Paralleling the increasing use of bariatric surgery, there is a high demand for body contouring surgery. A huge disparity exists between the number of subjects who desire a body contouring surgery and those who actually received it.

IntroductionNoma is a significant yet neglected disease which affects some of the least developed countries in the world. The long-term benefit and safety of Noma surgical reconstructive missions have recently been under scrutiny due to a perceived lack of measurable outcomes and appropriate follow-up. This study analyses and reports on classifications, outcome measurement tools and follow-up for reconstructive surgery after Noma disease.MethodsThis systematic review was undertaken following Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. The three medical databases Medline, EMBASE and Web of Sciences were searched, articles published between 1 January 1983 and 15 April 2020 were included. All primary evidence on reconstructive surgery following Noma disease, reporting data on outcome after surgery, follow-up time and complications were included. Extracted data were aggregated to generate overall and population corrected mean outcomes and complication rates.ResultsOut of 1393 identified records, 31 studies including 1110 Noma patients were analysed. NOITULP and Montandon/WHO were the most commonly used classification systems. Mouth opening (MO) and complication rates were the two most often reported outcomes. Overall mean complication rate was 44%, reported by 24 studies. Postoperative MO was reported by eight publications, of which, five reported long-term outcomes (>12 months). Mean MO improved by 20 mm when compared with mean population weighted preoperative MO (7 mm). At long-term follow-up, MO decreased to 20 mm.ConclusionsStudies reporting on neglected diseases in developing countries often lack methodological rigour. Surgeons should be mindful during patient examination by using a classification system that allows to compare preoperative versus postoperative state of disease. Short-term mission surgery is a vital part of healthcare delivery to underdeveloped and poor regions. Future missions should aim at sustainable partnerships with local healthcare providers to ensure postoperative care and long-term patient-oriented follow-up. A shift towards a diagonal treatment delivery approach, whereby local surgeons and healthcare staff are educated and empowered, should be actively promoted.PROSPERO registration numberCRD42020181931.

Trismus is a frequent complication of healed Noma infection and is caused by soft tissue and muscle contraction. Free-flap surgery is recommended to replace the missing oral mucosa and soft tissue. However, significant complications can occur if this surgery is performed in places like Africa, where conditions are usually less than optimal. In 2007, the authors started to treat patients with trismus in Niamey, Niger by distracting the soft tissue and muscle constriction between the jaws with a bone distractor continuously for 1 month with the aim of achieving a mouth opening of 3 cm. The distraction was limited to 1 mm/d. performed under local anesthesia with some sedation. Minor complications such as infection in the pin holes were easily managed. In 2009, 2 patients with trismus after Noma with a follow-up of 2 years were reported. Till date, the authors have successfully performed trismus release in more than 69 patients in Niamey and Guinea Bissau. The present study analyses the results of distraction therapy in 40 patients with follow-ups until 60 months. At the end of distraction, the mean interincisal distance was 2.7 ± 0.5 cm. Mouth opening 6 months after distraction had not reverted. However, 3 to 5 years after treatment, some signs of relapse were detected, with an average mouth opening of 1.5 ± 1.9 cm. Physiotherapy was unfortunately not feasible. The presented results strongly support the efficacy of distraction therapy to correct trismus in Noma patients.

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