Wednesday, December 31, 2014

Smilemaker..all about a SMILE

As a smilemaker,I often come in contact with people who ask me what I do for a living. This season was exciting because I had the opportunity to travel to Doha and India where some folks asked me about the work I was involved in.
I spent about 15 minutes at an immigration counter in Doha,Qatar ,with a young immigration officer who was very interested in the smile work ;he asked for the website link, to learn more about cleft children.

Later, during the week, I met some friends who had traveled all the way to the Indo Myanmar border villages,close to the north eastern part of India  . Many of these villages in Myanmar have seen severe conflict,neglect and poverty for hundreds of years. Thankfully, with the cooperation of the new govt in Myanmar, and the opening of  new international border trading posts with neighbouring India,some aid workers can now freely visit some of these remote villages.
Life in these villages is very harsh,without roads,transport,water supply or electricity. The villagers mostly live on a diet of yam and corn. Some mission posts have been built over the last two years by some of our friends,but there are no clinics or hospitals because it is impossible to ferry heavy equipment to these zones.  The only way to help cleft children from these regions is to sponsor their travel and treatment at govt hospitals in the neighbouring northeast of India where donors and volunteers from local church missions, and govt agencies  are willing to accommodate such patients and offer free services.
Some medical volunteers have already begun some basic health services in these villages and the work is growing.More help will be needed in the future to ensure a sustainable health delivery system to these target regions in Myanmar through hospitals and govt centres in neighbouring India.

Logistical challenges for smile missions in remote regions of the world




Many poor cleft children often find it impossible to reach the nearest cleft centre for help because their regions have no roads,electricity or transport. Some live on islands where the only way to reach a cleft centre is by air.This makes it impossible for them to travel for treatment.
The only way to offer sustainable smile services to some remote regions is to identify and equip the nearest hospital and register patients in those areas.  Some of these patients may live many hours or even days from the nearest treatment centre.In conflict zones,the problem is even worse because of the dangers of getting maimed or even killed during the fierce gun battles between warring factions.

Training sessions: basic concepts in cleft palate speech

Those of us who are involved in palate surgery wpould need some basic knowledge of cleft palate speech. Althpough this is not our specialty,it is useful to know some concepts in this complicated field.

Goals of palate surgery:
To facilitate normal speech
Normal hearing

Minimal or no  mid facial growth interference

Normal speech mechanisms:
Velopharyngeal closure refers to the normal apposition of the soft palate(velum) ,with the posterior and lateral pharyngeal walls.
The main mover of the soft palate is the levator veli palitini muscle which makes up about 50% of the soft palate bulk
Movement of the pharyngeal component depends on the contraction of the superior constrictor muscles and the palatopharyngeal muscles
The levator moves the soft palate upwards and backwards ;this is coupled with the mesial movement of the lateral pharyngeal walls and slight anterior movement of the posterior pharyngeal walls at the level of the C1 vertebra
As a result, the oral cavity is separated from the nasal cavity during speech and deglutination

VPI: velopharyngeal incompetence
Velopharyngeal incompetence occurs when the velum and lateral and posterior pharyngeal walls fail to separate the oral cavity from the nasal cavity during speech and deglutination
After primary palatoplasty,up to 20% have VPI and require secondary management
With early recognition and intervention,the chances for normal speech and hearing are increased
Structural defects of the velum or pharyngeal walls at the level of the nasopharynx
Tissue deficiency
Submucus cleft palate
Short or immobile cleft palate
Unoperated cleft palate
Palatal fistula
Large and deep nasopharynx

Speech assessment should always be done by an experienced speech therapist at a sp[eech centre  where facilities are available and results interpreted accurately.This enables the palate surgeon to choose the right procedure for correcting speech defects.



Happy 2015 to all

Happy 2015 to all my viewers



Appreciate the support and comments;i have tried to answer some of your queries online and will continue to answer questions on clefts and aesthetic  medicine.


Thanks to all of you who have been supporting the cleft lip and palate projects across several countries.

Many more children are smiling again,thanks to people who donate and make a difference. Our community fundraiser for Tibet cleft children received some more donors this season.The support for these programmes will continue through 2015.

