Secondary Logo

Journal Logo

990 Form: A Taxing Burden forCleft Organizations

Patel, Anup, B.S.; Persing, John A., M.D.

Plastic and Reconstructive Surgery: December 2009 - Volume 124 - Issue 6 - p 436e-437e
doi: 10.1097/PRS.0b013e3181bcf7a7

Section of Plastic and Reconstructive Surgery, Yale University School of Medicine, New Haven, Conn.

Correspondence to Dr. Persing, Section of Plastic and Reconstructive Surgery, Yale University School of Medicine, P.O. Box 8041, New Haven, Conn. 06520-8062,

Back to Top | Article Outline


Opponents of medical missions justify their stance by frequently citing the cost savings derived from allowing local surgeons to perform the operations. In Cambodia, it costs local surgeons U.S. $80 per cleft lip reconstruction, whereas an international medical mission may face expenses of U.S. $1000 for the same procedure.1 This reduces the argument to an economic one, where evaluations of cleft organizations are based heavily on 990 tax forms, focusing specifically on treatment costs and number of children treated. Using Operation Smile as a model, we demonstrate that such a myopic view fails to consider the feasibility of local surgeons performing cleft repair, the quality of the surgery maintained, and the intangible, unquantifiable stream of benefits of mission trips, all of which remain critical in evaluating cleft organizations.

The reality, however, is that all forms of support of children with clefts are important. In most developing countries, local surgeons receive little or no reimbursement for their efforts to routinely repair these cleft deformities, and the dearth of specialists such as pediatric anesthesiologists and intensivists prevents the assembly of multidisciplinary teams necessary for mitigating the risks in cleft repair.2,3 Therefore, many patients in these nations do not receive treatment from local providers and continue to experience clinical complications and the social stigma associated with these untreated facial deformities. Operation Smile's medical missions fill this void by providing surgical care for local populations while facilitating the training of local and international plastic surgeons and specialists through programs such as its annual Physicians' Training Program.4

As nonprofit rating services tend to rely heavily on the treatment expense per child for evaluating cleft charities, the pressure for these organizations to demonstrate a low treatment expense or a high annual number of children treated on their 990 forms continues to mount. Simple comparisons of 990 forms do not account for the organization that partially funds a mission (perhaps only the plane ticket for a surgeon on the trip) and still counts all the children treated on that surgeon's mission in its yearly total, inevitably lowering its treatment expense per child. Furthermore, the 990 form provides no information regarding how an organization handles postoperative complications, assuming a system has been implemented to notify the organization about these complications, nor do the forms include information regarding the credentials of those treating the children.

  1. Operation Smile's funds cover all aspects of the mission, from hotel rooms to speech therapists for children undergoing palate repair.
  2. Operation Smile's comprehensive care centers monitor and treat postoperative complications year round.
  3. Operation Smile's internal review ensures that all mission members meet standard accreditations.

Appraising intangible benefits that Operation Smile produces by advancing the understanding and management of congenital facial deformities through university partnerships or by inspiring individuals to pursue careers in international health care by permitting medical students and residents on missions is inherently difficult to quantify and list on a 990 form.

We recommend that those critics harping on the costs of mission trips consider the ethical dilemma of saving dollars at the expense of quality of care that occurs when paying local surgeons (who may lack the appropriate training) or other specialists necessary for optimal cleft repair. Analyzing other rubrics, including qualitative metrics not on a 990 form, will be a starting point for fathoming the value that cleft organizations such as Operation Smile engender for society and for evaluating cleft organizations more accurately.5

Anup Patel, B.S.

John A. Persing, M.D.

Section of Plastic and Reconstructive Surgery

Yale University School of Medicine

New Haven, Conn.

Back to Top | Article Outline


Neither of the authors has any commercial associations or financial disclosures that would create a conflict of interest with information presented in this article.

Back to Top | Article Outline


1. Dupuis CC. Humanitarian missions in the third world: A polite dissent. Plast Reconstr Surg. 2004;113:433–435.
2. Mulliken JB. The changing faces of children with cleft lip and palate. N Engl J Med. 2004;351:745–747.
3. Bermudez RLE. Operation Smile: Plastic surgery with few resources. Lancet 2000;356:S45.
4. Poe D. Operation Smile International: Missions of mercy. Plast Surg Nurs. 1994;14:225–230.
5. Collins J. Good to Great and the Social Sectors: Why Business Thinking Is Not the Answer. Boulder, Colo: Jim Collins; 2005.

Section Description


Viewpoints, pertaining to issues of general interest, are welcome, even if they are not related to items previously published. Viewpoints may present unique techniques, brief technology updates, technical notes, and so on. Viewpoints will be published on a space-available basis because they are typically less timesensitive than Letters and other types of articles. Please note the following criteria:

Authors will be listed in the order in which they appear in the submission. Viewpoints should be submitted electronically via PRS’ enkwell, at We strongly encourage authors to submit figures in color.

We reserve the right to edit Viewpoints to meet requirements of space and format. Any financial interests relevant to the content must be disclosed. Submission of a Viewpoint constitutes permission for the American Society of Plastic Surgeons and its licensees and assignees to publish it in the Journal and in any other form or medium.

The views, opinions, and conclusions expressed in the Viewpoints represent the personal opinions of the individual writers and not those of the publisher, the Editorial Board, or the sponsors of the Journal. Any stated views, opinions, and conclusions do not reflect the policy of any of the sponsoring organizations or of the institutions with which the writer is affiliated, and the publisher, the Editorial Board, and the sponsoring organizations assume no responsibility for the content of such correspondence.

©2009American Society of Plastic Surgeons