Elderly Patients

A common criticism of free flap reconstruction is that the techniques are complex and time consuming, and some clinicians are reluctant to subject elderly patients to free flap reconstruction for fear of a higher potential complication rate attributable to prolonged anesthesia. Many studies in recent years have shown no relationship between age and increased complication rates in patients undergoing free flap reconstruction.14-18 A study completed at our institution did not find significant differences in major surgical and medical complications in patients < 50 and > 50 years of age undergoing free flap reconstruction. The overall flap survival was 99%, and the authors concluded that advanced chronologic age alone does not play a significant role in surgical outcome and should not preclude free tissue transfer.14 A similar study by Urken et al., in patients older than 70 years of age undergoing free flap reconstruction did not find any differences in complications rates when stratified for premorbid factors including age; overall flap survival was 94% in this group.15 This is not to state that all free flaps in older patients are without risk; chronologic age, however, is not as important as biologic or physiologic age, as determined by the American Society of Anesthesiologists (ASA) classification of physical status, in predicting the risk of postoperative morbidity and mortality.14-16

The risk of major medical complications is highest for those patients judged to be ASA classes 3 or 4, with bronchopulmonary and cardiovascular events predominating.14'15'18 Postoperative pulmonary complications increased with age for all patients with head and neck cancer.37 Aging is associated with decreased vital capacity and increased alveolar-arterial oxygen gradient; compounding this is the decreased ability of head and neck cancer patients to protect the airway due to tumor or extirpative surgery.7,15 A history of smoking was found to be the most significant risk factor for the development of postoperative pulmonary complications in the head and neck surgery patient: the relative risk was calculated as 24 times the risk for non-smokers with risk increasing 3.6 times with each division of increased smoking history.7 The age of the patient, as it relates to the physiologic changes of the bronchopulmonary system and length of smoking, does appear to increase the risk of postoperative pulmonary complications. These facts, rather than precluding older patients from free flap reconstruction, should encourage strict protocols that minimize risks and maximize flap survival. At our institution, for all elderly patients scheduled for flap surgery, an electrocardiogram, chest radiograph, pulmonary function test, and hematologic and biochemical tests are performed and an ASA grade assigned. We have a dedicated expert in anesthesia as a member of our team managing head and neck patients. Invasive monitoring, careful intraoperative fluid management, and measures to ensure a warm, vasodilated patient are other key ingredients for flap success. Postoperatively, meticulous fluid and electrolyte balance, aggressive pulmonary toilet, and vigilant monitoring of the flap in special care units ensure against avoidable complications.

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