Regional head and neck centre: a 10-year review of free and regional flap outcomes

Introduction

Head and neck flap reconstructions are complex procedures that require extensive resources and considerable planning. While there is significant literature on flap selection and outcomes, most studies originate from high-volume tertiary centres in metropolitan areas. Existing studies comparing head and neck flaps in academic vs. community settings have shown no significant difference in the primary outcomes (1). Studies have also shown that low-volume centres achieve comparable flap outcomes, with outcomes improving as clinical experience increases (2,3).

The uneven geographic distribution of specialist services in Australia underscores the need to decentralise head and neck reconstructive care to regional and rural areas. However, resource limitations present significant challenges to service delivery, contributing to the limited literature on outcomes for head and neck patients in these settings (4-6). Furthermore, in most tertiary centres, head and neck free flap reconstructions are typically performed using a multi-specialty model involving otolaryngology, plastic surgeons, and oral and maxillofacial surgeons. Existing literature has demonstrated the feasibility of a single-speciality otolaryngology service model (7). The regional head and neck centre described in this study, operating as a single-service model, provides an opportunity to validate these findings in a regional Australian context. To date, no study has examined head and neck flap reconstruction outcomes performed by a single-service surgical model in a regional centre.

The advent of microsurgery has enabled the emergence of free flaps over pedicled flaps (such as pectoralis major myocutaneous pedicle flap) due to their improved functional and aesthetic outcomes (8-10). As the regional centre examined in this study performs both microsurgical free flaps and traditional pedicled flaps for head and neck reconstruction, the aim of this study is to compare the outcomes of these approaches to confirm or extend existing evidence.

This study aims to evaluate flap outcomes in a regional head and neck centre and to identify complication trends that may inform and optimise perioperative care. The primary endpoints are the immediate and long-term complication rates associated with free flap vs. regional flap reconstruction. Secondary endpoints include assessing the impact of rurality on perioperative outcomes across both temporal and geographic dimensions. Ultimately, the study seeks to determine the feasibility of performing head and neck flap reconstructions as a single service model in a regional setting, and provide insight into perioperative considerations in optimising patient care and follow-up.

Methods

This is a retrospective cohort study reviewing all head and neck patients who received a free or regional flap reconstruction at the Toowoomba Base Hospital, a public, secondary referral hospital in a regional centre in Queensland, Australia. The hospital operates as a single otolaryngology service where the same surgical team performs the excision and the reconstruction of head and neck cancers. The study is reported according to the STROBE reporting guidelines (available at https://www.theajo.com/article/view/10.21037/ajo-25-57/rc). The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study received ethics approval by the Human Research Ethics Committee (HREC) at Darling Downs Health (No. LNR/2024/QTDD/108056), the governing health authority for Toowoomba Base Hospital. Due to the retrospective nature of the study, a waiver of consent was granted.

Inclusion criteria comprised all head and neck patients who received free flap or regional flap reconstructions from January 2013 to December 2023. Free flaps are defined as flaps harvested from distant donor sites that are removed in its entirety and reconnected to the defect site via microsurgery. Regional flaps are defined as pedicled flaps harvested from a nearby donor site, maintaining an intact vascular pedicle to the defect. Exclusion criteria included local flaps, which do not rely on a defined vascular pedicle but instead on random-pattern blood supply, full-thickness skin grafts, and primary closure (11). Flap types were categorised as free flaps, large pedicled flaps, interpolated flaps, and other smaller myomucosal regional flaps. Free flaps and large pedicled flaps were primarily used for patients with large head and neck tumours. Interpolated flaps, including forehead flaps and facial artery musculomucosal flaps, involved two-stage procedures requiring subsequent division of the flap. All other pedicled flaps were classified as regional flaps.

Follow-up for each patient was 5 years post-treatment, as per the National Comprehensive Cancer Network (NCCN) head and neck cancer guidelines (12). Medical records were reviewed for clinical and demographic data, including age, gender, postcode, American Society of Anaesthesiologists (ASA) score; surgical data, including indication and flap choice; and peri-operative outcomes, including intra-operative and immediate post-operative results during the same admission. Long-term post-operative outcomes and follow-up challenges were further extracted from follow-up clinic appointments. Two independent researchers reviewed the data and categorised the peri-operative complications into intraoperative, immediate medical and surgical, as well as long-term complications. Patient distance from the hospital was estimated using the geodesic distance (in km) between the hospital’s location and the centroid of the patient’s residential postcode. Median and interquartile range (IQR) are used for reporting of this data due to the outliers.

