Wednesday, November 5, 2008 - 9:20 AM

Free Flap Breast Reconstruction in Advanced Age: Is it Safe?

Jesse Selber, MD, MPH, Meredith Bergey, MPH, MSc, Seema Sonnad, PhD, and Joseph M. Serletti, MD.

Background: Free flap breast reconstruction has become the method of choice for multiple centers performing autogenous reconstruction. Patients of advanced age may not be offered this most satisfactory method of reconstruction because of their increased prevalence of medical co morbidities and surgical risks.  The purpose of this study is to determine if the rate of medical and surgical complications following free flap breast reconstruction in patients of advanced age is higher than those in the general population.


Materials and Methods: A retrospective review of 970 free, muscle sparing TRAMs, DIEPs and SIEAs by a single surgeon over a 15 year period was performed.  The study population was subdivided into 920 patients under 65 years of age and 50 patients 65 years of age or older. Population variables included length of follow up, BMI, past medical history including hypertension, diabetes, peripheral vascular disease, heart disease, chronic obstructive pulmonary disease, preoperative and post-operative chemotherapy and radiation therapy, and history of smoking. Operative variables included timing of reconstruction, recipient artery and vein, anastamotic technique, intraoperative blood transfusion, and intra-operative use of heparin. Outcome variables included medical complications, length of stay, 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 also performed by procedure to see if there were differences by age for free TRAMs, DIEPs and SIEAs. Statistical Analysis included Chi-Squared Analysis and Fisher’s Exact test for all non-parametric outcome variables.


Results: The mean age of the population was 47, range 24-79 years old. 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 did have a higher prevalence of hypertension (40% v 19%, p < 0.001), a higher average BMI (31 v 28, p = 0.046), as well as 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%), including both donor site morbidity and flap complications. There was no difference in return to the OR, or operative revision rate.  When these variables were further analyzed among the operative sub-groups, fTRAM, DIEP and SIEA, there were no additional significant findings.


Conclusions: In spite of higher rates of hypertension, a higher average BMI, and a higher rate of intra-operative blood transfusions, the 65 and over group had an equivalent rate of medical and surgical complications, equivalent revision and take-back rates, and similar lengths of stay. Conventional wisdom suggesting that free flap breast reconstruction should be restricted to a younger, and thus hardier patient population, is not supported by this study.