Wester JL, Lindau RH, Wax MK. Efficacy of Free Flap Reconstruction of the Head and Neck in Patients 90 Years and Older. JAMA Otolaryngol Head Neck Surg. 2013;139(1):49-53. doi:10.1001/jamaoto.2013.1138
Author Affiliations: Department of Otolaryngology–Head & Neck Surgery (Drs Lindau and Wax), Oregon Health and Science University, Portland. Mr Wester is a medical student at the School of Medicine, Oregon Health and Science University.
Objective To determine the efficacy of free flap reconstruction in patients 90 years and older.
Design Retrospective medical chart review.
Setting Academic medical center.
Patients Patients 90 years and older who underwent a free flap reconstruction from 2002 through 2011 were identified.
Main Outcome Measures Clinical, demographic, and procedural data were recorded. Complications of surgery were either medical or flap related. Long-term follow-up was recorded to determine late flap complications, donor site morbidity, and functional outcomes.
Results Of 847 free flaps, 10 (1.2%) were performed in patients 90 years and older, with a median follow-up time of 8.5 months. Four medical complications (40%) occurred (1 case of pneumonia and 3 cases of arrhythmia). There were no mortalities. Two recipient site complications (20%) occurred (1 infection and 1 fistula). The flap failure rate was 0%. One late complication developed 7 months postoperatively involving infection and nonunion of the mandibular reconstruction. There was donor site morbidity in 1 patient. Functional status returned to baseline in 8 patients (80%) at the last follow-up visit.
Conclusions Medical and flap-related complications in patients 90 years and older are consistent with rates previously reported in elderly patients. Furthermore, patients 90 years and older can tolerate free flap reconstruction with favorable long-term outcomes.
The population 90 years and older is rapidly expanding. According to the US Census Bureau,1 in the past 3 decades, the number of Americans 90 years and older has tripled, reaching 1.9 million in 2010. By 2050, the 90-years-and-older population is predicted to more than quadruple, reaching 8 million, and account for 10% of the elderly population 65 years and older.1 In light of these population shifts, we are seeing more patients 90 years and older undergoing ablative head and neck procedures. Although free flaps are considered the standard of care for most defect closures of the head and neck, there is still hesitancy to use them in very elderly patients, given the expected perioperative difficulties.2- 4 These include preexisting medical conditions, prolonged operative time, an inability to handle metabolic stresses of surgery, and insufficient healing.5- 7
To date, there are several studies that have investigated outcomes of free flap reconstruction in elderly patients. These studies universally acknowledge that age increases risk of overall complications, although it is not a barrier or contraindication to surgery. Old age also does not seem to correlate with surgical outcomes or flap success.4,8- 14 Variations of what age is considered elderly, however, range from 50 to 80 years old.4,8,10- 14 We used the US Census Bureau definition of elderly as older than 65 years, with those 90 years and older considered very elderly. To our knowledge, no studies to date have exclusively investigated flap outcomes in patients 90 years and older; therefore, little data exist about the outcomes in this group. The purpose of our study was to determine the efficacy of free flap reconstruction of the head and neck in patients 90 years and older.
We retrospectively reviewed the medical charts of patients who underwent a free flap reconstruction after head and neck surgery from 2002 through 2011 at Oregon Health and Science University (OHSU), an academic tertiary-care referral center. Patients were identified by querying the microvascular reconstructive database. Only patients 90 years and older at the time of surgery were included. Demographic and clinical information was then recorded. Patient characteristics included age, sex, tumor diagnosis, medical comorbidities, and American Society of Anesthesiologists (ASA) class15 (class 1, normal, healthy individual; class 2, patient with mild systemic disease; class 3, patient with severe systemic disease; class 4, patient with severe systemic disease that is a constant threat to life; and class 5, moribund patient who is not expected to survive without the operation). Medical comorbidities included history of stroke or myocardial infarction, diabetes, peripheral vascular disease, chronic obstructive pulmonary disease, hypertension, and other. Free flap donor sites are given in Table 1. All flaps were monitored with a standard protocol and internal Doppler postoperatively.
