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Year : 2015  |  Volume : 8  |  Issue : 1  |  Page : 91-94  

Residual noma defect of upper lip reconstructed using Estlander flap

Department of Oral and Maxillofacial Surgery, AME'S Dental College Hospital and Research Centre, Raichur, Karnataka, India

Date of Web Publication8-Jan-2015

Correspondence Address:
Yadavalli Guruprasad
Department of Oral and Maxillofacial Surgery, AME'S Dental College Hospital and Research Centre, Raichur - 584 103, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0975-2870.148863

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Noma is a rapidly progressive, polymicrobial, opportunistic infection that occurs during periods of compromised immune function. It occurs in children with poor nutrition and compromised immune system. Early presentation is unclear as noma is often well progressed at initial presentation. Noma, unlike most infections, is able to spread through anatomic barriers such as muscle, which might also extend to other facial structures leading to extensive soft tissue and bony defects with or without temporomandibular joint ankylosis. Reconstruction of such type of defects poses a challenge for the surgeon as it requires staged surgical approach. A residual noma with a full-thickness defect of upper lip in a 6-year-old child was reconstructed using Estlander flap.

Keywords: Estlander flap, noma, upper lip reconstruction

How to cite this article:
Chauhan DS, Guruprasad Y. Residual noma defect of upper lip reconstructed using Estlander flap. Med J DY Patil Univ 2015;8:91-4

How to cite this URL:
Chauhan DS, Guruprasad Y. Residual noma defect of upper lip reconstructed using Estlander flap. Med J DY Patil Univ [serial online] 2015 [cited 2023 Sep 22];8:91-4. Available from:

  Introduction Top

Noma, or cancrum oris, is an uncommon disease that results in loss of tissue in the oronasal region secondary to gangrenous slough, and has been known since the time of Hippocrates and Galen. [1] The term noma is derived from the Greek word "nome" meaning "a spreading sore." [2] It is a devastating condition affecting malnourished children. Noma is rarely seen in the Western world, with most reports of the disease coming from Africa, Asia, and South America. [1],[3] Most of the affected patients are between the ages of 2 and 5 years. There may be a slight predilection for females over males. For a long time, it has been known that there is an association between noma and factors such as poverty, poor oral hygiene, malnutrition, malaria, preceding viral infections, especially measles, and immunosuppressive conditions including HIV infection. [1],[2],[3],[4] The pathophysiology of the disease is still as yet unclear, being a subject of several theories which include vascular, bacterial, and viral. Reconstruction is complex and demanding, involving both soft tissue and bone. Most children require multiple procedures. Reconstruction must be planned carefully and executed meticulously to restore the natural contours. [4] The highest degree of aesthetic camouflage in lip reconstruction is obtained by primary closure and with adjacent or local flaps. The Estlander flap is used for labial defects that include the commissure. The design of the flap is simple, and the pedicle becomes the new commissure and the transfer is completed in a single stage. We report a case of residual noma defect of upper lip in a 6-year-old female child, which was reconstructed using Estlander flap.

  Case Report Top

A 6-year-old female patient was referred to Department of Oral and Maxillofacial surgery with a chief complaint of deformed right upper lip for past 2 years. Examination of the patient revealed extensive scar contracture along with half of the upper lip missing, causing exposure of maxillary anterior teeth [Figure 1]. Her past dental and medical history was significant with history of severe illness at 4 years of age followed by a suppurative wound around the oral cavity. Since her parents were illiterate, we examined her past medical records which revealed noma of the right cheek and upper lip region. She was treated at a local hospital where the wound was surgically debrided and no reconstruction was done. Further examination revealed there was a full-thickness defect of half of the upper lip with severe scar contracture, thereby constricting the oris. The child was planned for staged surgical management under general anesthesia. After her blood reports were found to be normal, we planned for the first stage of lip reconstruction using Estlander flap [Figure 2]. Incision markings were made and local anesthesia with adrenaline was injected for local hemostasis. The flap was raised and mobilized, dissected carefully up to the vermillion on the pedicle side of the flap, and care was taken not to expose the labial vessels; the entire flap was rotated 90° into the defect [Figure 3], [Figure 4] and [Figure 5]. Layered closure was done for both upper and lower lips from inside out using 4-0 polyglactin and 5-0 prolene sutures [Figure 6] and [Figure 7]. Light adhesive bandage was applied. There was no postoperative complication observed and follow-up was done till 6 months. The functional outcome was good with no trismus and with satisfactory lip competence and commissure.
Figure 1: Frontal and lateral views of the patient showing residual noma defect of the upper lip causing severe contracture of the commissure and exposure of maxillary anterior teeth

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Figure 2: Schematic picture showing the design and steps of Estlander flap

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Figure 3: Intraoperative photograph showing incision design

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Figure 4: Intraoperative photograph showing incision and elevation of the flap

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Figure 5: Intraoperative photograph showing rotation of the flap held in place before fi nal suturing

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Figure 6: Intraoperative photograph showing fi nal suturing

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Figure 7: Postoperative photograph showing frontal and lateral views

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  Discussion Top

Noma was described by Tourdes (1848) [1],[4] as "a gangrenous affectation of the mouth, especially occurring in children affected by serious illnesses, especially exanthematous fevers." The disease is caused by Borrellia vincenti and Fusiformis fusiformis. [2],[5] Noma has been known since antiquity [6] and has a worldwide recognition. Starting initially as an innocently benign swelling, a boil or a rash, noma tends to affect both hard and soft tissues around the mouth, except the tongue, leaving its victim aesthetically unacceptable.

