Workhorse Soft Tissue Free Flaps in Head and Neck Reconstruction: 40 Years of Chang Gung Experience

Microsurgical free flaps have become the cornerstone for soft tissue reconstruction in the head and neck following tumor resection, offering improved functional and aesthetic outcomes with reduced donor site morbidity compared to traditional techniques. This retrospective review of over 14,000 cases from Chang Gung Memorial Hospital spanning 40 years highlights evolving trends in flap selection and their associated microsurgical outcomes. The anterolateral thigh (ALT) flap remains the dominant workhorse, with increased usage in recent years due to its versatility and reliability. The profunda artery perforator (PAP) flap has emerged as the second most commonly used flap, effectively replacing the radial forearm flap (RFF), whose use has largely declined because of donor site concerns and limited tissue bulk. While the medial sural artery perforator (MSAP) flap offers a pliable alternative, it carries a higher complication rate, underscoring the importance of surgical experience in its application. Our findings emphasize the importance of individualized flap selection based on defect characteristics, donor site considerations, and long-term reconstructive planning to optimize patient outcomes in head and neck microsurgical reconstruction.