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A Model Humanitarian Cleft Mission: 312 Cleft Surgeries in 7 Days

Background: There are many countries in the world where patients with cleft lip and palate cannot get access to specialized cleft care units. Cleft missions play an important role in providing surgical care to the areas of the world with limited resources. This article presents a model of cleft missions that can be adopted in many countries where expertise is available but resources are limited. Through proper utilization of local human resource, this type of mission can be a cost-effective and robust way of treating patients with cleft in countries with approximately 52% of the world’s population. Methods: We present a case series of patients of one of our cleft missions carried out in Khairpur, Pakistan, in March 2014 over a period of 7 days. Specific details concerning the organization of mission, gathering of patients, preparation for surgery, and carrying out surgical procedures in a safe and swift manner are presented. Results: A total of 312 patients were operated on in 7 days. There were 145 patients with cleft lip and 167 patients with cleft palate. There were 187 male and 125 female patients with mean age of 7 years. Contemporary operative techniques were utilized to repair different types of cleft lip and palate. Of 167 patients, only 16 developed fistula. Conclusion: A locoregional cleft team can be more effective to care for the patients with cleft in countries where surgical and other expertise can be utilized by proper organization of cleft missions on a national level.

derdeveloped regions of the world. 4 It helps to immediately fix the cleft lip and palate problems of a high number of patients in a short period of time, transforming them from the disabled to enabled members of the society. 5 Various organizations all over the world are carrying out cleft missions in such countries, but channelizing their efforts to get maximum benefit of the endeavors is the need of the hour.
Since 2004, our team has conducted 130 cleft missions, including 4 international missions. The first mission comprised 5 team members, which included 2 surgeons, 2 operating room (OR) assistants, and 1 coordinator, and a total of 63 cleft surgeries were performed in a short span of 7 days. Ever since, the team has been regularly operating upon patients with cleft at different hospitals in remote areas of Pakistan and Afghanistan. Over the years, the team evolved and grew in size through training and induction of new team members in surgery, anesthesia, OR, recovery, nursing care, and follow-up departments. Procedures and protocols have also been developed resulting in improved surgical outcomes and more cost-effectiveness.
This article presents a model of a cleft mission for performing quality surgical procedures within limited period of time. This model can be easily adopted in countries where surgical expertise and ancillary services are available, but the burden of cleft lip and palate is quite significant. Such countries represent 52.2% of the world's population 6 and locoregional teams and, when properly developed, can adopt the presented model to effectively address the stigma of cleft deformity in a more cost-effective way as compared with routine international missions.

MATERIALS AND METHODS
Under the auspices of Cleft Lip and Palate Association of Pakistan, a cleft mission was arranged at the Civil Hospital, Khairpur, from March 25 to April 2, 2014. Khairpur is capital of the Khairpur District in Sindh province of Pakistan. A Public Awareness Campaign was started 4 weeks in advance. Banners and posters with pictures of cleft lip and palate were affixed in adjoining districts; handbills were distributed while radio and cable TV were also used to disseminate information among the general public. Advertisements were also published in the local newspapers. A total of 467 patients with cleft reported at the outpatients' clinic who were examined by the plastic surgeon and the anesthetist according to criteria mentioned in Table 1. Patients found suitable were scheduled for surgery. This examination and screening process was carried out from March 25 to 28, 2014.
All the equipment required to set up fully functional operation theaters was brought in from cleft center in Lahore, about 300 miles away. It included operating tables, anesthesia and diathermy machines, cardiac monitors, pulse oximeters, operating instrument sets, emergency equipment, and all other necessary medicines and surgical items. The equipment and medicines were packed in wooden containers to be wheeled down into the van. Six operating tables were set up, 3 each in 2 ORs. Large-sized oxygen cylinders were connected to the anesthesia machines. Pulse oximeters and cardiac monitors were also set up for each operating table. Emergency medicine trays were always kept ready in the OR and wards as well.
The total number of personnel involved and their responsibilities are detailed in Table 2. There were 4 anesthesiologists, 2 in each room, to look after 6 operating tables. There were 5 surgeons to operate on patients with cleft. The sixth table was used to get the next patient with cleft ready. Each OR had 2 anesthesiologists, 3 surgery assistants, 1 anesthesia paramedic, and 1 circulating person to facilitate the team members. One paramedic was responsible for swift provision of sterilized instruments for surgery. After the surgery was completed, the patients were immediately shifted, with the endotracheal tube attached, to the recovery area where extubation and smooth recovery was allowed. The recovery area was taken care of by a paramedic with extensive experience of over 25 years in pediatric and adult anesthesia. He was assisted by another paramedic and supervised by anesthesiologists. Meanwhile, the next patient with cleft was brought to the operating table and intubated. No time was wasted during this changeover saving at least 30 valuable minutes between 2 surgeries. To reduce fatigue and physical stress, all surgeons used adjustable chairs while operating.
Extubation in the recovery room on average takes 35 minutes. When fully in senses, the patients were shifted to the wards, where our trained nursing staff looked after them. The patients remained in the ward overnight under the supervision of a doctor from the team and discharged the next morning if the doctor deemed appropriate. Training on postoperative wound care and food restriction was administered by the specialist nurses. Patients were given 1-page instructions in the local language for postoperative care and follow-up.
Anesthesiologists and surgeons resided in a nearby hotel with travelling time less than 20 minutes while the rest of the team stayed in the hospital. Surgeries commenced at around 9:30 am and continued till 11:00 pm every day. Every day at the end of all surgeries, 1 surgeon and 1 anesthesiologist carried out the round of all patients operated on during the day to find and rectify any problems.

RESULTS
A total of 312 patients, both male and female, were operated on in 7 days, including 145 patients with cleft lip and 167 patients with cleft palate. The age ranged from 3 months to 69 years with a mean age of 7 years. Further details of surgeries performed are shown in Table 3. A variety of different types of primary and secondary cases of cleft lip and palate were operated on, as shown in Table 4. Contemporary techniques of repair of cleft lip and palate were applied during the surgery to obtain satisfactory results. Table 5 summarizes the surgical procedures used. Figures 1-7 show some of the preoperative and postoperative results.
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.

DISCUSSION
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 Unilateral complete cleft palate 2 flap palatoplasty with levator dissection and retroposition 7 Bilateral complete cleft palate 2 flap palatoplasty with levator dissection and retroposition 8 Secondary cleft palate (short) Pharyngeal flap with levator dissection and retroposition 9 Secondary cleft palate (fistula) Closure of the fistula with re-repair of the palate  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   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.

CONCLUSIONS
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.

PATIENT CONSENT
Patients or their parents or guardians provided written consent for the use of the patients' image.