Complications were categorized as medical or flap related. Medical complications included perioperative death, myocardial infarction, arrhythmias, deep venous thrombosis, pulmonary embolism, stroke or transient ischemic attack, pneumonia, delirium, and other. Flap complications were either related to the recipient site or the donor site. Recipient site complications included flap failure, flap take back, breakdown or dehiscence, wound infection, hematoma, and fistula. Donor site morbidities included breakdown or dehiscence, loss of split thickness skin graft (STSG), infection, hematoma, seroma, prolonged healing, and functional limitation (weakness, paresthesia, or reduced range of motion). Long-term follow-up was additionally reviewed for late complications occurring outside of the perioperative period, donor site healing time, STSG take, functional status as compared with that before surgery, and time to disease recurrence. Death records and patient medical charts were reviewed to estimate the median duration of life achieved after resection and reconstruction.
Over this period, 10 of 847 free flap reconstructions (1.2%) were performed on patients 90 years and older. The median age of our patients was 91 years (range, 90-96 years) (Table 2). Patient characteristics are given in Table 2. Radial forearm free flaps were most commonly used (50%), one of which was an osteocutaneous flap (Table 1). Table 3 gives the free flap reconstruction results including median procedure length; medical-, surgical-, and flap-related complication rates; flap survival; length of hospitalization; and follow-up time. Seven patients (70%) had at least 1 complication (Table 4). There were 2 recipient site complications (20%) including 1 seroma, which secondarily developed into an infection, and 1 orocutaneous fistula. The recipient site infection healed completely within 2 months. The fistula resolved without intervention. The flap failure rate was 0%. There was 1 intraoperative complication for hand ischemia involving laceration of the ulnar artery during radial forearm free flap harvest that required an ulnar artery repair.
There were 4 medical complications (40%) (1 case of pneumonia and 3 cases of arrhythmia) (Table 4). All 3 patients who developed arrhythmias postoperatively were in normal sinus rhythm by discharge. One patient required direct current cardioversion and overnight intensive care unit admission. The patient who developed pneumonia had secondary complications of mucous plugging necessitating transfer to the intensive care unit and prolonged hospitalization. After resolution of the pneumonia, the patient recovered rapidly and was discharged in stable condition. Ultimately, however, the patient died 1 month after discharge. No other patients required intensive care unit admission and all were cared for on our surgical ward postoperatively.
Of the 10 patients, 9 (90%) were seen in clinic after hospital discharge, with a median follow-up time of 8.5 months (range, 1-60 months) (Table 3). On long-term follow-up, 1 late complication developed where the mandibular hardware became secondarily infected 7 months postoperatively in a patient who underwent an osteocutaneous radial forearm free flap procedure (Table 4). There was nonunion of the mandibular reconstruction requiring removal of the radial bone and hardware with transoral closure. The infection resolved. In addition, there was 1 donor site morbidity requiring rehospitalization for infection of the donor site and sepsis. After treatment with intravenous antibiotics the infection resolved, and there was an 80% take of the STSG. Overall, STSGs were used in 8 of 10 patients (80%). Six STSGs were used for closure of the donor site, and 2 were used in conjunction with latissimus dorsi flaps at the recipient sites. Two patients with anterolateral thigh flaps had primary closure of the donor sites and did not require STSGs. All STSGs had greater than 70% take and were fully healed within 2 months after surgery (Table 4). Four patients required tracheostomy during their procedure, and 3 of the 4 (75%) were decannulated prior to discharge.
Of the 10 patients, 8 (80%) were living independently before surgery. Seven of these patients returned to independent social situations. One patient who was previously independent developed multiple recurrences while recuperating in a skilled nursing unit and never left. Four patients developed recurrent disease (median time to recurrence, 3.5 months; range, 1-12 months). The patients who developed recurrent disease had a median survival of 6.5 months (range, 3-13 months) (Table 4). The median survival based on last follow-up or date of death for patients without known recurrence of disease was 23.5 months (range, 2-60 months). Four patients had normal diets at the last follow-up visit, 4 had modified diets (pureed or mechanical soft), and 2 required feeding tubes to maintain nourishment. Speech was intelligible in all patients during follow-up.
