Current concepts in anesthetic management for head and neck oncologic surgery and reconstruction: a narrative review

Introduction

Head and neck cancers are the seventh most common malignancy worldwide, with approximately 792,000 new cases and over 424,000 deaths reported in 2021. In Western countries, they account for about 3–4% of all cancer diagnoses (1,2). These tumors are more frequent in men, with a median age at diagnosis between 60 and 66 years. However, human papillomavirus (HPV)-related oropharyngeal cancers are increasingly observed in younger populations, particularly in high-income countries (3,4). Tobacco and alcohol remain the main risk factors, often acting synergistically. In addition, HPV infection—especially type 16—is a major etiological factor in oropharyngeal cancers, with a rising incidence. The incidence varies geographically, being highest in South Asia, followed by Europe and North America (3-5).

Reconstructive maxillofacial surgery for head and neck tumors is one of the most complex areas in perioperative medicine. Patients with head and neck malignancies frequently present with advanced disease, sequelae of radiotherapy or previous surgery, anatomical alterations of the airway, and significant comorbidities, all of which may significantly complicate anesthetic management.

Rationale and knowledge gap

The advances in both anesthetic and surgical techniques emphasize the need to identify enduring practices that improve surgical outcomes and reduce post-operative complications. Despite the numerous anesthetic techniques described for maxillofacial reconstructive surgery, there is a lack of best practises about anesthetic perioperative management in free-flap reconstructive maxillofacial surgery and this review aims to address.

Objective

This narrative review aims to examine common anesthesia techniques, perioperative management and defines best anesthesia practise for maxillofacial reconstructive surgery. By reviewing the available evidence on key aspects such as airway management, fluid therapy, hemodynamic target, vasopressor use, analgesic strategy and postoperative care, this narrative review aims to support clinical decision-making on the selection of anesthetic techniques and perioperative management strategies to improve surgical outcomes and flap survival. We present this article in accordance with the Narrative Review reporting checklist (available at https://joma.amegroups.com/article/view/10.21037/joma-2026-0011/rc).

Methods

In January 2026, a focused literature search was conducted using PubMed, Google Scholar, ClinicalKey, the Kaiser Permanente online library, Wiley Online Library, UpToDate, and Cochrane to identify publications from January 2001 through December 2025 concerning perioperative anesthetic management in reconstructive head and neck surgery. The review focused on studies addressing airway management, hemodynamic optimization, fluid therapy, and postoperative care. Search strategies were developed using the key terms reported in Table 1. Eligible publications included randomized controlled trials, meta-analyses, scoping reviews, cohort studies, and reports describing institutional perioperative practices. Studies were considered for inclusion if they were published in English, available in full text online, and relevant to the objectives of the review. The screening and selection process was performed independently by the first author (F.P.). Initially, titles and abstracts were reviewed for relevance, followed by detailed evaluation of the selected full-text articles.

Anesthesia for maxillofacial surgery

Maxillofacial reconstructive surgery requires careful perioperative anesthetic management. In the preoperative phase, the focus is on patient optimization, airway evaluation, and accurate planning, especially in complex or fragile cases. A complex or fragile patient is someone whose care is difficult because of multiple factors as several chronic diseases, multiple medications, functional limitations or disability, socio-economic challenges, frequent hospitalization, reduced physiological reserve. During the intraoperative phase, microsurgical procedures often require prolonged anesthesia and strict control of hemodynamics, fluid balance, temperature, and coagulation to ensure flap viability and prevent complications. In the postoperative phase, close monitoring is essential, together with adequate pain control and early recognition of complications such as flap failure or thrombosis (6,7).

Preoperative assessment

Preoperative assessment in patients with head and neck tumors requires a structured approach (Table 2).

Special attention should be given to preoperative airway assessment. Clinicians should follow established guidelines, with particular focus on predicting a difficult airway (Table 3). Key factors to consider include the site and extent of the tumor, as well as the presence of trismus, dysphagia, or dysphonia (11,12). A history of radiotherapy or previous tracheostomy is also important, as these may further complicate airway management (11,13). Preoperative imaging [computed tomography (CT) or magnetic resonance imaging (MRI)] provides valuable information regarding upper airway patency and should be discussed within the multidisciplinary team (14). International guidelines emphasize that early identification of a potentially difficult airway allows reduction of the risk of major adverse events (11,13) (Figure 1).

