From Minnesota with love, surgeons heal broken smiles, deliver hope

Volunteer doctors, nurses performing cleft lip, cleft palate surgeries

by Paul Chaderjian

Published: Saturday October 11, 2008

Yerevan - They came to Armenia from Minnesota and the Midwest - the American Heartland - on a medical mission. They came to heal those born with one of the most common birth defects around the world - cleft palates and cleft lips.

"Overnight we change people's lives," said volunteer Heidi Shafland, a pediatrics ICU nurse from Children's Hospital in Minnesota. "Many children with cleft lips or cleft palates don't go to school. They don't leave their house. They don't have jobs. They don't marry, and we can change someone's future overnight."

After more than a dozen hours of travel and little rest overnight, Ms. Shafland and 18 other volunteers from the United States - surgeons, anesthesiologists, nurses, coordinators, and medical record specialists - reported for duty at a local medical center last Saturday morning.

Ahead was a weeklong marathon of consultations, screenings, and back-to-back surgeries. Ahead were at least 250 patients to see and dozens of surgeries to perform.

"Since the screening process and through the end of the day Friday, we've completed 51 surgeries," said organizer Madlene Minassian, director of the Cafesjian Family Foundation's Health Outreach Program. "The surgeries have been extremely successful. It has been an amazing experience."
Smile Project

The Smile Project is the name of this collaborative mission led by the Cafesjian Family Foundation, Hope for the City, and the Smile Network International, in cooperation with the Arabkir Medical Center, Fund for Armenian Relief, Hand in Hand, Yerevan State University, and the ministries of health of the republics of Armenia and Nagorno-Karabakh.

"It seems that Armenia has been very proactive as far as actually taking care of these patients," said Dr. Raj Sarpal, a cardiac anesthesiologist from the University of Minnesota in Minneapolis.

The Armenian government offers a stipend to help underwrite the surgical costs to repair cleft lips and palates, but some families are not able to afford the incidentals or travel costs involved in cleft care. Some families said they did not know about the stipends. Others said they did not know these birth defects were reparable.

At least three families among those of the 250 patients screened this week had turned their children over to an orphanage because they couldn't feed or take care of them. One of those orphaned kids, a four-year-old boy, was one of the first children to be treated. He was reunited with his mother after surgery.

"We're not seeing a lot of older patients who've had unrepaired cleft palates or lips," said Dr. Sarpal. "In a lot of other countries we go to, we see a lot of older patients who haven't had the surgery."

Preparations for this medical mission began months in advance. The medical mission team was assembled by Minneapolis-based Smile Network International. The five-year-old nonprofit organization provides cleft care to children and young adults in developing countries.

These medical missionaries started their six-day visit with two days of patient screening, examining an average of 17 patients per hour. Patients with cleft care needs from all over the Republic of Armenia, Nagorno-Karabakh and the Javakhk region of Georgia had contacted or were contacted by the Smile Project; and after months of outreach through the medical community and Smile Project's media partners from CS Media and Armenia TV, the waiting rooms at Arabkir were filled to capacity with young and old patients with cleft-care needs.

"These trips are very rewarding because mainly you're taking a physical condition that's relatively simple to correct and in one-and-a-half, two hours, you're making a big difference," said Dr. Samir Mardini, a Mayo Clinic craniofacial and plastic surgeon from Rochester, Minnesota. "I think all of us who volunteer for these missions take off a lot of time from our jobs in order to participate. It is extremely rewarding. We get a lot out of it, almost as much as the patients get out of it."

On the first day of the screenings, there were so many families that the doors to one waiting room were locked with one nurse on each side, trying to control traffic.

In the main lobby of the Arabkir Medical Center, dozens of men, mostly dressed in black - in stark contrast to the nurses in white uniforms manning the information desk - waited in groups of three or four.

They waited without saying a word, hoping a loved one would come out of the screening with some encouraging reaction from the doctors from the United States.
World-renowned surgeons

Leading the medical mission on behalf of the Smile Network are doctors Les Mohler and Samir Mardini. They're known as two of the best cleft surgeons in the world. Dr. Mohler, now semiretired, is known for developing a cleft surgery technique that bears his name.

