RECONSTRUCTIVE Microsurgical Scalp Reconstruction in the Elderly: A Systematic Review and Pooled Analysis of the Current Data Michael Sosin, M.D. Benjamin D. Schultz, B.A. Carla De La Cruz, B.S. Edward R. Hammond, M.D., M.P.H., Ph.D. Michael R. Christy, M.D. Branko Bojovic, M.D. Eduardo D. Rodriguez, M.D., D.D.S. Baltimore, Md.; and New York, N.Y.

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Background: Microvascular reconstruction is the mainstay of treatment in complex scalp defects. The rate of elderly patients requiring scalp reconstruction is increasing, but outcomes in elderly patients are unclear. The purpose of this study was to systematically review the literature pertaining to free tissue transfer for scalp reconstruction in patients older than 65 years to compare outcomes among different free flaps and determine the safety profile of treatment. Methods: A systematic review of the available literature of patients undergoing microvascular scalp reconstruction was completed. Details for patients 65 years and older were extracted and reviewed for data analysis. Results: A total of 45 articles (112 patients) were included for analysis. Mean age of the patients was 73.3 ± 6.3 years (men, 69.4 percent; women, 23.4 percent; not reported, 7.2 percent). Mean flap size was 598 cm2 (range, 81 to 2500 cm2). The mean age of patients developing a complication was 72.8 ± 6.4 years and patients that did not develop a complication was 73.4 ± 5.5 years (p = 0.684). Overall, periprocedural mortality was 0.9 percent. Flap failures occurred in two cases (1.8 percent). The overall complication rate was 22.3 percent (n = 25). Complications by flap type varied without reaching statistical significance. Conclusions: Microvascular reconstruction in complex scalp defects is associated with successful outcomes, and chronologic age does not increase mortality or catastrophic flap complications. The most common flaps used to repair scalp defects are anterolateral thigh and latissimus dorsi, but a superior flap type could not be identified.  (Plast. Reconstr. Surg. 135: 856, 2015.)

T

he incidence of cutaneous malignancies of the head and neck is higher in elderly patients and continues to rise after age 65.1,2 Approximately, 40.3 million people, or 13 percent of the U.S. population, are aged 65 years or older (termed “aged”).3 The population of patients 65 years and older has increased by 5.7 percent, to From the Division of Plastic, Reconstructive, and Maxillofacial Surgery, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine; the Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health; and the Department of Plastic Surgery, New York University Langone Medical Center, Institute of Reconstructive Plastic Surgery. Received for publication August 7, 2014; accepted September 23, 2014. Presented in part at the Sixth Annual Johns Hopkins/University of Maryland Plastic and Reconstructive Surgery Research Symposium, in Baltimore, Maryland, June 12, 2014. Copyright © 2015 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000000959

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29.9 percent, over the past decade.3 As a result, elderly patients are expected to require more reconstructive operations (i.e., scalp reconstructions) in the future.4 Defects of the scalp and calvaria are often the result of invasive cutaneous malignancies but can also be the result of infection, osteoradionecrosis, trauma, or other malignancies.5,6 Multiple reconstructive options can be successfully implemented

Disclosure: Dr. Christy has received research and educational grant support and speaker honoraria for unrelated activities from DePuy Synthes CMF, Osteomed, and KLS Martin. Dr. Rodriguez has received research and educational grant support and speaker honoraria for unrelated activities from DePuy Synthes CMF. He has also received educational grant support and speaker honoraria for unrelated activities from KLS Martin. The other authors have no conflicts of interest to disclose.

