ABSTRACT
Major head and neck oncologic surgery is a high resource-demanding activity. The aim of this manuscript was to highlight the challenges encountered in the management of oncologic head and neck patients undergoing large cancer resection and immediate reconstruction with microvascular free flaps, in a COVID-19 dedicated hospital.
We retrospectively analyzed data from patients admitted at A. Gemelli University Hospital Foundation, during the most acute COVID-19 emergency phase from February 2020 to June 2021, who underwent complex head and neck oncological surgery with immediate reconstruction using microvascular free flaps. We therefore reported clinical and management issues encountered during the hospitalization.
Forty-two patients were treated with extended surgical resection of the tumor and immediate reconstruction with microvascular free flaps, perforator or not, single or multiple in more complex reconstructions. No donor-site complications were recorded. The overall flap survival (OFS) rate was 95.2% after at least two weeks of follow-up; only in two patients we observed partial flap necrosis.
Despite pandemic, the number of patients treated with large surgical tumor resection and reconstruction using microvascular or locoregional flaps did not diminished, but rather increased at our Institution. We also noticed a more advanced stage of the tumors at diagnosis, compared to pre-COVID era, and an increasing need of salvage surgery after chemoradiotherapy failure or interruption, and palliative surgery. In fact, we observed several patients in which tumor expansion was so large to make them not suitable for a radical curative surgical treatment.

IMPACT STATEMENT
During COVID-19 era, the major head and neck surgery had an increasing demand, along with a more frequent palliative purpose for advanced and unresectable cancers.