Free flap head and neck reconstruction in the elderly: what is the impact on quality of life?

Frailty as a predictor of adverse outcomes in head and neck reconstruction: A systematic review

BACKGROUND

Frailty has been shown to adversely impact outcomes in a number of surgical disciplines. In head and neck reconstructive surgery, frailty may represent a significant risk factor in predicting post-operative outcomes due to the common characteristics of the patient population undergoing these procedures.

OBJECTIVES

To summarize the available evidence about frailty as a predictor of post-operative complications, length of hospital stay and quality of life in patients undergoing head and neck reconstructive surgery.

STUDY DESIGN

Systematic Review.

METHODS

The study protocol was registered with PROSPERO, registration CRD42022302899. Methodology was in keeping with the PRISMA Guidelines for Systematic Reviews. MEDLINE, SCOPUS, EMBASE, Web of Science and CENTRAL were the databases searched. Qualitative synthesis of the included studies was carried out, and quality assessment was performed.

RESULTS

Nine studies that reported data on 10,457 patients undergoing reconstruction of the head and neck were included in the review. A number of different tools were used to assess frailty, with the modified frailty index being the most frequently used. In total, 8 studies reported increased rates of complications in patients with increased levels of frailty, irrespective of the frailty tool used, with varied levels of statistical significance across the studies.

CONCLUSION

An association is observed between increased rates of perioperative complications and increased levels of frailty in patients undergoing head and neck reconstruction. Frailty tools may represent a useful method to risk stratify patients undergoing reconstructive head and neck surgery.

Hyperspectral Imaging Allows Evaluation of Free Flaps in Craniomaxillofacial Reconstruction

INTRODUCTION

Treatment of extended defects after tumor resection in oral, maxillofacial, and facial surgery (craniomaxillofacial) is usually performed by free microvascular flaps. Evaluation of flap survival is crucial, especially in the first hours after insertion and connection. For flap evaluation various invasive and noninvasive methods have been developed. This retrospective clinical study examined the ability of a hyperspectral imaging (HSI) camera (Tivita, Diaspective Vision, Germany) to assess postoperative flap properties in comparison to established clinical parameters.

MATERIALS AND METHODS

Thirteen patients with tumor resection and free flap reconstruction were included for camera analysis and another 10 patients as control group. For this purpose, at defined time intervals and under standardized conditions, recordings of transplants 3 to 100 hours postoperatively were performed. Images were used to examine oxygenation (StO2%), tissue hemoglobin index, tissue water index, near infrared range perfusion index of free flaps quantitatively and qualitatively.

RESULTS

HSI provides values differing between patients observed with no intraindividual significant difference. After 24 hours a mean reduction of 16.77% for StO2%, 9.16% for tissue hemoglobin index and 8.46% was observed, going in line with no loss of flap was noted in the observation period.

CONCLUSION

HSI is suitable as a noninvasive measure for the evaluation of free flaps in craniomaxillofacial surgery in case of stable imaging conditions with respect to light, surrounding and position of the camera. However, clinical measurements are still the method of choice.

Donor Site Morbidity and Quality of Life after Microvascular Head and Neck Reconstruction with a Chimeric, Thoracodorsal, Perforator-Scapular Flap Based on the Angular Artery (TDAP-Scap-aa Flap)

Extensive defects in the head and neck area often require the use of advanced free flap reconstruction techniques. In this study, the thoracodorsal perforator-scapular free flap technique based on the angular artery (TDAP-Scap-aa flap) was postoperatively evaluated regarding the quality of life and the donor site morbidity using the standardized SF-36 and DASH questionnaires (short form health 36 and disabilities of the arm, shoulder and hand scores). Over a five-year period (2016−2020), 20 selected cases (n = 20) requiring both soft and hard tissue reconstruction were assessed. On average, the harvested microvascular free flaps consisted of 7.8 ± 2.1 cm hard tissue and 86 ± 49.8 cm2 soft tissue components. At the donor site (subscapular region), only a mild morbidity was observed (DASH score: 21.74 ± 7.3 points). When comparing the patients’ postoperative quality of life to the established values of the healthy German norm population, the observed SF-36 values were within the upper third (>66%) of these established norm values in almost all quality-of-life subcategories. The mild donor site morbidity and the observed quality of life indicate only a small postoperative impairment when using the TDAP-Scap-aa free flap for the reconstruction of extensive maxillofacial defects.

Postoperative and 1-Year Functional Outcomes After Free Flap Surgery Among Patients 80 Years or Older

OBJECTIVE

To evaluate the postoperative and 1-year functional outcomes after free flap surgery among patients ≥80 years old.

STUDY DESIGN

Retrospective chart review.

SETTING

Single tertiary care center.

METHODS

We conducted a retrospective review of 596 patients who underwent head and neck ablation and reconstruction with free tissue over a 7-year period. Patients ≥80 years of age were included.

RESULTS

Fifty patients were ≥80 years old, with an average age of 83.7 years. Ninety-day mortality was 12.0%, and those who died were of older age (87.5 vs 83.1 years, P = .036). Prior radiation therapy (odds ratio, 6.8 [95% CI, 1.1-42.7]) and a Charlson Comorbidity Index ≥3 (odds ratio, 10.0 [95% CI, 1.5-67.0]) were associated with an increased risk of 90-day mortality. Overall 21 (42.0%) patients experienced a 30-day complication; 7 (14.0%) were readmitted within 30 days; and 5 (10.0%) underwent additional flap-related operations. Flap failure occurred in 2 (4.0%) patients. Before surgery, 45 (90%) patients were living independently or within assisted living; among these, 19.5% declined to dependent functional status at 90-day follow-up. At 90 days, 2 (8.3%) of 24 patients remained tracheostomy dependent, and 20 (66.7%) of 30 patients required feeding tube supplementation. Among 42 patients, 36 (85.7%) had unrestricted or modified oral diets at 90 days. Charlson Comorbidity Index ≥2 was associated with an increased risk of 1-year mortality (odds ratio, 5.1 [95% CI, 1.4-18.6]).

