The consequences of noma relate to functional and esthetic problems. The acute and fulminating early stages of the disease indicate need for antibiotic treatment, while the chronic and disfiguring late stage requires surgical intervention: plastic and reconstructive surgeries designed to suit individual cases.
In the African settings where noma is overwhelmingly prevalent, there is also a shortage of qualified surgical teams to treat the number of patients requiring reconstruction [2, 25]. In some of these centers, such as the Noma Children’s Hospital in Sokoto, Nigeria, the local teams of surgeons and nurses are periodically supplemented by a volunteer team of expert representatives of humanitarian projects based in the developed countries .
The timing of surgical intervention in the management of noma is critical. All forms of invasive surgery in the vicinity of an acute phase lesion are discouraged because of the potential for such intervention to accelerate the destructive evolution of the disease. However, as soon as the acute phase is visibly contained, usually evidenced by clear fibrotic demarcation at the normal tissue-lesion interface (see Fig. 4) the design of surgical reconstruction should commence. Simultaneously, pre-surgical oral physiotherapy to relieve the trismus resulting from the fibrous strictures and ankylosis thereby enhancing intraoral access during surgery should also commence. In Nigerian centers, for example, graduated acrylic mouth screws are designed and fabricated, and these are employed to relieve trismus and enhance mouth opening. Physiotherapy continues postsurgical until acceptable or normal mouth opening is achieved.
Over the years, the surgical corrections of noma deformities have proved to be daunting because each new case appears to present a unique composite of reconstructive challenges. There is therefore no standard surgical approach common to all noma cases. Nevertheless, certain ground rules for surgical treatment of noma appears to exist, and include the postponement of treatment of lesions less than one-year-old (except where the sequelae created an urgent indication to improve nutritional intake), and the debridement of the lesion to avoid secondary infection . Routine presurgical clinical investigations, including full blood count and differentials, chest, skull and, when feasible, full mouth radiological examinations must be carried out and documented. Skull radiographs that usually include temporomandibular joint (TMJ) views reveal the extent of bony ankylosis and trismus present in a particular patient [11, 56-58]. Various profiles of presurgical photographs are also documented, and subsequently used side-by-side with postsurgical photographs and other clinical parameters to assess treatment outcome.
Surgery, which is invariably under general anesthesia, sometimes presents peculiar anesthetic technique challenges and risks. For example, because most noma patients with significant loss of orofacial tissues and scarring develop limited mouth opening, intubation for general anesthesia is sometimes challenging. Before the advent of fibreoptic technology , intubation for anesthesia of noma patients preparatory for surgery presented significant risks and challenges, often compounded by the shortage of experienced nursing staff at centers located in the noma “hot spots” in Africa. It was therefore not uncommon for patients who electively present for the repair of their defects for social reasons, to die from anaesthetic complications during or after surgery.
Generally, the surgical designs involve the raising and transposition of local and distant soft tissue flaps, depending on the extent of tissue loss (see Fig. 4). In cases of considerable loss of facial or jaw bone, bone grafting may be considered in the sequence of reconstructive design. While a discussion of the technical details for each of the reconstructive designs advocated by various practitioners, together with their philosophies, is beyond the scope of this review, references to these details are cited in the text. Nevertheless, the three fundamental principles underlying every good surgical reconstruction design for noma repair are summarized. First, due to the substantial tissue loss characteristics of most noma defects, designs must account for adequate vascular supply capable of sustaining flap viability [54, 60]. Therefore, both locoregional and pedicled flaps must maintain adequate distance from pathological tissues. Second, designs must aim for optimal length pedicles capable of anastomoses with local vessels in the area of repair [54, 59]. Third, an inner lining of the flap is required to prevent re-scarring and consequent functional impairment . The deltopectoral, pedicled latissimus dorsi, pedicled radial forearm, and various designs of forehead flaps are routinely employed to close noma defects and provide outer lining . Split-thickness skin grafts are commonly used to provide inner linings.
The deltopectoral flap has been used as both outer and inner linings with satisfactory results, and remains the most versatile flap for the reconstruction of facial defects [57, 62, 63]. The advantage of the deltopectoral flap lies in the relative simplicity of its design, minimal blood loss during surgery, and the viability of the flap after surgery [62, 63]. The various forehead flap designs are also simple. However, a main criticism of the forehead flaps is that they often result in unsightly appearance of the donor site.
The various myocutaneous flaps mentioned above are intricate and should be employed only by practitioners with the appropriate experience and where adequate postoperative care is available because of the associated longer morbidity. Nath and Jovic [62, 63] advocate that myocutaneous flaps be sparingly used, if at all, in children. However, it would appear that for some considerably large and sophisticated defects myocutaneous flaps would remain the only viable reconstructive option. The Abbe-Estlander, nasolabial, and temporoauricular (Washio type) are local flaps that produce excellent results in small to moderate defects involving the upper lip, paranasal, and nasal areas . Closure of oronasal fistulas can be achieved with the aid of tongue flaps . Overall, because of the complexity of most noma defects, single surgical procedures are not always feasible, and most cases require revision surgeries to correct residual undesired functional and esthetic outcome of initial treatment.