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Volume 135, Number 3 • Scalp Reconstruction in Elderly in complex scalp reconstruction. Patients that undergo initial scalp surgery may require future microsurgical intervention because of positive margins, recurrence of a lesion, or wound complications. Larger defects or composite tissue defects—specifically, those with exposed vital structures such as brain, dura, calvaria, or prosthetic material—require free tissue transfer. A plethora of case series have been reported supporting the latissimus dorsi flap,7 anterolateral thigh flap,8 rectus abdominis flap,9 parascapular or scapular flap,9 and other methods of free tissue transfer for scalp reconstruction.10 Although algorithms created for scalp reconstruction have been described, they have not gained popularity.11,12 Furthermore, opinions regarding a superior flap choice differ among institutions. Improvements in microsurgery techniques, anesthesia, and intensive care have improved outcomes, with current morbidity and mortality rates of 0 to 6 percent and 9 to 33 percent, respectively.13–18 Free tissue transfer in the elderly is historically associated with a mortality rate of 5.4 to 9.1 percent and complication rates as high as 59.3 percent.19–21 Nevertheless, operating on the aged population invokes an increased concern among microsurgeons, especially when reconstructing complex scalp defects.22 Currently, a critical understanding of microsurgical scalp reconstruction in the elderly population is lacking, and multiple studies report contradictory outcomes. Therefore, the goal of this study was to systematically review the literature pertaining to microsurgical reconstruction of scalp defects in the elderly to assess the outcomes of different flaps, determine complication rates, assess various factors associated with specific complications, and evaluate the safety profile of microvascular scalp reconstruction.

PATIENTS AND METHODS This study was conducted in accordance with the Declaration of Helsinki. A MEDLINE, PubMed, and Cochrane database literature search was completed of English articles published between 1970 and 2013. Free-text search terms “free flap and scalp,” “scalp reconstruction and elderly,” “elderly and free flap and scalp,” and “scalp reconstruction and microsurgery,” and Medical Subject Headings (MeSH) “free flap” (MeSH) and “scalp” (MeSH) and in combination with the Boolean operators AND or OR was completed. Duplicate titles were screened electronically and removed. Two independent reviewers (B.D.S. and C.D.L.C.)

identified any potentially relevant articles from the list of titles. Abstracts of all titles captured by both reviewers were screened by a third reviewer (M.S.) to include relevant articles and to consolidate any differences in selection between the initial two reviewers. Inclusion and exclusion criteria are presented in Table 1. The population of interest and data accumulation consisted of patients aged 65 years and older that had undergone microsurgical scalp reconstruction. Full-text articles were obtained and reviewed, and data extraction was completed based on inclusion criteria. Citations referenced in included articles were reviewed to identify any potential articles meeting requirements for inclusion. If an article included free flaps and other types of flaps, data regarding free flaps in the elderly were extracted and included in data analysis. Reconstructions of the neck or face were excluded, as were any scalp reconstructions not involving microsurgical free tissue transfer. Articles that did not report sufficient patient data were excluded. Articles that omitted information regarding radiation therapy, cranioplasty, and duraplasty were assumed to not use the aforementioned interventions. For continuous variables, statistical analysis was performed using unpaired two-tailed t tests. Two-tailed Pearson and Fisher’s exact tests were used to compare noncontinuous variables. Results were considered significant for values of p ≤ 0.05.

RESULTS In total, 3828 titles were identified following the initial database search, and 324 titles were selected for abstract review. Following abstract review, 75 articles were selected for full-text review, of which 31 were included in the final database (Fig. 1). All citations of included articles were reviewed for potential inclusion, yielding an additional 14 articles that met inclusion criteria. Patients, Cause, and Defects A total of 45 articles were included for analysis. A total of 112 patients (Table 2)4,7–15,23–57 underwent microsurgical scalp reconstruction (n = 112 flaps). Mean patient age was 73.3 ± 6.3 years; 69.4 percent of the patients were men, 23.4 percent were women, and sex was not reported in 7.2 percent. The various causes of scalp defects included cutaneous malignancy in 48 (56.5 percent), infection in 13 (14.9 percent), angiosarcoma in seven (8.2 percent), osteoradionecrosis in six (7.1 percent), trauma/burn in three (3.5 percent), arteriovenous malformation in one (1.2 percent),

