Fibula Free Flap Versus Reconstruction Plate Bridging for Segmental Mandibular Defects After Tumor Ablation: A Decision Analytic Cost-Effectiveness Model for Nigerian Public Hospitals

The choice between free fibula flap (FFF) reconstruction and reconstruction plate bridging (RPB) for segmental mandibular defects following tumor ablation in Nigerian public hospitals involves complex trade-offs between clinical outcomes, cost, resource availability, and patient quality of life. While FFF is the international gold standard, its high cost and dependence on microsurgical infrastructure limit its applicability across many Nigerian centers. This PhD study constructs a decision analytic cost-effectiveness model to compare FFF with RPB for segmental mandibular reconstruction in the Nigerian public hospital context, incorporating clinical, economic, and patient-reported outcome data. Primary data from 74 patients who underwent mandibular reconstruction by either technique at five Nigerian tertiary institutions across the South West, South East, and North Central zones were used to parameterize a Markov decision model over a five-year time horizon. Clinical outcomes modeled include reconstruction success, complication rates, revision surgery, recurrence, and death. Utility weights were derived from patient interviews using the EQ-5D-3L instrument. Costs were estimated from Nigerian public sector pricing data and institutional financial records. Base-case analysis indicates that FFF dominates RPB in settings with established microsurgical capacity, with an incremental cost-effectiveness ratio of N2.4 million per quality-adjusted life year (QALY) gained. Probabilistic sensitivity analysis confirms FFF cost-effectiveness at willingness-to-pay thresholds above N1.8 million per QALY. The study provides an original economic framework for mandibular reconstruction decision-making in Nigeria and recommends targeted government investment in microsurgical infrastructure at designated regional centers. Keywords: mandibular reconstruction, cost-effectiveness, free fibula flap, reconstruction plate, Nigeria.