Plastic and Reconstructive Surgery Global Open · 3 authors, 4 centres
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This narrative review examines the role of reconstructive surgery for four disfiguring neglected tropical diseases (mycetoma, lymphatic filariasis, leprosy, and noma). The authors find that while surgery can improve function and reduce stigma, its use is limited by weak health systems in endemic areas. They recommend prioritizing antibiotic therapy and prevention, while building local surgical capacity through training and standardized protocols.
**Background:** Neglected tropical diseases (NTDs) comprise at least 20 poverty-related infections affecting billions worldwide. Several NTDs cause severe disfigurement and disability, leading to social stigma, particularly among girls and women in poverty. The Lancet Commission on Global Surgery has highlighted the need to integrate simple surgeries into mass treatment programs. This review focuses on four highly disfiguring NTDs—mycetoma, lymphatic filariasis (LF), leprosy, and noma—where reconstructive surgery can play an instrumental role.
**Methods:** A literature review was conducted using PubMed from 2008 to 2021, searching for diseases listed as NTDs on the WHO or PLoS Neglected Tropical Diseases websites. Reference lists and WHO databases, including the Weekly Epidemiological Record, were also searched.
**Key Results:** - **Mycetoma:** A chronic granulomatous infection of subcutaneous tissue, over 82% of cases affect lower extremities. At the Gezira Mycetoma Center in Sudan, the most common operation was surgical excision (87.8%), while amputation was performed in 12.2% of cases. Even with aggressive surgical control, recurrence rates may be as high as 50%. Simple reconstructive techniques (split-thickness skin grafts, local flaps) are preferred in low-resource settings; perforator flaps and free tissue transfer are avoided due to higher failure rates. - **Lymphatic Filariasis:** An estimated 72 million people are infected globally, with lymphedema and hydrocele affecting over 30 million individuals. Advanced microsurgical techniques (vascularized lymph node transfers, lympho-venous bypasses) are effective but limited to specialty centers. Simpler debulking procedures like liposuction or the Charles procedure (radial excision and skin grafting) may be more feasible in low- and middle-income countries, though they carry risks of infection and disfigurement. - **Leprosy:** Affects about 500,000 people annually, with 3 million currently living with leprosy-associated deformity. Common surgeries include ulnar nerve release, flexor digitorum superficialis opponensplasty, and soft tissue release. A surgical camp in Gujarat, India successfully increased reconstructive surgery for leprosy, but more study is needed to evaluate this approach. - **Noma:** A necrotizing orofacial gangrene with an estimated 35,000 annual incidence and 210,000 prevalence, primarily affecting malnourished children in sub-Saharan Africa. Reconstructive surgery aims to release trismus and transfer tissue flaps, but due to complexity, it is mostly performed in strong medical systems or by NGOs.
**Clinical Implications:** The authors conclude that surgery is a promising treatment for disfiguring NTDs, but its success depends on standardization of surgical approaches, appropriate use of antibiotics, partnerships with local teams, and local capacity building. Prevention through hygiene and mass drug administration remains paramount. Mission-style surgical trips can provide immediate care, but sustainable solutions require training local health workers and developing universal surgical protocols. More clinical and long-term studies are urgently needed to determine the most effective surgical treatments and how to make them accessible in resource-poor settings.