Salvage flap reconstruction for recurrent head and neck cancer after radiotherapy: A systematic review.

Introduction: Recurrent head and neck cancer (HNC) after radiotherapy presents a reconstructive challenge. Whether pedicled or free flap reconstruction leads to better outcomes remains unclear. This review aims to assess the outcomes of pedicled and free flap reconstruction in patients with recurrent HNC after radiotherapy. Method: The protocol was developed prospectively, peer-reviewed and registered on the PROSPERO database. A search strategy was designed and conducted across multiple databases, including MEDLINE and Embase (1990-2024). Additional sources included hand searches, citation searches, and clinical trial registers. 9233 titles and abstracts were screened, full-text of 422 reports reviewed, and 27 cohort studies included. Quality assessment was performed using standardised risk of bias tools. Results: 27 cohort studies, representing a total of 6879 participants and 5919 flaps, were included. All studies included patients who underwent flap reconstruction for salvage of recurrent HNC following radiotherapy. Included study designs precluded a direct comparative analysis of differences between flap types. Reporting of patient-relevant outcomes such as swallowing or quality of life was poor. For free flaps, total flap loss ranged from 0 to 29 % and partial flap loss ranged from 0 to 14.7 %. The certainty of the evidence was judged to be very low. Conclusions: Reconstruction for recurrent HNC after radiotherapy can be achieved with consistency using pedicled or free flaps. A direct comparison cannot be made with available data. The heterogeneity in study designs and lack of comprehensive or patient-relevant outcome reporting underscore the evidence gap and need for well-designed studies to better inform clinical decision-making.