Plastic surgeons on humanitarian missions to less fortunate countries find that they can improve many people’s lives—including their own
Humanitarian plastic and reconstructive surgery missions in underprivileged countries require a high level of commitment and a team approach. The goals of many philanthropic organizations are to offer free reconstructive surgery to people—mostly children—in developing nations, and to help improve the state of health care in these countries. Surgeons are recruited not only to perform surgery, but to train host-country physicians and set up continuing educational programs.
In the past, surgeons would apply the techniques they were familiar with, and the nature of the surgery performed was less well defined in terms of surgical disciplines. The work that was performed was more general, rather than specialized, surgery. A surgeon would treat the patients who appeared at the clinic or hospital, assuming that he or she had the necessary experience and skills.
As surgery has become more specialized, so has the scope and size of humanitarian missions. Plastic surgery is well suited to the management of disease conditions found in developing countries, such as congenital malformations of the face or limbs, skin problems associated with burns and tropical diseases, various tumors, and traumatic injuries.
Even when performed for humanitarian reasons, plastic surgery should address the aesthetic dimension. Although the patient’s needs, in many cases, may be more functional than cosmetic, surgeons who thrive on participating in missions perform surgery with a view toward achieving an aesthetically pleasing result.
Regardless of geographic boundaries, one cannot underestimate the life-altering effects of a cosmetic improvement for all patients, especially children. It is often as important to the patient as the functional outcome in terms of his or her place in society.
These children are shunned by their communities because of their physical defects. Repairing a cleft lip in a little girl could be viewed as reconstructive surgery or as aesthetic surgery—reconstructive because it involves a repair of the lip muscles, but aesthetic because it involves her outward appearance.
Following a Legacy
Plastic surgery has a long tradition of doing good work. One of the founding fathers of aesthetic plastic surgery, Thomas D. Rees, MD, is the sole surviving founder of the African Medical and Research Foundation (AMREF; www.amref.org) and its Flying Doctors service.
During his first trip to Kenya in 1956, along with his colleagues Michael Wood, MD, and Sir Archibald McIndoe, MD, Rees came up with the idea to offer specialist health care and reconstructive surgery in remote areas of East Africa, and the Flying Doctors of East Africa was born. AMREF still provides air rescue service and emergency evacuations to disadvantaged people, and offers training to improve their health care.
Today, reconstructive surgery missions are usually planned by voluntary organizations or humanitarian groups. These organizations may specialize in plastic surgery—Interplast (www.interplast.org see the article on page 62) is an example—or they may include plastic surgery as part of a wider range of projects—Operation Rainbow (www.operationrainbow.org) offers plastic surgery as well as orthopedic surgery.
The composition of the teams varies with the mission. There may be only one surgeon on the team if the host facility has all of the other personnel required. In some cases, a complete team may have to be assembled so that it can operate independently. It may include several surgeons, operating room (OR) nurses, anesthesiologists, and a liaison to act as the facilitator. Having two or more surgeons allows the team to work in two ORs simultaneously, or to have one surgeon assist the other in complex operations.
The disorders encountered may be far removed from the conditions seen in everyday practice at home. The range of procedures to be performed can be vast and can include hand surgery, burn-scar revisions, maxillofacial surgery, surgery to restore limb function, and closure of the abdominal wall after the removal of massive tumors. The congenital deformities most frequently encountered are cleft lip and cleft palate.
The conditions may be unusual and overwhelming. For example, congenital or tumor-related malformations tend to be seen at very advanced stages that are not normally encountered in private practice. The surgeon must be able to manage very different aspects of his or her specialty that may not have been encountered since residency.
William B. Riley, Jr, MD, a plastic surgeon in Houston and the founder of Operation Rainbow, explains his motivation for starting this organization in 1978. “As a visiting plastic surgeon on my first trip to a developing nation, I was completely unprepared for the desperate need that I would be confronted with. Each child dreamed of having a normal face, and each of the parents was praying for a miracle. I resolved to return the following year with my colleagues, and that was how Operation Rainbow was formed.”