"We developed the Mohler technique in 1972 and didn't publish until 1987," said Dr. Mohler, "because I wanted to make sure I could follow the children and see that the result didn't change over the years."

Dr. Mohler, who averages about eight volunteer missions like the one to Armenia annually, said his technique is used in a cleft surgery to make a scar that mirrors an upper lip's natural dimple in the middle.

"In the mid-portion of the lip, we have what we call the philtrum," explained the surgeon. "On each side, you have a column. If you have a unilateral lip that's open, then I try to make the scar so that it will be a mirror image of a normal column. So, even though you have a scar there, it's in the correct position, and it basically creates that central portion of the lip that you want. There is no breakup in the line."

Before Dr. Mohler created his technique, surgeons used a zigzag line on the lip, which left a scar even though the lip was balanced.

"The scar was not acceptable," said Dr. Mohler. "By placing the scar in a position that will be a mirror image of the normal column, that's the advantage of the procedure."

Accompanying Dr. Mohler and running the second operating room this week is Dr. Mardini, who is referred to by some of his colleagues as "Magic Hands." Dr. Mardini has gone on 10 other missions like this one, and he believes cleft surgeries are challenging because surgeons can achieve very beautiful results if they do a great job.

"I think the closure itself is not so difficult," he said, "but achieving a good aesthetic outcome and good function is more challenging."
Smile Network

The Founder of the Smile Network, Kim Valentini, was also in Yerevan this week. The former schoolteacher said she travels the world as part of her current professional marketing and public relations career, and she created the Smile Network as a way to share her blessings.

"From a really young age, I was aware of the problem, how easily it is corrected, but how so often it goes uncorrected," said Ms. Valentini. ""As a mother, it seemed shameful to me that children would lead a life hidden away, ostracized, and sometimes left to die as a result of a birth defect that's so easily fixed. I think this is an opportunity for me to give back for those blessings that I've had with my two healthy, happy children."

Ms. Valentini's organization has provided more than 1,200 children with cleft surgeries, primarily in South America. She said she would have never have imagined that Smile Network would evolve into something on a global scale and come to help children in Armenia.

Next year, the nonprofit organization plans 700 surgeries and will be taking its volunteers to Africa and India.

"As a general rule of thumb, when you add up all the expenses, our average cost is $500 per surgery," said Ms. Valentini. "We bring a team to a country, we pay for their hotel and airfare, and on average we'll do 25 surgeries per surgeon during the course of a week."

The average cost for the surgeries taking place in Armenia this week will be closer to a thousand dollars per child.

"Still, for a thousand dollars you change everything in the future for that child," said Ms. Valentini. "One of things we're excited about in Armenia is what we've learned from our experiences in South America."

Ms. Valentini said in some foreign cultures her team has traveled to, children with cleft lips or palates are left to die in fields, because it's considered a family curse.

"People believe that if a child with a cleft is allowed to come into a village, their livestock will die, their crops will die and it will impact their village," she said. "These families love their children, but sometimes they're forced to make decisions that you or I would never be forced to make."

What Ms. Valentini finds interesting in Armenia is that she would have never imagined that in a post-Soviet, Westernized culture, some families place kids with a cleft in orphanages.

"I did not believe it until I saw it with my own eyes," she said, "and I really saw this mission as an opportunity to change the cultural perception and to educate people about how easily this is fixed. There is nothing wrong with these children. They're intellectually normal. They're emotionally normal, but they're going to spend a life being isolated in an orphanage as a result of this birth defect. So, I'm excited about the opportunity to change a cultural perception."
The volunteers

Debra Wallace, RN, works as an operating-room nurse in the plastic surgery department at Fairview Southdale Hospital in the Twin Cities. Home is Bloomington, Minnesota, but she has been going on missions with Smile Network for the past five years.

"Years ago I wanted to do mission work. But I had three daughters, so it wasn't a good time," said Ms. Wallace. "They're adults now, and I thought it was a great time to start."

