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BJPS - 2003 - Cancrum Oris - Reconstruction

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The British Association of Plastic Surgeons (2003) 56, 528–533
New split scar cheek flap in reconstruction of noma
sequelaeq
T.S. Kühnel*, R. Dammer, B. Dünzl, A.G. Beule, J. Strutz
Department of Otolaryngology, Head and Neck Surgery, University of Regensburg, Franz-Josef-StraußAllee 11, D-93042 Regensburg, Germany
Received 30 January 2003; accepted 2 June 2003
KEYWORDS
Cancrum oris; Noma;
Reconstruction; Split scar
flap; Results
Summary The use of a split-scar cheek flap is demonstrated for restoration of lining in
reconstructing the oral commissure in cases of noma.
Q 2003 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights
reserved.
Introduction
Cancrum oris or noma is a devastating ulcerativenecrotising gingivo-stomatitis which affects primarily undernourished and immunosuppressed young
children.1 Noma, if not fatal in the first place leads
to severe destruction of the mid-face, including lips
and cheek, maxilla, mandible, nose and, in rare
cases, the orbit. Whilst antibiotic treatment is
essential and effective in the initial stage of the
disease, the process will progress to noma by
transmission to the soft tissues in contact with the
gingival lesions if left untreated. In the end, the
afflicted are left with gaping holes in their faces.5
Without appropriate treatment, the mortality rate
reaches 70 – 90% (WHO 1994).6 The most common
soft tissue defect in noma is full thickness loss of
the cheek, involving the lateral parts of the lips.7,8
The surgical strategy aiming at these cheek and lip
defects is central to the presented study.
To achieve a good and lasting functional result,
q
The paper has been presented at the 72nd Annual Meeting of
the German ORL society.
*Corresponding author. Tel.: þ 49-941-944-9440; fax: þ 49941-944-9441.
E-mail address: [email protected]
an epithelium lining of the oral cavity is mandatory.
The defects require a three-layer closure, and an
inner lining must be created.9
The application of a new flap for reconstruction
of soft tissue defects in noma patients developed
and carried out in the years 1997, 1998 and 2000 is
described. It is a procedure that suits the requirements of the host country and provides favourable
functional and aesthetic results. The method
described can predictably rehabilitate patients
with noma defects of the cheek and lateral lips in
a single operative setting. The use of the split scar
cheek flap is illustrated, while functional and
aesthetic impact is emphasised. If the cases are
appropriate, we wish to recommend the technique
described as an alternative to micro-vascular or
pedicled tissue transfers.
Patients and methods
Patients who, after noma disease, were left with a
soft tissue defect of the chin and commissure,
chronic functional impairment with speech restriction, salivary leakage or inability to achieve
adequate food intake or social disadvantages due
S0007-1226/03/$ - see front matter Q 2003 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/S0007-1226(03)00225-X
New split scar cheek flap in reconstruction of noma sequelae
to cosmetic deformity were enrolled in this
prospective clinical study. Exclusion criteria were
acute disease and trismus. Informed consent was
given by all patients and parents, respectively. The
study was performed according to the declaration
of Helsinki/Tokio at the Department of General
Surgery Hopital National de Niamey in the Republic
of Niger. We included two male and five female
African children, ranging in age from four to 20
years with a mean age of 11.
An accurate assessment of every case was
achieved, including examination by ENT- and
maxillofacial surgeons and anaesthetists. Documentation and Op-plannings were performed with
the help of digital photography and patients
received preoperative nutritional preparation for
3 – 7 days. The features recorded were: age and
gender of patients, size of the defects including
adjacent scar, comorbidity and expectations of the
patient concerning the aesthetic result of surgery,
operation time per patient, length of postoperative
hospital stay, postoperative nutrition stage
improvement and subjective cosmetic results. As
stated before,10 the aim of this study was to allow
the patients to achieve an adequate level of selfnutrition.
Anaesthesia
Endotracheal intubation and general anaesthetic
were employed in all cases. A 4 mm fibreoptic
endoscope proved helpful for nasotracheal intubation. Induction was performed with thiopentone or
ketamine/midazolam sedation when fibrescopic
intubation was used. Anaesthesia was maintained
by halothane (due to the vaporisers available at the
hospital) supplemented by analgetic doses of
ketamine. No anaesthetic complications occurred.
Operative technique
After the onset of anaesthesia the steps of surgery,
modified by Montandon,13 were carried out as
follows: local infective foci were removed by
extraction of infected or displaced teeth, sequesters or scabs. Then the commissure was reconstructed. At this stage of the operation, the amount
of soft tissue necessary for reconstruction may be
estimated precisely. Before finally closing the
defect of the cheek, the continuity of the inner
lining in the oral cavity was reconstructed with the
help of the split scar flap utilising the facial scar,
which was split in half. The cases demonstrated
required special consideration of the vestibulum. It
had to be reconstructed, as the parietal layer had
been destroyed by Noma disease.
529
The split scar flap
The surgical strategy is comprised of three steps in
principal:
1. Closure of the commissure or lip defects
2. Construction of an ‘inner lining’ using the split
scar cheek flap
3. Closure of the cheek ‘outer lining’ using local flaps
1. The scar resulting from Noma is detached from
the parts of the lips in sound condition. For a
satisfying functional result, continuity of the
orbicularis oris muscle has to be obtained.
Reconstruction is carried out by either using an
‘Estlander’-transposition flap or primarily joining
the isolated stumps of the muscle.14 In the case
of a blunt commissure resulting from this
technique, a commissuroplasty has to be performed in a second step.
