On the seventh day after the surgery, sutures in patients with cleft lip were removed. Continuous skin sutures were used on the lip and nose which helped in suture removal. The team visited the local hospital 1 month later to examine the patients again, followed by a visit after 3 months. The speech therapist examined all the patients with cleft palate to guide and help for improvement in their speech. Further follow-up was planned at 6 and 12 months postsurgery.
Regarding the complications, 1 patient with cleft palate developed postoperative bleeding on the day of surgery. He was shifted to the OR, but the bleeding stopped with conservative measures; no other intervention was needed. Later this patient had an uneventful recovery. A total of 16 patients developed fistulae/dehiscence after cleft palate repair. The site and size of fistula are shown in Table 6. One patient developed unilateral dehiscence 2 days after lip adhesion for bilateral cleft lip with protruding premaxilla. He underwent resuturing of the dehiscence with uneventful recovery. There were no other complications, such as infection, pneumonia, or death.
Humanitarian medical missions temporarily overcome limitations, promote long-term solutions to the local healthcare system, and deliver immediate care to the patients in need.7 Especially pertaining to cleft care, they provide an unparalleled environment in which multidisciplinary treatment can be delivered to patients with cleft lip and palate.8 The cooperation of host hospitals and locally active nongovernmental organizations provides a sustainable model for providing treatment for cleft lip and palate.
Prof. Donald R. Laub founded Interplast (now Resurge) in 1969 to help poor patients in the developing countries.9,10 At present, many regional chapters of Resurge are providing free surgical care to the poor and needy patients around the globe. Operation Smile was founded in 1982 by William Magee and is the largest organization managing international cleft missions all over the world.11
The countries of the world can be divided into 4 groups (Table 7) depending on the workload of the patients with cleft and availability and utilization of cleft services. Group A comprises developed countries like United States, Canada, United Kingdom, Ireland, Schengen countries, Japan, Taiwan, Singapore, Australia, New Zealand, and the rich countries of Middle East, which have well-developed healthcare programs/resources to take care of patients with cleft. This group makes up approximately 13% of the world’s population.6 Group B includes the countries like China, India, Indonesia, Brazil, Pakistan, Iran, and Thailand, where surgical expertise and ancillary services are available, but the healthcare system is not beefed enough to handle the burden of patients with cleft lip and palate. These countries comprise of 52.22% of world’s population,6 and there is an urgent need to develop and train cleft mission teams from within the country to reduce the burden of patients with cleft. Our model cleft mission can be easily reproduced in all of group B countries. There is no language barrier between members of the team, so that coordination is better and more convenient. The local team members can easily provide follow-up at 1, 4, 12, and 24 weeks to the cleft patients operated. In our model, 1 qualified OR assistant with extensive experience in management of patients with cleft carries out the follow-up. In addition, he removes the sutures, addresses different complaints of the patients, and takes pictures as well. Continuation of care is demonstrated by the fact that any patient having both cleft lip and palate, and who has been operated on for lip or palate at one mission, can undergo second surgery after 12 or 24 weeks.
In group C are the countries like Argentina, Philippines, Bangladesh, Mexico, Vietnam, Iraq, Peru, Morocco, and some of the African countries such as Nigeria or Algeria with approximately 18% of the world’s population,6 which lack the expertise as well the resources to help the patients with cleft. A sincere effort should be made (especially by teams from group A and B countries) to train the human resource in all the disciplines of cleft care, in these countries. It is possible for reasonably good teams to be developed within 5–7 years which can become effective and more productive in helping more and more patients with cleft.
In group D are the poor countries of Africa, Asia, and Latin America which truly need international cleft missions to support and manage cleft care. The above-mentioned scheme of cleft care is supported by the fact that Operation Smile has organized 152 cleft missions in group B countries, 276 cleft missions in group C, and more than 239 cleft missions in group D countries since 2010.11
A team developed from within a country of group B can also visit the neighboring country of group C or D, to effectively reduce the burden of cleft care (like 4 cleft missions by Cleft Lip and Palate Association of Pakistan at Kabul, Afghanistan, to operate a total of 640 patients in the year 2013 and 2014). If our model is applied to group B countries, the resources of organizations like Operation Smile can then be focused on more cleft missions in group C and D countries. With the passage of time, international cleft missions will be needed only in group D countries.
The senior surgeon has developed a team for cleft missions as mentioned in Table 2. As the team has been routinely carrying out cleft missions over the last 10 years, many of the early problems have been resolved. There are many organizations that engage cleft surgeons from different parts of the world to work in remote areas of Africa, Asia, and South America.12 As different team members are selected in different cleft missions, these organizations have developed strict protocols which some of the participants might not feel comfortable complying with. Similarly, a language barrier can exist between the team members who arrive from different parts of the world. Duration of individual surgical procedures may also increase considerably if the surgical assistant has difficulty in understanding surgeon’s instructions.13 However, the model presented in this article caters for any possible lack of coordination as each member of the team knows his job well and is well versed with the task at hand. Because of this team approach, a lot of time is saved and near misses are avoided.
