Alternative Soft Tissue Free Flaps in Multi-Flap Head and Neck Reconstruction: A Propensity Score-Matched Analysis.

BACKGROUND: Multi-flap reconstruction is often required for extensive head and neck defects, especially in recurrent disease, prior reconstruction, or vessel-depleted necks. While traditional donor sites remain foundational, the reliability of alternative soft tissue free flaps is less defined. METHODS: This retrospective cohort study compared traditional and alternative soft tissue free flaps in multi-flap head and neck reconstruction. Outcomes were analyzed in unmatched and propensity score-matched cohorts. Primary endpoints included overall recipient site complications, flap loss, thrombosis, reoperation, and length of stay. RESULTS: The unmatched cohort included 171 patients and 347 flaps: 297 traditional (86%) and 50 alternative (14%). After matching, outcomes were comparable between groups. No statistically significant differences were seen in recipient site complications, reoperation, thrombosis, flap loss, or hospital stay. CONCLUSIONS: Alternative soft tissue free flaps appear safe and reliable when traditional workhorse flaps are unavailable.