Most defects resulting from noma involve the lateral and anterolateral aspects of the face and are often combined with severe functional deficits owing to impaired mandibular mobility up to full ankylosis. A subgroup, commonly called "central noma", comprises defects of the upper lip, maxillary soft tissues, the premaxilla, the nasal cartilaginous infrastructure and soft tissues. In contrast to unilateral involvement of the face, central noma does not affect jaw opening, still it results in severe mutilation with disfiguring three-dimensional defects erasing any individual traits from a face. The common surgical approach to centrofacial noma defects has been single stage reconstructive procedures using loco-regional flaps, however often leading to disappointing outcomes in complex cases.

Our concept for complex central noma defects is a staged approach using free flaps for soft tissue reconstruction of the upper lip and the maxillary vicinity serving as a versatile base to introduce loco-regional flaps for later functional and aesthetic refinements. Secondary surgery includes total nose reconstruction with a free cartilage framework and forehead flaps. We prefer to interpose vascularized flap tissue between any osteotomized surfaces, if preoperative ankylosis made resection arthroplasty for the temporomandibular joint necessary.

In our series (n=53) the free radial forearm (n=4), anterolateral thigh (ALT-) (n=1) and parascapular flap (n=7) proved suitable for the central face in terms of pedicle length, tissue pliability and bulk. All free flaps survived completely. Three total nose reconstructions by forehead flaps were done successfully as a secondary step. Free flap interposition seemed to be advantageous in prevention of "trismus" recurrence in at least two cases.

Being of limited use for a subtotal or total reconstruction of the outer nose, a microvascular tissue transfer as a first step preserves local and regional donor sites – in particular the forehead - for secondary reconstruction. In extensive cases, this approach may prevent the common pitfall of reconstructing the missing nose as the most disfiguring feature first without providing a solid tissue fundament to place it beforehand.