Abstract
Background
Free and pedicled flaps remain the principal reconstructive options following head and neck oncologic surgery. Although free flaps are most frequently used, pedicled flaps have re-emerged with modern techniques offering comparable outcomes with reduced complexity. The aim was to systematically compare surgical, functional and economic outcomes between free and pedicled flaps in head and neck reconstruction.Methods
A systematic search of PubMed and Embase was conducted from database inception to September 2025, following PRISMA guidelines. Comparative studies evaluating free versus pedicled flap reconstruction in adults were included. Two reviewers independently screened and extracted data. Pooled meta-analyses were performed for operative time, hospital stay and complications.Results
Twenty-five studies met inclusion criteria. Free flap reconstruction required a longer operative time (mean difference = +172.5 min; 95% CI 132.3-212.6, PI 2.5 to +342.5 min) and higher financial cost (1.3-3 × greater) compared with pedicled flaps. Hospital stay was similar between groups (mean difference = +0.6 days; 95% CI -2.7 to +3.9). Pedicled flaps exhibited slightly fewer overall complications, including wound dehiscence, infection and revision surgery. Flap failure was significantly more frequent with free flaps.Conclusions
Free flaps remain the standard for extensive or functionally demanding reconstructions, but pedicled flaps offer comparable outcomes with shorter surgery, lower costs and equivalent complication rates in selected cases. Flap choice should be individualised based on defect complexity, patient comorbidity and institutional expertise.