The impact of age on postoperative functional decline and length of hospital stay in free flap reconstruction for head and neck cancer

Background: Head and neck cancer predominantly affects those older than 65 years. The goals of resection and free flap reconstruction are oncological clearance, functional reconstruction and stability for adjuvant treatment. For many elderly patients, recovery of preoperative functional status and maintaining independence are more important than life extension. This study aims to evaluate the relationship between age and postoperative functional status, focusing on care needs and length of hospital stay. Methods: We retrospectively reviewed cases of head and neck cancer resection with free flap reconstruction at the Royal Brisbane and Women's Hospital in Brisbane, Australia, between January 2015 and December 2020. Patients were stratified by age (<65, 65–74, ≥75 years) and compared by demographics, surgical characteristics, and functional status changes from admission to discharge. Results: Functional decline, defined as an increase in care needs at discharge compared to baseline (e.g., requiring community support or inpatient rehabilitation) occurred in 16.50% (n=33) of the 200 included patients, and was most frequent in those aged ≥75 years (60.61%, n=20). Increasing age was a significant predictor of decline, with those aged 65–74 years [odds ratio (OR) 5.19, 95% confidence interval (CI): 1.32–20.38, P=0.018] and ≥75 (OR 27.17, 95% CI: 6.84–107.90, P<0.001) more likely to require increased care postoperatively compared with their younger counterparts (age <65 years). Functional status was unaffected by surgical factors including ablative site, free flap type or operative duration. Patients with functional decline had longer hospital stays {median 19 days [interquartile range (IQR): 11–28 days] vs. 14 days (IQR: 9–21 days), P<0.01}. Linear regression showed mucosal reconstructions and the use of latissimus dorsi free flaps increased hospital stays by 7.97 (95% CI: 4.04–11.90) and 8.79 days (95% CI: 3.49–14.09, respectively (P≤0.001). Conclusions: Increased age was associated with postoperative functional decline in patients undergoing head and neck cancer resection with free flap reconstruction in our cohort. Surgical factors did influence the length of hospital stay, but did not affect change in postoperative functional status. These findings underscore the importance of comprehensive preoperative counselling and individualized postoperative care strategies to address the unique needs of elderly patients, aiming to improve outcomes and support patient-centred care.