrapping and dangling of the flap was performed primarily with a duration of 5 minutes three times a day and increased daily by doubling the duration over a period of 4 days, reaching 60 minutes at day 5.

Before and immediately after each dangling procedure the flaps were clinically monitored under direct observation for color, capillary refill, venous congestion, flap turgor, and flap temperature.

Results In all cases the postoperative course was uneventful, resulting in a success rate of 100%. No adverse effects or flap compromise were seen due to the combined dangling/wrapping procedure.

Conclusion An early and aggressive start of a combined dangling/wrapping procedure does not compromise flap circulation and allows mobilizing patients after free flap transfer to the lower extremity at an early stage. This approach improves patient comfort, shortens the hospital stay, and therefore reduces socioeconomic costs.

Keywords

dangling - microcirculation - lower extremity - free flap - prospective study - randomized

• References

• 1 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: 15-19
• 2 Ridgway EB, Kutz RH, Cooper JS, Guo L. New insight into an old paradigm: wrapping and dangling with lower-extremity free flaps. J Reconstr Microsurg 2010; 26: 559-566
• 3 Isenberg JS, Siegal A, Sherman R. Quantitative evaluation of the effects of gravity and dependency on microvascular tissue transfer to the lower limb, with clinical applications. J Reconstr Microsurg 1997; 13: 25-29
• 4 Cherry GW, Myers MB, Ardran G, Ryan TJ. The effects of gravity on delayed and transplanted delayed tubed flaps. Plast Reconstr Surg 1979; 64: 156-162
• 5 Palmer B, Jurell G, Norberg KA. The blood flow in experimental skin flaps in rats studied by means of the 133 xenon clearance method. Scand J Plast Reconstr Surg 1972; 6: 6-12
• 6 Nathanson SE, Jackson RT. Blood flow measurements in skin flaps. Arch Otolaryngol 1975; 101: 354-357
• 7 Kerrigan CL, Daniel RK. Monitoring acute skin-flap failure. Plast Reconstr Surg 1983; 71: 519-524
• 8 Serafin D, Shearin JC, Georgiade NG. The vascularization of free flaps: a clinical and experimental correlation. Plast Reconstr Surg 1977; 60: 233-241
• 9 Henriksen O. Local sympathetic reflex mechanism in regulation of blood flow in human subcutaneous adipose tissue. Acta Physiol Scand Suppl 1977; 450: 1-48
• 10 Classen DA, Irvine L. Free muscle flap transfer as a lymphatic bridge for upper extremity lymphedema. J Reconstr Microsurg 2005; 21: 93-99
• 11 Eckert P, Schnackerz K. Ischemic tolerance of human skeletal muscle. Ann Plast Surg 1991; 26: 77-84
• 12 He W, Neligan P, Lipa J, Forrest C, Pang CY. Comparison of secondary ischemic tolerance between pedicled and free island buttock skin flaps in the pig. Plast Reconstr Surg 1997; 100: 72-81 , discussion 82–83
• 13 Serel S, Çavuşoğlu T, Uluç A, Ayva S, Saray A, Özbek MR. Tolerance of prefabricated skin flaps to ischaemia and reperfusion: experimental study. J Plast Reconstr Aesthet Surg 2011; 64: 394-400
• 14 Babovic S, Angel MF, Im MJ, Ress AM, Manson PN. Effects of tissue expansion on secondary ischemic tolerance in experimental free flaps. Ann Plast Surg 1995; 34: 593-598
• 15 Cooley BC, Gould JS. Influence of age on free flap tolerance to ischemia: an experimental study in rats. Ann Plast Surg 1993; 30: 57-59
• 16 Harder Y, Amon M, Georgi M , et al. Aging is associated with an increased susceptibility to ischaemic necrosis due to microvascular perfusion failure but not a reduction in ischaemic tolerance. Clin Sci (Lond) 2007; 112: 429-440
• 17 Harder Y, Amon M, Wettstein R, Rücker M, Schramm R, Menger MD. Gender-specific ischemic tissue tolerance in critically perfused skin. Langenbecks Arch Surg 2010; 395: 33-40
• 18 Harder Y, Amon M, Schramm R , et al. Heat shock preconditioning reduces ischemic tissue necrosis by heat shock protein (HSP)-32-mediated improvement of the microcirculation rather than induction of ischemic tolerance. Ann Surg 2005; 242: 869-878 , discussion 878–879
• 19 Liao Y, Tong TH, Wang TP, Han Y. [Effect of local injection of recombinant hirudin on survival of skin flaps with venous congestion in a rabbit model]. Zhonghua Shao Shang Za Zhi 2011; 27: 215-217
• 20 Douglas BK, Silverman DG, Weinberg H. Perfusion washout: increasing a microvascular free flap tolerance to ischemia. J Reconstr Microsurg 1989; 5: 151-155
• 21 Sumer BD, Gastman BR, Gao F, Haughey BH, Paniello RC, Nussenbaum B. Caspase inhibition enhances ischemic tolerance of fasciocutaneous flaps. Laryngoscope 2005; 115: 1358-1361
• 22 Forrest CR, Neligan P, Zhong A, He W, Yang RZ, Pang CY. Acute adenosine treatment is effective in augmentation of ischemic tolerance in muscle flaps in the pig. Plast Reconstr Surg 1997; 99: 172-182
• 23 Turk JB, Zhang WX, Babajanian M, Urken ML, Biller HF, Weinberg H. The use of a new perfusate in experimental microvascular flaps: a threefold increase in ischemic tolerance. J Reconstr Microsurg 1991; 7: 305-309 , discussion 311–312
• 24 Schaverien MV, Ludman CN, Neil-Dwyer J , et al. Relationship between venous congestion and intraflap venous anatomy in DIEP flaps using contrast-enhanced magnetic resonance angiography. Plast Reconstr Surg 2010; 126: 385-392