Reconstruction of advanced oral cancer defects with two or more free flaps: Long-term clinical outcomes

Advanced-stage oral squamous cell carcinoma (OSCC), particularly stage IV disease, often results in extensive composite defects following radical tumour ablation. Microvascular free flap reconstruction is essential for restoring form and function; however, data regarding long-term outcomes following reconstruction with multiple simultaneous free flaps remain limited. A retrospective review was conducted of patients with stage IV oral cavity cancer who underwent wide excision, neck dissection and reconstruction with two or more simultaneous free flaps between January 2013 and December 2023. Demographic data, comorbidities, tumour characteristics, surgical details, flap combinations, complications, recurrence and overall survival were analysed. Kaplan-Meier survival analysis was performed, and Cox proportional hazards regression was used to identify factors affecting survival. Fifty-three patients (52 men and 1 woman; mean age 56.6 years) were included. The most common flap combination was fibula osteocutaneous flap with anterolateral thigh musculocutaneous flap. The mean operative time was 508 min (range 220-1120 min). Complete flap loss occurred in two cases. All patients received adjuvant chemoradiotherapy. The 1-, 2- and 5-year overall survival rates were 75%, 61.2% and 43.3%, respectively. On multivariable analysis, a positive surgical margin was significantly associated with poorer survival (P = 0.033; hazard ratio [HR] = 0.14). Simultaneous reconstruction with two or more free flaps is a feasible and safe option for extensive stage IV oral cancer defects. Achieving clear surgical margins remains the most critical determinant of prognosis. These findings support the role of complex microsurgical reconstruction as an integral part of multidisciplinary management for stage IV oral cancer.