CLINICAL PAPER
Early Ambulation After Microsurgical Reconstruction
of the Lower Extremity
Michael J. Orseck, MD,*† Christopher Robert Smith, DO,‡ Sean Kirby, PA-C,‡ and Manuel Trujillo, MD*
Abstract: Successful outcomes after microsurgical reconstruction of the lower
extremity include timely return to ambulation. Some combination of physical
examination, ViOptix tissue oxygen saturation monitoring, and the implantable
venous Doppler have shown promise in increasing sensitivity of current flap
monitoring. We have incorporated this system into our postoperative monitoring
protocol in an effort to initiate earlier dependency protocols. A prospective anal-
ysis of 36 anterolateral thigh free flap and radial forearm flaps for lower extremity
reconstruction was performed. Indications for reconstruction were acute and
chronic wounds, as well as oncologic resection. Twenty-three patients were able
to ambulate and 3 were able to dangle their leg on the first postoperative day. One
flap showed early mottling that improved immediately after elevation. After
reelevation and return to baseline, the dependency protocol was successfully im-
plemented on postoperative day 3. All flaps went on to successful healing. Phys-
ical examination, implantable venous Doppler, and ViOptix can be used reliably
as an adjunct to increase the sensitivity of detecting poorly performing flaps dur-
ing the postoperative progression of dependency.
Key Words: free flap, ambulation, dependency, lower extremity, microsurgery
(Ann Plast Surg 2018;80: S362–S364)
F ree flaps are well established as a method of lower extremity recon-
struction after oncologic resection or trauma.1,2 The practice
patterns for postoperative flap monitoring and time to dangling or am-
bulation vary widely.3 Traditionally, lower extremity free flaps have
been followed by clinical and Doppler examination, and these patients
have been subject to long periods of bed rest. More recently, however,
reports of decreasing time to dependency and ambulation have been
published. Newer technologies such as implantable venous Doppler
and cutaneous tissue oximetry have been used as adjuncts to physical
examination. No single best protocol has been established in the litera-
ture. Requiring lower extremity free flap recipients to be in the hospital
or bed bound for longer periods puts these patients at increased risk for
venous thromboembolic events, pneumonia, delirium, and pressure ul-
cers. In this study, we sought to demonstrate that an early ambulation
and dangling protocol beginning the first postoperative day did not af-
fect flap survival.
MATERIALS AND METHODS
We conducted a prospective analysis of 36 free flaps for lower
extremity reconstruction. All were performed by a single surgeon over
a 3-year period. All arterial anastomosis were performed under a microscope
Received October 30, 2017, and accepted for publication, after revision November 21,
2017.
From the *Plastic Surgery—Spartanburg Regional Medical Center, Spartanburg;
†AHEC, Medical University of South Carolina, Charleston; and ‡Spartanburg
Regional Medical Center, Spartanburg, SC.
Previously presented at the Southeastern Society of Plastic and Reconstructive
Surgeons Annual Meeting; Sea Island, GA; June 2017.
Conflicts of interest and sources of funding: none declared.
Reprints: Michael J. Orseck, MD, 391 Serpentine Dr, Spartanburg, SC 29303. E-mail:
MOrseck@srhs.com.
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0148-7043/18/806S–S362
DOI: 10.1097/SAP.0000000000001346
S362 www.annalsplasticsurgery.com
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
in an end-to-end or end-to-side fashion with interrupted sutures. All ve-
nous anastomoses were performed using a vein coupler and monitored
with either a Cook-Swartz Doppler (Cook Medical, Bloomington, IN)
or Synovis Flow Coupler (Synovis, Birmingham, AL). Postoperative
flap monitoring was done by a combination of physical examination,
Doppler signals, and use of the ViOptix (ViOptix, Fremont, CA) tissue
oximeter. Patients not physically able to ambulate or dangle the affected
extremity on postoperative day 1 were excluded. Initial ambulation or
dangling was performed with the plastic surgeon, physician's assistant,
or surgery resident at the bedside (Fig. 1). The dangling protocol began
with 15 minutes of dangling twice daily. All patients received standard
deep venous thrombosis prophylaxis with subcutaneous injections of
enoxaparin or heparin. Primary end points were flap survival and return
to the operating room for flap salvage.
RESULTS
Of the 36 free flaps performed, 28 were physically able to dangle
or ambulate on postoperative day 1, 23 of these were anterolateral thigh
flaps and 5 were radial forearm flaps. Eight patients were unable to dan-
gle or ambulate the first day and were excluded. Of those remaining, the
median flap size was 62 cm2, with a range of 40 to 162 cm2 (Table 1).
Indications for reconstruction were trauma (19), chronic wounds (5),
and oncologic resection (4). In all, 24 patients were successfully able
to ambulate with physical therapy on the first postoperative day. In
addition, 3 patients were physically unable to ambulate but were able to
begin dangling. One patient, upon dangling, showed signs of mottling
and had a drop in tissue oxygenation. This flap was immediately
elevated and the dependency protocol was successfully reimplemented
on postoperative day 3. Of all 36 flaps, none required a return to the
operating room for flap salvage and no flaps were lost.
DISCUSSION
We were able to demonstrate in a small group of patients that
with close monitoring and clinical judgment, early dependency is pos-
sible with fasciocutaneous free flaps to the lower extremity. This was
done with the aid of implantable venous Doppler, continuous tissue ox-
ygenation measurements, and physical examination. Currently, we sug-
gest discharge on postoperative day 4 for well-performing flaps. This is
in stark contrast to many protocols published in the literature.
A survey published in 2009 of 5 surgeons that perform lower ex-
tremity reconstruction revealed vastly different times to dependency
and discharge. Start of dependency protocols ranged from postoperative
day 7 to day 28, and typical discharge dates ranged from postoperative
day 4 to 3 weeks.4 Although these protocols may have changed over the
past few years, these prolonged protocols may add morbidity to these
patients and certainly add cost to the hospitalization.
More recently, earlier times to dependency and ambulation have
been investigated. Jokuszies et al5 compared 2 cohorts with wrapping
and dangling protocols beginning postoperative day 3 or postoperative
day 7. Flap monitoring was performed by physical examination only,
and no flaps were lost. Miyamoto et al6 attempted early mobilization
of lower extremity free flap transfers using flow-through artery and vein
anastomoses. Within 1 week, 12 or 13 patients were able to dangle and
Annals of Plastic Surgery • Volume 80, Supplement 6, June 2018
Annals of Plastic Surgery • Volume 80, Supplement 6, June 2018 Early Ambulation

