European Journal of Cardiovascular Medicine

Soft tissue reconstruction of the head and neck region remains one of the most challenging aspects of reconstructive surgery due to the complex anatomy, functional significance, and aesthetic importance of this area. Defects in the head and neck commonly arise following oncologic resections, trauma, infections, or congenital anomalies. These defects often involve exposure of vital structures such as bone, vessels, nerves, and aerodigestive tract, necessitating prompt and effective reconstruction to restore form, function, and quality of life.^[1]

Reconstructive options for head and neck soft tissue defects have evolved significantly over the past few decades. Traditionally, local and regional flaps formed the backbone of reconstruction. Local flaps utilize tissue adjacent to the defect and offer advantages such as similar color and texture match, shorter operative time, reduced donor site morbidity, and technical simplicity. They are particularly useful in small to moderate defects and in patients with significant comorbidities where prolonged anesthesia may not be ideal.^[2]

The advent of microvascular free tissue transfer has revolutionized head and neck reconstruction, allowing surgeons to reconstruct large and complex defects with well-vascularized tissue. Free flaps provide versatility in terms of tissue composition (skin, muscle, bone, or composite flaps), reliable vascularity, and the ability to reconstruct extensive three-dimensional defects. However, free flap surgery requires advanced microsurgical expertise, longer operative time, intensive postoperative monitoring, and increased resource utilization. Furthermore, free flap reconstruction may not always be feasible in elderly patients, those with poor general condition, or in resource-limited settings.^[3]

Despite the widespread use of free flaps, local flaps continue to play an important role, especially in selected cases where defect size, location, patient factors, or institutional constraints favor their use. The choice between local flaps and free flaps remains a subject of debate and is influenced by multiple factors including defect characteristics, surgeon expertise, patient comorbidities, and expected functional outcomes.^[4]

AIM

To compare the outcomes of local flaps and free flaps in soft tissue reconstruction of head and neck defects.

OBJECTIVES

1. To evaluate and compare operative and postoperative outcomes between local flaps and free flaps.
2. To compare complication rates associated with local flap and free flap reconstruction.
3. To assess functional and aesthetic outcomes following reconstruction using both techniques.

Source of Data Data were collected from patients undergoing soft tissue reconstruction of head and neck defects at the study center during the study period. Study Design This was a hospital-based comparative observational study. Study Location The study was conducted in the Department of Plastic Surgery, Tirunelveli Medical College. Study Duration The study was carried out over a defined period of 18 months from January 23 to June 24. Sample Size A total of 100 patients requiring soft tissue reconstruction of head and neck defects were included in the study. Inclusion Criteria • Patients aged ≥18 years. • Patients requiring soft tissue reconstruction of head and neck defects following surgery, trauma, or infection. • Patients reconstructed using either local flaps or free flaps. • Patients who provided informed written consent. Exclusion Criteria • Patients with recurrent disease requiring revision reconstruction. • Patients with incomplete medical records or inadequate follow-up. • Patients with severe systemic illness contraindicating surgery. • Patients unwilling to participate in the study. Procedure and Methodology Eligible patients were evaluated preoperatively with detailed history, clinical examination, and relevant investigations. Based on defect size, location, patient factors, and surgeon discretion, reconstruction was performed using either a local flap or a free flap. Operative details including type of flap, duration of surgery, and intraoperative complications were documented. Postoperatively, patients were monitored for flap viability, wound complications, and donor site morbidity. Functional and aesthetic outcomes were assessed during follow-up. Sample Processing All clinical data were recorded in a structured proforma. Relevant perioperative and postoperative parameters were compiled and tabulated for analysis. Statistical Methods Data were entered into Microsoft Excel and analyzed using appropriate statistical software. Categorical variables were expressed as frequencies and percentages, while continuous variables were expressed as mean ± standard deviation. Comparative analysis between groups was performed using Chi-square test or Fisher’s exact test for categorical variables and Student’s t-test for continuous variables. A p-value <0.05 was considered statistically significant. Data Collection Data collection was done prospectively/retrospectively (as applicable) using patient records, operative notes, and follow-up assessments.

Table 1: Baseline Clinicodemographic and Defect Characteristics

Table 1 compares the baseline clinicodemographic variables and defect characteristics between patients undergoing local flap and free flap reconstruction. The mean age of patients in the local flap group was 46.7 ± 12.1 years, which was comparable to 44.3 ± 11.4 years in the free flap group, with no statistically significant difference (p = 0.310). Male predominance was observed in both groups, accounting for 58.5% in the local flap group and 61.7% in the free flap group, and this difference was not statistically significant (p = 0.744). Similarly, the proportion of malignancy-related defects was comparable between the two groups (71.7% vs 76.6%; p = 0.583), indicating a similar etiological distribution.

