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24 September 2014
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You are in: Inside Out > Yorkshire & Lincolnshire > Facial surgery in Ethiopia

Medical team at work

Making a difference in Ethiopia.

Facial surgery in Ethiopia

We follow a group of Yorkshire surgeons and their colleagues performing facial surgery on children from the poorest parts of rural Ethiopia. The children are suffering from Noma - a flesh eating disease which leads to horrendous facial deformities.

Noma fact file

Noma is an acute gangrenous infection affecting the face.

First described clinically by surgeon Carolus Battus from the Netherlands in 1595. Cases were also found in Nazi concentration camps where victims died as a result of malnutrition.

Noma had disappeared from most of Western Europe by the late 19th Century due to improved nutrition and hygiene among poor people.

The treatment of Noma became possible with the discovery of penicillin and the development of reconstructive surgery.

Noma remains the face of poverty in poor, underdeveloped developed countries.

Young children living in extreme poverty with malnutrition are at high risk.

Starts with mouth ulcers. Early detection and treatment with antibiotics and immediate nutritional rehabilitation important.

If left untreated, the ulcers develop into full-blown Noma very quickly. The cheeks or lips begin to swell - after a few days, the swelling increases and a blackish furrow appears and the gangrenous process starts. When the scab falls away, a gaping hole is left in the face.

The Noma mortality rate can be as high as 90%.

Survivors are left with facial disfigurement and functional impairment.

Source: Facing Africa

Note: The gallery shows the devastating effect of Noma on people living with the disease. Web users may find some of the images in this photo gallery upsetting.

Ethiopia is a welcoming country but one that struggles with a history of war, disease and famine.

Who can forget the images from 1984 of children dying in the streets?

Even today, half the population lives under the poverty line and one child in every 10 will die before its first birthday.

Hidden among the statistics of Ethiopia are the children who suffer with Noma - a terrible disease that eats the flesh from their faces.

It targets those who are malnourished. What starts off as an ulcer rapidly turns into a gangrenous infection.

Ninety per cent will die - the rest left to suffer with appalling scars and social exclusion.

The survivors are often left unable to speak or eat with devastating consequences.

Children with the condition turn up at their local doctors - usually in an advanced state of the disease.

They are often in a terrible state with half their faces missing - without help they'll die or suffer from facial disfigurement.

We follow a team of medics from Methley Park Hospital in Leeds - and their colleagues from London and Holland - who are trying to help Noma patients.

LeRoux Fourie is an eminent plastic surgeon based in Leeds.

He's been asked by the charity Facing Africa to assemble a team to travel to Ethiopia to operate on the victims of Noma.

It's a tough challenge but one which will make a positive impact on the lives of people with this condition.

"We can make such a difference - these people have nothing," says LeRoux.

Facing the facts

Facing Africa has identified 18 people from the remote and poor region of Harar to be brought to the city's main hospital.

The work carried out in the remote and poor regions was carried out by Project Harar Ethiopia, a partner charity of Facing Africa, which searches for and supports patients in isolated regions of Ethiopia. 

Facial disfigurement before treatment.

Facial palsy before treatment.

As word spreads that the medical team is in town more people turn up - some have travelled for days. But not everyone can be treated - for some the deformity is just too great.

In the end, 38 patients are identified who can be treated on the basis of need and priority.

One of the first to be treated is a young woman called Tess Fohassen - her operation is expected to take 90 minutes.

It's a simple procedure and one the local doctors can learn to perform.

Tess has been living with Noma since she was just one year of age.

She's one of the easier patients to treat.

But it doesn't come without a cost, as LeRoux explains:

"There's something we can do for her. But... she'll lose her teeth."

For others, there are no quick fixes. This is likely to be the first operation in a process that will be long and painful.

LeRoux Fourie, a Consultant Plastic Surgeon from Methley Park Hospital in Leeds tells us what it was like to go out to Africa in this web exclusive...

Changing lives in Africa

"Having been involved in the treatment of Noma patients in Sokoto, Nigeria in 2004, I was excited to be invited to Ethiopia in October 2007.

Facial palsy after surgery

Facial disfigurement after surgery.

"We were asked to put a team together by the Facing Africa Charity.

"The mission was a step into the unknown for the team as none of us had worked in Ethiopia before.

"We were lucky to have Dr Klaas Marck, a Dutch Plastic Surgeon and a world expert in Noma surgery joining us as medical co-ordinator.

"The rest of the team was made up of two Maxillofacial Surgeons, an Anaesthetist, a theatre sister, an operating department practitioner (to assist the anaesthetist) and a Plastic Surgeon (myself)."

Facing the challenge

"The first day was spent in outpatients where about 40 patients were assessed and theatre planning lists drawn up.

"Many of the patients required two operations: the first to prepare the skin flaps (bits of skin and muscle with a specific blood supply) and remove diseased teeth.

Treating a young boy

Treating a young boy in Ethiopia.

"The biggest challenge faced Joseph, the anaesthetist, as these patients' jaws were fused together and intubation had to be done via a fibre optic scope.

"During the first week we were also asked to see more patients with quite severe disfigurement or advanced facial cancers.

"Unfortunately we could not operate on all the patients we saw because of either a lack of theatre time or the complex nature of the disease.

"Part of our remit was also to teach the local surgeons surgical techniques and we consciously made the decision to teach the easiest, least complicated procedures that they could carry on doing when the surgical team left."

Fatigue and frustration

"Forty four procedures were carried out over 10 days, some very complicated, but life changing for the patients involved.

"The fatigue from operating long hours and the frustration, of not being able to help every one was balanced out, and sometimes exceeded, by the sense of changing lives and making a difference.

"Will we go back?

Mick, Anthea and young boy

Helping children to have better lives.


"The next team is planning a trip in April 2008 and the Yorkshire group will go in October 2008.

"We have come up with possible solutions to problems we encountered.

"More instrumentation and material is needed, and 'follow up' in the week when the team leaves needs to be addressed.

"But all in all we made a difference, not just to the patients involved but also in teaching new techniques to the local surgeons, anaesthetic staff and theatre personnel.

"A little bit of Yorkshire has hopefully had an impact in a small area of Ethiopia."

LeRoux Fourie FRCS

Note: The gallery shows the devastating effect of Noma on people living with the disease. Web users may find some of the images in this photo gallery upsetting.

All photographs courtesy of LeRoux Fourie and his medical team.

last updated: 14/11/07

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