Full text of DOI:10.1007/PL00006052

Eur J Plast Surg (2000) 23:1–6
© Springer-Verlag 2000
E U R A P S PA P E R
G. Noever · R. Feurer
The free radial forearm flap for reconstruction of facial defects
in noma patients
Received: 25 May 1999 / Accepted: 6 June 1999
Abstract Within a 2-year period ten patients aged 5–22 rapidly spread to the perioral soft tissues and the facial
years were treated for facial sequelae of noma. In six skeleton.
cases free radial forearm flaps were used, combined with
More recent descriptions of the disease and its treat-
local and regional flaps. The indications were defects lo- ment were given by Tempest [19], Durrani [7], Adolph
cated in the midface and perioral area. There were no [1], Montandon [12, 13] and Dean [4]. Up until the
free or regional flap losses in this series. The aesthetic 1960s, noma was not uncommon in Afghanistan, Viet-
and functional results were appreciated by the patients nam and the Philippines. In Germany and Japan it was
and there were no functional problems related to the do- seen in prisoner-of-war camps during World War II [1],
nor area because a suprafascial flap dissection technique whereas nowadays it is virtually unknown in Western
was used. In our experience the free radial forearm flap Europe and North America. There still are, however,
is a valuable option for facial reconstruction in NOMA many cases in certain areas in Africa. The exact inci-
cases. The advantages include: (1) A very long and large dence and mortality are not known. The youngest patient
calibre pedicle; (2) thin and pliable flaps of variable size described by Eisele [8] was 7 weeks old while the oldest
and configuration; (3) the possibility of single stage re- was aged 84 years.
construction in selected cases. The disadvantages include
The pathogenesis of this disease is still a matter of de-
the not always ideal colour match, both in black patients bate. Various bacteria such as Borrelia vincentis, Bacil-
and in white, and the unsightly donor area which, how- lus fusiformis, Staphylococcus aureus and non-haemolyt-
ever, has never led to functional problems.
ic Streptococci were isolated from infected patients [8].
Other associated agents include endotoxin-producing
Fusobacterium necrophorum and Pseudomonas aerugi-
nosa [7]. Contributing factors are bad nutrient state, vita-
min deficiency and poor oral hygiene. The disease may
also accompany systemic conditions such as eruptive fe-
ver, measles [1], scarlet fever, typhus, diphtheria, syphi-
lis and tuberculosis. Rare cases have been described in
Key words Free radial forearm flap · Facial
reconstruction · Noma
Introduction
Noma, or cancrum oris, is a disease which has been immunodeficient states, agranulocytosis, following che-
known since antiquity. The term ‘NOMA’ is of Greek or- motherapy and in AIDS patients [8, 9].
igin and means ‘to devour’. Hippocrates, Galen and Cel-
The condition begins with small, red, painful pustules
sus knew of this disease, but the first accurate and com- of the oral mucosa, and rapidly spreads to the molar re-
plete description was provided by Tourdes in 1848 [20]. gion. The mucosa becomes swollen and develops necrot-
He described a gangrenous infection of the oral cavity ic areas; following this the underlying skeleton is affect-
occurring mainly in small children with poor physical ed. The whole infected area turns into a malodourous
condition. Starting at the level of the oral mucosa it will black necrotic mass with bacterial superinfection. The
necrosis can extend to the upper and lower lip, hard and
soft palate, nose and orbital cavity, and even to the tem-
Presented at the 10th Annual Meeting of the European Association
of Plastic Surgeons (EURAPS), Madrid, Spain, May 20–22, 1999
poral, masseteric and platysmal muscles. Rare locations
are the scalp, neck, shoulder, lower extremity and the
genital area [19].
If antibiotic therapy is not available, 75% of the af-
fected patients will die [19]. The use of penicillin, the
first-choice antibiotic, can decrease the mortality rate to
G. Noever ( ) · R. Feurer
✉
Department of Plastic and Reconstructive Surgery,
Cantonal Hospital, CH-5000 Aarau, Switzerland
e-mail: georg.noever@ksa.ch
Tel.: +41-62-838-4731, Fax: +41-62-838-4743

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5%. Other primary treatment principles are fluid resus- cases of extra-articular origin. Following tissue loss in
citation and improvement of the nutritional status. Fol- the perioral area, scar contraction, tissue fibrosis and
lowing adequate debridement of necrotic tissue, the de- muscle contraction can lead to complete mandibular con-
fects close spontaneously by scar contraction leading to striction with ensuing problems of food intake, loss of
disfiguring and functionally disabling situations. Primary speech and constant salivation. Attempts have been
reconstruction is rarely performed because of the lack of made to categorise the defects following noma, allowing
available plastic surgical expertise.
for systematic therapeutic approaches to restore form
One of the most significant functional problems is and function in these often difficult clinical settings [11].
