Oral Surgery| Volume 135, ISSUE 1, P42-50, January 2023

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Impact of age on microvascular free flap perfusion in head and neck reconstruction


      Aging is associated with structural and functional cardiovascular changes that may affect microvascular free flap perfusion, which is a prerequisite for flap viability and flap success. This study is aimed to investigate the impact of age on flap perfusion.

      Study Design

      Intraoperative and postoperative flap perfusion of 348 patients who underwent successful reconstruction with a radial free forearm flap (RFFF), anterolateral thigh flap (ALTF), or fibular free flap (FFF) was retrospectively analyzed and compared between older (>70 years) and younger patients (≤70 years) using the Mann-Whitney test and linear regression models.


      Intraoperative flap blood flow and hemoglobin concentration (55.5 arbitrary units [AU] vs 69.3 AU, P = .004; 42.5 AU vs 47.3 AU, P = .016, respectively) were reduced in ALTFs in older patients compared with younger patients. These 2 differences did not persist in multivariable testing (P = .097 and P = .323, respectively). No other differences were observed between the older and younger patients in terms of intraoperative and postoperative flap blood flow, hemoglobin concentration, and hemoglobin oxygen saturation in RFFFs, ALTFs, and FFFs (all P > .05).


      Age has no impact on microvascular free flap perfusion in RFFFs, ALTFs, and FFFs. This could contribute to the observed equal success of free flaps in older patients.
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        • Kruse AL
        • Luebbers HT
        • Grätz KW
        • Obwegeser JA.
        Factors influencing survival of free-flap in reconstruction for cancer of the head and neck: a literature review.
        Microsurgery. 2010; 30: 242-248
        • Wong CH
        • Wei FC.
        Microsurgical free flap in head and neck reconstruction.
        Head Neck. 2010; 32: 1236-1245
        • Spyropoulou GA
        • Jeng SF
        • Hsieh CH
        • Tsimponis A
        • Shih HS.
        Microsurgical reconstruction for head and neck cancer in elderly patients.
        J Reconstr Microsurg. 2014; 30: 91-96
        • Ren ZH
        • Wu HJ
        • Tan HY
        • Wang K
        • Zhang S.
        Transfer of anterolateral thigh flaps in elderly oral cancer patients: complications in oral and maxillofacial reconstruction.
        J Oral Maxillofac Surg. 2015; 73: 534-540
        • Wang KY
        • Lin YS
        • Chen LW
        • Yang KC
        • Huang WC
        • Liu WC.
        Risk of free flap failure in head and neck reconstruction: analysis of 21,548 cases from a nationwide database.
        Ann Plast Surg. 2020; 84 (1S suppl): S3-S6
        • Sweeny L
        • Curry JM
        • Crawley MB
        • et al.
        Age and comorbidities impact medical complications and mortality following free flap reconstruction.
        Laryngoscope. 2022; 132: 772-780
        • Boss GR
        • Seegmiller JE.
        Age-related physiological changes and their clinical significance.
        West J Med. 1981; 135: 434-440
        • Karavidas A
        • Lazaros G
        • Tsiachris D
        • Pyrgakis V.
        Aging and the cardiovascular system.
        Hellenic J Cardiol. 2010; 51: 421-427
        • Petrie JR
        • Guzik TJ
        • Touyz RM.
        Diabetes, hypertension, and cardiovascular disease: clinical insights and vascular mechanisms.
        Can J Cardiol. 2018; 34: 575-584
        • Beckert S
        • Witte MB
        • Königsrainer A
        • Coerper S.
        The impact of the Micro-Lightguide O2C for the quantification of tissue ischemia in diabetic foot ulcers.
        Diabetes Care. 2004; 27: 2863-2867
        • Hölzle F
        • Loeffelbein DJ
        • Nolte D
        • Wolff K-D.
        Free flap monitoring using simultaneous non-invasive laser Doppler flowmetry and tissue spectrophotometry.
        J Craniomaxillofac Surg. 2006; 34: 25-33
        • Abdel-Galil K
        • Mitchell D.
        Postoperative monitoring of microsurgical free tissue transfers for head and neck reconstruction: a systematic review of current techniques—part I. Non-invasive techniques.
        Br J Oral Maxillofac Surg. 2009; 47: 351-355
        • Mücke T
        • Wolff KD
        • Rau A
        • Kehl V
        • Mitchell DA
        • Steiner T.
        Autonomization of free flaps in the oral cavity: a prospective clinical study.
        Microsurgery. 2012; 32: 201-206
        • Rahmanian-Schwarz A
        • Rothenberger J
        • Amr A
        • Jaminet P
        • Schaller HE.