Elderly individuals are the most rapidly growing subset of the US population.5 These numbers are expected to continue expanding, with those 90 years and older representing a much larger proportion of the elderly.1 Although case studies exist of successful free flap reconstruction of the head and neck in patients 90 years and older, to our knowledge, no studies have looked specifically at outcomes in this subset of the elderly population.16,17 Microvascular free flap reconstruction is the preferred procedure for defect closure after ablative surgical procedures of the head and neck. Free flaps are versatile, have superior functional and aesthetic results, and have high success rates with relatively minor differences in morbidity or cost compared with other forms of reconstruction.2,3,7,18- 21 However, free flaps often require longer operative time, which is an important consideration in elderly patients. While improved perioperative care has allowed surgeons to operate on high-risk elderly patients, guidelines are still not clear when to use primary closure for decreased surgical time as opposed to a functionally and aesthetically superior free flap.14 The balance of preoperative surgical risk, postoperative functional benefit, and quality of life is not always simple in very elderly patients, and thus free flap reconstruction requires careful consideration by the surgeon.7 Several previous studies have explored age as a factor in outcomes after free flap reconstruction, although few included patients 90 years and older.8- 14
Shestak et al8 and Shaari et al10 published some of the first studies to conclude that chronologic age should not be a decisive factor when considering a patient for free flap reconstruction. These studies reported flap successes of 99% and 100%, respectively. Beausang et al13 also showed a flap survival of 96% in patients older than 70 years (n = 53), which was higher than the overall series of the younger cohort. Interestingly, younger patients in their study had significantly less medical complications postoperatively.
Blackwell et al12 were the first to describe outcomes in octogenarians undergoing free flap reconstruction of the head and neck (n = 13). Their study showed 100% flap survival with only 1 complication limited to a minor donor site infection. While they concluded that free flaps were dependable in this age group, they cautioned against using free flaps in those at an advanced age, given a 4-fold increase in medical complication rates compared with a younger cohort (62% vs 15%). Even when controlling for a higher ASA class in octogenarians, there was still a statistically higher complication rate in elderly patients (67% vs 29%).
In an article published by Howard et al,4 the authors described 197 patients aged 70 to 79 years (n = 170) and 80 years and older (n = 27). This study was not limited to free flaps of the head and neck, although most (95%) fell under this category. Flap success was 100% for patients 80 years and older and 96.5% for those aged 70 to 79 years. Nevertheless, they found a significantly higher overall complication rate (59.3% vs 35.3%), medical complication rate (40.7% vs 11.8%), and perioperative mortality (18.5% vs 7.7%) in patients 80 years and older compared with those aged 70 to 79 years. Despite this, the authors concluded that free flap surgery can be performed successfully in well-selected elderly patients, but with increased medical complications.
Kesting et el14 recently published the first prospective trial comparing complication rates and short-term outcomes in older and younger adults after free flap reconstruction of the head and neck. Using age 70 years and older as their cutoff for elderly (n = 54), they found that older age (≥70 years vs 20-69 years) was associated with a higher overall complication rate (72.2% vs 49.7%). Age had no influence, however, on length of hospital stay, flap success, need for revisions, or mortality. This study only included 1 patient older than 90 years who had a successful flap.
In our study, we found that medical complications (40%), surgical complications (10%), flap survival (100%), and mortality rate (0%) of patients 90 years and older are consistent with previous studies of elderly patients, which range from 19% to 72%, 8% to 42%, 96% to 100%, and 0% to 18.5%, respectively.4,8- 10,12- 14,22 In addition, we compared our results with patients aged 70 to 79 years and 80 to 89 years during the same period at our own institution (unpublished data, 2012). There were 147 flap procedures performed on 136 patients aged 70 to 79 years. The flap-related complication rate was 27%, and the flap failure rate was 6.1%. Medical complications occurred in 23.5% of patients, with a mortality rate of 2%. In the group of patients aged 80 to 89 years, there were 72 flap procedures performed on 63 patients. The flap-related complication rate was 22%, with a flap failure of 2.8%. Medical complications occurred in 23.8% of patients, with a mortality rate of 3%. In comparison, our results suggest that medical complications are more common in patients 90 years and older. However, we observed no mortality, surgical and flap complications were minimal, and we had a high flap success rate. The durability of free flap reconstruction has consistently been shown to be reliable in the prior studies mentioned across all age groups. Medical morbidity, on the other hand, is highly variable in elderly patients, particularly in those older than 80 years, owing to small patient numbers.
