The evolution of volunteer plastic surgery

Over the past 3 decades, volunteer plastic surgery has evolved into highly specialized training programs geared toward bringing a specific aspect of plastic surgery to the region or hospital in need.

In the 1960s, through various charity programs, physicians and nurses began to be sent to developing world countries. The aim was to treat basic conditions like cleft lip and cleft palate in areas where there was no access to medical care.

Many of the American-trained plastic surgeons received their first exposure to volunteer medicine during their years in residency and continued their passion by starting their own programs in the 1970s and 1980s. However, as the number of visiting teams to developing world countries increased, the host countries began to question the “real need” for the visiting international teams in rural areas that had no hospital amenities or any knowledgeable physician to provide the aftercare of the patients.

In the 1990s, most of the volunteer teams would arrive at a local town and spend the first 1 or 2 days screening hundreds of patients. Usually the patients with the simplest problems would be selected, and the attempt would be made to do as much as possible on the patients since it was unclear if they would ever return again.

The end of the 1990s and the new millennium brought an intense level of scrutiny to the “metrics” of how much good the visiting teams were really bringing their host countries. With the evolution of technology in the new millennium, it became possible to coordinate the care of surgical patients so that they could be scheduled and followed with the help of host surgeons and the Internet. For example, local physicians in Mandalay, Myanmar, could obtain and share photographic information about their patients and send this information via the Internet to portals like The Smile Train (www.smiletrain.org), so that American physicians at a cleft conference in the Mandalay Bay hotel in Las Vegas could analyze and evaluate the benefits of their last volunteer visit.

This was an important step in the need to change the approach of volunteer plastic surgery, because it forced the visiting teams to recognize the need for outcomes research evaluation. The inevitable result of this change meant that visiting teams would now have to think longer-term than they had previously.

It was also important because it allowed us to bring the techniques and the knowledge that helped us really equalize the information gap. We will review the major developments that have enabled these changes.

Surgical Outreach Programs
Interplast (www.interplast.org) began more than 30 years ago as an organization that provided cleft lip and palate treatment in developing countries. During the past decade, international humanitarian organizations such as Interplast have evolved from being providers of direct care by medical volunteers—usually in the form of surgical trips to developing countries—to a focus of education, empowerment, and self-sufficiency of local surgeons and other medical staff who are committed to helping the impoverished in their own communities.

One way this focus has been realized is through permanent, year-round surgical outreach programs. Interplast now has eight such programs and supports each site through advanced medical training, quality review, technological support, and funding. Many of the programs evolved over a period of years, with volunteer surgical teams building both relationships and the level of the host team’s expertise, and supplementing such training with visiting educators and international fellowship programs.

Addressing Secondary Cleft Palatal Fistulas in Developing Countries


A cleft palate fistula before and after reconstruction.

During our visits to developing countries, we invariably encounter numerous children who have had multiple failed attempts at cleft palate repair. These children present with large palatal fistulas with scarred beds. Microsurgical free tissue transfer would be the procedure of choice for these difficult cases, but it is ruled out by the lack of supportive equipment for microsurgery in many of these countries.
As an alternative, we have successfully used facial-artery musculomucosal flaps. These are reliable, axial-pattern musculomucosal flaps that can be mastered by the host surgeon during one visit and are preferred because they bring similar tissue from an untraumatized region of the mouth.

The operation is done in a single stage and has proven to be extremely versatile and reliable in our experience with more than 30 patients in this setting. Best of all, host surgeons are now using this new approach on these difficult patients.
—KA and TD

This approach has met with great success in areas where native plastic surgeons are dedicated to expanding the spectrum of procedures available at their hospitals and to providing care for those who have no other access. In addition, groups like The Smile Train have provided financial support, educational assistance (conferences and procedural videos), and auxiliary tools (such as electronic medical records and libraries) that will help build the infrastructure of the specialty reconstructive surgery clinics in developing countries.

Focus: Interplast in Nepal
In 1986, Interplast began sending volunteer surgical teams to Nepal, where they met Shankar Man Rai, MD. After providing several years of advanced medical training and developing a partnership with Rai, Interplast initiated its first surgical outreach program with him in 1999. Rai assembled a team of local medical professionals to provide free surgeries, speech therapy, and other medical services year-round in Kathmandu and the underserved regions of rural Nepal.

In its first 3 years, this surgical outreach center treated more than 3,000 patients—more than 10 times the number that could have been treated through volunteer direct service trips to that location. It demonstrated that Interplast could dramatically expand access by directing more resources and support to locally managed programs.

Focusing on sustainability and self-sufficiency—training local medical professionals and providing them with more resources as an alternative to service trips of volunteers from the West—proved especially valuable in light of Nepal’s current political situation, which prevents many US volunteer groups from entering the country.

Today, Interplast provides support for eight similar surgical outreach centers in seven countries. This is a concerted global humanitarian effort to uplift the lives of underserved children everywhere by increasing year-round access to medical care and creating medical independence.

Visiting Educators
Interplast has been in the forefront in the new paradigm of providing medical education as its primary mission. Its Visiting Educator Program sends experts in specialized areas of plastic surgery to work with experienced surgeons in other countries to teach the treatment of specific problems or diseases. Past trips have included hand surgery, burn reconstruction, secondary cleft pal­ate surgery, and total ear reconstruction.