trismus [1, 15], a temporomandibular ankylosis, in most However, there is no universally accepted system of de-
Fig. 1 A 5-year-old girl with loss of the upper lip, both com- tion with rib grafts. D Radial forearm flap for the upper lip. E, F
missures, adjacent cheek, part of the palate and most of the nose. End result after nasal reconstruction with expanded forehead flap
A Frontal view. B Profile view. C Palate and alveolus reconstruc-

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Fig. 2 An 8-year-old boy with defects of the upper and lower lip Table 1 Classification of noma defects according to Montandon
and columella. A Preoperative view. B After upper lip and colum- [10]
.
ella reconstruction with free radial forearm flap. C, D Final result
with upper and lower lip reconstruction
1. Localized lip, commissure or cheek defect that normally can
be lined by local tissues and covered by a single flap
2
3
4
. Upper lip and nose amputation
. Lower lip and mandible amputation
. Large defects involving the lips, the cheek, the palate, the
maxillary bone, the floor of the orbit, etc.
fect categories and treatment modalities, thus a wide va-
riety of flaps and procedures are used.
Patients treated in local hospitals in Africa are gener-
ally reconstructed with local flaps and pedicled upper
arm flaps, as well as frontal and scalp flaps [6, 19]. Dean three cases combined with forehead flaps for nasal reconstruction
(
Table 2). All forearm flaps were raised using the suprafascial dis-
[
4] reports having used cervicofacial flaps in Nigeria.
section technique described by Lutz and Wei [10]. The donor ar-
eas were grafted and had no functional problems. All free flaps
were anastomosed to branches of the external carotid artery and
African patients treated in America by the same group
were reconstructed using free scapular and radial fore-
arm flaps. Adolph [1], a general surgeon in Niger, pre- accompanying veins enabling the anastomoses to always be per-
ferred deltopectoral and local flaps. Montandon [12,13]
favoured and extended the use of the pedicled epicranial
sandwich flap and pedicled latissimus dorsi flaps. Banic
formed in a non- fibrotic area far from the originally infected and
fibrosed tissues. There were no flap losses and the functional and
aesthetic results were satisfactory. The number of operations
ranged from one to seven per patient, depending on the complexi-
[
2] reconstructed facial defects with free osteocutaneous ty of the reconstruction.
scapular and iliac crest flaps. In our own experience ped-
icled latissimus dorsi flaps worked well for facial recon-
struction in the lower third of the face; however, these
will not reach the midface. In this situation the defects in
the perioral and midface region were reconstructed with
Clinical cases
Case 1
the free radial forearm flap. This flap has been used suc- A 5-year-old girl was admitted in 1997 for reconstruction of the
cessfully in oral and facial reconstruction after tumour midface following noma at the age of 2 years. There was complete
loss of the upper lip, both oral commissures and adjacent buccal
resection [16, 17].
areas, the anterior part of the hard palate and the alveolus, as well
as the distal part of the nose (Fig. 1). Her general state of health
was satisfactory.
Materials and methods
The reconstruction started with an expander implantation into
the frontal area to provide a large forehead flap for nasal recon-
Between 1996 and 1998 ten patients with post-noma facial defects struction. After adequate expansion of the forehead was achieved,
were treated. Ages ranged from 5 to 22 years, eight were children. the perioral scar tissue was debrided. The anterior part of the pal-
The defects included the upper and lower lip, hard palate, maxilla, ate and the alveolus were reconstructed with rib grafts stabilized
nose and central face. Three cases were reconstructed using latis- by miniplates. A free radial forearm flap was used to cover the rib
simus dorsi myocutaneous pedicled flaps, in combination with grafts intraorally and reconstruct the upper lip. The remaining na-
temporalis muscle and temporalis fascia flaps. On one occasion a sal skin was turned over to line the inner aspect of the nose, and
cervicofacial flap was needed. However, for all midfacial defects the forehead flap was used to reconstruct the nasal and columellar
and for the perioral region in six cases free radial forearm flaps skin. A rib graft fixed to the glabellar area with a miniplate pro-
were used, in four cases combined with local rotation flaps and in vided a satisfactory nasal bridgeline and tip.

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Table 2 Noma patients treated
with free radial forearm flaps
Patient
Age
Defect
Reconstruction
Number of
operations
D.G.
Y.S.
I.G.
5
8
5
Upper lip, palate, nose
Upper and lower lip
Radial forearm flap, rib grafts,
forehead flap
Two radial forearm flaps,
galea had partial necrosis
3
3
7
Partial upper lip, palate,
maxilla, nose, orbital floor
Maxillary osteotomy,
cranial bone graft, free radial
forearm flap, local flaps,
tibial bone graft, forehead flap
A.A.
O.I.