Figure 1 CT, computed tomography; EEG, ICU, intensive care unit; MAP, mean arterial pressure; MRI, magnetic resonance imaging; PET, positron emission tomography; PONV, RT, TIVA, total intravenous anesthesia; VTE.

Intraoperative management

Intraoperative anesthetic management in maxillofacial reconstructive surgery is complex and requires a balance between hemodynamic stability, adequate tissue perfusion, and optimal conditions for microsurgery, especially given the long duration and bleeding risk of these procedures. Several studies have compared different anesthetic techniques. In selected cases, regional anesthesia with sedation has shown better postoperative outcomes than general anesthesia reporting significantly longer pain-free intervals (159 vs. 60 minutes), reduced need for rescue analgesia, fewer episodes of postoperative nausea and vomiting, and earlier discharge from the post-anesthesia care unit (PACU) (18). Similar findings were confirmed with dexmedetomidine-based sedation, including shorter extubation times and less postoperative pain (19). When comparing total intravenous anesthesia (TIVA) and volatile anesthesia, both are valid options. TIVA is associated with lower rates of postoperative nausea and vomiting, while sevoflurane allows faster recovery. In one randomized trial, nausea and vomiting were significantly more frequent with sevoflurane whereas recovery time was shorter (20). Additional data confirm reduced hemodynamic fluctuations and less postoperative nausea with TIVA (21). The use of regional nerve blocks as adjuncts has shown important benefits. In a recent randomized study, bilateral V2–V3 blocks reduced postoperative opioid consumption by about 50% (25.5 vs. 45.7 mg on day 1; 35.8 vs. 64.5 mg on day 2), and also reduced intraoperative anesthetic requirements (22). The results reported so far concerned oral and maxillofacial surgery or orthognathic surgery. In free-flap reconstructive maxillofacial surgery, invasive arterial blood pressure monitoring is generally recommended in patients with hemodynamic instability, relevant cardiovascular comorbidities, or when significant fluid shifts and rapid blood pressure changes are expected. In these settings, continuous monitoring is particularly useful, as it allows detection of short hypotensive episodes that might be missed with intermittent cuff measurements. A mean arterial pressure (MAP) below 65 mmHg for around 15 minutes has been associated with worse outcomes, while targeting higher values (≥80 mmHg) does not seem to provide additional benefit (23,24). In maxillofacial surgery, especially when controlled hypotension is used to improve the surgical field, these targets need to be balanced carefully against the risk of hypoperfusion. In higher-risk patients, advanced hemodynamic monitoring systems (such as FloTrac, LiDCO, or esophageal Doppler) can be helpful to guide fluid therapy and assess cardiac output in high-risk surgery (25-27). However, in routine cases, standard invasive arterial monitoring is usually sufficient (28,29). More recently, predictive systems based on machine learning have been introduced, allowing identification of hypotensive events up to 15 minutes in advance (30). Monitoring the depth of anesthesia (e.g., BIS) can help avoid both over- and under-sedation, with typical target values around 40–60 during general anesthesia and 80–85 during moderate sedation. Some studies have also shown a reduction in anesthetic drug consumption with this approach (31-34). Finally, intraoperative nerve monitoring may be considered in selected procedures (34). Inferior alveolar nerve injury during mandibular osteotomies is relatively common, with temporary deficits reported in up to 56% of cases and permanent alterations in about 20%, although most are mild (35,36).

Free flap surgery: key anesthetic considerations

Reconstructive microsurgery with free flaps represents the current gold standard for complex head and neck defects. Its success depends on a combination of surgical and anesthetic factors, including flap perfusion, hemodynamic stability, fluid management, and coagulation control. In this context, prospective and retrospective cohort studies state the anesthesiologist plays a key role in maintaining optimal physiological conditions for flap survival (37). From a surgical perspective, reducing operative time is essential. The use of two surgical teams working simultaneously can improve efficiency and may help limit excessive fluid administration (38).

