Long-Term Functional Outcomes of Free Flaps Versus Locoregional Flaps in Soft Tissue Reconstruction for Oral Cavity Cancer: A Systematic Review

Background: The choice between free flaps and locoregional flaps for soft tissue reconstruction in oral cavity cancer patients is critical for determining long-term functional and oncological outcomes. This systematic review evaluates the efficacy of these reconstructive techniques, focusing on survival, recurrence, quality of life (QoL), and functional parameters such as speech, swallowing, and the need for gastrostomy or tracheostomy. Methods: A systematic review adhering to PRISMA guidelines was conducted using PubMed, Scopus, Cochrane, and EBSCO databases. The search strategy included terms related to oral cancer and reconstructive flap outcomes. Studies published between January 2000 and August 2024 were included if they reported statistical outcomes with at least a 3-month follow-up. A total of 32 studies involving 6620 patients met the inclusion criteria. Most patients were male, aged 45 to 65 years, with squamous cell carcinoma (SCC) accounting for over 70% of cases. Results: Free flaps, particularly radial forearm free flaps (RFFF) and anterolateral thigh (ALT) flaps, were predominantly used for larger tumor resections and demonstrated superior functional outcomes. These flaps were associated with higher 5-year survival rates (65%-75%) compared with locoregional flaps (50-60%) and a lower local recurrence rate (12% for free flaps versus 26% for sternocleidomastoid flaps; P<0.05). Free flaps also yielded better QoL scores, especially in speech, social interaction, and emotional well-being. Functional recovery was significantly better, with 76.8% of patients resuming normal oral intake within 6 months compared with 58.3% for locoregional flaps (P<0.05). Although locoregional flaps offered shorter operative times (mean: 6 h 53 min versus 9 h 18 min for free flaps) and faster initial recovery, they were linked to higher rates of flap necrosis and donor site complications. Conclusions: Free flaps, particularly RFFF, offer superior oncological and functional outcomes for complex oral cavity reconstructions. Although locoregional flaps, such as submental island flaps (SMIF) and sternocleidomastoid (SCM) flaps, may be suitable for smaller defects due to shorter operative times and faster recovery, their use is associated with poorer long-term functional results and higher complication rates. These findings support the preferential use of free flaps for extensive reconstructions. Future research should prioritize multicenter randomized trials to validate these findings and refine patient-centered reconstructive strategies.