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Plastic and Reconstructive Surgery • March 2015 Table 1.  Inclusion and Exclusion Criteria Criteria Inclusion  Microvascular reconstruction of scalp  Human case series and case reports  Patients ≥65 yr  Published articles from 1970–2013 Exclusion  Scalp as donor-site tissue  Hair transplantation cases or series  Animal studies and review articles  Skin grafts for scalp, alone  Acellular dermal matrix scalp reconstruction  Local tissue rearrangement of scalp  Forehead reconstruction  Human cases series and case reports with insufficient data

and other tumor in seven (8.2 percent). Defect locations are detailed by anatomical distribution in Figure 2. Flap Types and Vascular Anastomoses Free flaps were adipocutaneous in 26 cases (24.3 percent), myocutaneous in 40 cases (37.4 percent), muscle-only with skin grafting in

Fig. 1. Flowchart of article selection.

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40 flaps (37.4 percent), and reconstruction using a free omental flap in one patient (0.9 percent).23 A total of 35 studies used one flap type in all of their patients.12,16,23–36,39,40,42–57 The most commonly used flap was the latissimus dorsi in 68 scalp reconstructions (60.7 percent).4,7,9,12–14,24,25,27,28,30–34,37,38,40–43,46–48,50,51,53–57 The remaining flap options were the anterolateral thigh flap in 20 (17.9 percent),8,9,11,16,23,30,32,35,37,39,52 abdominal flap (rectus abdominis myocutaneous or deep inferior epigastric perforator flap) in 11 (9.8 percent),9,13,26,32,37,49 forearm flap in five (4.5 percent),28,45,55 thoracodorsal artery perforator flap in three (2.7 percent),38 serratus anterior flap in one (0.9 percent),56,57 scapular/parascapular flap in two (1.8 percent),39,41 and omentum flap in one (0.9 percent).36 Mean flap size was 598 cm2 (range, 81 to 2500 cm2). A total of 22 patients (19.6 percent) received postoperative radiation therapy, 15 patients (13.4 percent) underwent cranioplasty, and 16 patients (14.3 percent) required duraplasty. Ten patients had published data regarding previously failed scalp reconstruction.

Volume 135, Number 3 • Scalp Reconstruction in Elderly Table 2.  Included Studies and Patients for Analysis Patient Age (yr) Sex

Reference

Cause

Free Flap

Flap Size (cm2)

Amin et al., 2004

76 72

M M

SCC SCC

ALT ALT

160 140

Bailey et al., 201124 Beasley et al., 200425 Calikapan et al., 20068

76 69 70 72

M M M M

LD LD ALT ALT

128 — 288 506

Carey et al., 20124 Chang et al., 201026

91 75 66 77 82 91

M M M M F M

Trauma Melanoma BCC BCC, SCC, giant ­keratoacanthoma BCC Infection Infection SCC Angiosarcoma Malignant histiocytoma

LD RAM ALT LD LD Distal forearm

80 100 187 150 —

77 65 73 76 67 82 72 83 65 66 69 65 71 70 79 72 71 65

M F F M F M M M M M M M F M M F F M

SCC BCC BCC BCC BCC SCC ORN BCC, ORN SCC SCC SCC Meningioma (recurrent) BCC — — Melanoma — Angiosarcoma

RAM LD LD RAM LD RAM RAM RAM LD ALT, LD LD RAM LD LD LD LD ALT Omentum

— 240 — — — — — — — 710 — — — — — — 180 —

78 79 67 65 77 70 73 68 78 65 68 77

M M M F F M F M F F F F

— — — — — SCC (recurrent) Infection Infection Infection Infection Infection Angiosarcoma

— — — — — 300 300 150 170 300 150 150

Kruse-Losler et al., 2006 Kwee et al., 201239

72 83

— M

Hemangiosarcoma Osteoradionecrosis

LD LD LD LD DIEP LD TDA perforator LD TDA perforator TDA perforator LD Scapular and parascapular LD ALT*

