Microvascular free-tissue transfer, a reliable technique for head and neck reconstruction, was introduced in 1959 5
. Consistent success rates of 90-99% have been reported 6
. Complications can be divided into three main groups: general condition-related, recipient area-related and procedure- related.
Population demographics show a growing proportion of elderly people, and age has been regarded frequently as an independent risk factor for poor surgical outcome. Before the 1960s, the operative mortality rate for elderly patients undergoing elective surgery was two to six times higher than that in the general population 7
. Several wellaccepted reasons explain this difference. The first factor is heart failure; an elderly patient's ageing heart has a less efficient cardiac output when placed under the stress of surgery and anaesthesia 8
, and this condition is accompanied by lower renal blood flow resulting in larger water and electrolyte imbalances. The second factor is the compromise of pulmonary function with increased age due to smaller vital capacities and poorer gas exchange resulting from lung parenchyma deterioration 9
. However, the mortality rate in elderly patients has declined in the past 40 years. Today, the overall surgical mortality rate is about 0.9-2.4%, even for patients with cardiac disease 10
, largely as result of safer anaesthesia techniques. In addition, the average life expectancy of a 70-year-old man is 11 years and that of a 70-year-old woman is 14 years 11
In the literature, no exact age seems to be associated with the word ''elderly''. However, this lack of precision is not entirely relevant, as surgical indications should be based not on age, but on risk assessment. The ASA score is a commonly recommended tool for risk assessment 12
Studies of free-flap use have been conducted in elderly patients aged 50 13
, 60 14
, 65 3
, and 70 2
years. The flap loss rate in these studies ranged from 1% in a 92-patient series 6
to 16.7% in a 47-patient series 7
. This variation illustrates the difficulties of precisely defining the term ''elderly'' and of predicting morbidity rates in elderly patients. Many studies examining the relationship between age and free-flap complication have demonstrated that age is not an important factor influencing the success of microvascular free-flap transfer. However, surgery is often avoided in elderly patients because of the increased likelihood of various complications, regardless of the type of procedure chosen. In 1999, Pompei et al. 15
reported the results of 392 head and neck flap reconstructions, including those employing pedicled flaps; the authors found that complications in elderly patients were correlated with comorbidities, but not with age or operation length.
In 2000, Serletti et al. 3
analyzed 104 free-flap procedures in patients aged ≥ 65 years, and concluded that free-flap transfer in elderly patients achieved a success rate similar to that in the general population. They concluded that age alone should not be considered a contraindication or an independent risk factor when considering free-tissue transfer. The authors believed that ASA status was a reliable predictor of postoperative medical and surgical morbidity. They found that an operative time > 10 h was a significant factor in the development of postoperative surgical complications. Because elderly patients are also less capable of handling large fluid shifts and significant blood loss, proper fluid management and protein–calorie balance are important. Another significant factor in reconstruction failure seems to be the presence of peripheral vascular disease.
In 1994, Bridger et al. 16
found no significant difference in the rate of postoperative surgical complications between patients older (42%) and younger (37%) than 70 years, and concluded that age alone should not contraindicate head and neck microvascular procedures. Furthermore, in 2006, Classen and Ward 3
analyzed the complications of free-flap operations using the donor-site, flap and systemic complication categories. They found that age influenced only the systemic complication rate.
All of these studies evaluated factors that can lead to freeflap complication. However, precise analyses of how age influences free-flap complication have been infrequent. Moreover, some previous studies have included pedicled flaps in the analysis and have presented simple numerical complication rates without performing statistical analysis. Most of these studies have reported that age does not impact the free-flap complication rate, but the results have varied; a significant number of studies have reported that age may influence the rate of systemic complications.
In the present study, we assessed age as a variable affecting free-flap complication rate, morbidity and functional outcome. The proportion of elderly people with head and neck cancer is rising due to an overall increase in life expectancy. Our study used a 75-year cut-off value to define the elderly age group because no previously published paper has considered "elderly" patients of this age. Indeed, we believe it is valuable to assess similarly aged patients with head and neck cancer using a precisely defined cut-off value. The appropriate cut-off value for the definition of elderly patients has been a matter of much debate: Bonawitz et al. 12
defined elderly patients as those aged ≥ 60 years, Shestak and Jones 11
used a cut-off age of 50 years and Serletti 3
used 65 years.
In the present study, age was considered a continuous variable in the analysis of its association with donor-site, flap, systemic complications and major and minor surgical complication rates. Functional outcomes were also evaluated in both groups. No pedicled flap was included in this analysis. The major surgical complication rate was 9% in the young group and 11% in the elderly group.
Our results are similar to those of other published series. Shestak et al. 13
reviewed 19 patients who underwent microvascular head and neck reconstruction and found a 16% major surgical complication rate in patients aged ≥ 70 years, compared with 13% in patients aged < 70 years.
In the present study, multivariate analysis showed that ASA score was the only variable associated with an increased complication rate.
Similar to the findings of another recent report 16
, the present study found a higher medical morbidity rate in elderly patients, with two complications (postoperative delirium) occurring. Chick et al. 17
found that medical complications occurred in 35% of elderly patients, compared with 10% of younger patients.
In the present study, one elderly patient died during surgery; no death occurred in the younger population. Morgan et al. 18
noted that perioperative mortality increased significantly with age, but most series have reported rates of 3–6% in elderly patients undergoing head and neck reconstruction 19
. The present study also found no significant difference between the two groups in long-term swallowing, speech and chewing functions. Peri- and postoperative complications were correlated with ASA status.
In conclusion, the present analysis indicates that free-flap microvascular reconstruction can be considered a safe procedure in elderly patients with head and neck cancer. Surgical complication rates do not appear to increase in elderly patients compared with younger patients. Only slightly more systemic complications occurred in the elderly group than in the younger group in this study.