We hope there will be more support for upcoming cleft camps in the Indo Myanmar border regions and elsewhere this coming year.

abc.thespeakingpalate.org

Tuesday, December 30, 2014

Training sessions :Aesthetic Rhinoplasty in cleft nose deformities

Aesthetic rhinoplasty in cleft lip patients is a challenge even for the most experienced aesthetic rhinoplasty surgeon, because of the distorted anatomy

Observations in most cleft patients:
Bulbous tip
Deformed right ala cartilage
Drooping tip
Bulky nose
Loss of columella support
Caudal septal deviation to the left
Loss of nasolabial angle


before

after

Plan of treatment:
Correction of bulbous tip with interdomal sutures
Augmentation of nose and columella support with a cartilage/silicon implant
Tip graft with conchal cartilage
Debulking fibrofatty tissue of the nose
Resection of the caudal septum and after scoring it ,use it as an overlay graft for the right ala cartilage
Augment the deficient upper lip with posterior auricular fascia to improve the naso labial angle

after a conchal graft rhinoplasty


Training sessions: anatomical considerations in cleft palate surgery





1.The levator sling is created : the muscles are detached from their abnormal insertions on the palatal bone and retro positioned to make them meet in the midline at a distance of 7-10mm
2.A button hole incision below the middle of the maxillary tuberosity identifies the hamulus which is fractured to medialize the muscle complex

3.The tensor tendon is incised as it hooks around the hamulus process of the sphenoid bone
4.The palatal aponeurosis formed by the levator and tensor insert on the posterior surface of the palatal bone;this is incised with a sharp blade to release the muscle fully
5. the elevation of hard palate mucoperiosteum is made in the middle zone near the palatal rugae where the attachment is looser.
The neuro vascular bundle lies a few mm medial to the 2nd molar –care is taken to  dissect this structure so that the flap can be moved easily to the midline
* submucus cleft palate may be diagnosed by bifid uvula,zona pellucida due to muscle deficiency in the midline and osseous notch on the hard palate

Training sessions: know your lip landmarks before cleft surgery

Orofacial clefts which includes cleft lip and palate, are the most common craniofacial deformities ,occuring in 1:800 live births worldwide

Causes include genetic and environmental factors like smoking,alcohol and folic aid use in the first trimester of pregnancy


Training sessions:Some useful tips in unilateral cleft lip repair




NOTE:
•The Cupid’s bow is pulled up and the edge of
• the cleft lip is often thinned out because of the
• vermillion deficiency
•The orbicularis oris muscle in the lateral lip element ends upward at the margin of thecleft to insert into the alar wing.
•There are fibrous adhesions under the mucosa. The musculature between the philtral midline and the cleft is hypoplastic
•The philtrum is short and the ala cartilage on the cleft side is deformed .Two-thirds of the Cupid’s bow, one philtral column, and a dimple hollow are preserved
•The inferior edge of the septum is dislocated
•out of the vomer groove and presents with
•the nasal spine in the floor of the normal
•nostril.
•OUR GOAL
•1. Bring the Cupid’s bow to a more horizontal level
•2. Make both sides of the lip equal in size and length
•3. Exact placement of the stitch on the white roll
•4. Correct the alar defect as much as possible
•5. Eliminate the lip notch by a Z
•plasty/triangular mucosal flap after approximating the orbicularis marginalis area.

Training sessions: Revision-*5 Principles of bilateral lip repair


• The secret of success in the field of
aesthetic cleft lip surgery:
• 1.Symmetry
• 2.Primary muscle continuity
• 3.Proper philtral size and shape
• 4.Formation of the median tubercle
from lateral labial elements
• 5.Primary positioning of the lower
nasal cartilages to form the nasal tip
and columella.



• *J B MullikenCurrent Surgical management of bilateral
cleft lip in North America, Childrens Boston,
PRS129:1347, 2012 June
• Prof John B Mulliken, Harvard
Childrens Hospital MA

Waiting for a miracle smile 2015

Just returned from a short trip overseas, where some friends who had heard about our smile work presented some  of the smile needs in a remote region of Myanmar where there are no roads,no power or water supply.
The only mode of transportation in those impoverished areas are old Chinese made motorbikes which ferry people across villages,at an exorbitant cost.
There are several cleft lip and palate children in those regions ,and most have to live with their deformities for life, because they do not even know that treatments are available for free.
The task of transporting such underprivileged cleft patients will be a mammoth challenge ,because there are no roads.
2015 presents itself with newer frontiers and challenges.There are many requests and enquiries from developing regions where cleft children live in isolation and shame.
The smiles must go on and on...till every cleft child is smiling again


