That certain smile

Operation Smile is a medical charity that treats facially deformed children from developing countries. Anne Dempseyreports on a Dublin operation

One day last July in her village in south Morocco, 20-year-old Amima Kerroumi, who can't read or write, saw an ad on television that stopped her in her tracks. She had discovered that Operation Smile was coming to town as part of its international medical mission to perform free reconstructive surgery on children suffering from cleft lips and palates.

Amima looked down at her child, Abdul, then just over a year old and severely facially disfigured, and felt the stirrings of hope. With her husband Brahim, she took a taxi for the 90-minute journey to the hospital in Settat, and waited her turn. At first, all seemed lost. Abdul didn't get through the screening because his condition was too severe. But far from this being the end, it was only the beginning, as parents and child were seen by Irish plastic surgeon Dr Michael Earley, a medical volunteer with Operation Smile, who told them he believed he could help their son.

"When Abdul was born, I was shocked and sad. I cried. But he is my baby and I loved him no matter what," Amima says, sitting in the Top Flat Surgical Ward of the Children's University Hospital, Temple Street, Dublin, with Abdul on her lap.

Mother and child flew in before Christmas for successful reconstructive surgery and returned home together last Saturday to a new life. Amima had her own small room on the hospital corridor, but spent most nights on a mattress beside Abdul's cot.

After the operation there is a dramatic improvement in Abdul's looks. His clear-skinned face is now full of personality, and as he grabs my pen and refuses to give it back, he is agile and determined. After the operation, he is much better than Amima had hoped. Speaking through an interpreter, she says that while her child now has a hopeful future, children with disabilities in her country should be treated the same as everyone else.

This is a vain aspiration, says Michael Earley. "Without surgery, these children in the developing world don't stand a hope. They are never part of the schoolgoing population. Many are hidden at home, and in some countries, they will be placed in institutions," he says.

Helping children with cleft lips and palates began as a one-off trip to the Philippines in 1982 for US plastic surgeon William Magee and his wife Kathleen, a nurse and clinical social worker. It was the start of Operation Smile, now a world-wide charity. Today more than 100,000 children and young adults in 75 countries have been treated. Thousands of healthcare professionals have been trained in situ, with international teams leaving behind necessary equipment, so laying the groundwork for long-term self-sufficiency.

Earley joined Operation Smile in 2003 and was on his annual mission when he encountered Abdul. "I have seen only six other children with his condition, a bilateral cleft lip and an ocular facial cleft" (see panel). "I realised he would need the facilities of an intensive care unit with craniofacial back up. I nominated him as an Operation Smile World Care Patient, and began making arrangements for him to come to Ireland." He recalls his first sight of the baby that summer day in Settat.

"He had a fissure running from mouth to eye affecting skin tissue, muscle and bone. It affected his appearance, feeding and sight. He couldn't close his mouth round a bottle, dribbled all the time, and the fact that he was so well is a great tribute to his mother's love. The right eye is sightless. The fissure ran through the eye orbit into the eyebrow and abnormal skin had grown over. The operation itself took four hours, but the plan in your head takes much longer."

The surgery involved excising the cleft on either side of the face, reforming the face, repairing the lips so as to restore lip muscle allowing the mouth to close, closing the fissures in the eyelids as much as possible, repositioning the upper lids of the right eye to give more protection to the lower lid, taking some bone from the scalp to build up the left eyebrow, and building in bony support to cheeks and eyelids. The left eye is still vulnerable to grit and dust and will need further surgery, probably this autumn in Morocco, while future dental treatment is also needed. Sitting in a meeting room in Temple Street, he surveys the "before" and "after" photographs with obvious satisfaction. "The results are great, now he has a chance of a normal life.

"Treating cleft lip and palate is a low-risk procedure performed within a particular window of time. The training aspect is very important. The Moroccan surgeons got scrubbed up with me. There was a great collaboration, and sharing of ideas," he says.

"I joined Operation Smile at a point in my career which I felt was payback time. But I've learnt that being part of this organisation is like standing in quicksand. You tend to get dragged in and become more and more involved."

Teri Cosgrove, the chairwoman of Operation Smile Ireland, could be said to be responsible for that sinking feeling. An outgoing American who grew up on Wall Street, New York, she has lived here for 15 years and is married with three children - "though some people call Op Smile my fourth child".

The charity established here in 2003 now has a pool 40 volunteers - biomedics, anaesthetists, plastic surgeons, nurses, speech therapists, dentists - who donate part of their holidays each year to work in Ireland's partner countries: Belarus, Egypt, Ethiopia, India, Jordan, Kenya, Morocco, Russia and South Africa.

"An important aspect of our work is that we come in only when asked to by the Department of Health in the country. In many places, cleft lip and palate is not necessarily perceived as something that needs a response, even though the condition can cause children to be shunned," says Cosgrove.

"We do 35 missions a year. It's an ongoing relationship, they may need to come back and see the child and there may be extra work," she says. The Irish operation also raises awareness and funds to support the global medical programme.

The need is great and finances are compelling. Only one in 10 children in the developing world with cleft lip and palate receive treatment, even though curing the standard condition takes only 45 minutes and costs €250 per patient.

"We could take double the amount of volunteers we have, and have a particular need for paediatric anaesthetists and play therapist nurses," says Cosgrove. "Medical volunteers can initially doubt that they could be of help, but that's only before they've gone for the first time. When they come back, they invariably say they could not believe the difference they were able to make. We give people an opportunity to dramatically change a child's life. The power of that is phenomenal."

Operation Smile Ireland, 31 Pembroke Road, Dublin 4, 01-6676659, www.operationsmile.org. Cleft Lip & Palate Association of Ireland, 34 Sycamore View, Carpenterstown, Castleknock, Dublin 15, 087-1319803, www.cleft.ie