Head Free Flap Research Articles

Predictors for prolonged and escalated perioperative antibiotic therapy after microvascular head and neck reconstruction: a comprehensive analysis of 446 cases

Literature suggests that intravenous prophylaxis exceeding 48 h offers no additional benefit in preventing surgical site infections (SSI) in patients with microvascular head and neck reconstruction. However, protocols for antibiotic therapy duration post-reconstruction are not standardized. This study identifies factors predicting prolonged intravenous antibiotic use and antibiotic escalation in patients receiving free flap head neck reconstruction. A retrospective analysis of 446 patients receiving free flap reconstruction was conducted, examining predictors for antibiotic therapy > 10 days and postoperative escalation. 111 patients (24.8%) experienced escalation, while 159 patients (35.6%) received prolonged therapy. Multivariate regression analysis revealed predictors for escalation: microvascular bone reconstruction (p = 0.008, OR = 2.0), clinically suspected SSI (p < 0.001, OR = 5.4), culture-positive SSI (p = 0.03, OR = 2.9), extended ICU stay (p = 0.01, OR = 1.1) and hospital-acquired pneumonia (p = 0.01, OR = 5.9). Prolonged therapy was associated with bone reconstruction (p = 0.06, OR = 2.0), preoperative irradiation (p = 0.001, OR = 1.9) and culture-positive SSI (p < 0.001, OR = 3.5). The study concludes that SSIs are a primary factor driving the escalation of perioperative antibiotic use. Clinical suspicion of infection often necessitates escalation, even in the absence of confirmed microbiological evidence. Microvascular bone reconstruction was a significant predictor for both the escalation and extension of antibiotic therapy beyond 10 days. Furthermore, preoperative radiation therapy, hospital-acquired pneumonia, and prolonged ICU stay were associated with an increased likelihood of escalation, resulting in significantly extended antibiotic administration during hospitalization. Antibiotic stewardship programmes must be implemented to reduce postoperative antibiotic administration time.Trial registration The study was registered approved by the local Ethics Committee (Nr: 18-1131-104).

Association between blood transfusion and outcomes of free flap head and neck cancer surgery

ObjectiveInvestigate the impact of patient risk factors and blood transfusions in Head and Neck free flap surgeries. Study designRetrospective chart review. SettingSingle tertiary referral center. Methods400 patients were included undergoing free flap reconstruction from 2014 to 2020. The primary outcome measures were red blood cell transfusion and volume transfused. Race, sex, flap location and tissue type, pathology, dependent functional status, length of stay, and cancer recurrence were evaluated for association with red blood cell transfusion intraoperatively and/or postoperatively. Transfusions were indicated on patients with Hemoglobin <7–8 and/or symptomatic anemia. ANOVA and Chi2 statistical analysis were performed. The significance was set at p ≤0.05. ResultsOf the 400 patients included, 58 required red blood cell transfusion. Of these 67.8 % were males, racial demographics included 9.00 % African American, 1.30 % Asian, 1.00 % Hispanic/Latino, 87.8 % White, 1.00 % other. African American patients received a higher volume of transfused red blood cells versus white patients (855.00 mL vs. 437.07 mL, p = 0.005). Length of stay was significantly associated with red blood cell transfusion (5.95 days vs. 7.22 days, p ≤0.001). Dependent functional status and need for red blood cell transfusion were associated (p = 0.002). Type of free flap was associated with need for red blood cell transfusion (p ≤0.001) with anterolateral thigh flaps being the most common resulting in transfusion (34/58). ConclusionRed blood cell transfusion was significantly associated with race, dependent functional status and length of stay. Certain free flaps have a higher risk of blood transfusion.

Microvascular Free-Flap Head and Neck Reconstruction: The Utility of the Modified Frailty Five-Item Index.