Sunday, December 28, 2014

Training sessions: minimal incision palatoplasty with levator repositioning

2012 minimal incision palatoplasty with levator repositioning

In this method, I use a relatively bloodless
minimal incision method using 1:500,000
saline adrenaline hyrdro dissection by mixing
1mg adrenaline in 500 ml saline
Starting from the medial minimal incisions,using
fine curved sharp scissors,I dissect the
levators from their insertion on the palatal
aponeurosis / bony hard palate and
reposition the muscles in a transverse
position;the uvular is 2/3 retro positioned
I also add a small button hole incision over the
hamulus to fracture the bone,incise the
tensor and medialize the muscles.
The surgery takes 20-25 minutes and is very safe
The complete palate is closed in 2 stages- stage
one includes soft palate closure with levator
repositioning;the stage 2 minimal incision
palatoplasty is done after 6 months to a year
Ongoing study:over 270 cases,no intra/ post op
bleeds or hypoxia in any
• The levator repositioning improves
speech
• The nasal flaps are best approached
from the lateral side to prevent
tearing
• It is easier to raise the mucoperiosteal
flaps from the mid palate where the
tissue is loose and less vascular
• Palatal fistula is usually due to wrong
technqiue and too much tension on
the flaps and ,wound infection.

Friday, December 12, 2014

Patient number 1371 this December @Smile Train Yarim programmes

This week,the Smile Train  sponsored programmes operated patient number 1371 at Yarim hospital under the local medical team .
Patients from across the nation,Saadah,Sana,Jowf,Taiz,Ibb,Aden, Hodeidah and other regions reularly register at Yarim govt hospital for their free surgeries.
The local medical team is confidently able to help all Yemeni citizens at this hospital because of their years of experience and friendly relations with the villages and tribes across Yemen.




Thursday, December 11, 2014

Taking the measurements before cleft lip surgery



Pic 1: surgery done by an untrained surgeon using no landmarks ,corrected this week;she will need nasal correction later

Pic : below-what you can expect after taking correct  measurements,using landmarks




Handle with care-the large tongue in isolated cleft palate


The large tongue in isolated cleft palate can cause problems post operatively,so this had to be handled with care by the cleft palate surgeon. It is not a good idea to reposition the levator under tension in this case because it is sure to cause post op airway problems. I encountered one post op probems many years ago in such a case,and the patient had to be observed in the ICU for 48 hours post op.Thankfully, her airway problems  got better after the first 24 hours.The receovery was stormy in the initial 8-20 hours post op,but subsided after that period.
These days, I do a loose approximation of the levators in similar cases and do not face the same problems.

Monday, December 8, 2014

Dermal fillers for fine wrinkles

 



a 70 year old lady type 3 FP after intradermal injection of collagen for wrinkles ;the results are good post op and lasts for six months.

The perfect filler is non allergenic,has no down time and looks and feels natural.

Beauty and the beast: Challenges in aesthetic clinics



*Challenges in aesthetic clinics:

1. unrealistic expectations
2. obsessive compulsive behaviour
3.whims and fancies
4.indecisive patients
5.rudeness
6.over flattery
7.overly familiar
8.unkempt patient
9.imagined deformity
10.careless historian
11.VIP patient
12.uncooperative patient
13.overly talkative
14.plastic surgeon shopper
15.depression
16.plastic surgicoholic
17.price haggler
18.patient involved in litigation
19.patient you or your staff dislike

"better safe than sorry"
the worst nightmare for any plastic surgeon is to have a once friendly,chatty patient who wants the money back later even if a procedure is done accurately without complications,all because the patient wants more!

*
read: Tardy ME Face lift variations; Dermatology Surgery,NY 1988,p 1249

Fillers vs PRPM face lift?