6
22
Partial nose, cheek
Cheek, commissure,
trismus
Free radial forearm flap, local flaps
Free radial forearm flap, local flaps
1
2
I.K.
10
Upper lip, palate, nose
Free radial forearm flap, rib grafts,
forehead flap
3
Case 2
Discussion
An 8-year-old boy from Niger developed a noma lesion at the age
of 3 years resulting in perioral scarring and restriction of mouth Until about 15 years ago the horrific sequelae of noma
opening following the loss of the upper and lower lip and columel-
were virtually unknown in the western world. Publica-
la (Fig. 2). The first step in reconstruction of the upper lip and the
tions were limited in numbers, and thus there was no dis-
columella was performed with a free radial forearm flap connected
cussion about the methods and results of treatment. Tem-
to the external carotid vessels. At the same operation an epicranial
flap pedicled on the superficial temporal vessels was prelaminated pest [19] reported on a series of 300 children suffering
with a full thickness skin graft for lower lip reconstruction.
from the sequelae of NOMA and described the use of
After 3 weeks the lower lip was reconstructed with the prelam-
forehead flaps based on the superficial temporal vessels
inated flap, which initially necrosed. In a third operation the lower
for facial reconstruction. However, his favourite tech-
lip was further reconstructed with a free radial forearm flap. After
another 6 weeks, both forearm flaps were thinned to give better nique was a two-stage procedure transferring upper arm
contour resulting in an acceptable functional and aesthetic result.
skin to the face as the donor area could be easily con-
cealed, which is not true of the forehead flap. For very
large defects he recommended a combined abdominotho-
racic and upper arm flap.
Case 3
A 5-year-old boy from Niger developed noma at the age 2 years.
This led to a massive necrosis of the central face including the
nose, upper lip, anterior part of the hard palate with a cleft from
the palate into the left orbit (Fig. 3). The reconstructive procedure
began with the implantation of a skin expander under the frontal
Durrani [7] from Karachi preferred the forehead flap
treating ten patients and reporting a high rate of compli-
cations using the upper arm flap. Treatment approaches
changed dramatically with the advent of microsurgery,
skin to provide a large forehead flap. The left maxilla was then os- which allowed the number of operative steps to be re-
teotomized and bone grafted to reconstruct the cleft and the hard
palate. Intraoral soft tissue cover was achieved with a modified
duced in the treatment of these complex defects. Banic
[
2] used a free osteocutaneous scapular flap and a free
von Langenbeck procedure as in cleft palate reconstruction. Exter-
nal soft tissue cover was supplied by transplantation of a free radi-
osteocutaneous iliac crest flap in two noma patients.
al forearm flap anastomosed to branches of the external carotid Dean [4] used free scapular flaps and free radial forearm
vessels. The upper lip was reconstructed using the existing lip
flaps in a number of African patients treated in America.
Montandon et al. [12] presented a classification of facial
defects caused by noma (Table 1) and outlined principles
remnants and a swingslide plasty from the buccal area.
The next step in nasal reconstruction was to raise the radial
forearm flap and fold it on itself to provide inner lining of the
nose. Bony support was provided by a tibial bone graft fixed to the of treatment according to this classification. He favoured
glabellar area with a miniplate. The soft tissue cover, nasal dorsum and extended the use and versatility of the epicranial
and columella were created from the expanded forehead flap and
sandwich flaps based on the superficial temporal vessels.
small stents were used to prevent nostril collapse and keep the na-
In reconstruction of the lower third of the face classical
sal airway open. A good functional and aesthetic result was
reconstructive procedures such as the deltopectoral [1]
and latissimus dorsi flap [12] have been used successful-
ly.
achieved after a total of seven operations over a period of 9
months.
These pedicled flaps, however, cannot reach the cen-
tral face and thus other options have to be considered.
left orbit and part of the upper lip. A, B Preoperative view. C Pre- The free radial forearm flap, originally described by
operative X-ray. D Midface reconstruction by maxillary osteoto- Song [18], was used by Sadove [16] and Serletti [17] in
Fig. 3 A 5-year-old boy with a defect of the midface, nose, palate,
my, cranial bone grafts, free radial forearm flap and local cheek
reconstruction of the lower lip after resection of malig-
flap. E Postoperative X-ray. F Inner lining of the nose reconstruct-
nant tumours. It has one of the longest available vascular
ed by infolding of the radial forearm flap, suspended to a tibial
pedicles, thus the microsurgical anastomoses can be per-
formed far away from the infected and fibrosed tissues,
bone graft, expanded forehead flap for nasal soft tissues. G, H Fi-
nal result, frontal and profile views

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preferentially in the neck area. This avoids the need for
venous grafts. The flap is thin and pliable, and the size
will generally be sufficient for facial defects. Its pliabili-
ty allows for simultaneous restoration of internal lining
and external skin cover by partial de-epithelialization
and infolding of the flap. Del Bene [5] described this
technique in the closure of a post-noma defect similar to
that of a patient we treated in the same way.
