Functional outcomes of primary closure versus free flap reconstruction for T1 tongue cancer: A systematic review

To review evidence comparing functional outcomes of primary closure and free flap reconstruction in T1 oral tongue squamous cell carcinoma (OTSCC). PRISMA 2020 guidelines were followed (PROSPERO CRD420251121360). Ovid MEDLINE was searched for studies reporting validated outcomes (speech, swallowing, QoL) in T1 OTSCC treated by primary closure or free flaps. Comparative studies were eligible; case series, abstracts, and non–stage-specific reports were excluded. Of 767 records screened, four underwent full-text review; none met eligibility due to pooled staging, lack of a free flap arm, or absence of comparators. ROBINS-I assessment of the closest study (El-Shabrawi et al.) indicated serious bias. Excluded studies suggested primary closure often yielded better speech, while flap bulk aided swallowing but impaired articulation. QoL outcomes appeared more influenced by adjuvant therapy than reconstruction. No eligible studies were found, underscoring an evidence gap. Current literature suggests no functional advantage of free flaps in T1 OTSCC. Stage-stratified, multicentre studies with standardised measures are needed to guide practice.