Reconstruction of the Maxilla with Prefabricated Scapular Flaps in Noma Patients

Sir: We read with great interest the article entitled “Reconstruction of the Maxilla with Prefabricated Scapular Flaps in Noma Patients” by Vinzenz et al. (Plast Reconstr Surg. 2008;121:1964-1973), and we wanted to point out that although motivated by genuine humanitarian concerns, such projects may serve to promote “noma tourism” rather than significant improvements in the local medical infrastructure. Noma reconstructive surgery has become a challenge for plastic surgeons in the industrialized West; noma continues to afflict sub-Saharan countries as a community disaster. As awareness of this problem has become more widespread, increasing numbers of American and European surgeons are volunteering to go on short-term medical mission trips to perform repair operations in African countries or to organize transfer of patients to the industrialized countries. Why present a program with no chance of being performed locally and that implies enormous funding that could be used to promote local health programs? Accurate data collection, thoughtful study design, critical ethical oversight, logistical and financial support systems, and the nurturing of local capacity should be emphasized. The most critical elements in the development of successful programs for treating noma patients are a commitment to developing holistic approaches that meet the multifaceted needs of the noma victim and identifying and supporting local correspondents who can provide long-term success for such programs. In complete opposition to the strategies presented in the article by Vinzenz et al., the senior author has developed a large program of cooperation over the past 12 years regarding noma in Niger (Operation Sourire Medecins du Monde), including three surgical missions per year and acceptance of four Niger plastic surgeons in our fellowship program. More than 70 noma patients were treated locally.1 Our strategy was to develop effective surgical techniques that could be performed locally by local surgeons with funding by the nongovernmental organization. We present the case of a 12-year-old boy who was infected with human immunodeficiency virus and who developed noma during his early childhood. After the beginning of a classic World Health Organization anti–human immunodeficiency virus therapy and a complete nutrition program, we had to reconstruct these complex noma sequelae (Fig. 1). Reconstruction was performed by means of a single-pedicle latissimus dorsi flap with four skin paddles in a first mission to Niger in November of 2006. The flap was able to reach the cheek because of a cervical inverted Z-plasty with the aim of shortening the cervical area (Fig. 2). At the same time, a frontal flap was used to reconstruct the nasal rim. Three months later, in a second mission, a local Estlander flap and complete remodeling of the latissimus dorsi flap was performed. The result was achieved in only two missions with soft-tissue neosegmentation (Fig. 3), giving the patient a chance of socialization and the local surgeon a chance of performing such operations on his own one day.Fig. 1.: Preoperative view.Fig. 2.: After the first step: pedicle latissimus dorsi with inverted cervical Z-plasty.Fig. 3.: After the second step: modeling of the latissimus dorsi, Estlander flap, and frontal flap to reconstruct the nasal rim.The codes of conduct2,3 of nongovernmental organizations clearly stipulate in Article 6 that we shall attempt to build disaster response on local capacities and in Article 7 that ways shall be found to involve program beneficiaries in the management. The principle of “responsibility”4 must remain in the ethical guidelines for these humanitarian programs. The responsibility in this case is to build for the local surgeons a chance to solve local problems. Alain M. Danino, M.D., Ph.D. Service de Chirurgie Plastique Centre Hospitalier de l’Université de Montréal Hôpital Notre Dame Montréal, Quebec, Canada Jean Marie Servant, M.D. Service de Chirurgie Plastique Hopital Saint Louis Université de Paris Paris, France

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