With an increasing number of  men and women in their early thirties to forties opting for minimal down time,minimally invasive facial rejuvenation ,the number of patients lining up for PRPM facial rejuvenation using micro needles is on the rise.But it is not a completely painless procedure.One can expect some discomfort,depending on the pain threshold.
It is not difficult for a good aesthetic physician to separate the platelet rich plasma from about 8 ml of the patients own blood; used alone, or with a matrix former like calcium chloride,the results are obvious in a few days time and get better over the next few weeks.
You can expect the effects to remain for about a year.A revisit and re injection is usually necessary after a year.Patient selection is important-those with more advanced wrinkles would do better with a proper facelift.
Autologous filler materials always have an advantage over commercial fillers because there is no reaction to one's own tissue. This is not to say that HLA fillers are inferior.Cross linked HLA can give very good results and last for up to one year. The aesthetic physician should be well trained at a reputable institute and not work on one's own.
The advantages of using PRPM are manifold,promoting new collagen formation and wound healing among a few.This is what makes the face look a lot younger in a few weeks time.

Saturday, November 22, 2014

Double whammy peel ..one week later



day 1-3


day 7 

TCA peel 30% after six weeks of conditioning can give very good results.

Now you see how elegant the results of a good light TCA 30% peel can be.
Got for it!

http://www.youtube.com/watch?v=i88y5Zon5tM&feature=youtu.be


Friday, November 21, 2014

Double whammy peel? Do not try this at home,please!

We are always in the business of reinventing ourselves as aesthetic medicine folks. Sometimes, what a seasoned veteran shares with us publicly is held in reverence and awe, because he insists that the results are ELEGANT.


But let's just step back for a few minutes and dissect this thing called elegance, following a treatment session with chemodermabrasion using an old fashioned (and arguably, obsolete) 25,000 rpm diamond fraise dermabrader followed by TCA 15-30% application.
I ,for one ,am not comfortable with the diamond fraise,which I believe should be relegated to the shelves of aesthetic museums.It is just too traumatic ,albeit a low cost alternative to costlier skin abrasion methods using hydrofacials and fraxel lasers.
TCA 30% is not a pleasant peel for first timers. You will be out of commission and forced to hibernate for at least 7 days following this aggressive peel,also known in the past as the Blue Obagi peel(blue dye + 30% TCA). It will cause a significant amount of scabbing,oozing,scabbing for at least 5-7 days.
Are you prepared to pay such a price, to look ELEGANT?

On the flip side, I have to say that TCA 30% can give you some amazing post peel results. I reinvented the wheel and tried my fortune with a neo concept which I call chemopalmabrasion.
I tried this on myself using only a gentle one layer peel after microcrystal palmabrasion,mentioned in my earlier blogs.
The results in the first 4-5 days? Significant scabbing, a bit of oozing,and scabbing under my eye bags and lateral forehead,nose and cheek. This necessitated hibernation for 3-5 days,lots of moisturisers and sunblock.
The greatest temptation is to pick on the loose SCABS.Advice-do not TOUCH.Let them fall off on their own to prevent complications. Lots of sunblock to prevent post treatment pigmentation.

So much about the double whammy peel. But rest assured, this does make one get that ELEGANT look after the first 5-7 days. I did it for myself because I am staying indoors with some office work this month. Otherwise, I would suggest the milder LA peel after abrasion.

Pics : day one to day 5
day 2 peeling and scabbing (under eye,forehead)

pic: below,changes on day five after scabs fall off and peeling lessens
scabs fallen off day 5

 day 5 result 

video on day 6








Thursday, November 20, 2014

Smile Heroes of Arabia Felix

This is a blog to acknowledge the heroic efforts of my Yemeni Arab friends who make efforts to change the lives of thousands of cleft and plastic surgery patients in this part of the Arab world.




Since 1998 , over six thousand mostly plastic surgery (general minor and major as well)and cleft patients from this nation as well as other surrounding Arab and East African nations were treated for free at our charitable missions.Over 97% of the  medical team are local Yemeni Arabs,and not expats, except for the plastic surgeon and some of his close overseas friends.

One of the most significant accomplishments in Arab smile missions happened in a small and unknown Yemeni rural town called Yarim. When the Smile Train first launched the free cleft lip and palate programmes in January 2010 for underprivileged Yemeni families across the entire nation, Yarim General Hospital was the first to take on this mammoth challenge.
No promises or claims of registering thousands of cleft patients were announced to the internet press or media. Instead, the carefully chosen team decided to play by ear and give it their best shot.
The first week of text messaging by donor GSM companies brought in over 500 new registrations.The numbers swelled to over 1500 on less than  two years. Most of the work came to a standstill after the Arab uprisings of 2011.
From January 2010 till September 2014 over 1336 cleft patients received that second chance at life.
The follow up surgeries as a result of the registrations now stand at over three thousand cleft patients.

