[Objective]
With the trend of aging, more and more elderly head and neck cancer patients need to undergo microvascular free flap reconstruction. It is challenging to perform on elderly patients due to the high surgical risks, and the clinical outcome in these patients has not to been adequately reported. We aimed to evaluate the results, the associated risks, and the complication rate of the microvascular free flap reconstruction in elderly head and neck cancer patients.

[Materials and methods]
Elderly head and neck cancer patients (≥75 years) who underwent free flap reconstruction were included in this retrospective study between March 2010 to August 2022 in our institution. Predictive factors, such as flap types, recipient vessels, comorbidities/coexisting conditions, body mass index, American Society of Anesthesiologists (ASA) score, and albumin level before the surgery, were investigated for the outcome and postoperative complications.

[Results]
Among 44 head and neck cancer patients included in the analysis (26[59%] men and 18[41%] women) underwent free flap reconstruction. The median age was 80.5 years (range 75-91 years). The flap success rate was 84%. All patients used the ALT flap for the reconstruction. The complication (surgical and medical) rate was 15.9%. The variable associated with higher postoperative complication rates is the level of albumin. A higher ASA score was associated with more extended ICU stays and higher medical complications.

[Conclusions]
Advanced age did not seem to influence free flap survival. Low pre-operative albumin level is a factor predisposing to a higher complication rate. The length of ICU stay and medical complications are potentially associated with the ASA status.

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