Free Flap Breast Reconstruction in Advanced Age: Is it Safe?
Jesse C. Selber, MD, MPH, Meredith Bergey, PhD, Seema S. Sonnad, PhD, Joseph M. Serletti, MD, FACS.
University of Pennsylvania, Philadelphia, PA, USA.
Background: Because of concern over medical co-morbidities and surgical risk, patients of advanced age may not be offered free flap breast reconstruction. The purpose of this study is to determine if medical and surgical complications following free flap breast reconstruction are higher in patients of advanced age than in the general population.
Materials and Methods: A retrospective review of 1031 MS fTRAMs, DIEPs and SIEAs by a single surgeon over 15 years was performed. There were 976 patients under 65 years of age and 55 patients 65 years of age and older. Population variables included length of follow up, BMI, ASA status, past medical history including hypertension, diabetes, peripheral vascular disease, heart disease, chronic obstructive pulmonary disease, preoperative and post-operative chemotherapy and radiation therapy, and smoking history. Operative variables included timing of reconstruction, recipient vessels, anastamotic technique, blood transfusion, and use of heparin. Outcome variables included length of stay, medical complications, and surgical complications including abdominal hernia, fat necrosis, partial and total flap loss, vessel thrombosis, hematoma and seroma, mastectomy flap loss and wound infection. All analyses were repeated separately for the MS fTRAMs, DIEPs and SIEAs to determine if outcomes differ by age. Statistical analysis included Chi-Squared,Fisher’s Exact, and Kruskal-Wallis tests for significance.
Results: The mean age was 47 years (24-79). For population variables, there was no difference in length of follow up, history of smoking, diabetes, peripheral vascular disease, heart disease or COPD between the <65 and 65 and over groups. The older group had a higher ASA status (2.1 v 1.9, p = 0.05) higher prevalence of hypertension (40% v 19%, p < 0.001), a higher average BMI (31 v 28, p = 0.046), and lower rates of pre-operative (26% v. 4%, p = 0.001) and post-operative (16% v 2%) chemotherapy. In terms of operative variables, the older group received more intra-operative blood transfusions (8% v 2%, p = 0.023) and the coupler was used less often (10% v 29%, p = 0.023). For outcome variables, there was no difference in length of stay (3.5 days), medical complications (4%), or surgical complications (32%), take-backs or post-operative revisions. When analyzed separately for the fTRAM, DIEP and SIEA, results were similar.
Conclusions: In spite of higher ASA status, higher rates of hypertension, higher BMIs, and higher rates blood transfusions, the 65 and older group had outcomes equal to those of the general population. Thus, free flap breast reconstruction in patients of advanced age is safe, and should not be denied to this population.