Microvascular free tissue transfer is a common tool for the reconstruction of oncologic head and neck defects. Adequate preoperative assessment can aid in appropriate risk stratification and peri-operative optimization. The modified five-item frailty index (mFI-5) is a validated risk-assessment scale; however, its utility in head and neck free-flap reconstruction is unknown when compared with other common risk factors. A retrospective, single-institution chart review (2017-2020) was performed. Patient demographics, defect and repair characteristics, pre- and peri-operative factors, and flap outcomes were recorded. A high mFI-5 score was defined as greater than 2. The total score, as well as other patient factors, was correlated to postoperative flap complications. A total of 214 patients were deemed appropriate for conclusion. The mean age was 63.9 ± 12.8 years. There were an even number of males (52.8%) and females (47.2%). A fifth of subjects (20.8%) underwent preoperative radiotherapy. There were 21 cases (9.8%) of complete flap loss. A total of 34 patients (29.4%) experienced any postoperative complication related to flap outcomes. An elevated mFI-5 was significantly associated with a higher overall rate of postoperative complications (39.7 vs. 29.4%, p < 0.019) and total flap loss (16.7% vs. 6.6%, p < 0.033). Preoperative radiation was found to be associated with an increased complication rate (p < 0.003). The mFI-5 score may be a potentially significant tool in the risk stratification of patients undergoing head and neck free-flap reconstruction as opposed to commonly utilized risk factors. Preoperative radiotherapy is significantly associated with postoperative complications. Appropriate preoperative assessment may help tailor patient care preoperatively.

Complications of Reconstructive Surgery in Head and Neck Region: A Cross-Sectional Study from Bangladesh

Background Microvascular free flaps are ideal for reconstructing post-oncological surgery defects in the head and neck region. Free flaps provide ample tissue for reconstructing even large, complex defects, which gives oncosurgeons flexibility during tumor resections. Methods We performed 50 free flap head and neck reconstructions in 978 patients from June 2015 to September 2018. For reconstructing bone defects, our flap of choice was the free fibula. The surgical outcomes and complications according to flap were retrospectively reviewed and analyzed. Results The overall flap success rate was 98.1%. A total of 45 cases required emergency surgical re-exploration for compromised flaps and 19 of these flaps could not be salvaged. Venous insufficiency was the most common cause of surgical re-exploration. Flaps with delayed arterial thrombosis and vascular compression could not be salvaged. Other complications were partial flap necrosis, oro-cutaneous fistula, and donor site complications. No statistically significant differences were noted for complications in elderly and post-radiotherapy patients. Conclusions Free flap reconstruction is a robust and highly reliable option for head and neck defects and free flaps are a safe option for treating large defects. A second free flap should be the first choice in failed cases after the medical optimization of the patient. Free flap reconstruction is safe in elderly and post-radiotherapy patients.

The Role of Intraoperative and Early Postoperative Blood Pressure Variations, Fluid Balance and Inotropics in Fibula Free Flap Head and Neck Reconstruction: A Retrospective Analysis.

In head and neck reconstructive surgery, postoperative complications are a well-known concern. We examined 46 patients who underwent ablative surgery and received fibula free flap reconstruction. The main focus was to assess the influence of intraoperative blood pressure fluctuations and the administration of inotropic drugs on complications, either related to the flap or systemic, serving as the primary endpoint. Utilizing logistic regression models, we identified that intraoperative mean arterial blood pressure (MAP) drops did not correlate with the occurrence of either flap-related complications (MAP < 70, p = 0.79; MAP < 65, p = 0.865; MAP < 60, p = 0.803; MAP < 55, p = 0.937) or systemic medical complications (MAP < 70, p = 0.559; MAP < 65, p = 0.396; MAP < 60, p = 0.211; MAP < 55, p = 0.936). The occurrence of flap-related complications significantly increased if a higher dosage of dobutamine was administered (median 27.5 (IQR 0-47.5) vs. 62 (38-109) mg, p = 0.019) but not if norepinephrine was administered (p = 0.493). This correlation was especially noticeable given the uptick in complications associated with fluid overload (3692 (3101-4388) vs. 4859 (3555-6216) mL, p = 0.026). Intraoperative and immediate postoperative blood pressure fluctuations are common but are not directly associated with flap-related complications; however, dobutamine application as well as fluid overload may impact flap-specific complications.

Comparison between the high-definition 3D exoscope and the operating microscope in head and neck reconstruction

The purpose of this study was to compare the three-dimensional (3D) operating exoscope (OE) with the conventional operating microscope (OM) in head and neck reconstruction. A retrospective cohort study was performed including 50 consecutive patients with no history of previous surgery or irradiation (32 male, 18 female; mean age 59.2 ± 13.3 years), who underwent free flap head and neck reconstruction using a 3D OE (n = 25; OE group) or conventional OM (n = 25; OM group). The mean total operative time was 8.0 ± 1.53 h in the OE group and 7.6 ± 1.52 h in the OM group (P = 0.86). The median (interquartile range) anastomosis time was 78.0 (63.0–91.5) minutes in the OE group and 90.0 (75.5–115.0) minutes in the OM group (P = 0.06). The final free flap survival rate was 100%. Only seven patients experienced a free flap reconstruction-related complication, and they were similarly distributed between the two groups (four in the OE group, three in the OM group; P = 0.68). Secondary outcomes (length of hospital stay, tracheostomy dependence, feeding tube dependence) were comparable in the two groups (P > 0.05). The 3D OE is a viable alternative to the conventional OM for performing standard head and neck free flap reconstructive procedures.

