Comorbidities Are Not Contraindications to Free Flap Reconstruction in Elderly Patients with Advanced Head and Neck Cancer

Introduction

The fastest-growing demographic group in the United States is individuals aged 70 years and older1. By 2030, this group is expected to comprise approximately 20% of the population1. Life expectancy has also increased, reaching 77.5 years in Europe2. As a result, the number of elderly patients with head and neck cancer requiring microvascular surgery has increased.

Head and neck cancers in elderly patients are often diagnosed at locally advanced stages (stage III–IV)3. Microvascular surgery is the gold standard for defect reconstruction in these cases4. Advances in surgical techniques, reduced operative times, improved perioperative management of comorbidities, and developments in anesthesia have enabled the widespread use of microvascular surgery in the general population, with flap survival rates exceeding 90%5, 6. However, similar progress has been less evident in elderly patients. Prolonged operative and recovery times associated with these procedures contribute to hesitancy in this group. Although advanced age alone is not a contraindication to surgery, reduced physiological reserve and the presence of comorbidities—such as diabetes, hypertension, chronic obstructive pulmonary disease, ischemic heart disease, and chronic kidney disease—may increase perioperative morbidity and mortality7. To reduce treatment-related morbidity and mortality, extensive surgical excision—the standard treatment for advanced head and neck cancer—is often avoided in elderly patients. Instead, non-surgical approaches such as radiotherapy, chemotherapy, or combined chemoradiotherapy are preferred8, 9. As a result, many elderly patients experience reduced quality of life due to suboptimal treatment8, 9.

This study shows that surgical excision and free flap reconstruction can be performed successfully in elderly patients with advanced head and neck cancer. Advanced age and comorbidities alone should not be considered contraindications. Treatment decisions should prioritize quality of life, and elderly patients should be offered appropriate surgical options.

Materials and Methods

This retrospective study included 19 patients aged 70 years and older with chronic comorbidities who were treated at Cukurova University Hospital between 2007 and 2024. This study was approved by the Cukurova University Faculty of Medicine Ethics Committee (Decision No: 26, Meeting No: 159, Date: 03.10.2025). As no clear age threshold for the elderly population has been established in the literature, 70 years was selected based on previous studies6, 8, 9. All patients had head and neck tumors and underwent surgical excision with free flap reconstruction. When indicated, lymph node dissection, postoperative chemotherapy, and radiotherapy were performed. Postoperatively, patients were monitored in the intensive care unit when necessary and transferred to the ward once clinically stable.

Data collected included patient age, tumor type, free flap type and size, comorbidities, postoperative follow-up duration, ASA (American Society of Anesthesiologists) score, and Charlson Comorbidity Index (CCI). The CCI is a commonly used tool to assess preoperative comorbidity burden10 and was calculated from patients’ medical records. The ASA score, used to evaluate perioperative risk, was determined preoperatively by anesthesiologists11.

Results

Five patients underwent surgery for basal cell carcinoma (BCC), and 14 for squamous cell carcinoma (SCC). All tumors were advanced stage (III–IV) and located in the head and neck region. All patients underwent reconstruction with free flaps: five received radial forearm flaps (RFF), eight anterolateral thigh flaps (ALT), two latissimus dorsi flaps (LD), two deep inferior epigastric artery perforator flaps (DIEP), and one each transverse rectus abdominis muscle flaps (TRAM) and rectus abdominis muscle flaps (RAM). Tumor locations and other data are summarized in Table 1.

Table 1: Distribution of tumor types, anatomical locations, and free flap types in patients with advanced head and neck tumors.

Abbreviations: BCC, basal cell carcinoma; SCC, squamous cell carcinoma; RFF, radial forearm flap; ALT, anterolateral thigh flap; LD, latissimus dorsi flap; DIEP, deep inferior epigastric artery perforator flap; TRAM, transverse rectus abdominis muscle flap; Ex, exitus.

The smallest flap measured 6 × 15 cm and was used for nasal SCC reconstruction with an ALT flap. The largest flap was performed for a long-neglected frontal SCC with frontal bone destruction, intracranial extension, and pneumocephalus; a 25 × 30 cm ALT flap was used (Figure 1). The second-largest flap was used in a patient with BCC involving the entire face and measured 30 × 20 cm; reconstruction was performed with an LD flap (Figure 2).

