Functional Outcomes of Free Flap Reconstruction After TORS in Early‐Stage HPV‐Positive Oropharyngeal Cancer

ABSTRACT Objective In the unique clinical context of a retropharyngeal carotid artery (RPC), free flap reconstruction (FFR) may be used for small pathologic tumor (pT)1‐2 human papillomavirus (HPV)+ oropharyngeal squamous cell carcinoma (OPSCC) tumors to provide vessel coverage, providing a unique case‐control study model. This study aims to elucidate the impact of FFR on functional outcomes following transoral robotic surgery (TORS). Study Design Retrospective review of electronic medical records between 2010 and 2022. Setting Single‐institution tertiary care center. Methods Cohorts were defined as FFR (with RPC) and no FFR (nFFR). A 1:2 propensity score match (PSM) was performed. The functional oral intake scale (FOIS) was used to characterize swallowing outcomes. Statistical analysis was performed in R‐Studio. Results Post‐PSM, 93 patients met inclusion criteria (59.8 years, 92% white, 88% male). In total, 31 (33%) underwent FFR, 77 (83%) had pT2 tumors, and 87 (93%) underwent adjuvant treatment. The FFR cohort saw increased return to the operating room (FFR 19% vs nFFR 3.3%, P < .001) and mean hospital stay (7.2 ± 2.2 vs 4.9 ± 3.1 days, P = .02). Median preoperative FOIS was similar between groups (FFR: 7.00 [interquartile range (IQR) 6.00‐7.00] vs nFFR: 7.0 [7.00‐7.00], P = .2) with comparable decline at first follow‐up. The nFFR cohort had higher FOIS at 3 and 6 months (5.00 [5.00‐6.00] vs 6.00 [5.00‐7.00], P = .04). FOIS was similar after 1 year (6.00 [5.00‐7.00] vs 6.00 [6.00‐7.00], P = .3). Conclusion FFR achieved comparable functional outcomes to nFFR at 1 year. FFR is a viable reconstructive option for pT1‐2 tumors for which TORS that are amenable to surgical resection via TORS despite an anatomic barrier such as RPC.