CONCLUSION

The potential for functional decline and risk of 90-day mortality should be discussed with patients aged ≥80 years.

Health-Related Quality of Life, Psychosocial Distress and Unmet Needs in Older Patients With Head and Neck Cancer

Head and neck squamous cell carcinoma (HNSCC) is the most common cancer involving the mucosal surfaces of the head and neck and is associated with a number of etiological factors, including cigarette smoking, alcohol and betel nut consumption and exposure to high-risk human papillomavirus. The risk of HNSCC increases with age, peaking in the seventh and eighth decade, but this varies by anatomical and histological subtype. While several advancements have been made in the treatment of head and neck cancer (HNC) in recent decades, undertaking curative treatment still subjects the majority of HNSCC patients to substantial treatment-related toxicity requiring patients to tolerate a gamut of physical, psychological, and emotional demands on their reserves. In conjunction with other patient-related factors, clinicians involved in treating patients with HNSCC may incorporate advancing chronological age into their decision-making process when determining treatment recommendations. While advancing chronological age may be associated with increased concerns regarding physical treatment tolerability, clinicians may also be concerned about heightened vulnerability in various health and wellbeing outcomes. The available literature, however, does not provide evidence of this vulnerability in patients with advancing age, and, in many instances, older patients self-report greater resilience compared to their younger counterparts. While this data is reassuring it is limited by selection bias and heterogeneity in trial and study design and the absence of a consistent definition of the elderly patient with HNSCC. This narrative review article also includes a review of the measures used to assess HRQL, psychosocial outcomes and unmet needs in elderly or older patients with HNSCC.

Age and Comorbidities Impact Medical Complications and Mortality Following Free Flap Reconstruction

OBJECTIVE

Determine if age correlated with surgical or medical complications following head and neck free flap reconstruction.

STUDY DESIGN

Retrospective review of prospectively collected databases.

METHODS

Patients undergoing head and neck free flap reconstruction at three tertiary care institutions were included (n = 1972). Cohorts were based on age (<65, 65-75, 75-85, and >85). Outcomes reviewed operative duration, length of stay, surgical complications (free flap failure, fistula, hematoma, dehiscence, and infection), and medical complications (thromboembolism, stroke, cardiac, and pulmonary).

RESULTS

Anatomic site (P < .0001) and donor site varied by age (P < .0001). There was no difference in operative duration (P = .3) or length of hospitalization (P = .8) by age. The incidence of medical complications increased with increasing age. Pulmonary complication rates: <65 (3.9%), 65 to 75 (4.8%), 75 to 85 (7.1%), and >85 (11%) (P = .02). Cardiac complication rates: <65 (2.0%), 65 to 75 (7.3%), 75 to 85 (6.1%), and >85 (16.4%) (P < .0001). Mortality increased with age: <65 (0.4%), 65 to 75 (0.8%), 75 to 85 (1.1%), and >85 (4.1%) (P < .003). Medical complications correlated with mortality rates: pulmonary (3.5% vs. 0.6%; OR: 5.5; 95% CI: 1.5-20.0; P = .004); cardiac (3.3% vs. 0.6%; OR: 6.0; 95% CI: 1.6-21.8; P = .002); thromboembolism (4.6% vs. 0.7%; OR: 7.3; 95% CI: 1.6-33.6; P = .003); stroke (42% vs. 0.5%; OR: 149; 95% CI: 40-558; P < .0001); and sepsis (5% vs. 0.7%; OR 7.5; 95% CI: 1.0-60.5; P = .03). Age did not correlate with free flap success (P = .5), surgical complications (hematoma, P = .33; fistula, P = .23; infection, P = .07; and dehiscence, P = .37), or thirty-day readmission (P = .3).

CONCLUSION

Following free flap reconstruction, patient age did not correlate with development of a surgical complication. Patient age did correlate with development of a medical complication. Postoperative medical complications were found to correlate with perioperative mortality.

LEVEL OF EVIDENCE

4 Laryngoscope, 2021.

Maxillary reconstruction with scapular tip chimeric free flap

PURPOSE

Purpose of the article is to discuss the use of the scapular tip free flap (STFF) for the reconstruction of maxillary defects.

METHODS

A retrospective evaluation of patients who underwent maxillary reconstruction with STFF is presented. Patients were evaluated with respect to complications, function, and cosmesis.

RESULTS

Study population consisted of 53 patients. All flaps survived and partial bone resorption only occurred in a young patient. Minor complications included two instances of partial muscular necrosis. The donor site was primarily closed in all patients. Mouth opening was assessed as good (>3 cm) in 41 patients, partially limited (2-3 cm) in 9 patients, and limited (<2 cm) in 3 patients. Dental rehabilitation was achieved in 35 patients; esthetic results were assessed by patient as excellent in 19 patients, good in 28 patients, and poor in 6 patients.

CONCLUSIONS

The scapular tip chimeric free flap represents an indispensable tool for reconstructive head and neck microsurgery. The main advantages of this technique are very low donor site morbidity and a long pedicle, as well as the potential for harvesting multiple flaps in a chimeric design; STFF represents the first choice for treatment of small postero-lateral defects of the maxilla, and of wide and complex through-and-through defects involving all components of the midface.