Figure 1A Figure 1B

Figure 1A: Preoperative photo showing a large ulcerated, exophytic mass in the left frontoparietal scalp Figure 1B: Immediate postoperative photograph of the scalp defect reconstructed with a free ALT flap.

The most common comorbidity was hypertension (n=17), followed by diabetes (n=9). Additional comorbidities included ischemic heart disease (IHD) (n=2), COPD (n=1), arrhythmia (n=1), coronary artery disease (CAD) (n=4), and benign prostatic hyperplasia (BPH) (n=2).

Figure 2A Figure 2B

Figure 2A: Preoperative clinical photo of advanced BCC involving nearly the entire face. Figure 2B: Immediate postoperative view following radical tumor excision and reconstruction with a free LD flap.

Nine patients were ASA 4 and ten were ASA 3. Ages ranged from 71 to 93 years, with a mean of 75.3 years. One patient died of heart failure on postoperative day 1, one of renal failure in the second postoperative month, and two of infection in the first and 1.5th postoperative months. The overall mortality rate was 21%. Among the patients who died, ASA scores were 4 in all cases, while CCI scores were 12, 12, 11, and 13. The mean postoperative follow-up for the remaining 15 patients was 13 months. Flap loss occurred in one patient. Following ALT flap loss in a 77-year-old female patient, a lateral pedicled forehead flap was used for salvage reconstruction; however, the patient died on postoperative day 45. A free flap had been chosen as the primary option because of the large defect, the patient's refusal of a local facial flap due to aesthetic concerns, and the need for bulky, well-vascularized tissue in anticipation of adjuvant radiotherapy.

Discussion

Head and neck tumors are more common in older age. With increasing age and comorbidities, radical treatments are often avoided to reduce the risk of mortality and complications6, 12. Instead, non-surgical options such as radiotherapy and chemotherapy are frequently recommended. In this study, we aimed to show that major surgery can improve quality of life in elderly patients with chronic comorbidities who are otherwise managed with non-surgical treatments.

No definitive age cutoff for defining old age has been established in the literature. While some studies use 65 years10, others use 70 years6, 8, 12. In this study, the cutoff was set at ≥70 years. Age alone should not be considered a contraindication for microvascular surgery. Some reports suggest that elderly patients are not suitable candidates for free flap reconstruction12, 13. However, other studies have shown that mortality does not increase in elderly patients undergoing major head and neck surgery, and complication rates are comparable to those in younger populations14‑16. Reported flap survival rates in elderly patients range from 93% to 97%6, 10, 12. In our study, the flap survival rate was 95%; however, this was not statistically significant due to the small sample size. In addition, long-term flap survival could not be assessed in one patient who died on postoperative day 1.

Several parameters, including ASA and CCI scores, have been used to predict mortality and complications. A 2005 study reported a positive correlation between these scores and perioperative mortality and medical complications6. However, other study found no significant relationship between comorbidities and complications17. Similarly, in patients undergoing free flap surgery for laryngeal cancer, comorbidities and advanced age were not associated with complications; only tumor stage was significant18.

In another study, a relationship between ASA score and complications was observed but was not statistically significant19. In patients with oral cavity tumors, the CCI score was not significant, whereas the ASA score was significant10.

In our study, the patients who died had higher ASA and CCI scores than the others; however, this difference was not statistically significant due to the small sample size.

Several studies report that elderly patients with head and neck cancer are more likely to receive less aggressive, non-standard treatments than younger patients with the same stage of disease20‑22. A 2017 study showed that, in patients aged ≥70 years with locally advanced disease, radiotherapy alone was often used instead of multimodal treatment23. Among patients with stage III–IV cancer, 44% of those aged ≥70 years received only radiotherapy, compared with 16% in the 50–59 age group23. Similarly, the rate of trimodal therapy (surgery followed by chemoradiotherapy) was 25% in patients aged 50–59 years, but only 5% in those aged ≥70 years (p<.0001)23. Another study showed that chemotherapy did not improve survival in patients older than 70 years24.