Ms. Wallace said her role before the operations began was to make sure the screenings ran as smoothly as possible. Since operations began Monday, she is a circular nurse in the operating room, making sure the surgeons have what they need and the patients are scrubbed and draped, that sutures are available, and "everything goes right."

"I'm hoping that we can fix a lot of kids and some adults," said Ms. Wallace. Asked about jet lag and marathon back-to-back surgeries, she said, "We're probably looking at eight to ten operations a day, which is a typical day for us. I think we just put the fatigue and jet lag out of our heads. The adrenaline is so much that you don't think about being tired, and nurses are like that. We put in long hours. We sleep when we can."

The mission to Yerevan is ­Mandy Hanson's fourth one with the Smile Network. She's in charge of medical records. She says even with language barriers on these missions abroad, a smile always breaks barriers and sets parents and sometimes the kids at ease.

How does she think the mission in Armenia is going along? "I think as long as we do surgeries, it's a success."

Kim Kammeier, CRNA, is an anesthetist at the University of Minnesota Hospital. This is her first mission for the Smile Network, and she came along because Dr. ­Sapal asked her to. He's on his 14th mission, and he persuaded her that volunteering her time for a week on a life-changing mission would be a good thing to do.

One of the toughest jobs outside the operating room is Carolyn Walsko's. She is coordinating this trip and has coordinated six others.

"We're very excited," she said. "In other countries, we have language barriers, customs and cultural barriers. We run into those types of things. In some cultures, you don't take a picture of someone, because they feel you're taking their soul. So you have to be very careful. You have to understand the culture and respect the culture and also respect the medical staff that you're partnering with."

Ms. Walsko said that the volunteers' collective goal is to work with each other and their local partners as a team, "so that we are cooperating with the Armenians, and they're cooperating with us. That's what our goal is. We work as a team, and we walk away as a team."

Last November, as part of trip preparations, Mrs. Valentini and Hope for the City Founder and Cafesjian Family Foundation Board member Megan Doyle, came to Armenia on a fact-finding mission. The successes taking place this week in Yerevan were seeded in their initial visit. Mrs. Doyle and her husband Dennis Doyle have brought more than $40 million in medical equipment and medication to Armenia through Hope for the City and their partner, the Cafesjian Family Foundation.

"We do a site inspection before we decide to come on a mission," said Ms. Walsko. "We meet with the hospital administrator or the people supporting the mission. We tour the hospitals and tour the ­facilities to make sure what they have will work with what we are going to bring. Then we find out how many operating rooms they're going to use, and if somebody in country is going to be operating with us. We do all of that before we even decide to come on a mission."

Accompanying the Smile Network on this journey to Armenia is veteran documentary filmmaker Dennis Kane. In addition to his role as the head of National Geographic TV for more than 20 years, Mr. Kane produced 25 one-hour specials at ABC. He's retired now, but he accompanies organizations like Smile Network on overseas trips as a way of giving back.

"I had a wonderful career; couldn't have had a better career," said Mr. Kane. "I enjoyed myself immensely and just wanted to be able to help organizations like Smile Network and Save the Children. I volunteer for Catholic Relief Services and other groups." And what does a veteran filmmaker do? He uses his skills and documentary filmmaking skills to chronicle missions like the one to Yerevan, shoot the operations, and then turn the tapes over to the nonprofit to use as needed.
Ahead

Some patients, a few who were older and had previously been treated, but unsuccessfully, left Arabkir in tears after being told they would most likely not be a priority for the surgeons on this visit. But they were left with hope. Because of the large turnout, Project Smile is planning to host the Smile Network in Armenia once again.

"We will immediately begin raising funds for a second mission. Fund raising, regardless of what you're raising funds for, is difficult," said Ms. Valentini. "I think we have a little bit of an advantage, because this is really tangible. When you donate $500, you have the ability to change a life. You have the ability to take a child from darkness into light, from being hidden on to main street. It's tangible, because it's really visual. People really understand what the impact of their dollar is."