Center of Excellence for Reconstructive Microsurgery

Plastic & Reconstructive Surgery & the University of MD Medical System

Department of Rehabilitation

Rehabilitation Practice Guidelines

Skin Grafts, Local flaps & Free-Tissue Transfer

OT, PT, Nursing, & Allied health Care

1. Purpose

To establish a standardized approach to therapy management of patients following soft

tissue reconstruction. The guidelines will be utilized for those patients whose soft tissue
reconstruction is being managed by the STC Plastic and Reconstructive (PRS) Surgery
Service.

Patients whose soft tissue reconstruction is being managed by other services

(Orthopedics, General Surgery, Vascular, Trauma team, Soft tissue, etc) will require
specific orders for management from that service.

Example: If Orthopedics performed the LE graft, orders for management of the graft
must come from Orthopedics, not Plastics. Should Orthopedics wish to manage the graft
as per the guidelines, orders to this effect must be written.

2. Scope

This policy pertains to all therapists and assistants providing care in in-patient settings at
UMMC.

3. Responsibility

It is the responsibility of each therapist and assistants to comply with the stated
guidelines.

4. Definitions

Soft tissue and bone reconstruction includes the following procedures:

ƒ Split thickness skin grafts: a thin shaving of the upper layers of skin are
removed from a healthy area to an area with a skin defect

Revised 04/18/2013 TNKelley, CRNP/ ERodriguez, MD 1

 ƒ Local tissue flaps: a segment of tissue (muscle or fasciocutaneous) is rotated
to a defect while maintaining its own and/or original blood supply
ƒ “Free Flaps” or Microsurgical free tissue transfers: a segment of tissue
(muscle or fasciocutaneous) is transferred to defect at a distant area of the
body. The transfer requires complete division of the donor blood supply
(artery and vein) with re-anastomosis to an artery and vein at the recipient
defect.

5. Referral

Prior to initiating dangling or other therapeutic activities following the reconstruction

surgery, a referral from the managing service (i.e Ortho or Plastic Surgery) must be
received. The referral should be entered into the computer under “Physical Therapy
consults”. The referral should either indicate therapy intervention as per the stated
guidelines, and/or provide restrictions/ specifications for therapy intervention.

Examples: “PT for initiation of dangling to LLE on 9/1/2013 per PRS protocol.”

“PT for initiation of dangling to LLE on 9/1/2013, limit progression of time to 2 minutes
per session, limit OOB time to 1 hour per session”

6. Wound Care/Dressings changes for Recipient and Donor site tissue transfer.

Recipient site management

ƒ Wound dressings to recipient and donor sites are applied as prescribed in the
medical record (usually Xeroform, Adaptic, Wet to dry, Silver products,
Mepitel etc).
ƒ When a specific dressing in not prescribed, a non-adhesive dressing, such as
Xeroform, should be placed directly over the wound followed by loose gauze
if still draining.
ƒ STSG & Rotational flaps are typically supported with an ACE wrap over the
dressing.
ƒ Free-Flap’s should NEVER have a compressive dressing, such as an ACE
wrap over the flap or over the anastomotic vessel site.
ƒ It is also possible that no dressing is used. For example: rotational or free
tissue flaps that include skin.
ƒ Muscle Flaps and STSG’s (Split Thickness Skin Grafts) - These tissues should
always remain moist. When moist dressings are prescribed, the dressings
should ALWAYS be moistened with sterile saline BEFORE removing, so as
not to peel-off or remove any of the graft/flap. Pay careful attention to NOT
allow any shearing forces that would “tear-off” the STSG.
ƒ Wet to dry dressings may be prescribed to debride unhealthy tissue from an
open wound. These dressing are meant to “stick” to the wound bed and
remove unhealthy tissue when they are taken off. Please check if unclear of
the purpose of the dressing.

Revised 04/18/2013 TNKelley, CRNP/ ERodriguez, MD 2

 ƒ FTSG – Full Thickness Skin Grafts- Typically covered with a compressive
dressing called a “Bolster” made of xeroform and cotton. Do not remove the
bolster and keep clean and dry. OK to wash around the bolster.