The donor area is often regarded as the main draw-
back of this flap, but, in our series, healing of the split
thickness grafts has not been a problem as the flaps were
harvested in the suprafascial manner proposed by Lutz
and Wei [10]. Taking into account the ethnic and cultural
background of our patients where scars are not a major
concern, the advantages of this flap far outweighed the
potential disadvantages. There were no postoperative
problems related to the microsurgical part of the proce-
dure and all forearm flaps survived completely. In three
cases thinning operations were performed to improve
contour without compromising flap circulation. It was
References
1
2
. Adolph M, Yugueros P, Woods JE (1996) NOMA: a review.
Ann Plast Surg 37:657
. Banic A (1996) Erste Erfahrungen bei der Behandlung von
Noma-Kindern am Inselspital. Inselbote 3:26
3
4
. Dawson J (1945) Cancrum oris. Br Dent J 79:151
. Dean JA, Magee W (1997) One stage reconstruction for de-
fects caused by cancrum oris (NOMA). Ann Plast Surg 38:29
. Del Bene M, Amadei F, Petrolati M, Rovati LV, Confalonieri
PL, Caronni EP (1999) Radial forearm fasciocutaneous free
flap as a solution of NOMA. Microsurgery 19:3
. Dijkstra R, Abate-Green C, Yoo MC (1986) NOMA. Eur J
Plast Surg 9:46
5
6
7. Durrani K (1973) Surgical repair of defects from NOMA.
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8
. Eisele DW, Inglis AF, Richardson AA (1990) NOMA and
NOMA neonatorum. Ear Nose Throat J 69:119
. Giovanni M (1989) Gangrenous stomatitis in a child with
AIDS. Lancet 2:1400
9
1
0. Lutz BS, Wei FC, Chang SC, Yang KH, Chen ICH (1999) Do-
nor site morbidity after suprafascial elevation of the radial
forearm flap: a prospective study in 95 consecutive cases.
Plast Reconstr Surg 103:132
interesting to see that the colour match was also a prob- 11. Marck KW, de Bruijn HP, Schmid F, Meixner I, van Wijhe M,
lem in these patients. All flaps not harvested in the cervi-
cal or facial area were darker than the original skin al-
though this did not seem to disturb the patients.
van Poppelen RHM (1998) NOMA: the Sokoto approach. Eur
J Plast Surg 21:277
1
1
1
1
2. Montandon D, Lehmann C, Chami N (1991) The surgical
treatment of NOMA. Plast Reconstr Surg 87:76
3. Montandon D, Gumener R, Pittet B (1996) The sandwich epi-
cranial flaps. Plast Reconstr Surg 97:302
4. Mühlbauer W, Herndl E, Stock W (1982) The forearm flap.
Plast Reconstr Surg 70:336
5. Oluwasanmi JO, Lagundoye SB, Akinyemi OO (1973) Anky-
losis of the mandible from Cancrum oris. Plast Reconstr Surg
57:342
Conclusion
A series of six patients with facial defects following no-
ma is presented. They were reconstructed using seven
free radial forearm flaps, partly in combination with lo-
cal and regional flaps. The defect location was in the
midface and the perioral region. There were no compli-
cations related to the microsurgical procedures and the
functional and aesthetic results were satisfying. The free
radial forearm flap has become our favourite flap for
midface soft tissue reconstruction because of its ease of
1
1
6. Sadove R, Luce EA, McGrath PC (1991) Reconstruction of
the lower lip and chin with the composite radial forearm–pal-
maris longus free flap. Plast Reconstr Surg 88:209
7. Serletti JM, Tavin E, Moran SL, Coniglio JU (1997) Total
lower lip reconstruction with a sensate composite radial fore-
arm–palmaris longus free flap and a tongue flap. Plast Re-
constr Surg 99:559
1
8. Song A (1982) The forearm flap. Discussion. Plast Reconstr
Surg 70:343
harvesting, the long vascular pedicle, and size and pli- 19. Tempest MN (1966) Cancrum oris. Br J Surg 53:949
ability of the flap.
20. Tourdes J (1848) Thesis, Strasbourg; cited by Tempest MN,
Cancrum oris. Br J Surg (1966) 53:949
As with all flaps procured from distant areas other
than from the head and neck, colour match to the face is
not ideal. There were no functional problems related to
the donor site. Patients with deformity resulting from no-
ma sequelae may present varying reconstructive prob-
lems but generally require some kind of flap solution.
The free radial forearm flap is recommended in those
cases where pedicled flaps will not provide adequate
coverage, especially in the central facial area.
2
1. Winkler JR, Murray PA, Hammerle C (1989) Gangrenous sto-
matitis in AIDS. Lancet 8:108