However, a significant difference was noted in defect size, with free flap reconstructions being performed for considerably larger defects (67.9 ± 18.2 cm²) compared to local flaps (42.8 ± 13.6 cm²), and this difference was statistically significant (p < 0.001). In addition, composite defects involving both skin and mucosa were significantly more common in the free flap group (61.7%) compared to the local flap group (32.1%) (p = 0.003).

Table 2: Operative and Postoperative Outcome Comparison

Table 2 outlines the operative and postoperative outcomes between the two reconstruction techniques. The mean operative time was significantly shorter in the local flap group (142.6 ± 29.4 minutes) compared to the free flap group (312.8 ± 46.9 minutes), with a highly significant difference (p < 0.001). Similarly, intraoperative blood loss was significantly lower in patients undergoing local flap reconstruction (286.3 ± 84.5 ml) than in those receiving free flaps (412.7 ± 112.1 ml) (p < 0.001).

ICU admission was required in only 26.4% of patients in the local flap group, whereas a substantially higher proportion of patients in the free flap group (80.9%) required ICU care, and this difference was statistically significant (p < 0.001). The mean duration of hospital stay was also significantly shorter for local flap patients (8.7 ± 3.1 days) compared to free flap patients (13.4 ± 4.6 days) (p < 0.001). Additionally, patients in the local flap group resumed oral feeding earlier (5.3 ± 1.8 days) than those in the free flap group (7.6 ± 2.4 days), with this difference being statistically significant (p < 0.001).

Table 3: Comparison of Postoperative Complication Rates

Table 3 compares postoperative complications between local flap and free flap reconstruction. Although the overall complication rate was lower in the local flap group (26.4%) compared to the free flap group (40.4%), this difference did not reach statistical significance (p = 0.143). Rates of partial flap necrosis were comparable between the two groups (11.3% in local flaps vs 14.9% in free flaps; p = 0.589). Similarly, wound infection rates showed no statistically significant difference (13.2% vs 17.0%; p = 0.598).

Notably, total flap failure occurred exclusively in the free flap group, with 8.5% of patients experiencing complete flap loss, while no cases were observed in the local flap group, and this difference was statistically significant (p = 0.034). Donor site morbidity was significantly higher in the free flap group (23.4%) compared to the local flap group (5.7%) (p = 0.009).

Table 4 presents a comparison of functional and aesthetic outcomes between the two groups. Patients undergoing free flap reconstruction demonstrated significantly better speech intelligibility scores (8.3 ± 1.2) compared to those in the local flap group (7.1 ± 1.4) (p < 0.001). Similarly, swallowing function scores were significantly higher in the free flap group (8.1 ± 1.3) than in the local flap group (6.8 ± 1.6) (p < 0.001).

Table 4: Functional and Aesthetic Outcome Assessment

Aesthetic satisfaction rated as “good or above” was observed more frequently in the free flap group (80.9%) compared to the local flap group (64.2%), although this difference narrowly missed statistical significance (p = 0.058). Return to a normal diet was significantly higher among free flap patients (85.1%) compared to local flap patients (67.9%) (p = 0.045). Furthermore, patient-reported quality-of-life scores were significantly superior in the free flap group (79.4 ± 8.6) compared to the local flap group (71.6 ± 9.8) (p < 0.001).

Baseline Clinicodemographic and Defect Characteristics (Table 1): In the present study, both local flap and free flap groups were comparable with respect to baseline clinicodemographic variables such as age, sex distribution, and etiology of defects. The mean age in both groups was in the mid-forties, with no statistically significant difference, indicating appropriate group comparability. This finding is consistent with studies by Bender‐Heine A et al.(2021)^[6], who reported similar age distributions in patients undergoing head and neck reconstruction irrespective of flap choice. Male predominance observed in both groups reflects the higher incidence of head and neck malignancies among males, as also documented in large oncologic reconstruction series by Sittitrai P et al.(2023)^[7].

A majority of defects in both groups were malignancy related, which aligns with existing literature identifying oncologic resection as the most common indication for head and neck soft tissue reconstruction. Importantly, defect characteristics showed significant differences between the two groups. Free flaps were used for significantly larger defects and a higher proportion of composite defects involving both skin and mucosa. Similar observations have been reported by Louizakis A et al.(2024)^[8], who emphasized that free tissue transfer is preferred for extensive, composite, and three-dimensional defects due to its versatility and reliable vascularity.

Operative and Postoperative Outcomes (Table 2): The operative and postoperative outcomes demonstrated marked differences between local flap and free flap reconstruction. Operative time and intraoperative blood loss were significantly lower in the local flap group, consistent with previous reports by Bender‐Heine A et al.(2021)^[6], who highlighted the technical simplicity and shorter operative duration of local flaps. The significantly higher ICU admission rate in the free flap group reflects the need for intensive postoperative monitoring of microvascular anastomoses, as reported in multiple microsurgical series.

