Abstract
PURPOSE: This study aims to systematically compare free flaps and pedicled flaps in patients with head and neck cancer. By tracking postoperative complications, psychosocial adaptation, and quality of life through long-term follow-up, this research seeks to provide evidence-based, individualized flap repair strategies to reduce complications and improve overall treatment outcomes and quality of life. METHODS: In this single-center, clinical data of head and neck cancer patients undergoing flap reconstruction (2018–2024) were retrospectively extracted. Psychological and quality-of-life outcomes were prospectively collected at 1, 3, and 6 months postoperatively using validated scales (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 and Head and Neck Module 35, Zung Self-Rating Depression Scale, Zung Self-Rating Anxiety Scale). Variables were selected based on clinical relevance. The Mann-Whitney U test, chi-square test, Univariate and multivariate logistic regression analyses were conducted to evaluate the risk factors for postoperative complications and length of hospital stay after flap reconstruction. RESULTS: Among 736 head and neck cancer patients undergoing flap reconstruction, 178 (24.2%) and 558 (75.8%) received free and pedicled flaps, respectively. Complications occurred in 234 (31.8%) of patients, with flap-related and systemic complications accounting for 127 (17.3%) and 155 (21.1%). Multivariate logistic regression analysis identified Prothrombin time (OR = 1.26, 95% CI [1.01–1.58], p = 0.037) as a significant predictor of flap-related complications. Hypertension (OR = 1.85, 95% CI [1.22–2.82], p = 0.0039) increases the risk of systemic complications. Surgical duration exceeding three hours (OR = 2.4, 95% CI [1.21–4.79], p = 0.012; OR = 1.75, 95% CI [1.01–3.04], p = 0.045), N3 stage (OR = 1.76, 95% CI [0.74–4.17], p = 0.2; OR = 3.2, 95% CI [1.47–6.95], p = 0.00341) experience a higher incidence of both flap-related and systemic complications. Psychological health assessments showed that the pedicled flap group had significantly higher Zung Self-Rating Depression Scale score than the free flap group at both three and six months post-surgery (42.3 ± 6.1 vs. 40.1 ± 7.3, p = 0.025; and 44.7 ± 5.5 vs. 41.6 ± 6.7, p = 0.002, respectively). Evaluations using the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 and Head and Neck Module 35 scales confirmed that flap type did not affect any quality of life dimension. CONCLUSION: This study identified predictors of postoperative flap-related complications in head and neck reconstruction, including prolonged prothrombin time, surgery duration exceeding 3 h, hypertension, and advanced T stage. Furthermore, it revealed that patients receiving pedicled flaps reported higher postoperative depression scores, highlighting the importance of psychological considerations in surgical planning. Collectively, these findings provide a multidimensional evidence base for developing personalized preoperative reconstruction strategies. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s12893-026-03543-6.