2. Instead of radical excision of the scar, which is the
common practice,11,15 the scar is used to construct
the ‘inner lining’. An incision throughout half of
the layer is performed in the dorsal margin of the
scar (Fig. 1). Preparation proceeds in this plane
almost to the free rim of the scar anteriorly next to
the commissure (Fig. 2). In doing so, the scar is split
in half. Caution has to focus on the basis of the flap.
As the blood supply to the scar is poor anyway, it
has to be even broader than in common local
transposition flaps. The lateral, mobile part of the
flap is turned forward and is fixed to the
commissure and to the gingival mucosa (Fig. 3).
For satisfying functional results, a sufficient deep
oral cavity has to be designed. Any excess of scar
tissue may be removed at this time. The defect is
now covered by a first layer with its epithelium
facing the oral cavity (Fig. 4).
3. Next, the outer defect is covered with local
transposition flaps which originate from the submental, cervical and/or nasolabial region.
Results
Postoperative healing was uneventful in all cases.
Swallowing was re-established within a week.
Aesthetic results are shown in Figs. 5 –7. Trismus
caused by scarring associated with a new increase
of functional deficits was not seen during a 1-year
follow-up period. Operation time was 2 –4 h per
patient, while the postoperative hospital stay was
eight to 10 days. Moreover, postoperative nutrition
levels in all seven patients showed a clinically
significant improvement. All patients were highly
satisfied with their aesthetic results.
530
Fig. 1 Child with full thickness defect of the left cheek
and lateral lips. Preoperative show. (A) Drawing, (B)
photograph.
T.S. Kühnel et al.
Fig. 2 The drawing (A) shows the flap split in half layer
thickness, mobilised and turned forward. (B) Development of the split scar cheek flap anteriorly. To be closed
just beneath the nasolabial fold. Intraoperative aspect.
New split scar cheek flap in reconstruction of noma sequelae
531
Fig. 4 Detail of oral vestibulum: reconstruction of inner
lining with split scar.
Discussion
Noma or cancrum oris is a disease primarily found in
developing countries afflicting young children.1,16
Poverty, concluding malnutrition, faecal contamination of foods and water supplies and poor oral
hygiene are the predominant risk factors.2,12
Fig. 3 Defect just before closure. Mobilisation of the
local transposition flap to be added.
Long-term follow-up was accomplished by health
personnel of Hôpital National du Niamey within 1
year after the operations. No complications and no
new scar formation to disabling extent was
reported.
Fig. 5 Postoperative result (10th day).
532
Fig. 6 Preoperative aspect of another patient, operated
in a similar manner.
Besides social rejection, the affected children are
handicapped in terms of food intake and speech
production. Since awareness of surgical options is
more common nowadays, an increasing number of
patients opt for plastic reconstruction.8,9 Preven-
Fig. 7 Postoperative aspect of another patient, operated in a similar manner.
T.S. Kühnel et al.
tion of the disease is technically simple but until
socio-economic conditions improve, the disease
will continue to occur. Factors which would help
to prevent cancrum oris include the education of
parents, the availability of protein rich food, dental
healthcare and measles vaccinations, to address
the most important items.3,6,9
Consequences of the disease are both aesthetic
and functional.4,5,17 After having survived the acute
disease, patients suffer from immense scarring and
impairment of self-nutrition. Due to individual
defects, sophisticated reconstructive surgery
requires a wide spectrum of operative techniques
in order to suit individual cases. No single standard
is sufficient for all types of defects.1 Reconstruction
in cancrum oris sequelae is complex and is looked
upon as a surgical challenge that requires a hospital
equipped with the latest technology, which is not
always achievable in the origin countries.7
Local flaps provide excellent colour and texture
match1 and are recommended for a one-stage
method because of their short postoperative
course. Furthermore, one-stage methods of treatment offer several advantages: first, economising
expenses is an urgent requirement in the treatment
of these patients, who are all being treated on a
charity basis. Second, due to local implications
return to a hospital turns out to be very difficult due
to there being great distances between the
patients’ homes and the hospitals. Third, a short
operation time means less physical stress and risk of
postoperative wound infection. Complicated by the
typical conditions of malnutrition, these aspects
become of greatest value. To prevent complications, the patients in this study underwent
adequate preoperative nutritional preparation
prior to reconstructive surgery. A split scar flap
using the scar as the inner lining of the oral cavity
was implemented in soft tissue defects of the cheek
and lateral portion of the lips. Postoperative
recovery proved to be uneventful in all cases and
patients returned to their families within 10 days. In
detail, though the scar has a seriously impaired
blood supply, it is capable of establishing an inner
lining if covered by healthy tissue.
To prevent recurrence of functional impairment
by scarring, an inner lining of the oral cavity is
mandatory. As experience shows, a two layer
closure by mere transposition flaps is not
adequate.5 We introduce an alternative to microvascular tissue transfers, pedicled and prefabricated flaps; our alternative features a short
operating time, low surgical morbidity and
excellent functional and aesthetic results.
In contrast to prior publication,18 by integrating
the scar into the operative concept we succeeded in
New split scar cheek flap in reconstruction of noma sequelae
creating an inner lining that could be covered with
local flaps in all cases.
The aesthetic and functional results in these
cases compare favourably with those reported using
musculocutaneus flaps, such as pectoralis major
and latissimus dorsi flaps8 or forehead flaps.7
9.
10.
11.
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study. S Afr Med J 1997;87:1379—82.
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neglected scourge of children in sub-Saharan Africa. Am J
Trop Med Hyg 1999;60:223—32.
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Nigerian children: a review. Community Dent Oral Epidemiol
1985;13:190—4.
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1992. p. 42—8.
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and evolutive aspect. Acta Stomatol Belg 1996;93:17—20.
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