Temporal and spatial associations were also examined. Temporal associations were assessed in patients undergoing interpolated flaps requiring staged procedures with second-stage division, including forehead flaps and facial artery musculomucosal flaps. Spatial relationships were assessed using the distance between each patient’s residential postcode and the regional centre. All patient records were reviewed to identify patients who did not complete the 5-year cancer surveillance period.

Statistical analysis

Statistical analysis was performed using Minitab (State College, PA, USA). Normality was assessed using the Anderson-Darling test. Age was normally distributed and was analysed using independent samples t-tests to compare differences between groups. Distance travelled was non-normally distributed and was therefore analysed using the non-parametric Mann-Whitney U test. ASA score, treated as an ordinal variable, was also compared between groups using the Mann-Whitney U test. Fisher’s exact test was employed to examine associations between surgical modality and the occurrence of immediate postoperative medical, surgical, and long-term complications. Complication and recurrence rates were summarised with 95% exact (Clopper-Pearson) binomial confidence intervals (CIs). Between-group comparisons used Fisher’s exact test, and odds ratios (ORs) with exact 95% CIs were calculated using 2×2 contingency tables. A post-hoc power analysis was performed to estimate the ability of the study to detect differences in complication rates between free flaps and large pedicled flaps. Power calculations were conducted using a two-sample proportions test (normal approximation), two-sided, with an α level of 0.05, and post-hoc sample size estimates were used a power of 80%. For interpolated flaps, the relationship between the interval length (days between two-stage operations) and complication rates was assessed using the Mann-Whitney U test.

The association between rurality and follow-up challenges was evaluated using binary logistic regression. As loss to follow-up was a relevant outcome in this study, all patient data were retained in the analysis regardless of follow-up completeness. Outlier analysis using Grubb’s test identified two extreme distance values (673 and 1,194 km), which were excluded from the distance-related statistical analysis to reduce skew. A P value of <0.05 was considered statistically significant.

Results

A total of 159 free and regional flaps were performed on 154 patients over a 10-year period.

Patient demographics are summarised in Table 1. The mean age was 66±11.6 years, and the mean ASA score was 2.6±0.6, reflecting the medical complexity of the cohort. Half of the patients resided more than 94 km from the treatment centre. The cohort has a higher proportion of male patients (n=116) than female patients (n=43). Indication for surgery and the anatomical site for each reconstructive flap are represented in Table 2, with mucocutaneous cancer being the predominant indication for surgery. Revision surgery includes fistula following previous surgery or flap failure requiring conversion, which will be detailed further in the article. In regards to flap types, there were 36 free flaps, 42 large pedicled flaps, 55 interpolated flaps, and 26 other smaller myomucosal regional flaps. A detailed breakdown of the flap types by frequency is presented in Figure 1.

Figure 1 Distribution of flap types used in head and neck reconstructions [2013–2023].

Free flaps vs. large pedicled flaps

The first objective of this study was to compare outcomes between the free flaps (n=36) and large pedicled flaps (n=42) performed at a regional centre. Patient demographics (including age, gender, ASA score, and distance from hospital) were comparable between the two groups. There were no significant differences in perioperative complication rates or in rates of recurrence between patients receiving free flaps and those receiving large pedicled flaps (Table 3).

Intraoperative complication rates were comparable between free flaps (11.1%) and large pedicled flaps (4.8%), with no statistically significant difference (OR =2.50; 95% CI: 0.43–14.53; P=0.40). Notable intraoperative events included thoracic duct leaks and haematomas in both groups, while the free flap group also experienced one anaesthetic event requiring urgent tracheostomy and a coupling device failure, where a mechanical malfunction of the venous coupler device led to longer surgical duration. Immediate postoperative medical complications were more frequent in free flaps (22.2% vs. 7.1%), though this trend did not reach statistical significance (OR =3.71; 95% CI: 0.90–15.26; P=0.10). Medical complications included atrial fibrillation, pneumonia, oesophageal leak, and self-limiting issues such as chyle leaks and seromas.