To date, Operation Rainbow has treated more than 7,000 children all around the world and performs 10 to 12 missions every year.
Operation Smile (www.operationsmile.org) coordinates more than 25 mission sites in 24 developing countries to repair cleft lips, cleft palates, and other facial deformities, primarily in children. In many cases, the parents of these children are not even aware that their condition can be improved or repaired. Between 100 to 150 children are treated during a typical 2-week international medical mission.
Operation Smile’s medical volunteers work beside their local counterparts, training them to become self-sufficient. “We see thousands of children who have literally spent their short lives hiding in shame, and at the end of these missions they suddenly have a new life,” says William P. Magee, Jr, DDS, MD, of Norfolk, Va, Operation Smile CEO and cofounder. “The real power lies in the fellowship it creates between people of different cultures, races, religions, and nationalities.”
Overseas missions are certainly not for the weak at heart. There are no limousines, room service, or five-star luxury accommodations. The climate may be the tropics or the desert, and daily living conditions can be very crude.
A typical mission lasts for 2 weeks, and the hours are long. Volunteers are encouraged to prepare for the physical rigors of the trip as well as the emotional impact of working in this challenging environment.
The situations encountered will be very unfamiliar to most surgeons, because these missions typically go to countries where the need is greatest. That means geographic areas where the health care systems have limited infrastructure, training, supplies, and medications.
Although the surgical instruments required for plastic surgery are fairly compact and easily portable, the working conditions are quite different from what an American surgeon is accustomed to. The ORs may function poorly, power outages are frequent, sterilization facilities are unreliable, and the antiquated equipment is always in need of repair. There may also be lapses in administrative assistance and patient care, such as incorrect diagnoses, unprepared patients for surgery, incorrectly handled dressings, and the lack of any documentation.
Organizing a Mission
The mission director must be an experienced surgeon who can select the most reliable and simplest procedure in extreme situations. According to San Francisco plastic surgeon Timothy J. Marten, MD, FACS, founder of Operation Sunrise (www.operationsunrise.org), “The basic requirements for any overseas mission are that the authorities of the host country must agree to receive a team from abroad, that the necessary funding is available to ensure that a cohesive surgical team—including nurses and anesthesiologists—can be recruited, and that adequate policies and procedures are in place to ensure that surgeries are performed safely and that patients are appropriately cared for.”
Every mission requires the help and support of local medical and nonmedical personnel, and it must be carried out with the oversight of a local authority. Missions are usually organized under the auspices of the department of health of the host country, even when the mission is funded entirely from private donations and organized at a nonhospital facility. This makes obtaining visas and local permits much easier. The department of health may require certification and even a CV before letting a surgeon operate.
Maintaining a good relationship with the manager of the hosting hospital is also vital. There are usually some local formalities that make humanitarian missions run more smoothly in these countries. These can be in the form of gifts, bribes, equipment, and pharmaceuticals. Respecting local rules and institutions is mandatory. As a visiting physician, you cannot change customs that have existed for generations.
Employing someone to act as a liaison can be helpful to manage the day-to-day details and interface with the authorities in the host country. Having a dedicated person to look after the supplies and deal with the local representatives frees the surgeon from these activities, so that the medical team can devote more time to operating so as to treat the maximum number of patients. Each mission can treat only a limited number of patients. The hardest part of a mission is often deciding how to choose who is treated and who gets sent home.
Language barriers are a common difficulty. The patient’s history must be understood in the simplest way possible. Patients are managed with the consent of the local authority and with support from local practices. Surgeons cannot treat patients in a country without the agreement and the assistance of the physicians in that country.
For the visiting team to have patients to treat, the difficult cases have to be identified and selected by the local physicians. When a mission is completed, local physicians are needed to handle the patients’ follow-up.
On some missions, drugs and dressing materials tend to get lost or stolen. Making sure that patients get what has been prescribed can also be difficult. After the procedure, the patient’s mother will usually be the primary care provider. Just keeping wounds clean may prove to be an insurmountable task in some parts of the world where there is a shortage of clean water.
