Factors affecting outcome in free-tissue transfer in the elderly

Free-tissue transfers have become the preferred surgical technique to treat complex reconstructive defects. Because these procedures typically require longer operative times and recovery periods, the applicability of free-fla p reconstruction in the elderly continues to require ongoing review. The au thors performed a retrospective analysis of 100 patients aged 65 years and older who underwent free-tissue transfers to determine preoperative and int raoperative predictors of surgical complications, medical complications, an d reconstructive failures. The parameters studied included patient demograp hics, past medical history, American Society of Anesthesiology (ASA) status , site and cause of the defect, the free tissue transferred, operative time , and postoperative complications, including free-flap success or failure. The mean age of the patients was 72 years. A total of 46 patients underwent free-tissue transfer after head and neck ablation, 27 underwent lower extr emity reconstruction in the setting of peripheral vascular disease, 10 had lower extremity traumatic wounds, nine had breast reconstructions, four had infected wounds, two had chronic wounds, and two underwent transfer for lo wer extremity tumor ablation. Two patients had an ASA status of 1, 49 patie nts had a status of 2, 45 patients had a status of 3, and four had a status of 4. A total of 104 flaps were transferred in these 100 patients. There w ere 49 radial forearm flaps, 34 rectus abdominis flaps, seven latissimus do rsi flaps, seven fibular osteocutaneous flaps, three omental flaps, three j ejunal flaps, and one lateral arm flap. Four patients had planned double fr ee flaps for their reconstruction. Mean operative time was 7.8 hours (range , 3.5 to 16.5 hours). The overall flap success rate was 91 percent, and the overall reconstructive success rate was 92 percent. There were six additio nal reconstructive failures related to flap loss, all of which occurred mor e than 1 month after surgery. Patients with a higher ASA designation experi enced more medical complications (p = 0.03) but not surgical complications. Increased operative time resulted in more surgical complications (p = 0.01 9). All eight cases of reconstructive failure occurred in patients undergoi ng limb salvage surgery in the setting of peripheral vascular disease. Free -tissue transfer in the elderly population demonstrates similar success rat es to those of the general population. Age alone should not be considered a contraindication or an independent risk factor for free-tissue transfer. A SA status and length of operative time are significant predictors of postop erative medical and surgical morbidity. The higher rate of reconstructive f ailure in the elderly peripheral vascular disease population compares favor ably with other treatment modalities for this disease process.