Update on Noma: systematic review on classification, outcomes and follow-up of patients undergoing reconstructive surgery after Noma disease.

INTRODUCTION: Noma 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. METHODS: This 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. RESULTS: Out 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. CONCLUSIONS: Studies 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 NUMBER: CRD42020181931.

Distraction Therapy to Correct Trismus Following Noma.

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 ±â€Š0.5 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 ±â€Š1.9 cm. Physiotherapy was unfortunately not feasible. The presented results strongly support the efficacy of distraction therapy to correct trismus in Noma patients.

The prevalence of body contouring surgery after gastric bypass surgery.

BACKGROUND: As bariatric surgery has become more popular, more patients are undergoing body contouring surgery after massive weight loss. Many of the surgical procedures performed on the massive weight loss patient are complex and labor-intensive. Therefore, the plastic surgery unit needs to be prepared for a patient's demand. Little literature is available on how frequently patients who have undergone gastric bypass surgery receive body contouring surgery. METHODS: Two hundred fifty-two subjects (out of 425 who were mailed the questionnaire) who had undergone gastric bypass surgery between 2003 and 2009 completed the questionnaire, which obtained information on body image satisfaction and frequency of body contouring surgery after massive weight loss. RESULTS: Of all patients, 74% desire a body contouring surgery after gastric bypass surgery. Fifty-three patients (21%) have undergone a total of 61 body contouring procedures. The most common were abdominoplasties (59%), followed by lower body lifts (20%). In contrast to a positive judgment of the general aspect of the body image satisfaction after massive weight loss, both genders are unsatisfied with body areas like abdomen/waist, breast, and thighs. CONCLUSIONS: 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.

Correlative high-resolution MR-anatomic study of sciatic, ulnar, and proper palmar digital nerve.

Aim of this study was o evaluate the effectiveness of high-resolution MR imaging in demonstrating the anatomic structure of peripheral nerves of different diameter and composition. The dissected sciatic, ulnar, and proper palmar digital nerve of fresh cadavers were imaged at pre-selected landmarks on a 3T MR scanner. The nerves were then embedded in formalin, sliced, stained, and microscopically analyzed. The size, shape, and signal intensity of the sheath and axonal structures in the nerves at the landmarks were identified in MR images by comparison with histologic sections. The fascicles were clearly distinguished and counted in all specimens with MR imaging and showed only small differences from the histologic evaluation. High resolution MR imaging has the potential to visualize the fascicular structure in nerves of all sizes, which may be helpful in the preoperative assessment.