Navigating the ‘Silver Tsunami’ in Limb Salvage: Lower Extremity Free Flap Outcomes in Septuagenarians and Octogenarians

Background: As the United States population ages, an increasing number of elderly patients with chronic lower extremity (LE) wounds require reconstruction. Although prior studies have evaluated flap outcomes in elderly patients undergoing free tissue transfer (FTT), systemic postoperative complications and complication severity remain inadequately characterized. This study compared surgical and systemic complications after LE FTT between elderly and non-elderly patients. Methods: A retrospective review of 318 patients undergoing LE FTT between 2011 and 2024 was performed. Patients were stratified into elderly (≥70 years) and non-elderly (<70 years). Baseline characteristics, vascular status, operative variables, 30-day postoperative complications, and long-term outcomes were analyzed. Thirty-day complications were classified as systemic or surgical and graded using the Clavien–Dindo classification. Logistic regression and receiver operating characteristic analysis were used to evaluate predictors of complications. Results: Of 318 patients, 54 (17.0%) were elderly. Elderly patients experienced similar rates of any systemic complication (33.3% elderly vs. 22.7% non-elderly, p=0.099), although acute kidney injury was more common in elderly patients (27.8% vs. 12.9%, p=0.006). Surgical complications were also similar (33.3% vs. 28.4%, p=0.469). Overall complication severity did not differ between groups (p=0.701), and only 1.6% of patients experienced a life-threatening complication. Smoking history (OR 2.6, p=0.008) and diabetes (OR 2.7, p=0.027) independently predicted major complications, while age did not. The Charlson Comorbidity Index outperformed age in predicting both major (AUC 0.604 vs. 0.539, p=0.031) and minor complications (AUC 0.647 vs. 0.551, p=0.011). Septuagenarians and octogenarians did not differ significantly in complications, ambulation, amputation, or mortality. Conclusion: Lower extremity free tissue transfer is a safe and effective limb salvage option in elderly patients, with no difference in systemic or surgical complications. Patient selection and risk assessment for LE FTT should therefore be guided by comorbidity burden rather than chronologic age alone.