There were no significant differences in immediate postoperative surgical complications between free flaps (19.4%; 95% CI: 8.2–36.0%) vs. large pedicled flaps (26.2%; 95% CI: 13.9–42.0%; OR =0.68; P=0.59). Complications included flap failures, haematoma, and salivary leaks requiring operative intervention. Four free flap cases and nine large pedicled flap cases were successfully salvaged with the original flaps. Three free flap cases required conversion to large pedicled flaps; these cases are discussed separately below.

Long-term postoperative complications were also comparable between the two groups: free flaps (13.9%; 95% CI: 4.7–29.5%) vs. large pedicled flap (19.0%; 95% CI: 8.6–34.1%; OR =0.69; P=0.76). These consist primarily of functional issues such as neo-oesophageal stricture and wound breakdown requiring revision surgery. In the free flap group, two patients developed acute respiratory distress secondary to mucous plugging, and two were converted to regional flap. There were no significant differences in rates of recurrence or metastasis at 5-year follow-up: free flaps (19.4%; 95% CI: 8.2–36.0%) vs. large pedicled flaps (26.2%; 95% CI: 13.9–42.0%; OR =0.68; P=0.59). In both groups, 50% of patients with recurrence opted for palliative management. One patient in the free flap group declined further follow-up after learning of metastatic disease.

Post-hoc power analysis demonstrated limited power across all complication comparisons due to modest sample sizes and small differences in observed event rates. The power estimates for all complication outcomes ranged from 0.10 to 0.49, with projected sample sizes required to achieve 80% power ranging from 170 to 1,658 total patients, depending on the complication subtype (see Table S1), indicating that the study was underpowered to detect statistically significant differences between the two flap groups for these outcomes.

A total of five free flaps required conversion to regional flaps. Three occurred in the immediate postoperative period. First, a patient who received fibular free flap for retromolar trigone squamous cell carcinoma (SCC) developed a large neck haematoma on day 2, and an attempted re-anastomosis was unsuccessful, necessitating conversion to a pectoralis major flap. This patient had no further issues thereafter. Second, a patient who received radial forearm free flap for pharyngeal SCC showed no pin-point bleeding on day 1 and had a pectoralis major flap reconstruction. The patient experienced a prolonged admission due to aspiration pneumonia but did not have further reconstructive complications. And third, a patient who received radial forearm free flap for base of tongue SCC required conversion to a pectoralis major following its initial free flap being non-salvageable due to a day 2 haematoma. No further issues arose post-flap conversion. Two cases had flap conversions months to years after initial reconstruction. A radial forearm free flap for medial canthus SCC that required salvage surgery with a forehead flap following infected orbital hardware with resultant osteoradionecrosis at one and a half years. There were no further complications thereafter. Another case was of an initial radial forearm free flap for a large zygomatic SCC that developed flap dehiscence at 2 months and was revised to a pectoralis major flap. No further complications were noted. Additionally, one pedicled sternocleidomastoid flap required delayed conversion to a pectoralis major flap due to inadequate bulk, causing a persistent salivary leak.

Rurality vs. outcome: time and space

The second objective of this study was to examine the association between rurality and both postoperative complications and follow-up challenges, assessed across temporal and spatial dimensions. Specifically, this included:

• The effect of time between staged procedures on complication rates;
• The relationship between geographic distance to the hospital and the occurrence of follow-up challenges.

Temporal analysis: staged procedure interval and complications

For interpolated flaps requiring staged procedures (n=55), including forehead flaps and facial artery musculomucosal flaps, the mean interval between the two procedures was 26.8±10.6 days. Due to the low incidence of complications, all types were consolidated into a binary outcome variable indicating the presence or absence of any complication. The median time interval between stages was similar for patients with complications (27 days; IQR, 17 days) and those without complications (27.5 days; IQR, 9 days), with no statistically significant difference observed (P=0.48; 95% CI: −11 to 3 days). Reported complications included venous congestion requiring revision, which occurred in the immediate postoperative period and did not impact the timing of the second-stage procedure. Importantly, no patients were lost to follow-up between the two stages.

