Does Neoadjuvant Chemotherapy Increase Reconstructive Risk? A Comparative Analysis of Surgical Efficiency and Microvascular Success in Advanced OSCC

OBJECTIVE: To investigate the effect of neoadjuvant chemotherapy (NACT) by evaluating its impact on surgical efficiency and postoperative morbidity in patients undergoing complex free-flap reconstruction for advanced oral cavity squamous cell carcinoma (OSCC). METHODS: A retrospective comparative study was conducted on 86 patients (NACT cohort: n = 20; Primary Surgery cohort: n = 66) undergoing microvascular free tissue transfer. Primary outcomes included surgical efficiency (ischemic time, total operative duration) and postoperative complications (major microvascular events vs. minor wound issues) that were evaluated. RESULTS: The NACT group presented with significantly more advanced disease (100% Stage IV vs. 39.4%; p < 0.001). Despite this higher tumor burden, the NACT cohort demonstrated significantly shorter mean ischemic times (39.0 ± 7.5 vs. 52.5 ± 17.9 min; p = 0.001) and reduced operative durations (7.5 ± 0.8 vs. 8.6 ± 1.3 h; p = 0.001). Total complication rates were comparable (35% vs. 33.3%). However, minor wound-related complications were significantly more frequent in the NACT group (30% vs. 4.5%; p = 0.004). The flap salvage rate following re-exploration was high and comparable between groups (80.0% vs. 85.7%). CONCLUSION: No statistically significant differences were detected in major flap failure or vascular re-exploration, though the study was underpowered to establish definitive safety equivalence for these endpoints. In exploratory subgroup analysis of RFFF reconstructions, NACT was associated with reduced ischemic time (p = 0.017). These findings suggest that while NACT compromises soft-tissue wound healing, it does not preclude successful microvascular reconstruction when managed with appropriate perioperative care.