The literature includes numerous studies on free flap reconstruction in elderly patients with comorbidities. A 2014 study evaluated 33 patients aged <70 years and 714 patients aged ≥70 years with head and neck tumors. In the elderly group, hypertension was present in 54% and diabetes mellitus in 40%. The mortality rate was 6% in the elderly group and 0.2% in the younger group. No flap loss occurred in the elderly group, whereas the rate was 3.9% in the younger group. Despite a higher mortality rate in the elderly group, there were no statistically significant differences between the groups in terms of medical complications, surgical complications, or flap loss14.

A retrospective study by Howard et al. included 197 patients aged ≥70 years who underwent free flap surgery. In 95% of cases, reconstruction was performed for head and neck defects. The most common comorbidities were hypertension (45%), CAD (33%), diabetes mellitus (12%), and pulmonary disease (13%). The flap success rate was 97%, with a perioperative mortality rate of 9% and an overall complication rate of 38%. CAD and alcohol use were identified as independent risk factors for surgical complications. The CCI was associated with medical complications and perioperative mortality but not with surgical complications. The ASA score was associated with perioperative mortality but not with other outcomes. These findings support our results and suggest that elderly patients with comorbidities can be suitable candidates for free flap reconstruction12. The mortality rate in our series (21%) was higher than the rates of 6% and 9% reported in the literature12, 14. This difference is most likely attributable to the small sample size of our study.

As an example from our study, a 72-year-old patient presented with a stage IV tumor involving the left side of the face. The tumor originated from the left cheek, invaded the left eye, and involved the surrounding tissues. Given the patient’s advanced age and comorbidities (diabetes mellitus, hypertension), non-surgical treatment might have been preferred. However, after discussing the surgical risks with the patient, tumor excision and reconstruction with a free rectus abdominis muscle flap were performed with the aim of improving quality of life and achieving a tumor-free state (Figure 3). By choosing this approach, the patient was given a chance for cure. No recurrence was observed during the 3-year follow-up period.

Figure 3A Figure 3B Figure 3C

Figure 3A: Advanced SCC involving the left hemiface. Figure 3B: Intraoperative view following radical excision of advanced SCC involving the left hemiface. Figure 3C: Long-term postoperative photograph following reconstruction with a free rectus abdominus flap.

This study has certain limitations. The retrospective single-center design and small sample size limited statistical power and generalizability, which may explain why differences in ASA and CCI scores between survivors and non-survivors did not reach significance. In addition, the absence of a control group precluded direct comparison with younger patients or those treated non-surgically. Moreover, the follow-up period was insufficient to evaluate 5-year disease-free and overall survival. Larger prospective multicenter studies with longer follow-up and standardized quality-of-life and geriatric assessments are needed to confirm these findings.

Conclusion

The literature shows variability in the management of elderly patients with head and neck tumors. While some studies associate perioperative mortality and complications with age, others attribute these outcomes to ASA score or comorbidities.

This study demonstrates that definitive surgical treatment is feasible in elderly patients with advanced-stage head and neck cancer and comorbidities. In patients with high ASA and CCI scores, treatment decisions should not be based solely on minimizing perioperative risk. Instead, the potential for improved quality of life and the possibility of definitive treatment should also be considered. Elderly patients often prioritize quality of life over longevity; therefore, patient preference should be incorporated into treatment planning.

Author Contributions: Conceptualization, O.K. and E.K.; methodology, O.K., A.K. and G.K.Y.; validation, O.K., E.K. and I.T.; formal analysis, A.K. and G.K.Y.; investigation, O.K., A.K., G.K.Y. and I.T.; resources, E.K.; data curation, A.K. and I.T.; writing—original draft preparation, , E.K., G.K.Y., A.K., O.K. and I.T.; writing—review and editing, E.K., G.K.Y., A.K., O.K. and I.T.; visualization, A.K.; supervision, E.K.; project administration, O.K. and E.K. All authors have read and agreed to the published version of the manuscript. All authors have read and agreed to the published version of the manuscript.”

Conflict of Interest: The authors declare no financial interest related to the content of this article.