There are many surgical procedures that are not carried out routinely in many international cleft missions, for example, adult cleft palate repair.14 Our team has the protocol of operating upon all patients who are fit for surgery no matter what their age is. The average age of the patients in this mission was 7 years, and there were 82 patients of cleft palate whose age was 5 years or above. We believe that there is always significant improvement of speech in adults in addition to creation of an interface between oral and nasal cavities. Similarly, cleft rhinoplasty was routinely performed on all patients with cleft lip during this mission. Primary cleft rhinoplasty is not performed in many of the international cleft missions, either because of time constraints or lack of skill.15 Many organizations operate only on primary patients during the missions and avoid operating upon patients with secondary cleft because of increased risk of complications.16 Our team takes special care of patients with secondary cleft to reduce the risk of complications in these challenging cases. In the described cleft mission, we operated on 13 patients with secondary cleft lip and 22 previously operated patients with cleft palate. However, in many of our missions, the number of secondary patients was more than 25%.
One of the biggest problems identified as a limitation of a cleft mission is the follow-up of the patients operated on, due to financial and human constraints.17 Our team has a strong follow-up schedule. In the presented cleft mission, a follow-up of the patients has been done already at 1 week, 1 month, and 3 months from the time of surgery.
There are many cleft missions in the world where resident or trainee surgeons are encouraged to operate.18 This has resulted in the increased rate of complications of up to 50% palatal fistula formation among the palate patients.16 We train our surgeons at our cleft center in Lahore, and only fully trained surgeons are allowed to operate at cleft missions. The overall fistula rate in the presented cleft mission is 9.75%, which is comparable to international standards and is certainly much better than any of the cleft mission statistics.
After completion of surgical procedure, shifting the patient immediately to the recovery room saved 30–40 minutes. This has resulted in a marked increase in the number of surgical procedures carried out in limited time as depicted in Table 4. We used 2 operating tables in our first mission in the year 2004, and over the period of time, we have developed our team to run 6 operating tables simultaneously. We would suggest any cleft team to progress in the same way.
In some cleft missions, there are certain limitations such as use of tongue flap for large-sized palatal fistula or Abbe flap for philtral reconstruction. There was no such patient in this mission. Nevertheless, in such a situation, our policy is to select only those patients who are willing to come to Lahore for division and insetting 3 weeks after the surgery.
There is certainly a genuine need to organize the cleft missions in such a way that international missions be directed toward the poor and deserving countries only. Countries where surgical expertise is available, or can be developed, should be encouraged to organize national cleft mission teams, which can become cost-effective, robust, and more productive with better results. Around 52% of the world’s population can be benefited by model cleft missions like the one presented by our team.
Patients or their parents or guardians provided written consent for the use of the patients’ image.
We are thankful to Prof. Herman Sailer, Founder/Chairman of Cleft Children International, Zurich, Switzerland, for providing all the resources/support for this Cleft Mission.
1. Ganatra MA. Cleft surgery scenario in Pakistan. J Coll Physicians Surg Pak. 2007;17:581–582
2. Lee STWyszynski DF. International surgical missions in cleft lip and palate. In Cleft Lip and Palate from Origin to Treatment. 2002 Oxford University Press: New York:424–427
3. Mehboob EM, Ian JT, Omar E, et al. Epidemiology of cleft lip and cleft palate in Pakistan. Plast Reconst Surg. 2004;113:1548–1555
4. Abenovoli FM. Operation Smile humanitarian missions. Plast Reconstr Surg. 2005;115:356–357
5. Nicolai JP, Grieb N, Van Twisk R, et al. [Interplast in India. Review of 14 years]. Ann Chir Plast Esthet. 2004;49:291–293
7. Corlew DS. Estimation of impact of surgical disease through economic modeling of cleft lip and palate care. World J Surg. 2010;34:391–396
8. Zbar RI, Rai SM, Dingman DL. Establishing cleft malformation surgery in developing nations: a model for the new millennium. Plast Reconstr Surg. 2000;106:886–889; discussion 890
9. Marshall DR. The achievements of Interplast. Aust N Z J Surg. 1994;64:19–21
10. Gaynor E. Interplast: caring for children worldwide. J Hosp Supply Process Distrib. 1984;2:48–50
12. Ozgediz D, Jamison D, Cherian M, et al. The burden of surgical conditions and access to surgical care in low- and middle-income countries. Bull World Health Organ. 2008;86:646–647
13. Vyas RM, Eberlin KR, Hamdan US. Implementation of an emergency response protocol for surgical outreach initiatives. Plast Reconstr Surg. 2013;131:631e–636e
14. Morioka D, Yoshimoto S, Udagawa A, et al. Primary repair in adult patients with untreated cleft lip-cleft palate. Plast Reconstr Surg. 2007;120:1981–1988
15. Schneider WJ, Politis GD, Gosain AK, et al. Volunteers in plastic surgery guidelines for providing surgical care for children in the less developed world. Plast Reconstr Surg. 2011;127:2477–2486
16. Maine RG, Hoffman WY, Palacios-Martinez JH, et al. Comparison of fistula rates after palatoplasty for international and local surgeons on surgical missions in Ecuador with rates at a craniofacial center in the United States. Plast Reconstr Surg. 2012;129:319e–326e
17. Robinson OG Jr. Humanitarian missions in the Third World. Plast Reconstr Surg. 2006;117:1040–1041
© 2015 American Society of Plastic Surgeons
18. Campbell A, Sherman R, Magee WP. The role of humanitarian missions in modern surgical training. Plast Reconstr Surg. 2010;126:295–302