Contemporary Marking Technique of End-to-Side Venous Anastomosis with Internal Jugular Vein in Head and Neck Free Flap Cases: An Experience of 200 Cases.

Microvascular free tissue transfer is a popular option for reconstruction of the head and neck defects following tumor ablation. Many factors are involved in the achievement of a satisfactory outcome, namely, adequate selection of the donor flap and recipient vessels, proficient anastomosis technique and postoperative care including flap monitoring. Preferential use of end-to-side anastomosis to the internal jugular vein in head and neck reconstruction offers various advantages and has consistently yielded outstanding results. Presented is a series of 200 consecutive cases at one institution over 1year. In our institution, the internal jugular vein (IJV) has had the first priority in the selection of a recipient vein in free-flap head and neck reconstruction. An end-to-side anastomosis with the internal jugular vein has several advantages. We have devised a simple technique of marking the point of anastomosis with a needle prick at two points taking the diameter of pedicle vein to aid in identification of point of anastomosis. This method is very reliable to ascertain the suitable lie of the pedicle vein. The diameter of the lumen for anastomosis is maintained. We had a success rate of 100% with all the cases we applied this technique on.

D52. Long-term Clinical Outcomes following Free Fibula Flap Head and Neck Reconstruction with Immediate Dental Implant Placement

PURPOSE: Immediate dental implant placement (IDIP) at the time of ablative/reconstructive surgery for maxillomandibular cancer is a novel technique that has yet to be evaluated for its long-term clinical outcomes. This study describes long-term clinical outcomes with IDIP in free fibula flaps (FFF) for oncologic head and neck reconstruction. METHODS: A retrospective review for patients who underwent oncologic FFF reconstruction of mandibular or maxillary defects with and without IDIP was performed. Average length of follow-up and complication rates over two time periods (1-2 years and 2+ years) were analyzed. The number of patients who achieved dental rehabilitation in the IDIP cohort was also examined. RESULTS: 99 patients received FFF reconstruction with IDIP, and 120 historical patients received FFF reconstruction alone. The average length of follow-up was significantly longer in the historical group (1498.9±1700.6 days vs. 565.4±397.9 days, p=0.0005). 63/99 IDIP patients achieved dental rehabilitation. There was no significant difference in the complication rates between the IDIP and historical cohorts in either 1-2 year or 2+ year time period. CONCLUSION: IDIP is an effective method for rapidly achieving dental rehabilitation in patients undergoing maxillomandibular reconstruction with FFF. Long-term complications in IDIP patients were not significantly different from the historical cohort. Further studies investigating patient satisfaction and quality of life scores with IDIP are warranted to elucidate the full benefits of this treatment.

ASO Visual Abstract: The Use of Machine Learning for Predicting Complications of Free Flap Head and Neck Reconstruction.

ASO Visual Abstract: The Use of Machine Learning for Predicting Complications of Free Flap Head and Neck Reconstruction.

Cumulative Sum Analysis of the Learning Curve of Free Flap Reconstruction in Head and Neck Cancer Patients.

ObjectivesOwing to the functional and structural complexity of the head and neck area, the reconstruction of defects in these areas is challenging. Free flap surgery has become standard for the reconstruction of the head and neck with improvements in microvascular surgery. The aim of this study was to use the cumulative sum (CUSUM) method to evaluate the learning curve for free-flap head and neck reconstruction performed by a single surgeon.MethodsWe retrospectively reviewed the medical records of 47 patients who underwent free-flap reconstruction from 2017 to 2021. The clinical demographics and surgical outcomes were analyzed. The total operation time was analyzed using the CUSUM method, which is an analytical approach for visualizing patterns in data by converting raw data into an accumulation of deviations from the average value.ResultsCUSUM analysis showed two phases of the learning curve: phase 1 (cases 1–22) and phase 2 (cases 23–47). The operative time in phase 1 (579.9±128.2 minutes) was significantly longer than that in phase 2 (418.6±80.9 minutes) (P<0.001). The re-exploration rate was higher in phase 1 (31.8%) than in phase 1 (4%) (P=0.018). The flap failure rate was higher in phase 1 (9.1%) than in phase 1 (4%), but this difference was not statistically significant (P=0.593).ConclusionThe learning curve of free-flap head and neck reconstruction seems to stabilize after approximately 20 cases.

