Primary and secondary procedures in functional and aesthetic reconstruction of noma-associated complex central facial defects

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. Conclusion: 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.