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Related Experiment Video

Updated: Jan 8, 2026

An Experimental Human DIEP Flap Model to Investigate Preservation Strategies for Vascularized Composite Allografts and Free Flaps
07:58

An Experimental Human DIEP Flap Model to Investigate Preservation Strategies for Vascularized Composite Allografts and Free Flaps

Published on: December 5, 2025

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Timing of Dangle Protocol Initiation Following Lower Extremity Free Flap Reconstruction.

Adeem M Nachabe1, Genevieve E Messa1, Harel G Schwartzberg1

  • 1Division of Plastic and Reconstructive Surgery, Louisiana State University Health Sciences Center; New Orleans, LA.

Annals of Plastic Surgery
|December 19, 2025
PubMed
Summary

Early initiation of the dangle protocol after lower extremity free flap reconstruction may reduce hospital length of stay without impacting flap success. Further research is needed to confirm optimal timing for this critical post-operative care step.

Keywords:
dangle protocolfree tissue transferlower extremity free flaplower extremity reconstruction

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Area of Science:

  • Plastic Surgery
  • Microsurgery
  • Reconstructive Surgery

Background:

  • The dangle protocol is standard after lower extremity free flap reconstruction (LEFFR).
  • Current clinical practice shows variability in starting the dangle protocol postoperatively.
  • This study investigates the impact of early versus late dangle protocol initiation on LEFFR outcomes.

Purpose of the Study:

  • To evaluate the outcomes of different dangle protocol initiation times following LEFFR.
  • To determine if early dangle protocol initiation affects flap failure or complications.
  • To assess the effect on hospital length of stay (LOS).

Main Methods:

  • Retrospective chart review of adult patients undergoing LEFFR (January 2016 - December 2022).
  • Patients categorized into early (postoperative day [POD] 4-6) and late (POD 7-8) dangle protocol initiation groups.
  • Primary outcome: flap failure. Secondary outcomes: flap take-back, necrosis, congestion, ischemia, hematoma, seroma, infection, and pulmonary embolism.

Main Results:

  • 103 patients included; 46 early group, 57 late group.
  • No significant difference in flap failure rates between early (4.3%) and late (1.8%) groups (P=0.585).
  • Early initiation significantly reduced average hospital LOS (21.5 vs 25 days, P=0.010) without increasing complications.

Conclusions:

  • Early dangle protocol initiation (POD 4-6) may shorten hospital LOS post-LEFFR.
  • Early initiation appears safe, with no increase in flap failure or major complications.
  • Prospective studies are recommended to establish optimal dangle protocol timing.