Also, we chose to include an implanted Doppler device and ViOptix

in our postoperative flap monitoring. This could add unnecessary cost
because others, including Jokuszies et al,5 have safely demonstrated
early dependency without the use of these devices.
No single study investigating early-dependency protocols has a
large patient population. Because rates of lower extremity free flap sur-
vival are typically reported to be 95% or greater, none have sufficient
power to demonstrate a significant difference in flap survival rates be-
tween protocols. Hundreds of patients would be needed to have ade-
quate power to demonstrate significance if flap survival is as high as
reported in these early-dependency cohorts. Demonstrating decreased
hospital length of stay with earlier dependency protocols can be
difficult because many of these free flaps are performed on the
polytrauma patient. For this study, we did not distinguish elective
cases from those that were already admitted, and therefore, hospital
length of stay data are not reported. For similar reasons, comorbidities
and postoperative morbidities were not reported, although increased
morbidity with longer periods of immobilization is well documented
in surgical literature. The financial impact of longer hospital length of
stay is obvious.
We were able to demonstrate that dangling and ambulation on
the first postoperative day, with close monitoring, can be safely per-
formed without flap loss. Our early experiences with smaller muscle
flaps such as gracilis and split latissimus free flaps have also shown
promise tolerating early ambulation.

TABLE 1. Patients in Early-Dependency Group

Patient Defect Type Flap Size, cm2

1 Trauma ALT 88
FIGURE 1. Patient ambulating on postoperative day 1 with 2 Trauma ALT 63
physical therapist. Note ViOptix on the left and therapist 3 Trauma ALT 45
holding the Doppler monitor. 4 Trauma RF 40
5 Oncologic RF 42
6 Trauma ALT 70
10 of 13 were able to ambulate, and likewise, no flaps were lost. It has 7 Chronic wound ALT 65
previously been suggested that risk of flap congestion would be im- 8 Trauma ALT 77
proved with a flow-through venous anastomosis because it may help 9 Chronic wound ALT 60
preserve the foot and calf muscle pump mechanisms.7 Our study is 10 Oncologic RF 50
unique in demonstrating flap survival with ambulation on the first post- 11 Trauma ALT 75
operative day using end-to-end anastomoses. 12 Trauma ALT 85
Tissue oxygenation monitoring has been shown to be a sensitive 13 Trauma ALT 60
monitor of flap perfusion. The sensitivity, specificity, and accuracy of 14 Oncologic ALT 75
light spectroscopy have been found to be greater than those of Doppler 15 Chronic wound ALT 68
and clinical examination.8 Respondents to a recent survey were signif-
16 Chronic wound ALT 43
icantly more likely to return to the operating room because of concern
in oximetry readings than in an abnormal Doppler signal.9 Continuous 17 Trauma RF 52
tissue oximetry measurements may be useful when dependency proto- 18 Trauma ALT 71
cols are initiated earlier than historical controls. In our experience, some 19 Trauma ALT 62
drop in tissue oximetry was observed with early dependency that would 20 Trauma RF 59
resolve after elevation, which is consistent with previously pub- 21 Trauma ALT 69
lished reports. Although we did not wrap the affected extremities 22 Oncologic ALT 42
on the first postoperative day, a wrapping procedure beginning post- 23 Trauma ALT 43
operative day 7 has been shown to lessen the decrease in flap tissue ox- 24 Trauma ALT 51
ygenation with dependency and also hasten the time to return to normal 25 Trauma ALT 62
levels with elevation.10
26 Trauma ALT 58
This study is not without limitations. With one exception, the
fasciocutaneous flaps included in this study were relatively small. Reece 27 Trauma ALT 67
et al11 recently suggested a trend toward significance of flap complica- 28 Chronic wound ALT 162
tions with increasing flap size. It is possible larger fasciocutaneous flaps ALT, anterolateral thigh free flap; RF, radial forearm free flap.
may not tolerate early dependency.

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Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

Orseck et al
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S364 www.annalsplasticsurgery.com
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Annals of Plastic Surgery • Volume 80, Supplement 6, June 2018
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