644 946

Labow et al., 200940

65 66 67 68 72 72 75 76

M M M M M M F M

SCC SCC SCC SCC Osteoradionecrosis SCC Schwannoma Osteoradionecrosis

LD LD LD LD LD LD LD LD

435 380 250 475 310 350 675 350

82 82 83 65 76 69 68 70

F M M M F F M M

Angiosarcoma Arteriovenous malformation Osteoradionecrosis — — — — SCC

LD LD LD LD Parascapular LD LD LD

625 425 260 — — — — —

23

Davison and Capone, 201127 Furnas and Bernstein, 198228 Gliklich et al., 19989

Gordon et al., 198229 Haddock et al., 201130 Har-El et al., 199931 Hashem and Al-Qattan, 200532 Herrera et al., 201233 Hierner et al., 200734 Higashino et al., 201335 Irons et al., 198336 Jones et al., 198837

Kim et al., 201238

Kimata et al., 199910 12

Lackey et al., 200741 Law et al., 199242 Lee et al., 199943

Complication(s) Pulmonary embolism Wound dehiscence; meningitis

Osteoradionecrosis Donor site hematoma Marjolin ulcer Infection Flap failure (venous thrombosis)

Hematoma Flap tip necrosis; ­donor-site breakdown Wound edge breakdown

Delayed donor-site healing

(Continued)

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Plastic and Reconstructive Surgery • March 2015 Table 2.  (Continued) Patient Age (yr) Sex

Reference Lutz et al., 1998

44

Lutz, 200245

Maxwell et al., 198046 Mun et al., 200547 Nagasao et al., 201148 Oh et al., 201149 Ozkan et al., 200515

Pennington et al., 198950 Seitz et al., 20097 Selber et al., 201251 Shimizu et al., 201352 Shonka et al., 201114

Sullivan et al., 198953 Takayanagi and Tsukie, 198054 Thorton et al., 200655 Trigano et al., 201256 Van Driel et al., 201011 Wang et al., 200713

Wooden et al., 199557

Cause

Free Flap

Flap Size (cm2)

70 70 66 77 72 68 71 71 73 74 89 68 75 70 77 71 71 83 68 70 67 74 81 66 69 75 68 83 72 84 71 73 75 71 76 74 73 84 72

M F M M M M M M M M M M M M F M M M M M — — M M M F F M M F M M F F M M M M M

SCC BCC Adenocarcinoma SCC (recurrent) SCC (recurrent) — — — — — — Angiosarcoma — — Infection — SCC — — — BCC Dermatofibroma SCC — Metastatic cancer Infection Infection Intracranial tumor Skin cancer (unspecified) Skin cancer (unspecified) Infection Intracranial tumor Skin cancer (unspecified) Infection Skin cancer (unspecified) Skin cancer (unspecified) Skin cancer (unspecified) Angiosarcoma Burn

Radial forearm Radial forearm Radial forearm ALT ALT Radial forearm ALT ALT LD LD LD LD LD LD RAM ALT ALT — — — LD LD LD LD‡ ALT ALT LD LD LD LD Serratus anterior LD LD LD LD LD LD LD LD

100 81 86 88 — — — — 352 920 300 124 108 106 — 187 266 432 336 330 400 289 750 90 120 91 2500 2500 2500 2500 100 2500 2500 1250 2500 2500 2500 375 540

70 65

M M

SCC —

419 —

75 93 83 69

M M F M

SCC SCC BCC BCC

LD LD and serratus anterior LD ALT ALT LD, then VRAM

79 71

— —

SCC Neuroblastoma

ALT RAM

— —

79 72

— —

SCC SCC

LD LD

— —

65



SCC

LD



76

M

SCC

LD and serratus anterior



— — — —

Complication(s)

Partial flap necrosis

Partial flap necrosis

Infection

Infection

Flap failure; ­retroperitoneal ­hematoma Partial flap necrosis Cerebrovascular ­accident; death Respiratory failure; tracheostomy Myocardial infarction; pneumonia

M, male; F, female; SCC, squamous cell carcinoma; LD, latissimus dorsi; BCC, basal cell carcinoma; ALT, anterolateral thigh; RAM, rectus abdominis myocutaneous; ORN, osteoradionecrosis; DIEP, deep inferior epigastric perforator; TDA, thoracodorsal artery; VRAM, vertical rectus abdominis myocutaneous. *Bilateral ALT flaps.