Donor site management

ƒ STSG -These donor sites are typically covered with Xeroform, Aquacel
Ag, or Op site. Theses dressings are left in place, open to air, and function
as a “protective layer” while the newly forming skin is healing. They will
“fall off” when the epidermal tissue has healed under the original dressing.
ƒ Primarily closed donor sites may be washed with clean soap and H20
beginning POD #2, unless otherwise indicated.
ƒ Do not remove steri-strips from incision lines. These help to keep incision
approximated.

Free-flap Donor sites

ƒ Latissimus dorsi/ scapular muscle flaps - hematomas and seromas frequently

occur at the donor site. Drains are usually in place for a minimum of 7 to 10
days. Upper extremity ROM at the donor site may begin POD 1, depending
on patient’s tolerance. ROM is OK even if the drains remain in place.
ƒ Rectus abdominous muscle or DIEP (Deep Inferior Epigastric Perforator) skin
flaps – These flaps are obtained from the abdominal area and are often used to
reconstruct breasts after mastectomy. Two to four JP drains are usually placed
and removed by POD 7. This procedure does not disrupt all layers of the
abdominal wall, thus there is minimal risk of incisional hernia, dehiscence, or
evisceration. The patient should maintain hip flexion in a “beach chair”
position. Active abdominal flexion (sit-ups) should be avoided for 4-6 weeks.
ƒ Anterolateral Thigh – this site is typically primarily closed, thus there is a
theoretical risk for compartment syndrome. A drain is normally in place until
output less than 25cc/day for 48 hours consecutively. ROM may begin on
POD 1, *If a thigh donor-site flap is not on the ipsilateral (same side) as the
free flap, plan OOB to chair & weight bearing on POD 3,
• *If a thigh donor site flap is placed on the same leg, (such as a thigh flap
to a distal 1/3 tibia or ankle wound) then any ROM and weight bearing
will be restricted until POD 10-14.
ƒ All other donor sites will be handled on a case by case basis.

7. Compressive Wraps

STSG and rotational flaps

Patients with STSG’S or Rotational flaps are wrapped with a compressive (i.e
Ace-wrap) dressing prior to and during the dangling procedure. Ace wrapping
mimics the compressive/pumping action of surrounding musculature, with regards
to lymphatic and venous blood circulation. And ace wrapping, from a cosmetic
standpoint, assists with proper shaping of the graft/flap. Ace wrapping should be
performed typically by the standard figure-of-8 fashion. The involved extremity

Revised 04/18/2013 TNKelley, CRNP/ ERodriguez, MD 3

 is wrapped starting from the toes and progressing in a cephalad direction above
the level of the graft/flap. The therapist should wrap around pin sites when an
external fixator is present, while taking care not to apply shear forces to the
graft/flap.

Free Flaps

ƒ *Patients with free flaps are NOT to have ace wraps placed for dangling.

ƒ Patients with free flaps are NOT to start dangling until POD # 10 to 14
ƒ When a dressing is used, a small window should be left in the dressing so that
part of the flap can be observed during the dangling procedure.

8. Dangling Protocol for…

Split Thickness Skin Grafts (STSG) & Rotational Flaps

Progression may vary based on size/area of the graft or flap. The physician
should note deviation from standard progression in their orders.

