This report originally appeared in the December 2010 issue of DOTmed Business News

The Venezuelan woman spent more than half a century with a cleft palate. When she arrived at the country's Operation Smile site, Dr. Ruben Ayala, then a mission coordinator with the organization, couldn't help but wonder why the woman felt the need to get the surgery after 60 plus years.

"'I just want to be like any other woman, feel pretty and be able to wear lipstick,'" Ayala recalls the woman saying.

After the surgery, the female volunteers at the site pooled their beauty products together as a parting gift for the woman with a new smile.

"I think she has enough cosmetics to last a lifetime," jokes Ayala.

As someone who has moved through the ranks of Operation Smile, Ayala, now a medical officer, has accumulated a collection of cases showing the conversion through charitable surgery of misery into joy.

Ayala first encountered Operation Smile as a 17-year-old boy in Panama. One morning, he walked into a local hospital to serve as a translator for the American surgeons who were there to perform cleft procedures. He found himself surrounded by hundreds of children with cleft lips and palates, a powerful experience that led him to question the intentions of Panamanian physicians.

"I was very, very upset about seeing so many children who had not received any care. I judged my countrymen very harshly. I wondered what our physicians were doing and why these kids weren't being taken care of," he says.

Through scholarships, Ayala was able to attend college in the United States but ended up returning to Panama to serve as a translator for Operation Smile. As he walked out of the OR one day, the organization's staff leader asked him to join the team.

"It took me a microsecond to decide," he says. "It was certainly one of the happiest times in my life."

By the time Ayala was 22, his faith in Panamanian physicians was restored: he witnessed the first surgical mission carried out by local medical professionals. It was a moment of "incredible joy" for Ayala, a realized dream capturing the philosophy of Operation Smile - establishing local sustainability.

Restoring smiles
Operation Smile was born in 1982 when Dr. William Magee, then a young plastic surgeon, traveled to the Philippines with his wife to repair children's cleft lips and palates. When it was time to leave, hundreds of children still needed help. The dedication to the work stuck when the couple returned to the U.S. and today, Operation Smile has a presence in more than 60 nations and works in more than 30 countries worldwide.

Operation Smile bases its work on three models. The first, international medical missions, that bring physicians from countries like the U.S. to perform cleft surgeries in developing countries. The second the local medical missions that employ local physicians through partnerships and strive to develop an infrastructure to enable local entities to sustain the work. The final the comprehensive care centers, which provide services for patients year-round and offer some reconstructive surgery procedures. So far, the organization has established eight centers in seven different countries, with plans to establish two more in Ethiopia and India.

Last year, Operation Smile carried out more than 175 medical missions around the globe, treating more than 16,000 children. Two-thirds of the missions were completed through the local medical mission model, a top priority for the organization, says Ayala.

Through its missions, Operation Smile strives to go beyond just providing surgical procedures. It aims to deliver "a full package" by working with the in-country medical and non-medical team, explains Ayala. The organization focuses on creating legal entities and boards of directors and engaging with local business and social leaders. By working out logistical details and providing support, Operation Smile seeks to build a strong enough infrastructure to continue the medical mission after the team leaves the country.

The majority of the organization's funding comes from individual contributions and 10 percent stems from corporate donors.

The organization encourages both medical and non-medical volunteers to contribute their time and skills to its efforts - last year, more than 6,000 people did. Still, the need for more surgeries is overwhelming. Children with cleft conditions in regions of Sub-Saharan Africa, India and China are awaiting help, says Ayala.

For Ayala, the mission of Operation Smile is at the root of his life's work.

"For me, when I went to medical school, it was very simple why I wanted to do it," he says. "It was because I wanted to come back with Operation Smile as a physician and hopefully put a little of my energy and my life into something that is worthwhile. I don't think many people get the chance to realize at the age of 17 that it's what they want to do."

Help for Haiti
While Operation Smile works with children, the global need for cleft procedures for people of all ages is extensive. Dr. Seth Thaller, chief surgeon and professor, division of plastic surgery with the University of Miami Health System, knows that Haiti, the poorest country in the Western Hemisphere, is no exception. He has completed several charitable medical missions to the country, accompanied by a team of about 18 to 25 professionals and medical students.

Right after the devastating earthquake shook Haiti in January, the university's medical school sent physicians to offer assistance. They worked in tents set up as makeshift hospitals. This January, Thaller's team plans to take another trip to Haiti, where the team will concentrate on performing cleft lip and palate surgeries.

Project Medishare, a nonprofit organization founded by two doctors with the university's medical school in 1994, helps spread the word about the arrival of the surgical mission, a trip the physicians attempt to make on a quarterly basis, says Thaller.

Approximately 60 to 100 Haitians flock to Port-Au-Prince in hopes of getting surgeries when the mission is in town. After a triage process, about 20 to 40 people are chosen to undergo the procedure.

"Sometimes what we'll do if the patient is too young or doesn't look healthy enough is schedule them for the next trip or to come down for an evaluation for the next trip," says Thaller.

During one of the missions, a Haitian man in his thirties with a wide cleft lip traveled down to the capital from the mountains to see the surgeons. For most of his life, he avoided seeing his reflection. Taking the man's long journey into consideration, the doctors operated on him that night.