Although rare, late flap failures can be caused by infection several months after a patient is discharged from the hospital.23 One patient in our study had a late complication secondary to an infection, and their flap was removed. The infection, however, went untreated for a prolonged period before she was seen at follow-up, and this likely contributed to her outcome. In this case, we believe that the poor follow-up was secondary to the patient living several hours away and being managed medically in her home town, rather than to limitations because of her age.
In addition to medical and surgical complications, long-term functional impairment and overall well-being can be unfavorably affected by head and neck surgery.24 Free flaps are one way to minimize the adverse functional outcomes of large ablative procedures, although studying long-term results in very elderly patients is often difficult.21,25,26 In general, impairment of activity such as swallowing after head and neck surgery is expected to be greater in elderly patients compared with younger individuals.24,26,27 Worse functional impairment, however, can also be attributed to the normal aging process and should always be considered when selecting patients for surgery.
In our study, oral cancer resection was the most common indication for a free flap in 6 of 10 patients. Diet was most adversely affected, secondary to difficulties chewing and swallowing, with only 4 patients having a completely normal diet at the last follow-up visit. Only 2 patients required feeding tubes to maintain nourishment, one of which preserved some aspect of transoral diet. Speech was intelligible in all patients, and the majority were followed up by speech and language pathologists for rehabilitation. Unique to free flaps are the possible additional physical impairments from donor site morbidity. This was not, however, a significant impact in our study and was limited to 1 minor donor site infection. Of note, no fibular free flaps were performed in our study group, which in our experience with elderly patients has been associated with higher morbidity. Particularly, we have found that rehabilitation after a fibular free flap is generally more difficult and has the potential to leave elderly patients with long-term functional impairment in their ability to ambulate postoperatively.
Despite these expected local impairments after free flap reconstruction, the majority of patients 90 years and older were able to recover to their preoperative functional status and return to living independently. Obviously, many attributes that compose one's function of daily living were not evaluated or lacked data in long-term follow-up. Further studies using validated quality-of-life assessment tools would be helpful. These types of studies will become increasingly important, as more elderly patients are able to tolerate large procedures with high success rates of free flap reconstruction.
Another key point to emphasize in our study is the selection bias in choosing which patients will undergo free flap reconstruction. Careful selection of both the patients and planned flaps are critical to the success of reconstruction in elderly patients. Because this was a retrospective study, we have little information or data on patients who were deemed to be unsuitable for a free flap. As mentioned previously, no fibula free flaps were performed in our study group, which may contribute to our low flap complication rate. Our study is also limited by a small sample size, despite a 10-year study period. Larger studies will likely have to be multi-institutional, since patients 90 years and older represent a small, albeit increasing, subpopulation of the elderly. We considered comparing this group with the younger groups mentioned previously; however, the small numbers would make interpretation difficult, and statistical analysis would not be clinically relevant. Despite these study limitations, our results illustrate that free flap reconstruction can be successfully performed in patients 90 years and older, although with a high likelihood of medical complications.
In conclusion, our data suggest that medical- and flap-related complications in patients 90 years and older are acceptable and they can tolerate free flap reconstruction with favorable long-term outcomes. Thus, age 90 years and older should not preclude the use of free flaps as a safe and highly effective reconstructive tool after head and neck surgery.
Correspondence: Mark K. Wax, MD, FRCS, Department of Otolaryngology–Head & Neck Surgery, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, Mail Code PV-01, Portland, OR 97239 (firstname.lastname@example.org).
Submitted for Publication: August 10, 2012; final revision received October 3, 2012; accepted October 17, 2012.
Author Contributions: All authors had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Wester and Wax. Acquisition of data: Wester, Lindau, and Wax. Analysis and interpretation of data: Wester, Lindau, and Wax. Drafting of the manuscript: Wester and Lindau. Critical revision of the manuscript for important intellectual content: Wester and Wax. Administrative, technical, and material support: Lindau and Wax. Study supervision: Lindau and Wax.
Conflict of Interest Disclosures: None reported.
Previous Presentation: This study was presented as a poster at the Eighth International Conference on Head and Neck Cancer; July 21-25, 2012; Toronto, Ontario, Canada.