The predisposing factors for noma include malnutrition, poor oral hygiene, and debilitating diseases, especially measles and malaria fever. Measles is the highest known predisposing condition in our environment, followed by malaria fever. [4],[6] Other conditions that contribute to the occurrence of noma include poor or lack of maternal care, HIV infections, and following some courses of cytotoxic drugs used in the management of Burkitt's lymphoma. [7],[8] Noma also predominates in the low socioeconomic groups due to malnutrition, as found in our case.

Functional goals of lip reconstruction include maintenance of oral competence, sufficient oral access, and preservation of sensation. Aesthetically, facial units should be reconstructed with adequate tissue match in terms of color and texture, aiming at symmetry as well as preservation of the apparent commissure and philtral structures. The four main reconstructive options include secondary intention healing, skin grafts, primary closure, and local flaps. [9],[10] Advantages of local flaps include rapid healing and return to normal function, high success rate, and excellent aesthetics in most cases with low risk of complications. In addition to improving cosmetic results, flaps can add greater bulk to the reconstruction, specifically in larger defects. Thus, reconstruction of larger defects involves bringing in tissue from the melolabial fold and cheek area as a skin flap or from the opposite lip as a pedicled composite skin - muscle - mucosa flap. [10],[11] The reconstructive requirements are complex. Soft tissue and bony tissue loss, fistulas (orocutaneous, palatal), trismus, and the cosmetic deformity all need to be addressed. No single "standard" procedure can correct all these defects. Each reconstruction must be carefully planned and individualized. Local flaps should be used wherever possible because they provide better color and texture match. If the defects are too extensive, distant flaps may have to be considered. [12],[13] Newer plastic surgery techniques such as tissue expansion, prefabrication of flaps, and the use of microsurgical tissue transfers may facilitate reconstruction. Anesthetic difficulties, especially those related to poor mouth opening, may be overcome by the use of nasal or endoscopic intubation using fiberoptic techniques. [13],[14]

The Estlander flap is used for labial defects that include the commissure. The design of the flap is similar to that of the Abbe flap, but the pedicle becomes the new commissure and the transfer is completed in a single stage. It is usually indicated in medium-sized defects of the angle of the mouth. At least two-thirds of both lips must be preserved or the oral stoma will become too small. The Estlander flap can be combined with another flap in the same stage for treatment of large defects including the angle of the mouth and the cheek. [5],[14]

The functional importance is the fundamental goal of reconstruction; however, due to the prominence of the surgical site, obtaining the best aesthetic outcome should be a close second goal. [15] The choice of reconstructive technique depends on the site, size, the surgeon's preference, and the available expertise.

  Conclusion Top

Management of noma usually involves multiple-staged surgical approach. Local flaps should be used for repair of lip defects, which have less donor site morbidity and the overall tissue bulk, color, and texture. The choice of reconstructive technique depends on the site, size, the surgeon's preference, and the available expertise.

  References Top

Hurwitz S. A text book of skin disorders of childhood and adolescence. Clin Pediat Dermat 1981;24:245-7.   Back to cited text no. 1
Marck KW. A history of Noma, "the face of poverty". Plast Recons Surg 2003;111:1702-7.  Back to cited text no. 2
Kaimenyi JT, Guthua SW. Residual facial deformity resulting from cancrum oris: A case report. East Afr Med J 1994;71:476-8.   Back to cited text no. 3
Montandon D, Lehmann C, Chami N. The surgical treatment of noma. Plast Reconstr Surg 1991;87:76-86.  Back to cited text no. 4
Estlander JA. Eine Methode aus der einen Lippe Substanzverluste der anderen zu ersetzen (A method of reconstructing loss of substance in one lip from the other) (reprint from: Archiv für Klinische Chirurgie 1872;14:622). Plast Reconstr Surg 1968;42:361-6.  Back to cited text no. 5
Adolph HP, Yugueros P, Woods JE. Noma: A review. Ann Plast Surg 1996;37:657-68.   Back to cited text no. 6
Enwonwu CO, Falkler WA Jr, Phillips RS. Noma (cancrum oris). Lancet 2006;368:147-56.  Back to cited text no. 7
Enwonwu CO, Falkler WA, Idigbe EO. Oro-facial gangrene (noma/cancrum oris): Pathogenetic mechanisms. Crit Rev Oral Biol Med 2000;11:159-71.  Back to cited text no. 8
Yih WY, Howerton DW. A regional approach to reconstruction of the upper lip. J Oral Maxillofac Surg 1997;55:383-9.  Back to cited text no. 9
Nabili V, Knott PD. Advanced Lip Reconstruction: Functional and aesthetic considerations. Facial Plast Surg 2008;24:92-104.  Back to cited text no. 10
Montandon D, Pittet B. Lip reconstruction in noma sequelae. Ann Chir Plast Esthet 2002;47:520-35.  Back to cited text no. 11
Giessler GA, Cornelius CP, Suominen S, Borsche A, Fieger AJ, Schmidt AB, et al. Primary and secondary procedures in functional and aesthetic reconstruction of noma-associated complex central facial defects. Plast Reconstr Surg 2007;120:134-43.  Back to cited text no. 12
Woon CY, Sng KW, Tan BK, Lee ST. CASE REPORT Journey of a Noma Face. Eplasty 2010;10:e49.  Back to cited text no. 13
Yamauchi M, Yotsuyanagi T, Ezoe K, Saito T, Yokoi K, Urushidate S. Estlander flap combined with an extended upper lip flap technique for large defects of lower lip with oral commissure. J Plast Reconstr Aesthet Surg 2009;62:997-1003.  Back to cited text no. 14
Adeola DS, Obiadazie AC. Protocol for managing acute cancrum oris in children: An experience in five cases. Afr J Paediatr Surg 2009;6:77-81.  Back to cited text no. 15
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]

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