Poster Presentation Joint Scientific Meeting of the Australian & NZ Head & Neck Cancer Society & NZ Association of Plastic Surgeons

Wrapping and dangling in lower limb microsurgical reconstruction - can we do better? (1419)

Jan Janzekovic 1 , Raymond Li 1 , Jonathan D Wiper 1
  1. Plastic & Reconstructive Surgery, Princess Alexandra Hospital, Brisbane, QLD, Australia

Purpose. The immediate post-operative management of patients who undergo lower limb microsurgical reconstruction is often case and clinician based. The use of compression and introduction of gravity dependant conditioning - ‘wrapping and dangling’ - in the post-operative period are employed by most microsurgical centres, however a consensus on an optimal protocol is yet to exist. The timing and sequence of post-operative protocols has been speculated to impact outcomes in terms of wound healing, flap loss, function, and aesthetics. However, delay in initiation of wrapping and dangling can prolong hospital stay and patient immobilisation, thereby increasing hospital-related complications such as pneumonia, venous thrombo-embolism, and pressure injuries

Methodology. Retrospective analysis of single centre post-operative management of lower limb microsurgical reconstruction from consecutive cases between 2019 and 2020. Patient demographics, mechanism of injury, orthopaedic fixation, flap used, time to initiate wrapping and dangling, flap outcome, length of stay and complications were attained from hospital records

Results. 33 patients (34 flaps) underwent microvascular reconstruction of the lower limb. Most cases were for trauma (22), with the remainder comprising of oncology (7) and infection (4). Patients who had an unexpected return to theatre within the first 5 days were excluded from the study. Average time for commencement of compression was 6.4 days, with initiation of gravity dependant positioning at 7.1 days. There was no significant difference between fasciocutaneous and muscle flaps. Clinical monitoring and doppler ultrasound were for flap monitoring

Conclusion. Lack of a defined department-wide protocol for wrapping and dangling can delay patient discharge and lead to complications for both the patient and healthcare system. Unfamiliarity among allied health and junior staff with post-operative management can be a contributing factor. Herein we propose a streamlined protocol for both fasciocutaneous and muscle free flaps in lower limb reconstruction with the aim to educate junior staff

  1. McGhee, J.T., et al., Systematic review: Early versus late dangling after free flap reconstruction of the lower limb. J Plast Reconstr Aesthet Surg, 2017. 70(8): p. 1017-1027.
  2. Neubert, N., et al., Does an Early and Aggressive Combined Wrapping and Dangling Procedure Affect the Clinical Outcome of Lower Extremity Free Flaps?-A Randomized Controlled Prospective Study Using Microdialysis Monitoring. J Reconstr Microsurg, 2016. 32(4): p. 262-70.
  3. Seth, A.K., S. Diamond, and M.L. Iorio, Outcomes of an Early Protocol for Dependent Conditioning in Lower Extremity Microsurgical Free Flaps. J Reconstr Microsurg, 2017. 33(9): p. 670-678.
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