Perioperative Myocardial Infarction in Free Flap for Head and Neck Reconstruction.

Acute myocardial infarction (AMI) is a postoperative complication of major surgical procedures, including free flap surgery. It is the most common cause of postoperative morbidity and mortality. Moreover, patients receiving free flap reconstruction for the head and neck have significant risk factors such as coexisting coronary artery disease (CAD). Our primary aim was to ascertain predictors of perioperative AMI to enable early detection and consequently early treatment of perioperative AMI. Our secondary aim was to determine the group of patients who would be at a high risk for perioperative AMI after free flap surgery. This retrospective study enrolled patients who underwent free flap reconstruction surgery at the Division of Plastic and Reconstructive Surgery of Taipei Veterans General Hospital between 2013-01 and 2017-12. This study included 444 patients and 481 free flap head and neck reconstruction surgeries. Fifteen (3.1%) patients were diagnosed with perioperative AMI. Statistical analysis of the variables revealed that patients with underlying CAD or cerebrovascular accident (CVA) were at a high risk of developing perioperative AMI (odds ratio: 6.89 and 11.11, respectively). The flap failure rate was also higher in patients with perioperative AMI compared with those without perioperative AMI (P = 0.015). Patients with underlying diseases, such as CAD or CVA, constituted high-risk groups for perioperative AMI.

Proposed Prediction Model and Nomogram for Systemic Complications in Patients Undergoing Free Flap Head and Neck Reconstruction.

Postoperative complications in head and neck surgery are well-known, but a predictive model to guide clinicians in free flap reconstructions has not been established. This retrospective single-center observational study assessed 131 patients who underwent ablative surgery and received free flap reconstruction. Primary endpoint was the occurrence of systemic complications (PSC). Secondary endpoint was the generation of a nomogram of complications according to the CDC classification. In the ordinal regression model, postoperative administration of furosemide [1.36 (0.63–2.11), p < 0.0001], blood loss [0.001 (0.0004–0.0020), p = 0.004], postoperative nadir hemoglobin [−0.03 (−0.07–0.01), p = 0.108], smoking [0.72 (0.02–1.44), p = 0.043], and type of flap reconstruction [1.01 (0.21–1.84), p = 0.014] as predictors. A nomogram with acceptable discrimination was proposed (Somer's delta: 0.52). Application of this nomogram in clinical practice could help identify potentially modifiable risk factors and thus reduce the incidence of postoperative complications in patients undergoing microvascular reconstruction of the head and neck.

Are Two Veins Better than One in Free Flap Head and Neck Reconstruction?

Are Two Veins Better than One in Free Flap Head and Neck Reconstruction?

Differences in free flaps' reconstructions with and without coupling device for venous anastomosis.

&lt;br&gt;&lt;b&gt;Introduction:&lt;/b&gt; Introduction of the coupler devices for anastomoses of neck vessels changes planning and performance of the surgical procedures. The Rigid ring of the coupling devices keeps a vein open and less prone to occlusion. Therefore, this should improve the flap survival rate and surgery duration.&lt;/br&gt; &lt;br&gt;&lt;b&gt;Aim:&lt;/b&gt; The aim of the study was to point out the differences in surgery planning between couplers and sutures for venous microsurgical anastomoses.&lt;/br&gt; &lt;br&gt;&lt;b&gt;Methods:&lt;/b&gt; The medical records of 209 patients who underwent 212 microvascular free flap reconstructions from January 2011 till December 2017 were retrospectively analyzed; 103 received radial forearm free flap (RFFF); 43 - anterolateral thigh flap (ALTF); 51 - fibula free flap (FFF); 15 - iliac crest free flap (ICFF). In 189 cases, reconstruction was performed simultaneously with tumor resection and in 23 cases, reconstruction was secondary, after previous oncological treatment. Among 443 anastomoses, suturing was used for 212 arteries and 127 venous anastomoses, while coupling was used for 104 venous anastomoses.&lt;/br&gt; &lt;br&gt;&lt;b&gt;Results:&lt;/b&gt; The mean surgery duration for suturing was 452.82 min vs 358.88 min for coupling (P&lt;0.05). Differences in flap survival and partial necrosis rates between coupling and suturing groups were not statistically significant (P&gt;0.05). Donor vessel distribution in the neck was significantly different in both groups. Estimated costs of the surgical procedures performed with and without coupler devices were not equal.&lt;/br&gt; &lt;br&gt;&lt;b&gt;Conclusions:&lt;/b&gt; The use of couplers for venous anastomosis in free flap head and neck reconstructions impacts the surgery process by shortening surgery duration which leads to cost reduction.&lt;/br&gt.

