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Predictors of Adverse Outcomes from Salivary Leaks after Microvascular Head and Neck Reconstruction
Hong Hao Xu
*1, Jacob Y. Katsnelson
1, Fuat Baris Bengur
1, Armin Aryannejad
1, G. Zehra Kocyigit
1, Adriana M. Duncan
1, Matthew T. Bottegal
1, Seungwon Kim
2, Mario G. Solari
11Department of Plastic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA; 2Department of Otolaryngology-Head & Neck Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
Background: Salivary leak after microvascular head and neck reconstruction causes complications jeopardizing both the reconstruction and patient recovery. This study identifies patient, clinical, and surgical predictors of adverse outcomes following leak development.
Methods: We analyzed a prospective cohort of 764 oropharyngeal free flaps (August 2019-December 2025). Baseline characteristics, operative details, and 30-day outcomes, were analyzed to identify predictors of leak-associated infection, hemorrhage, flap loss, prolonged postoperative length of stay (LOS), leak persistence after discharge, and 30-day readmission. Descriptive, bivariate, adjusted multivariate, and receiver operating characteristic (ROC) analyses were performed.
Results: Salivary leak occurred in 87 cases (11.4%). Predictors of infection, hemorrhage, or flap loss included BMI ≥25 kg/m
2 (OR 3.88,
P=.04), smoking (OR 6.06,
P<.01), subscapular system-based reconstruction (OR 11.75,
P=.02), and prior re-exploration for flap compromise (OR 8.36,
P=.03). Prolonged LOS was predicted by infection/bleeding (121.2%,
P=.04), age ≥70 (128.4%,
P=.01), trauma cases (148.4%,
P=.04), and operative leak management (144.2%,
P<.001). Predictors of leak persistence and 30-day readmission included prior radiation (OR 10.30,
P=.04), pharyngeal leaks (OR 7.70,
P=.04), and segmental mandibulectomy (OR 23.56,
P=.003). Operative leak management (OR 0.08) and double free flap reconstruction (OR 0.03) were protective (
P<.01). ROC analysis identified a 5-day threshold for operative intervention (AUC: 0.739,
P=.03), associated with a 2.5-fold increase (53.3% vs 21.4%) in persistence, readmission, and flap loss (OR 4.070,
P=.04).
Conclusion: Elevated BMI, smoking status, advanced age, prior radiation, pharyngeal reconstruction, and segmental mandibulectomy identify patients at higher risk for adverse outcomes after salivary leak. A 5-day threshold for operative intervention provides evidence-based guidance for clinical decision-making. Findings enhance counseling, risk stratification, and perioperative management.
Title: Receiver Operating Characteristic Analysis of Critical Threshold for Delay between Leak Onset and Return to the Operating Room.
Abbreviations: ROC, receiver operating characteristic; AUC, area under the curve.
Title: Receiver Operating Characteristic Analysis of Critical Threshold for Delay between Leak Onset and Return to the Operating Room.