Spatial analysis: distance and follow-up challenges

With respect to follow-up outcomes in relation to distance from the regional centre, a total of 16 patients experienced follow-up challenges: 13 were lost to follow-up (uncontactable) and 3 patients declined further follow-up. A binary logistic regression analysis revealed a significant association between distance and follow-up challenges (P=0.024; OR =1.0065; 95% CI: 1.0007–1.0124), indicating that increased rurality may adversely affect continuity of care. For example, one patient who received a large pedicled flap and resided 350 km from the regional centre experienced a flap bleed into the airway 4 weeks postoperatively, requiring urgent retrieval and awake fibreoptic intubation; although the patient’s recovery was uneventful, this case highlights the practical challenges posed by long travel distances for complex head and neck cancer care. The two previously identified distance outliers were excluded from this analysis to reduce skew.

Discussion

This study supports the feasibility of head and neck flap reconstruction at a regional centre operating under a single-service surgical model. There were no significant differences in immediate or long-term complication rates between free flaps and large pedicled flaps, demonstrating comparable outcomes to those reported in metropolitan, multi-specialty centres. In evaluating the role of rurality on patient outcomes, both temporal and spatial dimensions were considered. A significant association was observed between distance from the hospital and follow-up challenges, underscoring the need for accessible healthcare for patients residing in regional and remote areas. The higher proportion of males than females in the cohort is consistent with the known epidemiology of head and neck cancer. To our knowledge, this is the first study to demonstrate the feasibility of a single-surgical model in a regional centre offering a versatile reconstructive repertoire for head and neck cancer.

There remains a scarcity of literature examining the outcomes of head and neck flap reconstructions in regional centres (4,6). Studies from rural Indian hospitals have demonstrated the feasibility of microvascular free flap reconstruction when supported by careful planning and access to multidisciplinary teams, while also highlighting resource limitations as a key barrier (6,13). Other research has shown that free flaps can be safely performed in low-volume county and community hospital settings, with no significant difference in surgical complication rates compared to high-volume university hospitals (1,14).

This study further validates existing literature supporting the feasibility of a single-service surgical model for head and neck free flap reconstruction (7,15). It also corroborates previous work conducted at the same centre, which demonstrated comparable outcomes of forehead flap reconstructions to those performed at tertiary centres (15). The adoption of a single-service model may offer a practical alternative for regional hospitals that lack the specialist resources required for the conventional multidisciplinary approach (7).

This study found comparable outcomes between free and large pedicled flaps when examining perioperative complications and recurrences, which aligns with that of existing literature. Free flaps are recognised for their greater versatility to reconstruct larger defects, function as a composite graft with bony component, and enhance cosmesis (16-19). Nevertheless, the literature suggested that regional flaps remain useful in the reconstruction of locally advanced tumour resection, salvage free flap failure, and in patients who are elderly or have significant medical comorbidities, where free flap failure rates are increased due to vascular insufficiency (8,19,20).

In this study, four free-flap cases were successfully salvaged in the immediate postoperative period, whereas five cases required conversion to pedicled flaps. These findings align with existing literature, which identifies cardiovascular comorbidities, smoking, and obesity as key risk factors for flap failure (18,19). In general, the literature suggests that in the case of initial free flap failure, a second free flap is a more reliable reconstructive option than conversion to a regional flap (16,18). Studies suggested that salvage free flap has a 93.3% success rate if completed in the first 5 days postoperatively, or if not possible, after 30 days (19,20). Indications for conversion to pedicled flap included the need for urgent reconstruction and reconstruction between postoperative days 6 and 30 (20).

This study also demonstrates that distance is a significant barrier to follow-up care. Although limited data exist for this specific head and neck cancer population, rurality and travel distance have been shown to negatively impact follow-up across surgical populations generally (21). Despite the relatively small sample size, the 95% CI (1.0007–1.0124) was narrow and statistically significant. The OR of 1.0065 indicates that with every additional kilometre travelled, the odds of being lost to follow-up increase by 0.65%. This effect compounds over longer distances, with odds increasing by approximately 38% per 50 km and 91% per 100 km. While these findings underscore the importance of healthcare accessibility related to distance, other factors such as transportation challenges, health literacy, and social determinants also contribute to follow-up difficulties (21). Overall, these findings reinforce the need to decentralise specialist healthcare services in regional and rural areas to improve access and outcomes for this vulnerable patient population (5,21).