Intraoral Hirudotherapy for Venous Congestion following Free Flap Head and Neck Reconstruction: Novel Intraoral Technique

Intraoral hirudotherapy is traditionally used for venous congestion following head and neck free flap reconstruction. Many institutions and healthcare teams have been reluctant to use intraoral leech therapy due to risks such as migration into the airway, increased infection from intraoral manipulation, and patient discomfort. Several protocols recommend blocking the path to the oropharynx via gauze or leaving a tracheotomy in place to protect the airway. This report pre­sents a novel technique for intraoral hirudotherapy that is safe and simple for treatment of free flap venous congestion. The base of a clear cup or a plastic lid is utilized, and the leech is attached onto the inside of the lid with 2 sutures near each end. Several cups with leeches attached are made at a time to reduce delay and difficulty of application by less experienced clinical staff. The leech is then applied onto the compromised flap and then simply removed once it has unlatched from the flap. This method allows the leech to be applied with ease by multiple members of the healthcare team, decreases the need for intraoral manipulation, and reduces the risk of migration into the aerodigestive tract. Future prospective studies are warranted to assess the efficacy of this technique.

The use of machine learning for predicating complications of free flap head and neck reconstruction.

e18633 Background: The use of machine learning (ML) in plastic and reconstructive surgery has increased over the last decade. However, its use to predict surgical outcomes in head and neck reconstruction has not been well studied. The goal of this study is to assess the performance of ML algorithms trained to predict surgical outcomes of head and neck free flap reconstruction. Methods: Our study cohort included routinely collected data from 4000 patients who underwent free flaps for reconstruction of head and neck defects between January 2005 and December 2018. We developed and tested nine supervised ML algorithms to predict three outcomes of a.) any complication, b.) any major recipient-site complication, and c.) total flap loss. Results: In our sample, 33.7% of patients experienced any complication, 26.5% experienced a major complication at the recipient site and 1.7% experienced total flap loss. The k-nearest neighbors algorithm demonstrated the best overall performance for predicting any complication (AUROC = .61, sensitivity = .60). Regularized regression had the best performance for predicting major recipient site complication (AUROC=.68, sensitivity = .66), and decision trees were the best predictors of total flap loss (AUROC = .66, sensitivity = .50). Conclusions: We demonstrated that ML models trained using routinely collected data can make clinical useful predictions about who will experience complications. Our models correctly identified between half and two-thirds of patients who experienced post-surgical complications including total flap loss. These models can be applied to readily available clinical and perioperative data to facilitate decision making. Further performance improvements are likely possible with the inclusion of additional variables related to patient health and behavior.

An improved predictive model for postoperative pulmonary complications after free flap reconstructions in the head and neck.

Commonly used predictive models for postoperative pulmonary complications (PPCs) do not perform when applied to head and neck cases. A head and neck-specific risk prediction tool is needed. Data on 794 free flap head and neck surgery cases at a single center were abstracted from the electronic medical record. Each case was reviewed for the development of PPCs. A predictive model was developed and was then compared to existing predictive models for PPCs. The least absolute shrinkage and selection operator procedure identified age, alcohol use, history of congestive heart failure, preoperative packed cell volume, preoperative oxygen saturation, and preoperative metabolic equivalents as predictors of PPCs in the head and neck population. The model demonstrated an area under the receiving operating characteristic curve of 0.75 (0.69-0.80) with moderately good calibration. Comparisons to the performance of existing models demonstrate superior performance. The model for the development of PPCs developed in this article displays superior performance to existing models.

