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Outcomes of Free-Flap Reconstructive Microsurgery in Frail Head and Neck Patients
Roee Noy1, Monther Graieb2, Yotam Shkedy3
1Resident, Department of Otolaryngology - Head and Neck Surgery, Rambam Health Care Campus, Haifa, Israel; Resident, Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel.
Background:
Head and neck cancer frequently requires extensive ablative surgery, often resulting in complex defects that necessitate microvascular free-flap reconstruction. Optimizing perioperative management in these patients is essential to reduce complications and improve surgical outcomes.
Purpose:
This study aimed to evaluate the safety and feasibility of head and neck microsurgical reconstruction in frail patients.
Study Design, Setting, Sample:
This retrospective cohort study included subjects who underwent free-flap reconstruction for head and neck defects at Rambam Healthcare Campus, Haifa, Israel, a tertiary referral center. Patients with incomplete records or inadequate follow-up were excluded.
Predictor Variable:
Frailty was assessed using the modified 5-item frailty index (mFI-5) (higher scores indicate greater frailty) and the Norton scale (lower scores indicate greater frailty), with frailty defined as mFI-5 ≥2 or Norton ≤14.
Main Outcome Variables:
The primary outcome was free-flap success in frail patients, defined by flap viability at 1 month as complete survival, partial loss, or complete failure. Secondary outcomes included postoperative complications, length of stay, 30-day reoperation, and emergency department visit rates, and 30-day and 1-year mortality (time-to-event).
Covariates:
Demographic data, subject-specific factors, and surgical outcomes.
Analyses:
Univariate and multivariable analyses. A P value of < .05 was considered statistically significant (two-tailed).
Results:
One hundred and twelve subjects met the inclusion criteria (mean age 56.2 years, SD 5; 63.3% male). Of these, 34(30.3%) had an mFI-5 score ≥2, and 5(4.5%) had a Norton scale score ≤14. Frail patients demonstrated similar outcomes compared to nonfrail patients, including proportions of free-flap success (29/36 vs 61/76, P = .9), postoperative complications (13/36 vs 27/76, P = .9), reoperation rates (9/36 vs 16/76, P = .8), and 30-day mortality (1/36 vs 0/76, P = .7). Patients with mFI-5 ≥2 demonstrated significantly higher 1-year mortality compared with those with mFI-5 <2. On Kaplan-Meier analysis, frail subjects showed reduced overall survival (log-rank P = .01). In addition, subjects with Norton ≤14 had significantly higher 30-day emergency department visit rates compared with those with higher Norton scores (60 vs 14%, P = .03). Surgical site infection was the only factor linked to flap failure (adjusted odds ratio, 0.27; 95% CI: 0.03 to 0.8).
Conclusions And Relevance:
In patients undergoing head and neck free-flap microvascular reconstruction, frailty was not associated with higher rates of flap failure, reoperation, or postoperative complications. Further research is needed to evaluate additional risk stratification tools in these patients.
