Free fibula flap for secondary mandibular reconstruction after gunshot injuries in Tigray, northern Ethiopia : A 5-year review of microsurgical challenges and outcomes in a war zone.

Background: Surgical care in Africa, particularly in conflict regions like Tigray, Ethiopia, faces unique challenges. Over 5 years a team of plastic and trauma surgeons conducted 5 humanitarian missions at Mekelle Referral University Hospital to reconstruct mandibular defects caused by shotgun injuries using free fibula flaps.

Methods: This retrospective study analyzed 44 free fibula transfers performed between 2019 and 2023, with 33 cases involving mandibular reconstruction. Flaps were elevated using magnifying loupes; microscopes were employed when electricity was available. Postoperative flap monitoring and follow-up visits were conducted when feasible.

Results: Of 33 mandibular reconstruction patients (3 females, 30 males; mean age 29.5 years), a microscope was available in only 28% of cases due to electricity interruptions. The mean surgery time was 532.7 min. The flap failure rate was 24% (8 of 33 cases), 8 microsurgical complications required intraoperative revision and 6 nonmicrosurgical complications (18%) were observed, primarily wound infections. Early outcomes varied: 21% had good results, 24% acceptable, 27% moderate, 24% no significant change and 3% worsened. Follow-up was incomplete; 29% of patients did not attend any postoperative visits.

Conclusion: Microsurgical reconstruction in conflict-affected, resource-limited settings like Tigray is feasible but complicated by factors such as inconsistent electricity and loss to follow-up. Despite these challenges, acceptable complication and flap survival rates were achieved, highlighting the importance and feasibility of complex reconstructive surgery even under adverse conditions. Limitations include difficulties ensuring standardized operative environments and consistent long-term follow-up.