Patients undergoing local flap reconstruction experienced shorter hospital stays and earlier initiation of oral feeding, findings that mirror those of Spoerl S et al.(2020)^[2], who noted faster recovery and reduced resource utilization with local flaps.

Postoperative Complication Rates (Table 3): Although the overall complication rate was numerically lower in the local flap group, the difference was not statistically significant, suggesting comparable overall safety profiles. Rates of partial flap necrosis and wound infection were similar between groups, consistent with findings by Zhang M et al.(2024)^[4]. However, total flap failure occurred exclusively in the free flap group, a recognized risk associated with microvascular reconstruction and reported failure rates ranging from 3–10% in the literature.

Donor site morbidity was significantly higher in the free flap group, reflecting the additional surgical insult at the donor site, a concern emphasized by Escandon JM et al.(2023)^[9] and later studies.

Functional and Aesthetic Outcomes (Table 4): Functional outcomes, including speech intelligibility and swallowing function, were significantly superior in the free flap group. This aligns with studies by Papanikolaou A et al.(2023)^[10], who demonstrated improved functional restoration with free tissue transfer, particularly in composite and mucosal defects. Return to a normal diet was also significantly higher among free flap patients, further supporting their functional advantage.

Although aesthetic satisfaction was higher in the free flap group, the difference narrowly missed statistical significance, suggesting that local flaps can provide acceptable cosmetic outcomes in appropriately selected cases. Patient-reported quality-of-life scores were significantly better in the free flap group, corroborating findings by Qiao QH et al.(2024)^[11], who reported superior long-term quality-of-life outcomes following free flap reconstruction.

The present comparative study evaluated the outcomes of local flaps and free flaps in soft tissue reconstruction of head and neck defects. The findings demonstrate that both reconstructive techniques are effective and safe when appropriately selected. Local flaps were associated with significantly shorter operative time, reduced intraoperative blood loss, lower requirement for ICU admission, shorter hospital stay, and earlier resumption of oral feeding. These advantages make local flaps a reliable and resource-efficient option for small to moderate, non-complex defects, particularly in patients with comorbidities or in resource-limited settings. In contrast, free flaps were preferentially utilized for larger and composite defects and were associated with superior functional outcomes, including better speech intelligibility, swallowing function, higher rates of return to normal diet, and improved patient-reported quality of life. However, free flap reconstruction was associated with longer operative duration, increased postoperative resource utilization, higher donor site morbidity, and a small but significant risk of total flap failure. Overall, the study highlights that the choice between local flaps and free flaps should be individualized and defect-oriented rather than technique-driven. Local flaps remain a valuable reconstructive option with favorable outcomes in selected cases, while free flaps provide optimal functional rehabilitation for extensive and complex head and neck defects. A balanced, patient-specific approach considering defect characteristics, patient condition, and institutional expertise is essential for achieving optimal reconstructive outcomes. LIMITATIONS OF THE STUDY 1. The study was conducted at a single tertiary care center, which may limit the generalizability of the results to other settings. 2. The sample size, although adequate for comparison, may not have been sufficient to detect differences in less frequent complications. 3. Allocation to local flap or free flap reconstruction was not randomized and depended on defect characteristics and surgeon preference, introducing potential selection bias. 4. Long-term functional, oncologic, and quality-of-life outcomes beyond the follow-up period were not assessed. 5. Objective scoring systems for functional and aesthetic assessment could have been supplemented with standardized validated tools for greater accuracy.

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4. Zhang M, Fu J, Liu X, Liu B, Mao X, Hu Z. Application of free flaps in reconstruction of head and neck soft tissue defects with bone exposure. Annals of Plastic Surgery. 2024 Aug 1;93(2S):S11-4.
5. Tabares BG, Geithner CM, Pierpoline J, Mosquera C. Long-Term Functional Outcomes of Free Flaps Versus Locoregional Flaps in Soft Tissue Reconstruction for Oral Cavity Cancer: A Systematic Review. Journal of Craniofacial Surgery. 2024 Jun:10-97.
6. Bender‐Heine A, Sweeny L, Curry JM, Petrisor D, Young G, Hyzer J, Cave T, Li R, Cannady S, Miles B, Wax MK. Management of the acute loss of a free flap to the head and neck a multi‐institutional review. The Laryngoscope. 2021 Mar;131(3):518-24.
7. Sittitrai P, Ruenmarkkaew D, Klibngern H. Pedicled flaps versus free flaps for oral cavity cancer reconstruction: a comparison of complications, hospital costs, and functional outcomes. International Archives of Otorhinolaryngology. 2023 Jan;27(01):e32-42.
8. Louizakis A, Antoniou A, Kalaitsidou I, Tatsis D. Free Tissue Transfer Versus Locoregional Flaps for the Reconstruction of Small and Moderate Defects in the Head and Neck Region: A Narrative Review. Cureus. 2024 May 23;17(5).
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