The Journal of Craniofacial Surgery  Volume 31, Number 7, October 2020
7. Choi J. Faces of the Face. Arch Plast Surg 2017;44:251–256
FIGURE 4. Fixation point (dots) and direction of reposition (arrows) in
proposed midface lift based on the concept of periorbital and perioral areas.
Arrowhead: direction of buccal fat pad.
The proposed midface lift based on the concept of these 2
regions are:
(1) Reposition of the periorbital area to the floor of prezygomatic
space after release of zygomatic, masseteric retaining
ligaments (Fig. 4).
(2) Reposition of medial smas-platysmal flap of perioral area into
lateral immobile SMAS or platysma auricular fascia (Fig. 4).
In conclusion, I noticed that the face consists of the 2 pairs of
holes and 1 large hole, which correspond to the eyes, nose, and the
mouth and soft tissues of their cover. In this paper, through the
review, I attempted to divide the face into the less mobile periorbital
and, the more mobile perioral region and proposed a midface lift
based on this concept. The detailed results of this surgical technique
based on the concept of these 2 regions will be followed.
ACKNOWLEDGMENT
The author thanks Hye Won Hu, BA, Division in Biomedical Art,
Incheon Catholic University Graduate School, for her illustrations.
REFERENCES
1. Skoog T. Plastic Surgery: New Methods and Refinements Philadelphia,
PA: Saunders; 1974:300–330
2. Hamra ST. The zygorbicular dissection in composite rhytidectomy: an
ideal midface plane. Plast Reconstr Surg 1998;102:1646–1657
3. Mendelson BC. Correction of the nasolabial fold: extended SMAS
dissection with periosteal fixation. Plast Reconstr Surg 1992;89:822–833
4. Vincent D. Short scar rhytidectomy techniques. In: McLane L, ed.
Contemporary Rhytidectomy: An Issue of Atlas of the Oral &
Maxillofacial Surgery Clinics. 1st ed. Amsterdam, Netherlands: Elsevier;
2014:37–52
5. Burkitt AN, Lightoller GS. The facial musculature of the Australian
aboriginal: Part I. J Anat 1926;61:14–39
6. Lightoller GH. Facial muscles: the modiolus and muscles surrounding the
rima oris with some remarks about the panniculus adiposus. J Anat
1925;60:1–85
# 2020 Mutaz B. Habal, MD
Copyright © 2020 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Brief Clinical Studies
8. Darwin C. The Origin of Species. New York, NY: Cosimo Classics; 2007
Investigation of Free-Flap
Transfer Reconstruction in
Elderly Patients and Oral
Intake Function
Satoshi Onoda, PhD, Masahito Kinoshita, MD,
and Yukino Ariyoshi, MDy
Abstract: The authors retrospectively examined 39 patients with
head and neck reconstruction using a free-flap transfer with micro-
surgery in elderly patients aged over 80 years in our hospital. They
investigated postoperative local complications, postoperative
systemic complications, day of ambulation, the presence of delir-
ium, the postoperative oral intake ratio, and the reconstructive
method in mandibular reconstruction patients. There were 12 post-
operative local complications. And postoperative systemic compli-
cations were detected in 19 patients; however, 17 of these were
respiratory disorders due to pneumonia. There were 17 patients with
postoperative delirium. Oral intake was resumed after an average of
14.9 days. Of these, 34 patients were eventually able to eat some
kind of food. The incidence of local complications in elderly free-
flap reconstruction patients was similar to that in young people.
However, the rate of systemic complications was much higher in
elderly patients. The authors suggest that free-flap reconstruction
can be performed relatively safely in elderly people when a detailed
preoperative surgical plan.
Key Words: Head and neck reconstruction, postoperative
complication, radiation therapy, recipient vessel, secondary
reconstruction
D ue to advances in medical technology and the improvement in
life expectancy year after year, there are many opportunities to
treat very elderly patients.1–6 The standard therapy for head and
neck cancer is a combination of surgical treatment, chemotherapy,
and radiation therapy. This treatment regime is a burden on all
From the Department of Plastic and Reconstructive Surgery, Kagawa
Rosai Hospital, Kagawa; and yDepartment of Plastic and Reconstructive
Surgery, Graduate School of Medicine, Dentistry and Pharmaceutical
Science, Okayama University, Okayama, Japan.
Received February 4, 2020.
Accepted for publication March 9, 2020.
Address correspondence and reprint requests to Satoshi Onoda, PhD,
Department of Plastic and Reconstructive Surgery, Kagawa Rosai
Hospital, 3-3-1 Joto-cho, Marugame, Kagawa 763-8502, Japan;
E-mail: satoshiprs18@gmail.com
The authors report no conflicts of interest.
Supplemental digital contents are available for this article. Direct URL
citations appear in the printed text and are provided in the HTML and
PDF versions of this article on the journal’s Web site (www.jcraniofa-
cialsurgery.com).