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Volume 135, Number 3 • Scalp Reconstruction in Elderly Table 3.  Classification and Definition of Complications

Fig. 2. Defect by anatomical distribution.

Recipient arterial anastomotic location was not described in 99 flaps (88.4 percent), and the recipient venous anastomotic location was not described in 81 flaps (72.3 percent). Of the flaps for which the recipient arterial anastomoses were described, six (46.2 percent) were to the superficial temporal artery, three (23.1 percent) were to the external carotid artery, one (7.7 percent) was to the facial artery, and three (23.1 percent) were to other vessels (i.e., posterior auricular artery, occipital artery, and zygomatico-orbital artery). Of the flaps for which recipient venous anastomoses were mentioned, 17 (54.8 percent) were to the superficial temporal vein, three (9.7 percent) were to the internal jugular vein, two (6.5 percent) were to the external jugular vein, one (3.2 percent) was to the facial vein, one (3.2 percent) was to the occipital vein, one (3.2 percent) was to the mandibular branch vein, and six (19.4 percent) were located “in the neck.” Complications The mean age of patients developing a complication was 72.8 ± 6.4 years, and the mean age of patients that did not develop a complication was 73.4 ± 5.5 years (p = 0.684). Complications were recorded and categorized based on a classification as major or minor and flap-related or non– flap-related (Table 3). Multiple complications in the same patient were recorded as separate events per flap type for statistical evaluation. The overall complication rate was 17.9 to 22.3 percent (n = 20 patients, 25 distinct complications) of scalp reconstructions. The minor complication rate was 11.6 to 12.5 percent (n = 13 patients, 14 distinct minor

Major  Death within 30 days of surgery  Free flap failure requiring return to the operating room  Retroperitoneal hematoma  Pulmonary embolism  Cerebrovascular accident  Pneumonia  Respiratory failure (requiring tracheostomy)  Myocardial infarction  Meningitis  Osteoradionecrosis Minor  Wound dehiscence  Delayed donor-site healing/breakdown  Donor-site hematoma  Marjolin ulcer  Hematoma  Partial flap necrosis  Infection Flap-related  Free flap failure requiring return to the operating room  Osteoradionecrosis  Wound dehiscence  Delayed donor-site healing/breakdown  Donor-site hematoma  Marjolin ulcer  Infection  Hematoma  Flap edge necrosis Non–flap-related  Death within 30 days of surgery  Retroperitoneal hematoma  Pulmonary embolism  Cerebrovascular accident  Pneumonia  Respiratory failure (requiring tracheostomy)  Myocardial infarction  Meningitis

complications), and the major complication rate was 7.1 to 9.8 percent (n = 8 patients, 11 distinct major complications). The flap-related complication rate was 12.5 percent (n = 15 patients, 15 distinct flap-related complications), and complication rate unrelated to the flap was 7.1 to 8.9 percent (n = 8 patients, distinct 10 nonflap-related complications). The overall flap failure rate was 1.8 percent (n = 2). Perioperative mortality was 0.9 percent (n = 1 death). Complications by Flap varied. The complication rate of the anterolateral thigh flap was 20 to 30 percent (four patients, 6 distinct complications), latissimus dorsi 19.1 to 22.1 percent (n=13 patients, 15 distinct complications), rectus abdominis or DIEP flap 18.2 to 27.3 percent (two patients, three distinct complications), radial forearm 0 percent, thoracodorsal artery perforator 0 percent, serratus anterior flap 0 percent, scapular/parascapular 100 percent (one patient, one distinct

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Plastic and Reconstructive Surgery • March 2015 Table 4.  Complications by Age, Cause, and Flap Type* Complication

Age, yr  65–69  70–79   >80 Cause  Cutaneous malignancy  Infection  Osteoradionecrosis  Angiosarcoma  Other tumor Flap type  ALT  LD  Other

