First complex maxillofacial reconstruction with free flaps in the Gaza Strip, occupied Palestinian territory: case series from an area under conflict

Abstract

BackgroundLarge mandibular and maxillary defects are repaired by maxillofacial reconstructive microsurgery (MRM) using free flaps, which is challenging to perform in austere settings owing to its demanding nature in terms of time, equipment, and trained personnel. Humanitarian missions refrain from performing MRM procedures in the host country and instead transfer patients to their home country to perform surgery. We report on the first nine MRM procedures in Gaza. MethodsA French medical mission performed the surgical operations at Al Shifa Hospital, Gaza, occupied Palestinian territory. Fibula free flap, radial forearm free flap, scapular free flap, and thoracodorsal perforator free flap were performed. We recorded the patients’ demographics, diagnoses, and immediate postoperative and follow-up status. We also report the special considerations required to perform the surgery in Gaza's austere and resource-poor environment. FindingsNine patients (five female, four male; mean age 22 years) underwent ablative head and neck surgery from January, 2017, to March, 2019. Before arrival, the missions closely coordinated with local surgeons, who assisted in performing the surgeries and followed the patients postoperatively. Essential surgical equipment needed for the surgery (such as loupes, microvascular sutures, and titanium plates) were donated by the foreign missions. Patients were followed up by local surgeons for a period ranging from 5 to 12 months. No complications occurred at the donor or recipient sites. There was no extrusion of hardware or breakage of the titanium mini plates or reconstructive plates. Patients remained in the intensive care unit postoperatively for at least 48 h. Owing to financial restraints, removable prostheses were used. Rehabilitation was provided by a local dental team despite the lack of professional dental rehabilitation services. Patients had stable bony union and acceptable facial contour. Patients regained satisfactory masticatory function, resumed their normal diets after 6 months without weight loss, and maintained intelligible speech. InterpretationMRM can be successfully performed in conflict settings such as Gaza. Although the study population was small, the study suggests that further investigation into the conditions and elements needed to perform complex surgeries in conflict settings is warranted. Selection of health-care professionals in the surgical and postoperative care teams, effective coordination with local doctors, availability of essential equipment, and postoperative follow-up protocols could all be carefully considered to optimise the results of surgery. In addition, starting rehabilitation as soon as possible following surgery may restore and improve functional and aesthetic outcomes. FundingThe Palestine Children's Relief Fund (PCRF).