Copyright # 2020 by Mutaz B. Habal, MD
ISSN: 1049-2275
DOI: 10.1097/SCS.0000000000006534
e679
Brief Clinical Studies The Journal of Craniofacial Surgery
patients, especially elderly patients. Therefore, we need to deter-
mine an appropriate treatment strategy for elderly patients who may
present with age-related deterioration in respiration and cardiovas-
cular system function as well as various chronic diseases. Tumor
resection and reconstructive surgery for advanced head and neck
cancer is the standard operative method, but it is very invasive and
may not be indicated in elderly patients with poor overall condition.
Therefore, we investigated the use of free-flap reconstruction in
elderly people aged over 80 years. We examined the need for
surgery, the safety of the surgery, and the crucial factors involved in
reconstruction surgery performed on elderly people.
METHODS
We retrospectively examined 39 patients with head and neck
reconstruction using a free-flap transfer with microsurgery in
elderly patients aged over 80 years in Okayama University hospital.
Our research was approved by ethics committee of Okayama
University Hospital (1804-023). The mean age of patients was
84 years (range: 80–92 years), and there were 18 men and 21
women. Eighteen patients were classified as American Society of
Anesthesiologists (ASA) grade I, 14 were ASA grade II, and 7 were
ASA grade III. The ASA Physical Status Classification system
reflects a patient’s overall preoperative status (Supplementary
Digital Content, Table 1, http://links.lww.com/SCS/B422).
We investigated postoperative local complications, postopera-
tive systemic complications, day of ambulation, the presence of
delirium, the postoperative oral intake ratio, and the reconstructive
method in mandibular reconstruction patients. We also investigated
vital prognosis and observation period. The incidence of post-
operative local complications, including transferred flap necrosis,
was compared to the incidence in 216 patients who were younger
than 80 years. In addition, we examined the incidence of post-
operative systemic complications and local complications in ASA
grades I, II, and III patients.
RESULTS
The primary tumor site was the maxillary or upper gum in 7
patients, the tongue or oral floor in 9 patients, the mandibular in
11 patients, the hypopharynx in 3 patients, and cervical esophagus
in 6 patients, and check mucosal cancer and parotid gland and
stomach duct cancer in 1 patient, respectively. The flaps used were
an anterolateral thigh flap in 18 patients, a rectus abdominus
myocutaneous flap in 10 patients, a free jejunum or supercharge
of alimentary canal flap in 8 patients, and a thoracodorsal system
flap in 3 patients.
There were 12 postoperative local complications (31%), includ-
ing 3 fistulas (7.7%), 3 patients with flap necrosis (7.7%), 2 abscess
formations (5.1%), 2 patients with cellulitis of the cervical skin
(5.1%), 1 postoperative hemorrhage (2.6%), and 1 reconstructive
plate infection (2.6%). Postoperative systemic complications were
detected in 19 patients (48.8%); however, 17 (43.6%) of these were
respiratory disorders due to pneumonia. In addition, there were 2
patients with ileus, 1 duodenal ulcer, and 1 patient with cholecystitis
and hernia complicated by pneumonia. The systemic complications
that were not pneumonia were 1 lower limb thrombosis and 1
common bile duct stone. The average time of ambulation was 3.7
days (range: 2–8). There were 17 patients (43.6%) with post-
operative delirium. Postoperative gastrostomy (intestinal fistula)
was performed in 17 patients, and 4 patients underwent additional
surgery to improve deglutition, such as laryngectomy, cricophar-
yngeus muscle amputation, and larynx elevation.
Oral intake was resumed after an average of 14.9 days (range:
8–42). Of these, 34 patients (91.9%) were eventually able to eat
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Copyright © 2020 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
 Volume 31, Number 7, October 2020
some kind of food. Nineteen patients died and of these, 17 died due
to cancer. The average follow-up period of these 19 patients was
2 years and 9 months. The mean survival of the 15 survivors was
3 years 11 months. There were no significant differences in post-
operative local complications in patients older than 80 years com-
pared to those younger than 80 years (Supplementary Digital
Content, Table 2, http://links.lww.com/SCS/B422). The rate of
local systemic complications was higher in patients classified as
ASA grade III compared to patients classified ASA grade I or II
(Supplementary Digital Content, Table 3, http://links.lww.com/
SCS/B422).
DISCUSSION
Recently, there have been a few reports about head and neck
reconstruction using microsurgery in elderly people. Reiter et al
examined 31 patients with head and neck reconstruction in patients
aged over 75 years and reported a similar rate of flap survival to that
of younger patients; however, the ASA score did correlate with the
onset of postoperative complications.7 Chen et al reported on 24
patients older than 85 years and also reported a rate of flap survival
similar to young people, but the postoperative complication rate
was higher. And tracheotomy has been reported as a factor associ-
ated with postoperative complications, and it is recommended to
avoid it if possible.8 With respect to other factors, there are no
studies that report systemic complications, including delirium and
the postoperative oral intake in addition to local complications.