Major

Minor

Flap-Related

Non–Flap-Related

Mean ± SD (%)

p

Mean ± SD (%)

p

Mean ± SD (%)

p

Mean ± SD (%)

p

Mean ± SD (%)

p

73.4 ± 0.7 7 (21.9) 14 (22.6) 3 (17.6)

0.684 0.967 0.965 0.910

69.9 ± 3.7 6 (18.8) 5 (8.1) 0 (0)

0.106 0.102 0.680 0.296

74.5 ± 5.5 1 (3.1) 5 (16.1) 3 (17.6)

0.498 0.110 0.333 0.777

73.4 ± 5.8 3 (9.4) 9 (14.5) 3 (17.6)

0.988 0.613 0.946 0.876

72.4 ± 5.7 3 (9.4) 6 (9.7) 0 (0)

0.696 0.756 0.741 0.396

14 (29.2) 1 (7.7) 3 (50) 2 (28.6) 2 (28.6)

0.813 0.200 0.406 0.930 0.930

6 (16.7) 0 (0) 0 (0) 2 (28.6) 2 (28.6)

0.805 0.248 0.642 0.606 0.606

5 (12.5) 1 (7.7) 2 (50) 0 (0) 0 (0)

0.959 0.978 0.120 0.662 0.662

7 (16.7) 1 (7.7) 2 (50) 2 (28.6) 0 (0)

0.859 0.878 0.344 0.762 0.458

5 (12.5) 0 (0) 0 (0) 0 (0) 2 (28.6)

0.565 0.455 0.895 0.800 0.258

6 (30.0) 15 (22.1) 4 (16.7)

0.539 0.934 0.636

1 (5.0) 6 (8.8) 3 (12.5)

0.805 0.961 0.773

4 (20.0) 9 (13.2) 1 (4.2)

0.456 0.770 0.296

3 (15.0) 12 (17.6) 2 (8.3)

0.980 0.525 0.463

2 (10.0) 4 (5.8) 2 (8.3)

0.945 0.789 0.798

ALT, anterolateral thigh; LD, latissimus dorsi. *Data analysis was completed based on rates of total number of complications per total number of patients for each age group, total number of patients with a designated cause of defect, and total number of flaps performed.

Table 5.  Subgroup Analysis of Muscle Flaps versus Flaps Devoid of Muscle Complication Any Minor Major Flap-related Non–flap-related

Muscle Flaps (%)

Flaps Devoid of Muscle (%)

p

18.8 11.3 8.8 12.5 6.3

18.5 12.5 12.5 14.8 12.5

1.00 1.00 0.69 0.75 0.41

complication), and omentum 100 percent (one patient, one distinct complication). Complications based on age, cause, and flap type are listed in Table 4. Of the flaps containing muscle, 18.8 percent developed a complication (14 myocutaneous and one muscle-only with skin grafting) compared with 18.5 percent of flaps devoid of muscle (four adipocutaneous and one omentum) that developed a complication (p = 1.000). No significant differences among minor, major, flap-related, and non–flap-related complications were observed (Table 5).

DISCUSSION The safety and efficacy of specific operative procedures for elderly patients influence the riskto-benefit profile and the proclivity of surgeons to operate on an aged patient. Numerous systemic changes will occur with aging, even in the absence of apparent clinical disease. Multiple studies show that aging may impact immunocompetence, delay wound healing, decrease cardiac output (with a linear decline in maximal work capacity of the heart), decrease vital lung capacity, impair renal

