SA3 - Free Flap or Local Flap? A Comparative Review of Reconstructive Outcomes in Pediatric Head and Neck Cancer

Abstract:
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Background: Adoption of microsurgical techniques for oncologic reconstruction in children may be limited by technical difficulty. While the choice of reconstructive techniques after head and neck cancer resection in adults is well-studied, the relative morbidity profile of free versus local flaps in children is less studied. In this study, we compare postoperative outcomes between free and local tissue transfer within a pediatric head and neck cancer population requiring resection and reconstruction.

Methods: A retrospective review of patients undergoing reconstruction was conducted after head and neck tumor resection at a major children’s hospital between 2007 and 2024. Local flaps were defined as those based on a named axial blood vessel that did not require microsurgery. Primary outcomes included flap failure, wound healing complications, recipient and donor site revision procedures, operative time, duration of hospitalization, readmission, and follow-up period. Statistical analyses were performed using Pearson’s chi-square test and Student t-test.

Results: A total of 40 patients with an average age of 9.9 years were included in the study. Of them, 17 underwent free flap reconstruction and 23 underwent local flap reconstruction. The most common free flaps included anterolateral thigh (35.3%) and fibula (35.3%), while the most common local flaps included temporalis muscle (26.1%) and pectoralis muscle (13.0%). The most common primary diagnoses were osteosarcoma (20.0%) and rhabdomyosarcoma (12.5%). Overall flap survival rate was 97.5%. As compared to free flaps, the local flap cohort demonstrated significantly higher revision rates for exposed hardware and wound dehiscence (P = .030), though shorter hospitalization durations and operative times (P < .05). There was no significant difference in the incidence of flap failure, follow-up times, or hospital readmission between the two cohorts.

Conclusion: Our study demonstrates significantly higher revisions of exposed hardware and wound dehiscence in the local flap group. This highlights the advantages of free tissue transfer allowing greater recruitment of tissue. Given its versatility and multifaceted nature, free tissue transfer offers more reliable soft and hard tissue coverage. Our study shows a comparable complication profile between free and local flap reconstruction in children with head and neck cancer. These findings challenge the hesitancy toward microsurgical techniques in pediatric oncologic reconstruction. With appropriate expertise and patient selection, free flaps can be safely deployed to expand our versatility in the reconstruction of pediatric head and neck cancers.