"The next day he got a mirror and he looked at himself for the first time and cried," says Thaller.

When in Haiti, the surgeons work long hours, with the missions usually lasting four days. The procedures are carried out in Haitian hospitals and spending any more time would take away from other procedures that need to take place in the few available operating rooms.

As for supplies, the medical mission team brings "everything," says Thaller. The surgeons are currently working with Project Medishare to enhance the infrastructure of a hospital in Port-Au-Prince in hopes of reducing the need to stuff their suitcases with medical supplies.

Much of the funding for the missions comes from fundraising by the university's medical school students and grants from entities such as the Plastic Surgery Education Foundation, the research and philanthropic arm of the American Society of Plastic Surgeons. Sometimes, the physicians pay for their own flights or lodging.

Close supervision of residents and the inclusion of students into the trips are vital features of the university's medical missions.

"Students have to be educated in giving back. When I'm too old to go, you want to make sure that somebody's gotten the bug," says Thaller. "I think every one of the medical students we brought has taken something back with them."

The training of local surgeons, anesthesiologists and nursing staff is another critical component of the mission. Thaller says he is committed to working with the Haitian medical professionals he's been training and the local authorities he's met on the trips, until his services are no longer needed.

"Our goal with our charitable missions is to put ourselves out of business," he says.

Shaping Guatemala
Another group of medical professionals is focusing its charitable efforts on a different part of the world - Guatemala, the most populous country in Latin America.

Plasticos Foundation, a Huntington Beach, Calif.-based nonprofit organization, is working to establish a plastic and reconstructive surgery training program for local surgeons and an innovative business model to increase the number of procedures.

Dr. Larry Nichter, the foundation's president and founder, has been on more than 50 medical missions around the world, training surgeons and performing surgeries on children with burns or birth defects.

Early in his career, he realized that although many charitable organizations were doing good work abroad, they didn't place enough emphasis on training local medical teams.
Throughout his travels and research, Nichter found that plastic surgeons in Guatemala are trained outside the country and return to practice mostly in Guatemala City, leaving more than half of the nation's indigenous population without care. There are no recognized Plastic and Reconstructive Residency training programs in the country.

His response to the problem came along in 1997, when he established the Plasticos Foundation with the goal "to make people self-sufficient," he says.

Today, the organization takes two to three trips abroad annually. In early fall, it conducted the first Advanced Plastic Surgical Symposium for all of Guatemala.
However, there are challenges to overcome.

"[Plastic surgeons] make enough that they can afford a car and a small apartment but not much else," says Nichter. "The amount of money that's available to treat these patients at the Social Security hospital is extremely small."

Dr. Ernesto Cofiño, chief of plastic surgery for Instituto Guatemalteco de Seguridad, the country's largest hospital, currently has a waiting list of more than 250 patients. Private facilities don't fare much better.

"The doctors can't afford to provide their services in private clinics because there's no one to pay for it," says Nichter.

To not only cultivate the interest of surgeons in reconstructive surgery, but also to enable patients to pay for it, Nichter is looking to Dr. Muhammad Yunus' concept of a social business model. Yunus, an economist and winner of the Nobel Peace Prize, is the founder of Grameen Bank, a microfinance organization that began by making small loans to the impoverished in Bangladesh and is currently doing so throughout the world.

Based on Yunus' model, Nichter intends to have Plasticos Foundation start a microfinance project for surgery in Guatemala.

"No one has ever really done a pure [microfinance] model for surgery that I know of in the entire world," he says.

The goal is to have microloans available for patients who are in need of surgeries. Once they undergo the procedure and get back into the workforce, they would then pay back the loan with a reasonable amount of interest. The Plasticos Foundation is looking into carrying out feasibility studies to determine how the system can work best.

"The key is to have feasibility studies to see how much people can pay back in a period of time with some amount of interest, which would eventually build enough money to be loaned out to others," says Nichter.

"We're really trying to get to the next step of leveraged care and trying to figure out how we can create entities that will be never-ending," he says.

Complex cases at home
Although many surgeons choose to contribute their time and expertise abroad, some physicians work to address the needs of the people here at home.

Dr. Munish Batra grew up in a small village in India but is now a plastic surgeon on the West Coast. He spent some time working abroad but recognized the need for charitable surgery in his own community. In 2002, he co-founded Doctors Offering Charitable Services, an organization of about 10 surgeons.

"People definitely need surgeons [abroad] but they also need surgeons to take care of people here," says Batra. "In Southern California, we tend to see a lot of Mexican immigrants that don't have insurance and they just get pushed aside. My feeling has always been that I'm really fortunate to be where I am and I have no reason not to give back."

The surgeries the organization takes on tend to be very complex in nature, oftentimes requiring six to seven different stages, explains Batra. So far, DOCS has performed approximately 40 cases.

Ian Grado was the organization's first case. He was a 21-year-old Marine stationed at California's Camp Pendleton when during a heavy rainstorm, the car he was in drove off the road, flipping over several times before coming to a stop. Grado sustained serious spine trauma that left him paralyzed and severe craniofacial damage, resulting in deformities of his face and skull.