In this examination, nearly half of the patients survived. Most
of the deceased patients died due to cancer. Considering that
the patients in this study were mostly high stage patients who
needed wide resection and reconstruction, we believe that we
were able to prolong the survival period in many patients. In
addition, maximum care should be taken to prevent postoperative
complications because wound healing results in the delayed return
to health.
Local Complications
Our results showed no differences in postoperative local com-
plications in patients aged over 80 years and young people.9 – 12
Given that the prevalence of systemic diseases, such as vascular
calcification and diabetes due to hypertension, are high in elderly
people, the likelihood that these diseases will influence free-flap
survival rate should be considered.13 We performed multi-detec-
tor-low-computed tomography preoperatively to assist with the
development of a detailed surgical plan and, if required, to inves-
tigate the state of the recipient vessels.14,15 When there is cervical
skin loss and a large cervical death space, we fill the dead space
with secondary skin paddle, a deltoid-pectoral flap, or a pectoralis
major myocutaneous flap to prevent postoperative compli-
cations.16 However, among the patients aged over 80 years with
a preoperative ASA grade of III, the incidence of complications
was very high. A challenge for the future is choosing appropriate
treatment plans for patients with both a poor general state and a
high age.
Systemic Complications
This examination showed a high rate of systemic complications
and delirium in elderly patients. Furthermore, most of the systemic
complications were respiratory disorders due to pneumonia. We
usually administer sedative management on the day of surgery,
many patients can wake up and walk on next day. But the average
ambulation day was prolonged by 3.7 days in patients with
advanced age. We suggest that the incidence of postoperative
pneumonia in elderly people influenced the delay in ambulation.
# 2020 Mutaz B. Habal, MD
The Journal of Craniofacial Surgery  Volume 31, Number 7, October 2020
Furthermore, a longer period spent lying in bed decreased muscular
strength. Additionally, about delirium, it is thought that a getting up
delay and many patients holding correcting factor of a delirium as
insomnia in patients with advanced age. The onset of these systemic
complications causes a delay in wound healing, postoperative
rehabilitation, oral intake initiation, and the administration of
additional postoperative treatment. Therefore, we must consider
the use of drugs in the early prophylactic postoperative stage to treat
pneumonia and delirium.
Oral Intake Function
Various factors are associated with oral intake, including overall
status, age, resection area, reconstructive methods, and the number of
remaining teeth.17,18 Especially, oral intake function can be limited
by lack of laryngopharynx perception and decreases in occlusal force
in elderly people. There were 9 reconstruction patients for tongue
cancer and oral floor cancer, which naturally influence the deglutition
function. Of these, 3 patients underwent gastrostomy postoperatively.
Furthermore, the average starting date for oral intake was 14.9 days
(range: 8–20). Including gastrostomy patients, all patients were able
to eventually intake food orally (4 soft diets, 4 rice porridge, and 1
normal food). For tongue or oral floor reconstruction patients, we
decided to start oral intake after confirming pharyngeal perception
and clearance using nasal fibers if there were no significant compli-
cations 1 week after surgery.13 Therefore, the resumption of oral
intake was later in elderly patients than younger reconstruction
patients, but many elderly patients became able to ingest oral intact
with continued rehabilitation.
Mandibular segmental resection was performed in 11 patients,
and of these, scirrhous reconstruction using a reconstructive plate
and soft tissue was performed in 8 patients and reconstruction using
only soft tissues was performed in the other 3 patients. All patients
who underwent reconstruction using a reconstructive plate were
able to intake food orally.19 Whereas, oral intake was impossible in
2 patients with reconstruction using only soft tissues. Generally, the
indication for scirrhous reconstruction after segmental resection is
based on the extent of resection, age, the state of the remaining
teeth, and overall preoperative status. We often reconstruct using
only soft tissues due to the problems of prolonged surgical time and
postoperative complications that are higher in patients with poor
overall status. However, the results of this study suggest that
reconstruction using a reconstructive plate should be the preferred
procedure.20,21 Some problems in this study can be attributed to the
retrospective design for small patients. For example, there are
different reconstructive part patients and postoperative observation
periods patients in this study. In future, a prospective study of head
and neck reconstruction on elderly people, including a multivariable
analysis would be of interest.
CONCLUSION
The incidence of local complications in elderly free-flap recon-
struction patients was similar to that in young people. However, the
rate of systemic complications was much higher in elderly patients.
We were thought to be candidates surgical treatment for the
resectable patients in the elderly people needed wide resection.
We suggest that free-flap reconstruction can be performed rela-
tively safely in elderly people when a detailed preoperative surgical
plan postoperative treatment plan are formulated.
ACKNOWLEDGMENT
The authors thank Yoshihiro Kimata (Okayama University), without
which this study could not have been completed.
# 2020 Mutaz B. Habal, MD
Copyright © 2020 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Brief Clinical Studies
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