Postoperative care in microvascular free flap reconstruction of the lower extremity: A systematic review

Background: Free tissue transfer is a commonly used procedure to reconstruct defects of the lower extremity. However, measures of postoperative care to promote flap maturity vary greatly. Dangling protocols tend to be highly divergent regarding the start, duration, schedules and monitoring of dangling, as well as the additional use of compression stockings or bandaging. The aim of this systematic review to review and evaluate current literature and to provide recommendations. Methods: A systematic literature review was performed in accordance with PRISMA guidelines. Literature databases were searched for relevant articles about early ambulation following lower leg reconstruction. Results: A total of 10 articles met the inclusion criteria: 2 randomized controlled trials and 7 case-series and one cohort study. The optimal start, duration and frequency of the dangling and compression procedures remain unclear, and so does the necessity of dangling and compression in general. An early and aggressive dangling procedure can be safely introduced on postoperative day (POD) 3, taking possible comorbidities into consideration. Early initiation might help shorten hospital stay, thereby reducing associated medical costs. Furthermore, compressive wrapping applied to the dangled leg seems to have a positive effect on flap perfusion and patient comfort. Conclusion: Based on the current literature, it is suggested that an early and aggressive dangling procedure can safely be started on POD 3. Compression therapy during dangling increases perfusion and venous return of the free flap and increases the comfort of the patient.