Head and neck free flap reconstruction in frail patients with the Awake Integrated Microsurgical approach

General anesthesia (GA) is the standard of care for head and neck free flap reconstruction but may pose significant risks in elderly or medically fragile patients. In this study the authors present their experience with the innovative Awake Integrated Microsurgical approach (AIM), comparing peri-operative complications and post-operative results from patients undergoing head and neck free flap reconstruction with GA with those performed under loco-regional anesthesia and sedation (AIM). A retrospective cohort study was conducted on 40 patients undergoing microvascular head and neck reconstruction (excluding intraoral location) after oncological resection (20=GA; 20=AIM). Combined soft tissue and bone defects were more frequent in GA (60% vs. 37%) but this difference was not statistically significant. LD and ALT/VL represented 85% of the flaps employed. Peripheral and neuro-axial nerve blocks were combined with sedation in 90% and 40% of the AIM group. AIM patients were significantly older (p=0.004) and had higher comorbidity burden (p =0.004). Despite higher anesthetic risk, all AIM procedures were completed without conversion to GA. Operative time was shorter under AIM (p= 0.001), while ischemia time, transfusion rate, and flap outcomes were comparable. No AIM patient required ICU admission (p= 0.047). Rates of major surgical complications (Clavien-Dindo ≥ III) and total or partial flap loss were similar. The AIM approach allowed safe, effective, and resource-sparing microvascular reconstruction in frail patients unfit for GA, reducing anesthetic exposure, operative time and ICU utilization. These findings may help expanding the role of awake microsurgery to selected low-risk patients within ERAS protocols.