Donor-site local anaesthetic infusion catheter as an opioid-sparing agent in free flap reconstruction of the head and neck: a valuable adjunct to an enhanced recovery protocol

This paper presents the results of a retrospective case-controlled cohort study to investigate the effectiveness of a donor-site local anaesthetic infusion protocol to reduce opioid requirements, length of intensive therapy unit (ITU) stay, and incidence of postoperative delirium. Adult free flap head and neck patients were identified from a prospective database (n = 86). There was a significant reduction in mean opioid requirements (p < 0.001). Postoperative delirium was observed in 12 of 35 patients before introduction of the protocol, and in 10 of 51 patients after its introduction (p = 0.139). Donor-site local anaesthetic infusion reduces opioid requirements for patients undergoing head and neck free flap reconstruction, and is a valuable adjunct to an enhanced recovery protocol.

Changing practice to face the future: direct-to-ward post-operative care for major free flap head and neck reconstruction

Introduction: Rapid recovery has been employed to provide safe, streamlined post-operative care with shorter hospital stays. It is supported by a strong evidence base in several surgical specialties. We present our experience in changing practice; diverting immediate post-operative management for patients undergoing free flap head and neck reconstruction with/without tracheostomy away from ICU/HDU directly to the ward.

Impact of Prior Oncologic Treatment on Complications and Functional Outcomes in 1751 Head and Neck Free Flap Reconstruction Patients: An Institutional Analysis Using American College of Surgeons National Surgical Quality Improvement Program Methodology

PURPOSE: Patients with head and neck squamous cell carcinoma (HN-SCC) frequently present with locally advanced disease, and many develop locoregional recurrence. Treatment of locally advanced or recurrent HN-SCC often involves neoadjuvant chemotherapy and/or radiation. However, a knowledge gap exists regarding the interplay of toxicities from prior oncologic treatments on successful reconstruction. The aim of this study was to evaluate the effect of prior oncologic treatment, including chemotherapy, radiation, and/or surgery, on long-term outcomes and functional status after head and neck free flap reconstruction utilizing a prospectively maintained database modeled on the American College of Surgeons National Surgical Quality Improvement Program (NSQIP). METHODS AND MATERIALS: This is a retrospective review of all head and neck free flap reconstructions at our institution from 2012 to 2019. Data were retrieved from our database, which utilizes NSQIP methodology modified to track major head and neck oncologic reconstructive outcomes. In contrast to the NSQIP, which limits prior treatment to 3 months before the index procedure, our database includes any prior oncologic treatment. RESULTS: One thousand seven hundred fifty-one patients were identified, 1093 of whom received prior oncologic treatment before the principal operative procedure for tumor extirpation and immediate free flap reconstruction. Patients without prior treatment were more likely to be active smokers (25% versus 18%; P < 0.0001) and have body mass index ≥25 (67% versus 53%; P <0.0001), hypertension (55% versus 47%; P < 0.0001), and diabetes (18% versus 12%; P < 0.001). Patients receiving prior treatment had higher rates of steroid use (8% versus 5%; P = 0.019) and preoperative G-tube placement (15% versus 3%; P < 0.0001). On multivariate analysis, prior treatment did not increase the risk of postoperative complications including: flap loss, fistula, infection, hematoma, seroma, reoperation, or readmission (P > 0.05). However, there was a significant increase in the risk of transfusion (odds ratio [OR], 2.01; 95% CI, 1.60–2.53), death within 12 months (OR 1.43; 95% CI, 1.05–1.95), G-tube dependency at 3 months postoperative (OR, 1.42; 95% CI, 1.11–1.81), and poor speech scores (OR, 1.40; 95% CI, 1.01–1.95). When comparing prior surgery versus chemotherapy versus radiation, multivariate analysis indicated that chemotherapy was associated with the highest risk of: transfusion (OR, 2.51; 95% CI, 1.96–3.22), death within 12 months (OR, 1.67; 95% CI, 1.20–2.33), and G-tube dependency at 3 months postoperative (OR, 1.78; 95% CI, 1.37–2.32). Prior radiation as associated with the highest risk of poor postoperative speech scores at 3 months (OR, 1.82; 95% CI, 1.27–2.61). CONCLUSIONS: The goals of HN-SCC treatment and reconstruction include disease stabilization, prolonging survival, and improving quality of life. This study demonstrates prior oncologic treatment is not associated with flap loss or postoperative wound-healing complications, after controlling for confounding factors. It is associated with higher mortality and worse functional outcomes, which may reflect disease burden. Our results demonstrate that free flap head and neck reconstruction is a reasonable choice for well-selected patients with advanced and recurrent HN-SCC, even in the setting of multiple prior treatments, and has the potential to improve quality of life and reduce functional deficits.