ƒ POD 1-2 Bedrest with recipient extremity (stsg/flap) elevated, unless

otherwise indicated.
ƒ POD 3 OOB to chair with strict elevation of recipient site. Preferably near the
level of the “heart.”
• OT to make neutral dorsiflexion splint for LE or UE to maintain affected
extremity in neutrally functional mobile position. Straps may NOT touch
or put pressure on the STSG or rotational flap.
ƒ POD 4 STSG- may begin to Dangle as long as interstices are
epithelialized/closed. Gait training may begin at this time as long as it does
not exceed the dangling time
• *Dangling should be performed a minimum of BID with a goal and
maximum of TID, depending on patient tolerance. PT, OT, or Nursing
may assist and monitor the patient during a dangling session.
• 1st day dangle - 5 minutes TID. Increase dangling time by 5min TID q day
as tolerated and no signs of complications. For example:
• 2nd day- 10 minutes TID
• 3rd day- 15 minutes TID
• 4th day- 20 minutes TID etc…
ƒ POD 5 Rotational Flaps- may begin to Dangle 5 minutes TID
• Dangle time increases by 5 minutes q session/q day, as tolerated and no
signs of complications. (Progress the same as STSG, see above)
ƒ Dangle with P.T. until patient or caregiver is independent with dangling or
discharged with dangling discharge instructions.
ƒ If a patient is also receiving OT, activity should be coordinated between the 2
services as the patient can only have the lower extremity in the dependent
position TID at this time.

Revised 04/18/2013 TNKelley, CRNP/ ERodriguez, MD 4

 ƒ Patients may continue to progress dangling time as per protocol as long as
there are no signs of complications. There is NO maximum time for dangling
in the absence of complications.
ƒ Projected length of stay is 1-2 days after initiation of dangling if the patient
does not have any complications during the procedure.
ƒ May begin weight bearing when cleared by plastics and/or orthopedics.

9. ROM Exercises for…

STSG and Rotational flaps

ƒ POD 1 ROM of uninvolved joints can begin

ƒ POD 5 ROM to joints in close proximity to the graft or flap.
ƒ POD 10 ROM can begin for flaps or grafts that cross a joint. If a patient is
showing significant loss in ROM prior to the stated days guidelines above,
contact PRS to discuss if ROM can be initiated earlier.
ƒ ROM at the ankle of at least neutral dorsiflexion is desirable for functional
mobility. In individual cases, if significant decreases in ankle ROM are noted,
particularly with dorsiflexion, use of a foot splint by PT is encouraged, as long
as it does not touch or apply pressure to the graft. If the splint will touch the
wound, a Plastics MD must be contacted for clearance, or, for an order for a
custom fabricated splint and/or footplate by O.T, when an external fixator is
present. Splint may be applied POD 3.
ƒ Patients with lower extremity external fixators should have toe slings placed
to prevent toe flexion contracture.
ƒ Donor sites may receive ROM exercises as tolerated following surgery. It is
not uncommon for the STSG donor site to ooze blood or serum. Such oozing
is not contraindicated to continue therapy intervention.

10. Dangle Protocol for…

Microsurgical Free tissue transfer (“Free flaps”)

ƒ POD 1-3 Strict bed rest – 72 hours.

ƒ POD 3 OOB to chair- with the flap elevated if on an extremity.
• OT to make neutral dorsiflexion splint for LE or UE to maintain affected
extremity in neutrally functional mobile position. Straps may NOT touch
or place pressure on the free-flap.
ƒ POD 4-(10-14) Continue OOB to chair with STRICT ELEVATION of free
flap if on an extremity.
ƒ POD 10-14 - Initiate Dangling protocol ONLY if cleared by PRS team. If
patient is discharged, dangling will be determined at initial post-op clinic
appointment)

**No ace wraps are to be used with free flaps, and a small window should be
left open in the dressing (if applicable) to observe the flap during dangling.

Revised 04/18/2013 TNKelley, CRNP/ ERodriguez, MD 5

 ƒ Dangle – Start 5 minutes TID. Terminate dangling if excessive pain and/or
throbbing, excessive edema, blue or pale color, congestion or bleeding are
noted. Notify plastic service MD if session terminated as per above.
ƒ *Dangling should be performed a minimum of BID with a goal and maximum
of TID, depending on patient tolerance. PT, OT, or Nursing may assist and
monitor the patient during a dangling session.
ƒ If a patient is also receiving OT, activity should be coordinated between the 2
services as the patient can only have the lower extremity in the dependent
position a maximum of TID at this time.
ƒ POD 11-15 Increase dangling time by 5 minutes every 3 days (not q day) if
preceding day’s dangling without complications
ƒ May begin weight bearing when cleared by plastics and/or orthopedics
ƒ Length of stay for most Free-flap procedures is 5 to 7 days.