One of the highest honours this project received was the invitation to present a  poster session  on the Arabia Felix Smile Train work for 1314 cleft children, at the April 72nd ACPA cleft craniofacial congress in Palm Springs California where delegates from all nations would be sharing their work and papers.
I am pleased to inform you that as the submitting author, the following abstract has been accepted for a POSTER presentation at the 72nd Annual Meeting & Pre-Conference Symposia of the American Cleft Palate-Craniofacial Association (ACPA), to be held April 20-25, 2015 at the Westin Mission Hills hotel, Palm Springs, CA, USA. 
Congratulations, and we look forward to your presentation in Palm Springs next year.

Sincerely,
Robert J. Havlik, MD
2015 Program Chair
American Cleft Palate-Craniofacial Association
Yarim Govt Hospital team did an outstanding job in helping thousands of underprivileged Yemeni cleft lip and palate children and deserve honour for what they have achieved so silently.

Wednesday, November 19, 2014

So what's new in 2014?11th Congress Aesthetic Medicine Las Vegas



So what's new in Aesthetic Medicine 2014? Thankfully for us, not too much has changed since the last conference in 2013. There was the usual talk on how to  build your aesthetic business without being a one trick pony, salmon DNA related stuff,multipolar RF,stem cells,probiotics ,omega 3 and camu berries.But nothing out of the ordinary.
However,I found the conference stimulating and the sessions gave me much food for thought.
There were some  presentations on the controversial topic of female genital rejuvenation and the use of fraxels intravaginally to improve sensual performance. A bit too early to comment on such ideas. We seem to be re inventing the same old concepts in newer packages.
For instance, what was presented on PRP as a filler is not completely accurate because PRP is a collagen stimulator within a week of injection and not really a filler.One would be more correct in calling it a fertilizer for collagen.
And personally, after many years in this sort of speciality and business, I would prefer to err on the side of extreme caution while strutting my aesthetic knowledge. The often sensational and power packed resale items often give way to more realistic and humbler outcomes in real practice.Also,I like to go by protocol and prefer evidence based medicine where there is ample data and retrospective analyses to show a technique really is a gold mine of sorts. When we first started out with lasers many years ago in the early 2000s in Singapore and elsewhere,there was a lot of excitement an we would pride ourselves as " laser persons"  and all that bull. Today, we look back and realise that lasers are only a small ,albeit significant contribution to the plastic surgical world.And mesotherapy is not a well accepted or scientifically based treatment in plastic surgery.One has to be careful of making big claims about such procedures to well informed doctors in the plastic surgical world and even more ,to clients.
We still have miles an miles to go in this exciting world of aesthetic medicine.But only time tested procedures will last for generations.



Sunday, November 16, 2014

Mini Home Spa blogs

                                                 
                                             http://minihomespa.blogspot.com


           A new blogsite for non invasive aesthetic solutions in the privacy of one's own home






Sunday, October 26, 2014

Making Little Miss Sunshine

This cheerful two year old girl came for cleft lip surgery .The follow up picture is after three years.

One of the innovations I designed in our mega smile camps was a simple procedures called crescent 
incision or curved line cheiloplasty. I avoid complicated designs so that the tissue heals much faster and looks better after the surgery.
I make a curved incision to bring down the deformed lip to a more horizontal and natural position and advance the other side after making the measurements.The lip is redesigned using a small mucosal flap.
The method is easy to learn and looks like this after the surgery. Many surgeons have attended our camps and workshops and are able to do this surgery.


Saturday, October 25, 2014

U R D 1 i 1 ...:-) a song for my viewers

Hey all,
Thanks for the views which have crossed 305,000 in the last two years alone
I appreciate your helpful and kind comments
Hope to catch up with some of you guys in NYC in about ten days from now and also meet some of ya'll in Las Vegas when we attend the American Aesthetic Medicine Conference.

