OBJECTIVE: In the unique clinical context of a retropharyngeal carotid artery (RPC), free flap reconstruction (FFR) may be used for small pathologic tumor (pT)1-2 human papillomavirus (HPV)+ oropharyngeal squamous cell carcinoma (OPSCC) tumors to provide vessel coverage, providing a unique case-control study model. This study aims to elucidate the impact of FFR on functional outcomes following transoral robotic surgery (TORS). STUDY DESIGN: Retrospective review of electronic medical records between 2010 and 2022. SETTING: Single-institution tertiary care center. METHODS: Cohorts were defined as FFR (with RPC) and no FFR (nFFR). A 1:2 propensity score match (PSM) was performed. The functional oral intake scale (FOIS) was used to characterize swallowing outcomes. Statistical analysis was performed in R-Studio. RESULTS: Post-PSM, 93 patients met inclusion criteria (59.8 years, 92% white, 88% male). In total, 31 (33%) underwent FFR, 77 (83%) had pT2 tumors, and 87 (93%) underwent adjuvant treatment. The FFR cohort saw increased return to the operating room (FFR 19% vs nFFR 3.3%, P <
.001) and mean hospital stay (7.2 ± 2.2 vs 4.9 ± 3.1 days, P = .02). Median preoperative FOIS was similar between groups (FFR: 7.00 [interquartile range (IQR) 6.00-7.00] vs nFFR: 7.0 [7.00-7.00], P = .2) with comparable decline at first follow-up. The nFFR cohort had higher FOIS at 3 and 6 months (5.00 [5.00-6.00] vs 6.00 [5.00-7.00], P = .04). FOIS was similar after 1 year (6.00 [5.00-7.00] vs 6.00 [6.00-7.00], P = .3). CONCLUSION: FFR achieved comparable functional outcomes to nFFR at 1 year. FFR is a viable reconstructive option for pT1-2 tumors for which TORS that are amenable to surgical resection via TORS despite an anatomic barrier such as RPC.