title: Primary and secondary procedures in functional and aesthetic reconstruction of noma-associated complex central facial defects.
abstract: BACKGROUND
  Most defects resulting from noma involve the lateral and anterolateral aspects of the face and are often combined with severe functional deficits. A subgroup, commonly called "central noma," is composed of defects of the upper lip, maxillary soft tissues, premaxilla, nasal cartilaginous infrastructure, and soft tissues. In contrast to unilateral involvement of the face, central noma does not affect opening of the jaw; however, it results in severe mutilation, with disfiguring three-dimensional defects erasing any individual traits from a face. The common surgical approach to centrofacial noma defects has been single-stage reconstructive procedures using locoregional flaps, but this approach often leads to disappointing outcomes in complex cases.
  
  
  METHODS
  The authors' concept for complex central noma defects is a staged approach using free flaps for soft-tissue reconstruction of the upper lip and maxillary vicinity. This approach serves as a versatile base for introducing locoregional flaps for later functional and aesthetic refinements. A secondary procedure includes total nose reconstruction with a free cartilage framework and forehead flaps.
  
  
  RESULTS
  In this series (n = 53), free radial forearm (n = 4), anterolateral thigh (n = 1), and parascapular (n = 7) flaps proved suitable for the central face in terms of pedicle length, tissue pliability, and bulk. All free flaps survived completely. Three total nose reconstructions by forehead flaps were performed successfully as a secondary step.
  
  
  CONCLUSIONS
  Being of limited use for subtotal or total reconstruction of the outer nose, microvascular tissue transfer preserves local and regional donor sites--particularly the forehead--for secondary reconstruction.
authors.affiliation: Ludwigshafen, Ulm, Bad Kreuznach, Murnau, and Stuttgart, Germany; and Helsinki, Finland From the Departments for Hand, Plastic, and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen and BG Trauma Center Murnau; Department of Maxillofacial Surgery, Plastic Operations, German Armed Forces Hospital Ulm; Department of Plastic Surgery, Töölö Hospital, Helsinki University Hospital; Clinic for Plastic, Reconstructive, and Aesthetic Surgery, Diakonie-Hospital, Bad Kreuznach; and Clinic for Plastic Facial Surgery, Marienhospital Stuttgart.
authors.forename: Goetz A
authors.initials: GA
authors.lastname: Giessler
authors.forename: C Peter
authors.initials: CP
authors.lastname: Cornelius
authors.forename: Sinikka
authors.initials: S
authors.lastname: Suominen
authors.forename: André
authors.initials: A
authors.lastname: Borsche
authors.forename: Alexander J
authors.initials: AJ
authors.lastname: Fieger
authors.forename: Andreas B
authors.initials: AB
authors.lastname: Schmidt
authors.forename: Helmut
authors.initials: H
authors.lastname: Fischer
mesh_terms: D000293:Adolescent; D000328:Adult; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D003906:Developing Countries; D004954:Esthetics; D005145:Face / Q000503:physiopathology / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006084:Graft Rejection; D006085:Graft Survival; D006801:Humans; D008046:Lip / Q000601:surgery; D008297:Male; D008437:Maxilla / Q000601:surgery; D008875:Middle Aged; D009625:Noma / Q000175:diagnosis / Q000601:surgery*; D009666:Nose / Q000601:surgery; D019651:Plastic Surgery Procedures / Q000379:methods*; D012189:Retrospective Studies; D018570:Risk Assessment; D012720:Severity of Illness Index; D013019:South Africa; D013524:Surgical Flaps; D014945:Wound Healing / Q000502:physiology