Transitioning from a surgical outreach program to the Visiting Educator Program assumes that host surgeons have mastered the care of simple primary operations such as cleft lip and palate and are now eager to learn how to take care of complications such as complex burn contractures or cleft palate fistulas.

Prior to the visit, an initial survey of the number and case mix of patients is performed. The survey is followed by a visiting educator workshop geared toward a low volume of cases but a high quality of education; volunteers and local medical professionals collaborate in setting objectives to meet the needs in their specific communities. Many of these workshops take place at the surgical outreach centers, but they may also occur at other sites where more training is needed to move the facility to the medical independence level of a surgical outreach center.

Very small teams of volunteer educators—sometimes just one volunteer plastic surgeon who specializes in a needed topic—provide direct, hands-on training and lectures for local physicians in the required subject. This builds the supply of trained physicians who are dedicated to offering aid in their own communities.

Most workshops last 1 week, but the training does not stop when the visiting educators return home. Innovative Web-based technology allows surgery training to continue after the visiting educator workshop. It also allows future cases to be reviewed for quality and safety assurance by experienced volunteer surgeons in the United States and Canada.

We performed one such mission with Interplast in November 2005. The focus of this undertaking was on complicated burn contractures, large palatal fistulas, and large head and neck defects. Given that there was no access to microsurgical instruments, we elected to perform regional flap procedures to cover the defects. We also taught the local surgeons the versatile bilateral facial-artery musculomucosal flap technique for coverage of wide cleft palatal fistulas and the use of local fasciocutaneous flaps for coverage of burn contractures.

The Visiting Educator Program is creating virtual teaching hospitals around the world by sending experts in crucial procedures to the most important audience: surgeons and physicians working in their own communities to benefit the poor. Providing advanced training and support for local physicians helps ensure that more impoverished children will receive the life-changing surgery they need for years to come.

Focus: Interplast Myanmar
One recent Visiting Education Program sent Lawrence Gottlieb, MD, of Chicago and a team of physicians to Mandalay to work with host physicians who were fully trained and experienced plastic surgeons. The trip focused on the advanced reconstruction of burn, head and neck, and cleft palate patients.

Gottlieb described the teaching focus of the trip: “Mandalay sees a lot of head and neck cancers in young people from chewing beetlenut leaves, which are highly carcinogenic. Mandalay has many excellent plastic surgeons that are trained in these reconstructions, but doing several cases over 2 weeks, accompanied by detailed discussions, gives the surgeons a better comfort level in these cases.”

International Fellowship Programs
The final step of “leveling the playing field” for the host program is to instill the concept of multidisciplinary care that is prevalent in the West. In many countries, the local surgeon is extremely capable and dedicated, but is limited by the facilities and circumstances of the hospital.

The transition to multidisciplinary care requires education; and international fellowships, such as the one offered by the American Cleft Palate–Craniofacial Asso­ciation (ACPA, www.acpa-cpf.org), have been established to bring health care providers to the United States so that they can not only learn the technical aspects of their field, but learn how to establish a multidisciplinary care team that benefits specialists and patients alike.

ACPA established its visiting scholar program to identify and select individuals with the potential for establishing or directing an interdisciplinary team located in its members’ home practice localities for the comprehensive management of individuals with craniofacial anomalies. The program is in its 12th year; it has been made possible through a generous grant from a leading medical-device manufacturer.

ACPA members recommend candidates and coordinate several aspects of the scholar’s visit. Visiting scholars are hosted by three cleft and craniofacial teams, each with distinguishing features, for 1 week at a time to witness how a team functions logistically, how members from the different specialties interact, how patients are followed, and how care is coordinated among specialties. In addition, the visiting scholar attends ACPA’s annual meeting for a wide range of participation in scientific sessions and networking events.

Scholars and host centers find their scientific and cultural exchanges immensely rewarding, and the program remains highly sought-after by scholars interested in delivering cleft and craniofacial team care in un­derserved areas at home. For more information, please visit [removed]www.acpa-cpf.org/news/vsp.htm[/removed]

Teaching to Learn
Volunteer plastic surgery is beneficial not only for the host providers and patients, but for the visiting physicians as well. Just as competitive athletes have to cross-train to avoid getting “stuck” when performing the same exercises and moves, surgeons must go beyond the normal routines of their practices to challenge their minds and training. They need to consciously step into situations where they face great unknowns and use their knowledge and intuition to perform.

Surgeons can truly become students again to learn from their environment instead of trying to control it. With each trip that we have made, our intention has been to provide care for the local population and to teach the local providers what we know in patient care. But each and every time, we have learned more from the humility and humanity of our host providers and patients. Ultimately, that is why we keep going back.

Kaveh Alizadeh, MD, FACS, and Thomas Davenport, MD, are partners in the Long Island Plastic Surgical Group (Garden City and West Islip, NY, and New York City), the largest and longest continuously running plastic surgery practice in North America. They have more than 20 years’ combined experience of volunteer service in 20 countries as diverse as Bolivia, Iran, and Nepal. Davenport was the recipient of the prestigious Webster fellowship in reconstructive volunteer surgery from Interplast in 2000; Alizadeh received a competitive training and educational grant for volunteer cleft surgery from The Smile Train in 2003, and he has served as an adviser for several medical nonprofit organizations. They can be reached at [email protected] or [email protected]