J Reconstr Microsurg 2009; 25(1): 015-019
DOI: 10.1055/s-0028-1090600
© Thieme Medical Publishers

A Recommended Protocol for the Immediate Postoperative Care of Lower Extremity Free-Flap Reconstructions

Christine Rohde1 , Brittny Williams Howell2 , Gregory M. Buncke3 , Geoffrey C. Gurtner4 , L. Scott Levin5 , Lee L.Q Pu6 , Jamie P. Levine7
  • 1Columbia University Medical Center/New York-Presbyterian Hospital, New York
  • 2Department of Surgery, New York University Langone Medical Center, New York, New York
  • 3The Buncke Clinic, California Pacific Medical Center, San Francisco, California
  • 4Division of Plastic Surgery, Stanford University Medical Center, Stanford, California
  • 5Division of Plastic, Reconstructive, Maxillofacial and Oral Surgery, Duke University Medical Center, Durham, North Carolina
  • 6Division of Plastic Surgery, University of California-Davis Medical Center, Sacramento, California
  • 7Institute of Reconstructive Plastic Surgery, New York University Langone Medical Center, New York, New York
Further Information

Publication History

Publication Date:
31 October 2008 (online)


The success of lower extremity microsurgical reconstructions may be compromised postoperatively secondary to several factors, including thrombosis, infection, bleeding, and edema. To address edema, surgeons may use protocols for gradually dangling and/or wrapping the affected extremity. Such protocols vary widely among surgeons and are typically based on training and/or prior experience. To that end, we distributed surveys to five plastic surgeons who are experienced in microvascular lower extremity reconstruction at five different institutions. The surveys inquired about postoperative management protocols for lower extremity free flaps with regard to positioning, compression, initiation and progression of postoperative mobilization, nonweightbearing and weightbearing ambulation, assessment of flap viability, and flap success rate. These protocols were then evaluated for similarities to create a consensus of postoperative management guidelines. Progressive periods of leg dependency and compression therapy emerged as important elements. Although the consensus protocol developed in this study is considered safe by each participant, we do not intend for these recommendations to serve as a standard of care, nor do we suggest that any one particular protocol leads to improved outcomes. However, these recommendations may serve as a guide for less experienced surgeons or those without a protocol in place.


Jamie P Levine, M.D. 

530 First Avenue, Suite 8V, NYU Plastic Surgery Associates

NYU Medical Center, New York, NY 10016

Email: [email protected]