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function thereby affecting metabolism of anesthetics and drugs, and decrease tolerance of exercise and stress.58 However, the impact of altered physiology in the aged population is variable. The effect of age in reconstructive procedures has prompted multiple studies to assess elderly patients as a unique population in an effort to better predict complications and optimize outcomes.59–63 For instance, reconstruction of soft tissue in traumatic lower extremities in the elderly has shown favorable ambulation rates.60 In addition, free tissue transfers to the mandible, tongue, and maxilla has shown to be safe in patients older than 90 years.61 Furthermore, the impact of microsurgical intervention on quality of life in aged versus young populations has shown to be equivalent.59 Moreover, no correlation has been found between chronologic age and complications in studies assessing hand, lower extremity, and breast reconstruction with microsurgery.62,63 Although improved outcomes have largely been attributed to advances in microsurgical techniques, an age cutoff or optimal flap type for repairing scalp defects in the elderly remains in question. The ability to tolerate general anesthesia is a principal concern when performing complex, microsurgical reconstructions in the elderly. Traditionally, higher complication and mortality rates correlate with American Society of Anesthesiologists risk scores and medical comorbidities.18,21,26,58,59,64,65 Although dogmatic medical principles suggest that the elderly are commonly afflicted with chronic diseases, the geriatric literature does not support the notion that chronologic age is a predictive method of assessing risk in

Volume 135, Number 3 • Scalp Reconstruction in Elderly elderly patients requiring surgery.66 In fact, American Society of Anesthesiologists score and age do not correlate in patients undergoing microsurgical free flap reconstruction.18,64 Once patients are deemed suitable surgical candidates, the duration of surgery should not be a benchmark in minimizing morbidity, as it was not a predictor of medical complications following free flap surgery.58,64 Nevertheless, multiple studies support a one-stage procedure and a two-team approach, which can save the patient time, stress, and the need for multiple procedures.13,16,67 Microsurgical reconstruction of scalp defects has been reported extensively throughout the past 20 years. In 2006, Van Eeckhout et al. conducted a systematic review of microsurgical repair of scalp defects from 1989 to 2005, compiling a total of 227 patients.68 The inclusion criteria in the study failed to capture many studies using microsurgical techniques for scalp reconstruction, and an outcomes analysis was not completed, leaving many questions unanswered. To date, most reports convey their institutional experience or describe a case report, but an overall complication rate typically ranges from 16 to 33 percent among multiple studies.11–13 Traditionally, the most commonly used flap is the latissimus dorsi,11,14,33,34,50,68,69 but the anterolateral thigh flap has gained popularity within the past decade.8,16,22,26,39,56,70 This study acknowledges a gap within the current literature regarding safety, complications, and outcomes of scalp reconstruction in the elderly. The findings of this study elucidate several key concepts. The age of patients who developed a complication was comparable to patients who did not develop a complication. The overall flap survival rate was 96.4 percent in this population, the complication rate was 17.9 to 22.3 percent (depending on the method of data analysis), and the mortality rate was 0.9 percent, comparable to published rates of nonelderly populations undergoing microsurgical scalp reconstruction. A more critical evaluation of complications and free flaps did not show a superior method of reconstruction or an increased risk of developing a complication in the presence of a specific disease. The latissimus dorsi flap consistently showed fewer complications than the anterolateral thigh flap besides major complications and flap-related complications (Table 2) without reaching statistical significance. However, all “other” flaps demonstrated fewer complications than both the latissimus dorsi and the anterolateral thigh flaps. This is likely because of publication bias, as successful use of unlikely flaps for scalp reconstruction is more

