Free Tissue Transfer Versus Locoregional Flaps for the Reconstruction of Small and Moderate Defects in the Head and Neck Region: A Narrative Review.

Reconstructive surgery for oral cavity defects has progressed from early pedicled locoregional flaps, like the pectoralis major myocutaneous flap, to sophisticated microvascular free flaps, driven by the need to restore critical functions such as speech, swallowing, and chewing, alongside aesthetic outcomes essential for patient quality of life. This narrative review compares the effectiveness, outcomes, and current roles of microvascular free flaps versus locoregional flaps in reconstructing small to moderate oral cavity defects. A narrative literature review was conducted, analyzing retrospective studies, meta-analyses, and clinical series, focusing on flap success rates, functional and aesthetic outcomes, complications, and resource utilization for key flaps, including radial forearm free flap (RFFF), anterolateral thigh flap (ALT), submental island flap (SMIF), supraclavicular artery island flap (SCAIF), and facial artery musculomucosal (FAMM) flap. Microvascular free flaps achieve high success rates and excel in complex three-dimensional reconstructions, offering superior functional outcomes, but demand prolonged operative times, specialized expertise, and significant resources, limiting their feasibility in low-resource settings. Locoregional flaps provide comparable success for smaller defects, with shorter operative times, lower costs, and suitability for high-risk patients. Both approaches yield favorable aesthetic results when appropriately selected, with locoregional flaps offering better tissue matching in facial reconstructions. Free flaps remain the gold standard for complex defects, while locoregional flaps are effective, cost-efficient alternatives for smaller defects, particularly in comorbid patients or resource-constrained environments. Clinical decisions should consider defect complexity, patient health, and institutional capabilities, with future advancements in tissue engineering and surgical training poised to enhance outcomes and accessibility. The aim of this review is to clarify the differences between the traditionally used locoregional flaps and the more recent microvascular free flaps.