This review examined the relationship between free flap survival in older patients and whether this correlated with specific co-morbid conditions and a ‘cut off’ age.
The authors did exclude some papers that specifically focused on one co-morbid condition, such as diabetes, which may have biased the overall results given this was a particular co-morbidity of interest. Data was pooled and stratified to a series of age groups, however, severity of co-morbid conditions were based on a varied group of scoring systems thus limiting aspects of a comparative analysis to fewer papers. Perhaps flap related reports should be standardised by having to report ASA grade as a minimum to allow some form of coherent comparative analysis. Overall this study did report some interesting trends. Flap success, donor complications and overall complications increased with age. Significantly more elderly patients were on aspirin versus younger cohorts. Of interest, this study isolated diabetes and chronic obstructive pulmonary disease (COPD) as two co-morbid conditions that significantly impair free flap success, whereas cardiovascular disease did not.

The discussion could have explored these results in more depth. For example, it is touched upon that advanced age may not be disadvantageous because these patients are physiologically selected, but paradoxically, if they have more overall complications of surgery, it is possible there is no subsequent physiological reserve to heal appropriately. In addition, significantly more elderly patients taking aspirin may be a source of the superior flap survival rates observed. Ultimately, flap survival is a good end point but in head and neck surgery aspects of the demographic are changing. The typical young nutritionally bereft tobacco and alcohol abusers are now HPV positive non-smokers. Thus, elderly patients requiring head and neck reconstruction will possibly be represented by more people with advanced soft tissue tumours and cutaneous cancers where status is superior and they are physiologically superior to the head and neck cancer sufferers of recent decades. Nonetheless, this review supports many of our practices worldwide that the best chance of a single stage reconstructive solution is microsurgical.

Relationships of comorbidities and old age with postoperative complications of head and neck free flaps: A review.
Hwang K, Lee JP, Yoo SY, H Kim.


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Daniel B Saleh

Newcastle Hospitals, UK.

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