Preoperative Iron and Blood Transfusions in Head and Neck Free Flap Reconstruction: A Retrospective Cohort Study

OBJECTIVE: To evaluate whether preoperative intravenous iron infusion is associated with reduced postoperative packed red blood cell (PRBC) transfusion risk and transfusion volume among patients undergoing head and neck free flap reconstruction. STUDY DESIGN: Retrospective cohort study. SETTING: Tertiary head and neck cancer centre. METHODS: Adult patients undergoing free flap reconstruction for head and neck cancer between January 2022 and May 2025 were included. Starting June 2022, patients with baseline hemoglobin <130 g/L underwent routine preoperative transferrin saturation testing. Patients with transferrin saturation <20% who subsequently received preoperative intravenous iron infusion were compared with those who did not. Primary outcome was receipt of postoperative PRBC transfusion. Multivariable logistic regression was used to assess predictors of transfusion. Negative binomial regression was used to model transfusion volume among transfused patients. RESULTS: Among 324 patients, 32 (9.9%) received preoperative intravenous iron and 59 (18.2%) required postoperative PRBC transfusion. Preoperative iron infusion was not independently associated with postoperative transfusion risk (aOR 1.26, 95% CI: 0.51-3.08, P = .62) or with number of PRBC units transfused (aIRR 1.00, 95% CI: 0.41-2.38, P = .997). Higher preoperative hemoglobin was associated with reduced transfusion risk (aOR 0.96 per g/L increase, 95% CI: 0.94-0.98, P < .001), while advanced tumor stage was associated with increased transfusion risk (aOR 2.55, 95% CI: 1.13-5.77, P = .024). These findings were unchanged in sensitivity analysis restricted to patients receiving iron ≥7 days preoperatively. CONCLUSION: Short-term iron repletion alone may be insufficient to mitigate transfusion requirements, highlighting the importance of earlier and/or more comprehensive anemia optimization strategies in this high-risk population.