Experiences with microsurgical tissue transfers in elderly patients

The combination of advances in microsurgery and the improvement of anesthetic management with increased understanding of the physiology of preoperative and postoperative care has significantly raised the upper age limit for free-flap transfer in elderly patients. Despite pessimistic opinions regarding elderly patients who have poor recovery potential and decreased physiological reserves, the unique feature of free-tissue transfer is that it allows the transfer of well-vascularized tissue to defects in a single-stage procedure, and leads to improved quality of life. In this report, a retrospective analysis of 55 patients aged 50 and older who underwent microsurgical tissue transfer is presented. Hospital and our own records were used to review various parameters. The preoperative medical status of each patient was assessed using the American Society of Anesthesiologists (ASA) Classification of Physical Status. Each patient's preoperative medical records, age, sex, transferred tissue type, and length of operation were outlined. Postoperative recorded parameters were the fate of flaps and the short-term postoperative outcome, including surgical complications, medical morbidity, and death within 30 days of surgery. Fifty-eight microvascular tissue transfers were performed in 55 consecutive patients. The study comprised 38 male and 17 female patients, with a mean age of 64.8 years. ASA classification status was class 1 for 15 patients, class 2 for 26 patients, and class 3 for 14 patients. Twenty-five flaps were used for lower extremity reconstruction, 32 flaps were used for head and neck reconstruction, and 1 was used for breast reconstruction. The average operative time was 5.7 h, ranging between 2-13 h. There were 14 major medical complications, resulting in an overall medical complication rate of 25%. There were 3 deaths within 30 days postoperatively. Thus, the overall surgical mortality rate was 5.4%. The longer operation times were associated with the development of postoperative total medical and surgical complications (P = 0.008). While the relationship between ASA class and medical complications was significant (P = 0.0007), no significant relation was determined between ASA class and surgical complications (P = 0.66). It was revealed that the greater the age group, the greater the occurrence of postoperative medical complications (P = 0.0001). The relationship between postoperative surgical complications and age groups was not significant (P = 0.07). It was also demonstrated that the advanced age of patients was associated with a higher ASA class (P = 0.0017). Eleven flaps required reoperation for vascular compromise. While 10 of these were salvaged with vascular anastomosis revisions, one flap was lost. Thus the overall flap success rate was 98.3%. In conclusion, if a patient's medical problems do not constitute a handicap, age itself should not be considered a barrier to free-flap transfer. It is important to be familiar with preoperative medical problems and possible postoperative medical complications in order to achieve a successful outcome. Contrary to what is generally suggested, surgical complications do not constitute a special consideration in older patients.