Anesthesia technique

Among anesthetic options, growing evidence supports the use of propofol-based TIVA. A randomized trial in 70 patients showed a significant reduction in postoperative pulmonary complications with TIVA compared to inhalational anesthesia [14.3% vs. 40%; odds ratio (OR) 0.25] (39). Similarly, retrospective data demonstrated that TIVA required less fluid administration and was associated with fewer pulmonary complications (OR 0.41) (40). These effects may be related to better hemodynamic stability and reduced inflammatory response. Emerging approaches such as opioid-free anesthesia (OFA) also show promising results despite the currently low level of evidence. In a cohort study, OFA reduced overall complications (53.3% vs. 78.9%, P=0.012), intensive care unit (ICU) length of stay (3.4 vs. 5.2 days), duration of mechanical ventilation (9 vs. 67 hours), and need for vasopressors (10% vs. 46.6%) (41).

Hemodynamic management and perfusion

Maintaining adequate perfusion pressure is essential for flap survival. Some studies propose targets >75 mmHg or within 10% of baseline to minimize hypotension (42). Values below 65 mmHg, especially if prolonged, are associated with increased complications. Goal-directed hemodynamic therapy has been shown to improve outcomes. A randomized study reported higher flap survival rates and shorter ICU stays compared to conventional management when using dynamic parameters such as stroke volume variation and cardiac output (43).

Fluids and transfusion strategy

Fluid management remains critical. An optimal range of 3.5–6.0 mL/kg/h is generally recommended to balance perfusion and avoid overload with a level of evidence 2b (44). Excessive fluids can lead to tissue edema and impaired flap perfusion, while insufficient resuscitation may increase thrombosis risk (42,43). A restrictive transfusion strategy is preferred, with suggested thresholds of hemoglobin <7 g/dL in most patients, <8 g/dL in cardiac disease, and <10 g/dL in active ischemia (42). Blood transfusion does not improve flap survival and may increase complications.

Vasopressors and inotropes

The use of vasopressors is no longer considered contraindicated. Current evidence shows that norepinephrine, when used in low doses, does not increase flap failure and may be preferable to excessive fluid administration (45). In selected cases, dobutamine may be useful, as it can increase blood flow through the microvascular anastomosis and improve cardiac output (42).

Temperature, coagulation, and metabolism

Maintaining normothermia is crucial, as hypothermia impairs coagulation and increases infection risk (42,46). Active warming strategies and continuous temperature monitoring are therefore recommended. Coagulation management should be individualized, balancing thrombotic and bleeding risks. Notably, dextran is not recommended due to lack of benefit and increased complications (44). There is still no universal consensus on anticoagulation protocols. Finally, glycemic control is important, as hyperglycemia has been associated with increased infection rates and poorer flap outcomes (47) (Figure 1).

Postoperative management and intensive care

The postoperative period represents a critical phase in the perioperative pathway of patients undergoing reconstructive maxillofacial surgery. Despite intraoperative optimization of hemodynamic and microcirculatory conditions, the first 24–72 hours after surgery are characterized by a high risk of respiratory, hemodynamic, and microvascular complications. In this context, anesthesiologic and intensive care management continues to significantly influence flap survival and overall clinical outcomes (37). Airway management is one of the most critical aspects in the postoperative period. Even when intubation was uneventful, factors such as edema, bleeding, and anatomical changes can compromise airway patency. Early extubation may be safe in selected patients undergoing less extensive procedures and with stable clinical conditions (48,49). However, in more complex cases, delayed extubation is often preferred, as it reduces the risk of emergency reintubation, which is associated with increased morbidity (50). In practice, the decision should always be individualized and shared within a multidisciplinary team (48,51). Delayed extubation is typically performed after 12–24 hours in a protected setting such as the ICU, with immediate availability of difficult airway equipment. Postoperative flap monitoring is essential for early detection of microvascular complications. Clinical evaluation remains the gold standard and includes assessment of color, temperature, capillary refill, and bleeding response (pinprick test) (38,52,53). Instrumental techniques such as Doppler ultrasound or near-infrared spectroscopy may provide additional information, but they do not clearly outperform careful clinical monitoring and are mainly useful when direct assessment is difficult (53,54). The first 24–48 hours are critical, as most vascular complications occur during this period. For this reason, monitoring should be frequent (often hourly), then progressively reduced after the third postoperative day in stable patients (42,52,55,56).

