A systematic review of head and neck free flaps in the geriatric population over 90 years of age.

Abstract

Free flap reconstruction in nonagenarians is approached cautiously owing to limited physiological reserves, comorbidities, frailty, and postoperative complications. Advances in microsurgery and perioperative care may improve feasibility in selected patients. To summarize flap survival and perioperative outcomes in nonagenarians undergoing head and neck free flap reconstruction and describe functional recovery when reported. We hypothesized that flap survival would be comparable to that in younger cohorts, with a higher risk of complications. PubMed, Cochrane, Google Scholar, Scopus, MEDLINE, Embase, Web of Science (1980-2023), and reference-list screening. Retrospective cohorts, case series, and case reports including patients aged ≥90 years (English/French). Outcomes included flap survival, complications, mortality, functional recovery, length of stay, or discharge destination. Extremity-only studies were excluded; mixed-site studies required an identifiable ≥90-year head and neck subgroup. Study-level risk of bias was assessed using ROBINS-I. Outcomes were synthesized qualitatively using descriptive reporting of ranges and narrative comparisons, reflecting heterogeneity in study designs and outcome reporting. Seven studies (105 nonagenarians) were included, mainly head and neck defects. Flap survival was high (92%-100%), with low 30-day mortality (1.3%). Complication reporting was heterogeneous across the studies. Surgical site complications were reported in approximately 10-20% when specified, arrhythmias up to 30-40%, and pneumonia in 1-5%. Functional outcomes were generally described as preserved or restored in the subset of studies. Small samples, observational designs, heterogeneous outcomes, and inconsistent functional reporting. Head and neck free flap reconstruction appears feasible in selected nonagenarians; age alone should not be a strict contraindication.