        A postoperative analysis of perfusion dynamics in deep inferior epigastric perforator flap breast reconstruction: a noninvasive quantitative measurement of flap oxygen saturation and blood flow.
        Ann Plast Surg. 2012; 69: 535-539
        • Kolbenschlag J
        • Sogorski A
        • Kapalschinski N
        • et al.
        Remote ischemic conditioning improves blood flow and oxygen saturation in pedicled and free surgical flaps.
        Plast Reconstr Surg. 2016; 138: 1089-1097
        • Hölzle F
        • Rau A
        • Loeffelbein DJ
        • Mücke T
        • Kesting MR
        • Wolff KD.
        Results of monitoring fasciocutaneous, myocutaneous, osteocutaneous and perforator flaps: 4-year experience with 166 cases.
        Int J Oral Maxillofac Surg. 2010; 39: 21-28
        • Nao EE
        • Dassonville O
        • Chamorey E
        • et al.
        Head and neck free-flap reconstruction in the elderly.
        Eur Ann Otorhinolaryngol Head Neck Dis. 2011; 128: 47-51
        • Kesting MR
        • Hölzle F
        • Wolff KD
        • et al.
        Use of microvascular flap technique in older adults with head and neck cancer: a persisting dilemma in reconstructive surgery?.
        J Am Geriatr Soc. 2011; 59: 398-405
        • Vaz JA
        • Côté DW
        • Harris JR
        • Seikaly H.
        Outcomes of free flap reconstruction in the elderly.
        Head Neck. 2013; 35: 884-888
        • Heidekrueger P
        • Heine-Geldern A
        • Ninkovic M
        • et al.
        Microsurgical reconstruction in patients greater than 80 years old.
        Microsurgery. 2017; 37: 546-551
        • D'Andréa G
        • Scheller B
        • Gal J
        • et al.
        How to select candidates for microvascular head and neck reconstruction in the elderly? Predictive factors of postoperative outcomes.
        Surg Oncol. 2020; 34: 168-173
        • Mitchell O
        • Kelly E
        • Ethunandan M
        • Horlock N
        • Sharma S
        • Singh RP.
        Outcomes of free flap reconstructive surgery in head and neck cancer patients over 80-years old.
        Br J Oral Maxillofac Surg. 2021; 59: 1090-1094
        • Latza U
        • Hoffmann W
        • Terschüren C
        • et al.
        Rauchen als möglicher confounder in epidemiologischen studien: standardisierung der erhebung, quantifizierung und analyse.
        Gesundheitswesen. 2005; 67 ([in Italian]): 795-802
        • Üstün GG
        • Aksu AE
        • Uzun H
        • Bitik O.
        The systematic review and meta-analysis of free flap safety in the elderly patients.
        Microsurgery. 2017; 37: 442-450
        • Gee MH
        • Gottlieb JE
        • Albertine KH
        • Kubis JM
        • Peters SP
        • Fish JE.
        Physiology of aging related to outcome in the adult respiratory distress syndrome.
        J Appl Physiol. 1990; 69: 822-829
        • De Backer D
        • Foulon P.
        Minimizing catecholamines and optimizing perfusion.
        Crit Care. 2019; 23 (suppl): 149
        • Hohlweg-Majert B
        • Ristow O
        • Gust K
        • Kehl V
        • Wolff KD
        • Pigorsch S.
        Impact of radiotherapy on microsurgical reconstruction of the head and neck.
        J Cancer Res Clin Oncol. 2012; 138: 1799-1811
        • Thijssen DH
        • Carter SE
        • Green DJ.
        Arterial structure and function in vascular ageing: are you as old as your arteries?.
        J Physiol. 2016; 594: 2275-2284
        • Liu W
        • Chen Z
        • Ortega D
        • et al.
        Arterial elasticity, endothelial function and intracranial vascular health: a multimodal MRI study.
        J Cereb Blood Flow Metab. 2021; 41: 1390-1397
        • Hölzle F
        • Mitchell DA
        • Rau A
        • et al.
        Assessment of the perfusion and morbidity of the buccal mucosal donor site for grafting of urethral strictures.
        J Craniomaxillofac Surg. 2012; 40: 47-50
        • Mücke T
        • Rau A
        • Merezas A
        • et al.
        Changes of perfusion of microvascular free flaps in the head and neck: a prospective clinical study.
        Br J Oral Maxillofac Surg. 2014; 52: 810-815
        • Dornseifer U
        • Fichter AM
        • Von Isenburg S
        • Stergioula S
        • Rondak IC
        • Ninkovic M.
        Impact of active thermoregulation on the microcirculation of free flaps.
        Microsurgery. 2016; 36: 216-224
        • Gabrysz-Forget F
        • Tabet P
        • Rahal A
        • Bissada E
        • Christopoulos A
        • Ayad T.
        Free versus pedicled flaps for reconstruction of head and neck cancer defects: a systematic review.
        J Otolaryngol Head Neck Surg. 2019; 48: 13