Pain control

Adequate pain control is fundamental in the postoperative management of reconstructive maxillofacial surgery. Uncontrolled pain may trigger adverse neuroendocrine responses, increase oxygen consumption, and cause hemodynamic instability, potentially impairing flap perfusion. Current evidence supports multimodal analgesia strategies, aimed at reducing opioid consumption and related side effects (Table 4).

Complications after free-flap reconstructive maxillofacial surgery

Flap-related complications remain one of the main concerns in head and neck reconstructive surgery (Table 5). Overall, total flap loss occurs in about 5–6% of cases, while partial necrosis is reported in a further 6%. Despite this, microvascular reconstruction remains highly reliable, with an overall success rate of approximately 95.6% (64-67). In around 5–9% of patients, flap compromise requires a return to the operating room for vascular revision (66). The risk of complications also varies depending on the type of flap. Fibular free flaps, the most commonly used osseous flaps, show rates of 6.1% total loss, 6.6% partial loss, 9% infection, and 10.4% fistula formation, with wound dehiscence reported in up to 17.1% of cases. Deep circumflex iliac artery (DCIA) flaps tend to have higher complication rates, particularly fistulas (16.7%) and wound dehiscence (29.7%), as well as hardware-related problems (8.1%) Scapular flaps, although versatile, are associated with longer operative times (around 715 minutes) and a higher rate of anastomotic revision (up to 25%) (68) (Figure 1).

Limitations

This narrative review draws on multiple research databases and incorporates a range of study types, including randomized controlled trials (RCTs), meta-analyses, scoping reviews, cohort studies, and institutional standard practices, to identify evidence-based perioperative anesthetic management for free-flap reconstructive surgery. However, it does not encompass all existing literature on the subject. The articles included in this review were independently selected by the first author and only those available in English were included which may introduce potential bias to this review. Expanding this research could standardize perioperative anesthetic management and improve outcomes of patients undergoing free-flap reconstructive surgery.

Future perspectives and challenges

Future perspectives in anesthesia for reconstructive maxillofacial surgery are increasingly focused on the implementation of personalized perioperative management strategies, advanced airway assessment, and multidisciplinary planning. Recent technological innovations, including virtual surgical planning, three-dimensional imaging, and artificial intelligence, may improve the prediction of difficult airway management and perioperative complications, thereby enhancing patient safety and surgical outcomes (69). Furthermore, the adoption of enhanced recovery after surgery (ERAS) protocols and advanced intraoperative monitoring systems could contribute to reducing postoperative morbidity, shortening hospitalization, and optimizing functional recovery (70). At the same time, several challenges remain unresolved, particularly in patients with previous radiotherapy, extensive oncologic disease, severe anatomical alterations, or multiple comorbidities, all of which may significantly complicate anesthetic management. Future research should therefore focus on validating predictive models, improving multidisciplinary collaboration, and integrating emerging technologies into routine clinical practice in order to further optimize perioperative care in reconstructive maxillofacial surgery.

Conclusions

Reconstructive maxillofacial surgery for head and neck tumors represents one of the most challenging settings in modern anesthetic practice. In this context, perioperative anesthetic management plays a central role in both patient safety and surgical success. Current evidence supports a structured and individualized approach throughout the entire perioperative pathway. Careful preoperative assessment—particularly of the airway and overall functional status—is essential for appropriate planning. Intraoperatively, maintaining hemodynamic stability, adopting goal-directed fluid therapy, using vasopressors judiciously, and ensuring normothermia are key elements for preserving flap perfusion and reducing complications. Importantly, flap success appears to depend less on the specific anesthetic technique used and more on the overall quality of physiological management and the coordination of the multidisciplinary team. In the postoperative phase, decisions regarding airway management, flap monitoring, pain control, and the level of care (ICU or high-dependency unit) continue to have a major impact on outcomes. Overall, anesthesia in this setting should be viewed as a continuous process that extends from preoperative evaluation to postoperative care. A multidisciplinary, patient-centered, and evidence-based approach remains the cornerstone of optimal management.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://joma.amegroups.com/article/view/10.21037/joma-2026-0011/rc

Peer Review File: Available at https://joma.amegroups.com/article/view/10.21037/joma-2026-0011/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://joma.amegroups.com/article/view/10.21037/joma-2026-0011/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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