After months of rehabilitation and multiple surgeries, Grado regained control of his limbs. However, the consequences of the accident were still visually evident. Grado was able to receive help from DOCS when he came to see Batra.

"I was in the military and he was a military serviceman, so I had that kind of connection with him," says Batra. "He was basically turned away by the VA hospitals because of the complexity of his reconstruction."

Years after his reconstructive surgeries, Grado continues to be a huge DOCS supporter.

In May, the organization got a taste of national exposure. The Oprah Winfrey Show ran a segment that featured Batra and Dr. Michael Halls, the two founders of DOCS. The show highlighted another complicated case the surgeons took on - that of Ana Rodarte, who was born with neurofibromatosis, a genetic disorder that causes the growth of large, benign tumors on the body.

When DOCS met Rodarte, she couldn't see out of her left eye and had difficulty speaking, eating and breathing due to the large tumor on her face. It took nearly four years and seven major surgical procedures to free Rodarte of the tumor and its associated complications.

DOCS' portfolio is filled with such cases. The surgeons operated on a 41-year-old woman with fibrous dysplasia, a disease that causes bony tumors to appear on the face and skull. They helped save a 27-year-old man from having to undergo an amputation of his arm after a car accident by transferring nerves and muscles from his back to his arm. In another case, the surgeons performed complete reconstructive jaw and facial nerve surgery on a 27-year-old woman, who was shot in the face and shoulder with a shotgun.

To perform the lengthy procedures, DOCS makes arrangements with hospitals. For example, the organization currently has a breast cancer survivor in need of surgery.

"[This patient] falls through the cracks because she's not poor enough to apply for community assistance," says Batra, "but her house is in foreclosure, she lost her insurance and her job and she needs her breast reconstructed because it's painful and gives her problems."

Since October is National Breast Cancer Awareness Month, DOCS approached a hospital pointing out the good publicity the story could generate and was able to secure OR time to do the procedure.

For other cases, DOCS may use future referrals as leverage for the pro bono use of the facilities.

"The hospitals will kind of see what benefit they'll gain out of it, so we negotiate," says Batra.

A lot of financial support for DOCS comes from the patients in the surgeons' plastic surgery practices. Batra also donates 5 percent of his annual salary to the organization.

Restoring faces
While DOCS takes on complicated cases, another U.S.-based organization focuses on helping women who were victims of domestic abuse. Started in 1992 through a partnership with the National Coalition Against Domestic Violence, Face to Face offers reconstructive surgeries to women who were disfigured by abusive partners. The organization is the humanitarian arm of the Education and Research Foundation for the American Academy of Facial Plastic and Reconstructive Surgery.

"Unfortunately, when a lot of women [are in] an abusive relationship, they usually don't work, they're very controlled by their aggressor," says Dr. Andrew Jacono, the organization's national chairman. "They don't have money or even health insurance to get treated, even though they may be very disfigured."

The organization completes about 150 to 200 charitable surgeries per year and approximately 400 surgeons offer their expertise.

As an initial qualifier for the surgery, a woman must be completely separated from her partner for at least a year, often enlisting the help of resources offered by the National Coalition Against Domestic Violence to accomplish this.

However, a complete separation from an abusive partner is not a guarantee for the surgery.

"Just because somebody has a problem in terms of disfigurement doesn't mean that it can be well-repaired or healed," says Jacono. "It depends on what you start with - there may not be a lot of surgical options. We don't just do surgery for the sake of doing, we do it because we know we can make the difference."

And the disfigurements tend to be severe.

"Pretty much anything you can imagine could happen with a baseball bat or a sharp object," says Jacono.

For Jacono, the work of Face of Face is some of the most gratifying in his practice as a plastic surgeon. Public awareness about the available help is key he says, as the organization strives to help women put their abusive past behind them.

Challenges & benefits
The underlying challenge of pro bono surgery boils down to one factor - money.

At board meetings, the Plasticos Foundation often debates what regions of the world it should go to next, as capital is limited.

"We have a waiting list of countries that we'll never be able to afford to go to," says Nichter.

Between the cost of flights and supplies, a trip for a team of 16 people adds up to $40,000 to $60,000. Fortunately, the advent of the digital age has enabled the Plasticos Foundation to shave off a few days from its missions. E-mail and digital photos allow doctors to partially screen patients before they arrive to the site and determine what supplies are most critical.

Although the missions are financially burdensome, it's impossible to place a monetary value on the significance of restoring a normal life to a child or the personal rewards for those who choose to go on medical missions.

"At times, these trips become almost addicting for participants. They come back with this new appreciation. We go to places where people don't travel to," says Nichter. "I cannot tell you the number of times I've heard people say that their lives have been changed by a single trip by changing forever the lives of others."

Operation Smile's Ayala recalls meeting a man in the Philippines, who had two sons with cleft lips. His wife had just passed away and he promised her that he would take care of their children. The man went back to his hometown to bury his wife. After his two sons underwent their surgeries, Ayala asked the man how he felt.

"He said to me, 'I feel great. I just wish my wife could see our children now,"' says Ayala. "Somehow, I have to believe that his wife could."