ABSTRACT Objective To compare head and neck free flap outcomes and complications among patients with a history of alcohol use disorder. Methods This is a multicenter retrospective study from January 1, 2010 to July 31, 2025 using data from 73 healthcare organizations in the United States. Adult patients 18 years or older with head and neck cancer undergoing non‐bony or bony free flap reconstruction were divided based on presence or absence of a history of alcohol use disorder before surgery. Primary outcomes examined up to 30 days after surgery included flap failure, need for vascular repair, and flap revision. Results Patients with a history of alcohol use disorder within 6 months of surgery who underwent bony reconstruction had an increased risk of needing flap revision surgery and pneumonia (RR: 1.2931.018, 1.642; 1.9471.337, 2.836). A history of alcohol use disorder within 1 year prior to non‐bony free flap surgery had a higher risk of flap revision. (RR: 1.2181.008, 1.472). Sepsis and pneumonia were noted to have increased risks in relation to alcohol use disorders (RR: 1.5221.055, 2.196; 2.0111.568, 2.581). The risk of flap failure was not associated with a history of alcohol use disorders (RR: 1.1590.878, 1.531). Conclusion Alcohol use disorder within 6 months prior to surgery is associated with an increased risk of flap revision surgery for bony reconstruction cases. For both non‐bony and bony free flaps, the risks of sepsis and pneumonia also increase significantly with alcohol use disorder. Level of Evidence Level 3.
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