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

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 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.

Publication History

Received: 10 June 2025

Accepted after revision: 03 November 2025

Accepted Manuscript online:
05 November 2025