Free Flap Scalp Reconstruction in a 91-Year-Old Patient under Local-Regional Anesthesia: Case Report and Review of the Literature

Abstract

In the elderly population with significant medical comorbidities, the safety of general anesthesia is often in question. In the head and neck, where regional and extradural anesthesia are not options, reconstruction of defects requiring free tissue transfer becomes a particular challenge for patients in whom general anesthesia is contraindicated. We present a case of a scalp reconstruction utilizing a latissimus dorsi free flap in a 91-year-old man performed entirely under local and regional anesthesia. General anesthesia was contraindicated secondary to the patient's multiple medical comorbidities. A paravertebral block was used for the harvest of the latissimus dorsi muscle and skin grafts. The microvascular portion of the procedure and the inset were performed under local anesthesia alone. The patient tolerated the procedure, and the operation was successful. This case is unique in that there are no published reports of head and neck free tissue transfer being performed entirely under local-regional anesthesia. We conclude that despite the medical challenges of performing complex reconstruction in elderly patients, expedient free tissue transfer can offer patients access to successful reconstruction.

Lessons Learned in Scalp Reconstruction and Tailoring Free Tissue Transfer in the Elderly: A Case Series and Literature Review

“…10 Carey et al elegantly demonstrated a tailored method of treating an elderly patient by achieving free tissue transfer using only regional and local anesthesia. 11 However, avoiding general anesthesia is seldom necessary. Chronological age alone should not deter the reconstructive surgeon from operating on complex defects.…”

“…19,31,60,61 We advocate for musclesparing adipocutaneous free tissue transfer to prevent longterm atrophy as seen in case 7 with the muscle-only latissimus dorsi (►Figs. [9][10][11]. Nevertheless, historically multiple studies support the latissimus dorsi myocutaneous flap or muscle only with STSG as the workhorse for reconstruction.…”

“…10 This inevitably has and will lead to more operative procedures in elderly patients. 11 Although, free tissue transfer in the elderly is associated with a 5.4 to 9.1% mortality rate, these rates were reported over a quarter century ago. 12,13 Recently, Howard et al reported similar mortality rates with complication rates as high as 59.3%.…”

Emerging Paradigms in Perioperative Management for Microsurgical Free Tissue Transfer

“…51 Free flap operations under epidural anesthesia alone have been reported in cases where general anesthesia was contraindicated. 52,53 Several clinical studies have also demonstrated that peripheral nerve blocks reduce vasospasm and improve perfusion of replanted or revascularized digits. 20,21,54,55 …”

The Pedicled Latissimus Dorsi Flap in Head and Neck Reconstruction: An Old Method Revisited

“…In some patients, the method of reconstruction may be limited by general health factors precluding general anesthesia, and even a microvascular reconstruction with a latissimus dorsi free flap has been preformed under locoregional anesthesia. 29 In spite of this, not all patients will survive complex surgical treatments and more simple reconstructive options will always be needed. The SP-LD offers many qualities required in these situations.…”