Mandibular Reconstruction in the Elderly: Are Outcomes Comparable to Younger Patients?
Sina J. Torabi1, Fouad Chouairi, BS1, Jacob Dinis, BS2, Henry Hsia, MD1, Michael Alperovich, MD1.
1Yale School of Medicine, New Haven, CT, USA, 2Yale School of Medicine, north haven, CT, USA.
PURPOSE: Definitive reconstruction following extirpative mandibulectomy or glossectomy is critical for ensuring airway stability, restoring swallowing and speech, maintaining isolation of oral contents from critical vascular structures, and optimizing aesthetic outcomes. While microvascular free flaps have become the gold standard in head and neck reconstruction, the increased morbidity and operative time has limited their use in the elderly population where local pedicled flaps have remained popular. To date, no large, national studies have evaluated peri-operative outcomes and complications following head and neck reconstruction in the elderly population. A better understanding of the outcomes for elderly patients undergoing head and neck reconstruction can aid surgeons in future decision making, pre-operative counseling, and selection of reconstruction technique.
METHODS: An "older" (≥71 years) cohort undergoing reconstruction after mandibulectomy or glossectomy was compared to the remaining population in a 9-year analysis of the National Surgical Quality Improvement Program. Chi-square analyses for demographics, comorbidities, type of ablative procedure, and type of reconstructive flap were performed. Outcomes were compared and stratified by reconstruction type. A Bonferroni correction was applied to all univariate chi-square analyses according to the largest family of comparisons. Multivariate regressions were performed to calculate the impact of age on length of hospital stay (LOHS) and operative time.
RESULTS: A total of 966 patients who underwent concurrent mandibulectomy or glossectomy with reconstruction were identified. Ablative procedures were comparable, but older patients received local flaps compared to microvascular reconstruction at significantly higher rates (22.5% vs 9.6%; p<0.001). Although the older population had more comorbidities (higher ASA class, diabetes, and hypertension), univariate analysis revealed no differences in adverse events, operative time, or LOHS compared to the remaining population. Univariate subgroup analysis of soft tissue and bone/composite microvascular flaps revealed similar outcomes between cohorts except for increased medical complications in the older cohort undergoing a bone free flap. Controlling for demographic factors, comorbidity number, and procedure type, older age resulted in longer hospital stay only (B: 1.5; 95% CI: 0.1 to 2.8; p=0.032), but not operative time.
CONCLUSION: To our knowledge, we present the first national study characterizing differences in demographics, comorbidities, surgical factors, and reconstructive outcomes for older patients undergoing mandibulectomy with microvascular reconstruction. While local flaps are more commonly performed in the older cohort (≥71 years), a majority of older patients receive microvascular reconstruction with outcomes comparable to the remaining population except for a slightly longer hospital stay. Comorbidities rather than age predict post-operative outcomes. Age alone does not preclude microvascular reconstruction in the head and neck. Current practice patterns from this study suggest that surgeons may already be choosing the reconstruction type based on the patient's overall health status. Among patients who received microvascular reconstruction, there were no differences in proportion of higher ASA class patients between the older cohort and the remaining population. Given the aging population nationally, a better understanding of post-operative outcomes for head and neck reconstruction in the older population is essential.
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