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Salivary Leak after Microvascular Head and Neck Reconstruction: Clinical Course, Infectious Complications, and Management Outcomes
Hong Hao Xu
*2, Fuat Baris Bengur
2, Jacob Y. Katsnelson
2, G. Zehra Kocyigit
2, Armin Aryannejad
2, Adriana M. Duncan
2, Matthew T. Bottegal
2, Seungwon Kim
1, Mario G. Solari
21Department of Otolaryngology-Head & Neck Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA; 2Department of Plastic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
Background: Salivary leak after microvascular head and neck reconstruction is morbid, with reported incidences exceeding 20%, yet its clinical course and management remain incompletely characterized. This large-cohort study evaluates the timing, infectious associations, and treatment outcomes of salivary leaks.
Methods: A prospective database of consecutive microvascular head and neck reconstructions (08/2019-12/2025) was queried for patients with oropharyngeal defects complicated by postoperative salivary leak. Demographics, disease characteristics, complications, and management were analyzed using descriptive, comparative, and Cochran-Armitage trend statistics.
Results: Of 847 cases, 764 met inclusion. Salivary leak occurred in 87 patients (11.4%), at a mean of 6.1 postoperative days. Leaks significantly prolonged hospital stay (18.4 vs 10.9 days,
P<.001) and increased rates of bleeding (14.9% vs 6.8%,
P=.02) and flap loss (6.9% vs 1.9%,
P=.01). Antibiotics were administered in 92.0% of cases, yet purulent infection developed in 44.8%. Forty-four patients (50.6%) required return to the operating room (RTOR), at a mean of 10.1 postoperative days, most commonly for persistent/worsening drainage (81.8%), wound breakdown (68.2%), or neck erythema/pain (43.2%). Debridement/re-inset without additional flaps was performed in 88.6% of cases. Patients requiring repeat RTOR were more likely to undergo flap-based salvage (44.4% vs 11.4%,
P=.02). Overall repeat RTOR rates were similar between flap and non-flap strategies (20.5%,
P>.99). Infection rates significantly increased (
P<.001) with escalating management intensity: conservative (25.6%), RTOR (60.0%), repeat RTOR (77.8%).
Conclusion: Salivary leaks substantially increase risks of bleeding, flap loss, and infection despite antibiotics. Concurrent infection drives management escalation. Flap-preserving and flap-based salvage strategies offer comparable effectiveness but remain associated with ongoing morbidity. Future studies should focus on risk stratification and preventive strategies to improve outcomes.
Title: Management Flow and Patterns of Salivary Leaks Managed Operatively.
Abbreviations: RTOR, Return to Operating Room.
Footnotes: * 4 pedicled flaps and 1 free flap. ** 3 pedicled flaps and 1 free flap.
Title: Management Flow and Patterns of Salivary Leaks Managed Operatively.