likely to be reported and subsequently published. Defect cause did not seem to impact the likelihood of complications, but a trend toward minor flap-related complications approached significance in those patients with osteoradionecrosis. Interestingly, the mean age of patients developing major complications was among the youngest of the study (69.9 ± 3.7 years; p = 0.106). Based on our experience with atrophic muscle flaps in the elderly,71 we attempted to analyze muscle flaps [n = 107 (95.5 percent)] versus flaps devoid of muscle [n = 5 (4.5 percent)]. However, because of a skewed proportion of muscle flaps, a meaningful analysis could not be completed. This study debunks the notion that there is a superior flap choice in reconstructing scalp defects in the elderly. Nevertheless, a careful interpretation of such findings is essential for optimizing outcomes in the aged population undergoing microsurgical scalp reconstruction. Free tissue transfer provides advantages that far outweigh those associated with skin grafts and local flaps for complex soft-tissue deficits. Avoiding free tissue transfer simply because of patient age may prove to be detrimental for long-term patient outcomes. An individual’s functional status and potential for donor-site morbidity should aid in determining flap selection. This is especially pertinent in the elderly, for whom ambulation and activities of daily living are crucial for social independence. Carey et al.4 revealed an individualized method for treating elderly patients with free tissue transfers using only regional and local anesthesia. However, based on the global experience as shown in this systematic review, it is often unnecessary to avoid general anesthesia, as chronologic age should not dissuade the reconstructive surgeon from operating on complex scalp defects. Algorithms for scalp reconstruction have been reported, but they are not universally accepted by reconstructive surgeons.11,12,72,73 Borah et al.73 reported the rectus abdominis, followed by the latissimus dorsi flap, as being their most reliable and frequently used flap. Potparić and Starović72 provided an algorithm wherein the latissimus dorsi flap was the first option followed by the rectus abdominis flap, and, lastly, a radial forearm flap. Others, such as van Driel et al.,11 promote the latissimus dorsi as the principal flap, with the anterolateral thigh flap as a close second. In patients older than 65 years, simply following an algorithm for reconstruction of the scalp is not recommended, and currently there is a lack of evidence to support any of the aforementioned algorithms. Using a patient-centered individualized approach

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Plastic and Reconstructive Surgery • March 2015

CODING PERSPECTIVE

cpt

This information provided by Dr. Raymund Janevicius is intended to provide coding guidance.

15756  Free muscle or myocutaneous flap with microvascular anastomosis 15757 Free skin flap with microvascular anastomosis 15758 Free fascial flap with microvascular anastomosis 49906 Free omental flap with microvascular anastomosis • Codes are selected by the type of free flap that is performed. Code 15756 is used to report muscle or myocutaneous flaps, such as rectus abdominis or latissimus dorsi flaps. Code 15757 is used to report free skin flaps such as the anterolateral thigh flap or thoracodorsal artery perforator flap. • All free flap codes are global and include: °  H  arvest of flap. °  Straightforward closure of flap donor site. °  Transfer and inset of flap. °  Dissection and preparation of recipient vessels. °  Microvascular anastomosis of one artery and two veins. °  Closure of recipient site. • Use of the operating microscope is included in free flap codes, so 69990 is not reported separately. • The tumor resection procedures are not included in the free flap codes and are reported separately. Consider a wide excision of a 4-cm squamous cell carcinoma with 1-cm margins and latissimus dorsi free flap reconstruction. This would be reported as follows: °  1  5756, latissimus dorsi free flap. °  11626-51, wide excision squamous cell carcinoma.

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in reconstructing scalp and cranial defects in the elderly can optimize long-term outcomes.71 There are inherent weaknesses to this study, including publication bias, inconsistently reported data, and scarce reporting of patient comorbidities and follow-up time. The benefits of this study include the study size, integration of multiple institutional experiences, delineation of types of complications, and the ability to compare flap selection and outcomes. Future prospective studies will better elucidate best practices in microsurgical scalp reconstruction in the elderly. Currently, this study supports free flap reconstruction in the elderly as the criterion standard for large, complex defects of the scalp, with a safety profile comparable to that of the nonelderly population.

CONCLUSIONS Free tissue transfer for the reconstruction of large, complex scalp and calvarial defects in the elderly should be considered the standard of care. No increase in mortality, morbidity, or flap failure is associated with increasing chronologic age. There is a lack of evidence to support a superior flap type for reconstruction. Eduardo D. Rodriguez, M.D., D.D.S. Department of Plastic Surgery New York University Langone Medical Center Institute of Reconstructive Plastic Surgery 305 East 33rd Street New York, N.Y. 10016 [email protected]

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Microsurgical scalp reconstruction in the elderly: a systematic review and pooled analysis of the current data.

Microvascular reconstruction is the mainstay of treatment in complex scalp defects. The rate of elderly patients requiring scalp reconstruction is inc...
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