Regarding the temporal association between the two staged procedures and complication rates, this study found no significant relationship between the timing of the second surgery and postoperative complications. Traditionally, division of interpolated flap pedicles occurs approximately 3 weeks after the primary surgery (15,22,23). In this cohort, the average interval between the two procedures was 26.8±10.6 days, consistent with prior findings at the same regional centre. Factors influencing the timing included availability of public sector operating theatres and patient cardiovascular risk profiles, with some evidence that delayed pedicle division allowed for improved outcomes by providing a longer wound healing period (15). Recent studies have suggested that earlier pedicle division within 3 weeks may be associated with improved quality of life for patients (23,24).

This study has several limitations. First, its small sample size and retrospective design limit the power and generalisability of the findings to all patients undergoing head and neck reconstruction. Incorporation of post-hoc power analysis highlighted the limited statistical power of the current study to detect differences in complication rates between free and large pedicled flaps. A future direction could be to collect longer-term data or work with other regional centres to increase data numbers, in aim of determining whether meaningful differences in complication profiles exist between these reconstructive approaches in regional settings.

Secondly, the retrospective design nature of this study introduces potential selection bias in flap choice, documentation variability, and surgeon decision-making. On selection bias, reconstructive flap options were determined by clinical judgement, patient characteristics, and surgeon preference rather than randomisation. These factors may also influence complication profiles independent of the reconstructive method itself. Additionally, although a broad range of clinical variables were collected, missing data is unavoidable as not all data points were uniformly documented. In particular, comorbidity severity, detailed tumour staging, and intraoperative decision-making factors. This introduces the possibility of bias and limits the ability to control for all relevant prognostic factors. To note, as with any retrospective analysis, unmeasured confounders may influence outcome. For example, variations in perioperative care, surgeon experience, patient socioeconomic factors, and recovery behaviours. Together, these highlight the need for future prospective, multicentre studies with standardised data collection, predefined selection criteria, and comprehensive tracking of clinical variables. Such studies would allow for more robust adjustment for confounders and more reliable determination of flap-specific differences in outcomes. Nonetheless, this is the first study to investigate perioperative outcomes of head and neck cancer reconstruction in a regional centre operating under a single-service model, providing valuable insights perioperative considerations and follow-up challenges.

Thirdly, the data included only cases performed at a public hospital, excluding those treated in the private sector. It therefore does not capture all patients with head and neck cancer who received treatment in this regional setting. A future direction would be to compare perioperative outcomes across different hospital settings, including public vs. private sectors, as well as regional centres vs. metropolitan tertiary hospitals. Additionally, this study focuses primarily on objective perioperative outcomes. An important area for future research is to incorporate subjective patient-reported outcomes, such as quality of life, satisfaction with function and cosmesis, and the impact of factors improving healthcare accessibility—such as indigenous liaison officers, travel assistance programs, and cancer care coordinators. Working with allied health professionals on these aspects may provide valuable insights in how patient-centred quality care can be optimised and enhanced.

Finally, the use of distance from postcode to hospital as a metric for rurality has inherent limitations. Postcodes may cover broad geographic areas that do not accurately reflect a patient’s actual travel distance or time. This measure also does not capture factors such as transportation availability, socioeconomic barriers, or mode of travel, all of which can significantly affect access to follow-up care.

Conclusions

Overall, this study demonstrates the feasibility of head and neck flap reconstruction by a single surgical team at a regional centre. The comparable outcomes between free and large pedicled flaps align with existing literature and emphasize the importance of patient selection, including medical comorbidities and patient preference, when determining flap choice. The significant association between distance and follow-up challenges underscores the critical need for accessible healthcare and supports the decentralisation of specialist services to regional and rural areas, with the goal of improving healthcare equity. Future directions may include the use of telehealth to facilitate follow-up for patients in remote areas, as well as emerging artificial intelligence triage tools to predict risk and optimise resource allocation, potentially further enhancing patient care and system efficiency.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://www.theajo.com/article/view/10.21037/ajo-25-57/rc

Data Sharing Statement: Available at https://www.theajo.com/article/view/10.21037/ajo-25-57/dss

Peer Review File: Available at https://www.theajo.com/article/view/10.21037/ajo-25-57/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://www.theajo.com/article/view/10.21037/ajo-25-57/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study received ethics approval by the Human Research Ethics Committee (HREC) at Darling Downs Health (No. LNR/2024/QTDD/108056), the governing health authority for Toowoomba Base Hospital. Due to the retrospective nature of the study, a waiver of consent was granted.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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