Failure of preoperative co-morbidity indices to predict the successful use of the composite scapula free flap for maxillofacial reconstruction in patients with significant medical co-morbidities

The aim of this study was to evaluate the accuracy of validated preoperative patient co-morbidity assessments, including the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP), with the use of the composite scapula free flap (CSFF) in maxillofacial reconstruction in patients with significant medical co-morbidities. A retrospective cohort review was performed at an academic institution, covering the period from July 2010 through January 2019. All patients who underwent reconstruction with a CSFF with significant medical co-morbidities were included. Co-morbidity assessments and risk factors were analyzed by comparing predicted versus observed early and late medical and surgical complications. Forty-five patients met the inclusion criteria. The surgical complication rate was 47%; the medical complication rate was 38%. Over 90% of patients returned to successful function at 3 months post-surgery. The ACS-NSQIP prediction of complications ranged from 58% to 75% for accuracy, 76% to 100% for sensitivity, and 50% to 69% for specificity. The prediction of a serious complication was statistically significant in patients with a Charlson Co-morbidity Index ≥7. Age ≥80 years did not significantly increase the risk of a serious complication (P = 0.23). The ACS-NSQIP failed to predict the successful use of the CSFF for patients with significant co-morbidities undergoing maxillofacial reconstruction. The selection of patients who will tolerate complex reconstruction cannot be based solely on co-morbidity charts and standardized preoperative indices.