State of the Art Review Free Flaps in Head and Neck Reconstruction after Oncologic Surgery: Expected Outcomes in the Elderly Otolaryngology– Head and Neck Surgery 2015, Vol. 152(5) 796–802 Ó American Academy of Otolaryngology—Head and Neck Surgery Foundation 2015 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0194599815576905 http://otojournal.org Alberto Grammatica, MD 1 , Cesare Piazza, MD 1 , Alberto Paderno, MD 1 , Valentina Taglietti, MD 1 , Alessandra Marengoni, MD 2 , and Piero Nicolai, MD 1 No sponsorships or competing interests have been disclosed for this article. Abstract Objective. To provide surgeons and clinicians with a critical review of microvascular reconstructive options and their expected outcomes after head and neck cancer resection in the elderly. Data Sources. Medline, Isiweb, and Cochrane databases. Review Methods. A literature search was performed in May 2014 and included studies published between 2000 and 2014. Keywords were used for articles identification, and inclusion criteria were defined for consideration in the present review. Conclusions. Evaluation of the pertinent literature is ham- pered by a number of biases, such as a lack of general con- sensus of a definition of ‘‘elderly,’’ differences among scales used to quantify comorbidities, and subjective evaluation of flap-related and systemic complications. However, our find- ings showed no differences in terms of free flap success, sur- gical complications, or mortality rate between older and younger patients. Moreover, recipient site complications do not seem to be affected by age. Implication for Practice. Microvascular reconstruction in the elderly can be performed with high success rates, even though medical complications can occur more frequently compared to younger patients. Minor and major surgical complications in the elderly appear to be comparable to those in the younger population and do not affect final out- come or the perioperative mortality rate. Flap outcome does not seem to be significantly affected by age. Careful preoperative assessment and postoperative monitoring are mandatory to prevent adverse events, and prompt manage- ment is warranted whenever present. Keywords head and neck cancer, reconstruction, free tissue transfer, free flaps, microsurgery, elderly, advanced age Received July 17, 2014; revised January 14, 2015; accepted February 19, 2015. L ife expectancy is increasing worldwide as a result of better medical and surgical treatments and improve- ments in overall social and economical status. This demographic change has led to a progressive expansion of the proportion of ‘‘old’’ and ‘‘very old’’ individuals in the general population. It is well known that cancer-related morbidity and mortality are linked to age, with about 60% of all tumors arising in patients .65 years and 70% of all cancer-related deaths occurring in this age group. 1-4 A large number of head and neck cancer (HNC) cases occur after the sixth decade. This finding was underlined in a retrospec- tive HNC review showing that 12% of patients with HNC are .70 years of age 5 ; different single-institution reports in Europe documented that 6% to 32% of HNC patients are between the ages of 70 and 75 years. Squamous cell carci- noma is the most common histology (95% of cases) among HNC in this age group, most frequently involving the larynx, oropharynx, and oral cavity. 6,7 Since the introduction of reconstruction after HNC abla- tion in the 1970s as a mainstay of surgical practice, the use of free flaps has progressively evolved, reaching success rates ranging between 90% and 98%, with a relatively low rate of surgical complications in the general population. 8-14 Nowadays, free tissue transfer after HNC resection has become the gold standard due to its excellent capability of addressing complex 3-dimensional tissue defects. The main strengths of microvascular reconstructive techniques, com- pared to less sophisticated methods, are the possibility to choose the best defect-adapted tissue, to tailor the flap in a 3-dimensional fashion to minimize postoperative functional deficits, and, most important, to bring highly vascularized tissue into the surgical bed, thus speeding up the healing process. Yet, its drawbacks include a steep learning curve, 1 Department of Otorhinolaryngology–Head and Neck Surgery, University of Brescia, Brescia, Italy 2 Department of Geriatrics, University of Brescia, Brescia, Italy Corresponding Author: Alberto Grammatica, MD, Department of Otorhinolaryngology–Head and Neck Surgery, University of Brescia, Piazzale Spedali Civili 1, 2512 Brescia, Italy. Email: albertogrammatica@libero.it at SOCIEDADE BRASILEIRA DE CIRUR on May 11, 2015 oto.sagepub.com Downloaded from