“Wherever our mission work has taken us, we have met many outstanding people along the way and have seen great skill and dedication. The local doctors and nurses have also provided the critical link between our surgical team and the patients and their families,” says Mary C. Heylin, RN, of San Francisco, a volunteer surgical nurse and director of OR services with Operation Sunrise.
“The teams in the host countries are usually very kind and extremely dedicated. They throw themselves into the work, and pay great attention to the nursing techniques demonstrated by visiting medical teams.”
Humanitarian missions are designed to provide an open exchange of ideas. One of the main purposes of a mission is the training of foreign colleagues in the techniques used in daily practice. Ideally, carefully selected simple and specific techniques are taught that can be practiced by the local surgeons. In most cases, the surgeons are trained at the local facility so that techniques can be tailored to the conditions encountered locally.
Physicians report that they prefer to teach one or two techniques that can be applied to the widest range of local patients. Some of the more advanced techniques may be too difficult to teach or to apply. The local physician also may not have the necessary tools available to carry out these procedures after the mission team leaves.
“Many of the children and young adults we treat through Operation Sunrise would otherwise live their entire lives with a physically and emotionally crippling disfigurement,” Marten says. Still, patients show great courage in having surgery. Just think of what it must be like for a little child from a small remote village to be brought to a clinic for the first time in his or her life. For many of these children, it will be the first time they have ever traveled outside of their village or been exposed to strangers.
“Imagine what must go through their heads when they see an operating light shining down on them and people moving around, speaking in a language they have never heard before. The experience can be terrifying for the children and their parents, and they are putting their faith in the visiting surgeons.”
Operation Restore Hope Australia Ltd (www.operationrestorehope.org) is Sydney plastic surgeon Darryl J. Hodgkinson, MD’s international charity mission that provides plastic and other specialty surgical services to children in the Philippines. “One of the stories of courage from our very special children is a little girl called Corazón who presented with a cleft lip deformity. Corazón was never treated because she suffered from a heart condition. This brave young girl was aware of the dangers of surgery. She told us that she was not afraid to die but that she wanted to go to heaven with her lip closed.
“Our surgical team was assisted by the local doctors to allow us to help Corazón realize her dream,” Hodgkinson says. “Corazón has now has been sponsored through our Operation Restore Hope for orthodontia and is getting schooling for the first time in her life. We are really proud of Corazón, who has gone from disfigured and waiting to die, to living every day constructively and to the fullest. She is just one of our many special kids from over the years.”
It is tragic to witness children’s lives that are devastated by birth defects, disease, or disfigurement. Medicine can add years to their lives; plastic surgery can add life to these years.
“Reconstruction of a congenital facial birth defect is one of the most gratifying of all surgeries. The transformation of young, shy children into proud, self-confident children is truly amazing,” says Thomas Romo III, MD, president of the Little Baby Face Foundation (www.littlebabyface.org) and a facial plastic surgeon in New York City. “Having the opportunity to give a disfigured child new hope gives new inspiration to surgeons as well.”
For anyone who wants to do his or her part, there are many ways to contribute. Each humanitarian organization is in desperate need of funding, so every contribution counts. Donations can be made online and by mail, and many organizations can accept stock certificates and airline mileage as well. Medical supplies, suture kits, and basic equipment are also greatly needed.
Another way to participate is to host an event, such as a luncheon or reception, in your community and invite your patients. The proceeds can be sent to the organization of your choice. Your support can help provide the resources needed to help children and young people worldwide have better lives.
Of course, the ultimate way to participate is to volunteer for a mission in the United States or abroad. Instead of spending another 2 weeks dealing with demanding aesthetic patients, you may find tremendous satisfaction in offering your surgical skills to people who are truly in need. In the time it takes to suction one pair of thighs or perform a lower blepharoplasty, you can literally transform a child’s life forever.
Most surgeons who volunteer agree that the rewards far outweigh the sacrifice. You will not regret it.
Wendy Lewis is a contributing writer for Plastic Surgery Products, author of America’s Cosmetic Doctors (Castle Connolly), and the editorial director for MDPublish.com, a medical marketing and publishing group. She can be reached via her Web site, www.wlbeauty.com.