NOTE for PT/OT: Patients are usually discharged to home, subacute, or nursing
home prior to dangling. If patients are not going to Rehab confirm patients dangling,
ROM, and weight bearing restrictions and directions. They will most likely continue
strict elevation per PRS orders depending on patient understanding and reliability.

11. ROM Exercises for free flaps

ƒ POD 1 - ROM of uninvolved extremities may begin.

ƒ POD 7 - ROM of joints in close proximity may begin.
ƒ POD 14 -ROM of joints crossed by flap.
ƒ A custom OT splint may be necessary for flaps on the anterior portion of the
leg if patient is developing plantar flexor or equinas deformity.

Dangling Discharge Instructions - same as for STSG/rotation flaps, except

progression of dangling time is increased by 5 minutes every 3 days in the
absence of complications.

12. Guidelines for evaluation of tolerance and progression

ƒ All flap/grafts should be inspected by the physical therapist before and after
dangling unless instructed otherwise by PRS.
ƒ After elevation of the flap when dangling time completed, the flap tissues
should return to their baseline coloration. Allow the same amount of time as
the flap was dangling to return to its prior color. (i.e. if the flap was pink prior
to dependent positioning, then turned bluish after 10 minutes of dangling,
then, it should regain original color within ~10 minutes after re-elevation).
ƒ The physical therapist should notify the plastic surgeon if the following signs
or symptoms occur:
♦ Signs of infection - foul smell, cloudy drainage or pus, visible tissue
necrosis, warmth, erythema, disproportionately severe pain, etc.
♦ STSG failure - loosening or blistering of the skin graft, pale
discoloration of the graft, late increase in drainage from beneath the
graft. Skin grafts are pale for the first two to three days, after which

Revised 04/18/2013 TNKelley, CRNP/ ERodriguez, MD 6

 they become dusky (bluish) for the next three days, and finally, when
not dependent, they regain their initial pinkish coloration.
♦ Hematoma or seroma collection in or beneath the flap/graft
♦ Excessive bleeding or drainage
♦ Excessive edema or swelling
♦ Excessive pain.
♦ Deep Venous Thrombosis - localized pain over the clotted vein; pain
and swelling of the affected extremity.
♦ Persistent color changes after elevating LE for equal amount of time as
dangling. Venous outflow problems are common, especially with free
tissue transfer (microsurgical) flaps. These flaps become engorged
with venous blood and become more purple-blue in coloration while
dependent. Prolonged venous engorgement leads to edema, which
impairs STSG take, and microsurgically anastomosed blood vessels
may clot.

13. Documentation

When documenting on dangling, therapists should remember to remark on:

• Pre-dangle: color of flap/graft, drainage, edema, pain, condition of flap

• Dangle: type of dressing, ace wrap (if applicable), time of dangling
procedure
• Post-dangle: same as for pre-dangle, except noting any changes that have
occurred
• Notes should also include mobility sections (as applicable) for assist
required or for gait and transfer training (as done with other progress
notes) and any education to patient or family/caregivers in regards to the
procedure.

14. Discharge Dangling Instructions

Instruct the patient to dangle with proper dressing (and ace wrap if STSG or rotational
flap) in dependent position, 3 times a day. Please provide the “Dangling Directions &
Worksheet for Patients and Families...” Instruct the patient to follow these instructions
until their follow up visit with the Plastics MD, unless otherwise indicated by MD upon
D/C from hospital.

15. Billing/charge posting

Charges should be posted for therapeutic activity for direct one-on-one interventions
during the procedure. However, if the treatment also includes gait training or therapeutic
exercise during dangling, charges should be posted for the specific intervention according
to the charge posting policy.

