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133 Surgery: skeletal muscle mass, systemic inflammation and flap reconstruction The prevalence of low SMM and high NLR found in the entire cohort was 54.2% and 50.5%, respectively. For HNSCC patients, the prevalence of low SMM and high NLR was 57.0% and 48.3%, respectively. A previous study performed in colorectal cancer with 2470 patients found similar prevalence of low SMM (44%) and elevated NLR (46%). A significant prognostic value of these markers for decreased overall survival was also found. 36 SMM and inflammation have been associated with increased risk of postoperative complica- tions andmortality in various types of cancer such as lung cancer, gastrointestinal cancer, pan- creatic cancer, hepatobiliary cancer, breast cancer and cancers of the reproductive system. 37–42 Virchowwas the first to provide a possible link between inflammation and cancer by observing the presence of leukocytes within tumors in the 19 th century. Since then, various studies pub - lished about the significant role of inflammation in cancer and only during the last decade clear evidence has been obtained to show the critical role of inflammation in tumorigenesis. 43 It is also known that local inflammation in themicroenvironment of the tumor leads to chronic systemic inflammation with significant effects on patient’s body weight and amount of lean tissue of which SMM is the largest contributor, also known as cancer cachexia. 44 Also, neutro- phils and lymphocytes are host inflammation markers which provide angiogenic, epithelial and stromal growth factors that may cause tumor progression. 45 The role of patients’ grade of systemic inflammation in surgically treated patients has been increasingly recognized over the past decade. 42,46–51 Muscle mass and inflammation also gained increased attention in the field of medical on- cology, especially in HNC patients. Low SMM has shown to be predictive for chemotherapy dose-limiting toxicities 13 , radiotherapy toxicities, increased risk of pharyngocutaneous fis- tulas in patients undergoing laryngectomy 52 , decreased survival in patients with oral cavity cancers 53 and increased risk of FFF failure and other surgical complications in oral cancer patients. 20 Low SMM has also shown to be prognostic for decreased OS and DFS. 6 Our previous finding showed that low SMM is a significant predictor of surgical complications and prognos- tic for OS in oral cancer patients undergoing FFF surgery, in this cohort we confirm this and found that the combination of low SMM with elevated NLR (OR 4.3; p<0.05) was predictive for surgical complications. Due to the low flap failure rate, especially in patients with FFF surgery (n=7) it was not possible to specifically evaluate the impact of low SM on failure rate, however we assume that the dire effects of low SMM on physical recovery also applies to this flap and that low SMM is a predictive factor for failure rate, as found in our previous study cohort. 20 In this cohort, we found a significant predictive and prognostic impact of elevated NLR. Pre - vious research also shows the prognostic impact of elevated NLR for decreased survival in patients with HNC. 54 To date, only few articles describe the impact of elevated NLR in surgically treated HNC patients. Kuzucu et al. conducted a study in 145 patients undergoing parotidec - tomy and 83 healthy persons and found that elevated NLR was significantly higher in patients undergoing surgery for malignant parotidmass. 55 This supports the link between inflammation and cancer. Son et al. performed a retrospective study in 369 patients and found that elevated 7