Longitudinal Outcomes of Free Fibula Flap Mandibular Reconstruction in Nigeria: Establishing Benchmarks for Sub-Saharan African Practice

Free fibula flap (FFF) reconstruction following segmental mandibulectomy for malignancy or aggressive benign pathology is considered the gold standard in reconstructive maxillofacial surgery globally. Its application in Nigeria is constrained by limited microsurgical infrastructure, shortage of trained reconstructive teams, and paucity of robust longitudinal outcome data from the African context. This prospective longitudinal study establishes the first comprehensive Nigerian benchmarks for FFF mandibular reconstruction outcomes at three centers with established microsurgical capability: LUTH Lagos, UCH Ibadan, and UNTH Enugu, spanning the South West and South East geopolitical zones. Sixty-two patients who underwent FFF mandibular reconstruction between 2017 and 2023 were followed for a minimum of 36 months. Primary outcomes include flap success rate, bony union, implant-based dental rehabilitation rate, and cancer-specific survival at 36 months. Secondary outcomes include functional assessments of mastication, speech intelligibility, and swallowing using validated instruments, alongside patient-reported quality-of-life using the UW-QOL questionnaire. Overall flap success rate was 85.5%, with primary anastomotic failure in 9 cases. Bony union was confirmed radiographically in 91.5% of successful flaps. Only 22.6% of eligible patients achieved implant-based dental rehabilitation due to cost barriers. Mandibular-only resections demonstrated significantly better functional outcomes than composite resections at all time points. The study establishes Nigerian-specific performance benchmarks and advocates for structured microsurgical training, government-funded implant programs, and inter-center clinical governance networks. Keywords: free fibula flap, mandibular reconstruction, microsurgery, longitudinal outcomes, Nigeria.