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Article

Evolution and Optimization of the HALP Formula for Predicting Free Flap Failure: A Progressive Analysis of Predictive Accuracy

1
Department of Medicine, Section of Maxillo-Facial Surgery, University of Siena, Viale Bracci, 53100 Siena, Italy
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Department of Maxillo-Facial Surgery, Azienda Ospedaliera Santa Maria di Terni, Viale Tristano di Joannuccio, 05100 Terni, Italy
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Department of Maxillo-Facial Surgery, Hospital of Perugia, Sant’Andrea Delle Fratte, 06132 Perugia, Italy
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Department of Maxillofacial Surgery, Federico II University of Naples, Via Pansini, 5, 80131 Naples, Italy
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Department of Neurological Sciences, Division of Maxillofacial Surgery, Marche University Hospitals-Umberto I, Via Conca 71, 60126 Ancona, Italy
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Dipartimento di Ingegneria Informatica, Automatica e Gestionale, Università La Sapienza, Via Ariosto, 25, 00185 Roma RM, Italy
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Department of Surgery and Biomedical Sciences, Section of Maxillo-Facial Surgery, University of Perugia, Piazzale Gambuli 1, 06129 Perugia, Italy
*
Author to whom correspondence should be addressed.
Surgeries 2025, 6(2), 44; https://doi.org/10.3390/surgeries6020044 (registering DOI)
Submission received: 1 March 2025 / Revised: 25 May 2025 / Accepted: 29 May 2025 / Published: 30 May 2025

Abstract

Background: Reconstructive surgery with free flaps is a fundamental component in head and neck surgery, but flap failure remains a significant concern. The hemoglobin, albumin, lymphocyte, and platelet (HALP) score is a prognostic factor commonly applied in the evaluation of patients suffering from malignant tumours. This score has emerged as a potential preoperative risk assessment tool; however, its predictive accuracy for free flap failure has not been fully evaluated. The potential of this formula, in the cervical–facial reconstructive area, has not yet been well studied in the international literature. Methods: This retrospective study included patients who had undergone free flap reconstruction in the maxillofacial surgery departments of Perugia and Ancona over the past ten years. To optimize the HALP formula, advanced machine learning technologies, mainly the Julius AI platform, were applied. The HALP formula was refined through three phases: the original formula, a weighted version, and the final “Modified HALP.” Predictive performance was assessed using ROC curve analysis, multivariate logistic regression, and internal validation. Results: The final version of the HALP score, created in the present study, achieved an AUC-ROC of 0.95 (95% CI: 0.91–0.99), outperforming the original and weighted versions. At the optimal cut-off, the final “Modified” HALP score demonstrated 90.91% sensitivity and 92.36% specificity, remaining an independent predictor of flap failure after adjusting for confounders. Conclusions: The aim of the study was to optimize the HALP score by integrating clinical information with the aim of making significant progress in the prediction of failure in reconstructive flaps. The Modified HALP score emerges as a powerful tool for preoperative risk stratification in free flap surgery, potentially improving patient outcomes through targeted interventions. Future research should focus on external validation and exploring the underlying biological mechanisms.
Keywords: HALP score; free flap failure prediction; machine learning; surgical risk stratification; predictive analytics medicine HALP score; free flap failure prediction; machine learning; surgical risk stratification; predictive analytics medicine

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MDPI and ACS Style

Monarchi, G.; Committeri, U.; Gilli, M.; Salzano, G.; Troise, S.; Consorti, G.; Benedetti, R.; Balercia, P.; Tullio, A. Evolution and Optimization of the HALP Formula for Predicting Free Flap Failure: A Progressive Analysis of Predictive Accuracy. Surgeries 2025, 6, 44. https://doi.org/10.3390/surgeries6020044

AMA Style

Monarchi G, Committeri U, Gilli M, Salzano G, Troise S, Consorti G, Benedetti R, Balercia P, Tullio A. Evolution and Optimization of the HALP Formula for Predicting Free Flap Failure: A Progressive Analysis of Predictive Accuracy. Surgeries. 2025; 6(2):44. https://doi.org/10.3390/surgeries6020044

Chicago/Turabian Style

Monarchi, Gabriele, Umberto Committeri, Massimiliano Gilli, Giovanni Salzano, Stefania Troise, Giuseppe Consorti, Roberto Benedetti, Paolo Balercia, and Antonio Tullio. 2025. "Evolution and Optimization of the HALP Formula for Predicting Free Flap Failure: A Progressive Analysis of Predictive Accuracy" Surgeries 6, no. 2: 44. https://doi.org/10.3390/surgeries6020044

APA Style

Monarchi, G., Committeri, U., Gilli, M., Salzano, G., Troise, S., Consorti, G., Benedetti, R., Balercia, P., & Tullio, A. (2025). Evolution and Optimization of the HALP Formula for Predicting Free Flap Failure: A Progressive Analysis of Predictive Accuracy. Surgeries, 6(2), 44. https://doi.org/10.3390/surgeries6020044

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