Free vs. Local Tissue Transfer and Reconstruction in Pediatric Head and Neck Cancer Patients: A Comparable Complication Outcome Review

<i>Background and Objectives</i>: Reconstructive outcomes following head and neck (H&N) cancer resection in pediatric patients remain understudied, particularly regarding the comparative efficacy of free versus local tissue transfer. <i>Materials and Methods</i>: A retrospective review was conducted on pediatric patients undergoing malignant H&N tumor resection at a tertiary center from 2007 to 2024. Patients were stratified by reconstruction type (free vs. local flap), and outcomes assessed included flap failure, wound complications, revision rates, operative time, hospital stay, and 30-day readmission. <i>Results</i>: A total of 41 patients (mean age: 10.6 years) met inclusion criteria; 18 underwent free flaps and 23 received local flaps. Common diagnoses included osteosarcoma (21.9%) and rhabdomyosarcoma (12.2%). Anterolateral thigh (44.4%) and fibula (33.3%) were the most common free flaps; temporalis (21.7%) and pectoralis (13.0%) were common local flaps. Flap survival was high in both groups (94.4% vs. 100%). However, local flaps had significantly higher rates of hardware exposure (34.7% vs. 5.5%, <i>p</i> = 0.025) and wound dehiscence (39.1% vs. 5.5%, <i>p</i> = 0.045). Free flaps were associated with longer operative times (10.3 vs. 6.5 h, <i>p</i> = 0.011) and hospital stays (29.1 vs. 13.9 days, <i>p</i> = 0.036). <i>Conclusions</i>: While both approaches achieved high flap survival, free flaps may offer more durable reconstruction and reduce wound-related complications in complex pediatric H&N oncologic cases.