Example:

Revised 04/18/2013 TNKelley, CRNP/ ERodriguez, MD 7

 ƒ POD 1, a patient’s leg is dangled for 5 minutes but the complete treatment
is 20 minutes.

ƒ Charge posting: therapeutic activity 8-22 minutes.

ƒ POD 2, the patient’s leg is dangled for 10 minutes, during which gait
training is initiated. The entire procedure takes 25 minutes.
ƒ Charge posting: gait 8-22 minutes, therapeutic activity 8-22 minutes.

16. Education

Handouts are available for patients as well as physical therapists to assist

with guiding them through these procedures post-discharge. Education of
the patient and family should begin as soon as possible so that they will be
comfortable with the procedure by the time of discharge.

STC Plastic Surgery Department

Office 410.328.3058 Fax 410.328.8862

STC Department of Physical Therapy

Office 410.328.5516 Fax 410.328.2909

Revised 04/18/2013 TNKelley, CRNP/ ERodriguez, MD 8


Intervention STSG or Rotational Flap
Positioning Same as intra-op position for
24 hours, No dangling
ROM POD 1: distal and unaffected
joints
POD 5: joints in close
proximity of STSG or
rotational flap
POD 10: joints crossed by
graft or rotation flap
Initiate POD 2 or 3 STSG
OOB to
chair with POD 3 Rotational flap
LE elevated
Neutral dorsiflexion splint to
affected extremity as ordered
Initiate POD 4 STSG
Dangling
POD 5 Rotational flap
Progression 1st day: 5 minutes TID
of dangling
Increase 5 minutes TID q day
Monitor for signs of
Revised 04/18/2013 TNKelley, CRNP/ ERodriguez, MD
SUMMARY OF ACTIVITY & DANGLING PROTOCOL
Free Flap to extremity Free Flap to head or neck Free Flap to Chest (i.e. DIEP)
Same intra-op position for 24hrs Same intra-op position x 24hrs HOB(~30-40◦) x 24hrs
No dangling. LE donor site elevated 2 pillows Waist flexed in “Beach Chair”
Donor site elevated 2 pillows if UE donor site elevated 2 pillows position
on contralateral side Prone position prohibited
POD 1: distal and unaffected POD 1: Elevate HOB 15 degrees POD 1: Log roll side to side ~ 30◦
joints x24hrs. Abduction/Forward flexion of
*NO lateral head turning shoulders limited to ~90◦
POD 7: joints in close proximity POD 2: Rotate Head 15 degrees Keep elbows lower than 3rd-4th
Left/Right intercostal space
POD 14: joints crossed by free Progress ROM of head/neck per PRS
flap team. ROM will be strictly limited for
minimum of 7 days.
Strict bedrest x 72 hrs POD 2: Elevate HOB 30-45 ◦ POD 3: OOB with Abdominal Binder.
POD 3: OOB Ambulate as tolerated
POD 3 – OOB
Neutral dorsiflexion splint to
affected extremity as ordered
POD 10-14 (usually closer to POD 3: May dangle donor extremity
14) site
1st day (POD 10-14) 5 minutes Donor site as tolerated
TID
Increase by 5 minutes every 3rd
day as tolerated.
Monitor for signs of
9
 complications, contact plastics complications, contact plastics
& hold dangle for concerns & hold dangle for concerns

Dressing As ordered, or Dressing as ordered As ordered to face As ordered

Non-adherent dressing
followed by moist gauze,
Kerlex, then ACE wraps
Weight May begin weight bearing
Bearing when cleared by plastics
and/or orthopedics
As ordered to donor site Xeroform to suture lines
*NO ace wraps
May begin weight bearing when NWB if Fibula donor for 4-6wks No lifting > 10lbs with upper
cleared by plastics and/or FWB/ROM if Iliac or ALT extremities
orthopedics (AnteroLateral thigh) donor No “sit-ups” x 4-6 weeks

Revised 04/18/2013 TNKelley, CRNP/ ERodriguez, MD 10