Timing and Necessity of Dangling after Lower Limb Free Flap Reconstruction: A Systematic Review and Meta-Analysis

Abstract Dangling (graduated limb dependency) is widely used after lower limb free flap reconstruction, but protocols vary and its clinical benefit is uncertain. Previous reviews have examined the timing or intensity of dangling in patients who all underwent dangling; recently published randomized evidence allows its necessity to be considered. We systematically searched Medline, Embase, Cochrane Library and three trial registries to March 2026 for clinical studies of lower limb free tissue transfer reporting a defined dangling protocol or unrestricted mobilization. Eighteen studies (845 patients or cases) were included and pooled in random-effects single-arm meta-analyses of flap survival, with subgroup analyses by dangling strategy and mean patient age. Pooled flap survival was high (97–98%) with low heterogeneity, and did not differ significantly between early, late and no-dangling strategies or between age groups. Early dangling or unrestricted mobilization was not associated with more complications and was associated with comparable or shorter hospital stay in several cohorts. Because most studies were non-comparative and direct comparative evidence is limited, these findings indicate that a benefit of formal dangling has not been demonstrated, rather than that no benefit exists. Adequately powered randomized trials within enhanced recovery pathways, including patient-reported outcomes, are needed.