Here is a clip I made for all you viewers and supporters!..enjoy

http://www.youtube.com/watch?v=7JT9PQjGFJg

abc.thespeakingpalate.org



Friday, October 24, 2014

Leaving a smile legacy in missions

One of the ways to sustain smile missions is to ensure a good training programme for local surgeons and medical personnel.
Over the years, I have had the privilege of demonstrating thousands of aesthetic plastic and recon procedures to local an expat surgeons in our units.
Cleft palate surgery is not very popular in many developing country units because of the long operating time , bleeding during the surgery and post operative risks like airway obstruction and bleeding.
I am thankful that the large numbers enabled me to design a very safe and useful method of  1:500,000 saline adrenaline hydrodissection so that the operating time is short and post op recovery very fast.
Hundreds of surgeries using hydrodissection ,were demonstrated to trainees during our palate workshops across the nation.

The technique is very safe and has been mentioned in the US Task Force paper on palatoplasty ( www.cleft2013.org). The paper is available online in the US as well as in the Hamburg, Euro cleft craniofacial cleft conference(Sept 2013).

 I am thankful to Prof Jeffrey L. Marsh,former Head of of Saint Louis Childrens Craniofacial/ Kids Plastic Centre ,Missouri for inviting me to initiate the online discussions for the US Task Force on palatoplasty  for latecomers (www.cleft2013.org) .The experience helped me to share this innovative and relatively bloodless,palate surgery method in the manuscript for the benefit of doctors and patients alike.

You Tube: http://www.youtube.com/watch?v=I_3hsVask7s


Getting it right the first time in smile surgery


Getting it right the first time in smile surgery is important for the cleft child because subsequent adjustments are much easier.
I am thankful for my time as a visiting craniofacial scholar several years ago at Taipei Chang Gung Craniofacial Centre, where some of the most renowned experts in the field allowed me to scrub with them and learn the newer advances in aesthetic lip surgeries, as well as routine craniomaxfacial surgeries.
We always stress the importance of accurate measurements before the surgery because the aesthetic outcomes are superior to surgeries where measurements are ignored. One of the big challenges in mega smile missions is the mediocre or poor outcome of surgery because of the factory line procedures where details are very often replaced by numbers. 
Aesthetic lip surgery requires good planning  for the lip and nasal floor as well as the alar correction.

The pictures below are from our unit after the time spent with world leaders at Taipei's world famous Chang Gung Craniofacial and Cleft Centre.







Pic: Pic of a baby with a complete cleft lip before and after surgery in Sana city,Yemen


Below: Taiwanese cleft child with a complete cleft lip,Taipei Chang Gung


Thursday, October 23, 2014

The making of an aesthetic smile



There is a huge difference between functional smile surgery and aesthetic smile surgery. Large smile numbers by a surgeon do not necessarily mean good aesthetic outcomes.
Aesthetic cleft surgery always includes lots of imagination on the part of the aesthetic plastic surgeon, as well as experience with routine aesthetic and functional procedures.

I like to compare aesthetic surgery to complicated fingerstyle pieces which require intensive study and practice. Sometimes it takes me several months to master a complicated jazz piece which has lots of variations and tricky chord progressions. I am not always able to master some of the complicated scores and make do with simpler improvisations,which sound reasonably good but need more fine tuning later.

In the photo shown above, the technique involves accurate marking of the proposed philtrum columns, designing the upper lip and Cupids bow,designing the sniffle ridge using sutures at different depths,removing the midline prolabial mucosa an using lateral lip elements, adequate dissection of the orbicularis muscles and approximating the muscles in the midline under slight tension,15-20% overcorrection of the upper lip repair,everting the upper lip with everting sutures, mucosal avancement cheiloplasty and regular post op cleansing and dressings.


Wednesday, October 22, 2014

Bottlenecks in smile charity work

With the growing threat of tribal blood feuds and conflicts across the region,most cleft children are now unable to travel to our charity units.Most of these families come from remote,mostly inaccessible villages where there are no proper health services.
This month witnessed a series of killings and conflicts during the Eid season ,where many were killed in violent and bloody clashes across the whole country.People are afraid to venture out and many who have registered for free smiles under the Smile Programmes now remain behind locked doors or in the safety of their own villages.
Cleft lip an palate surgeries take lots of time and effort .The children often require many interventions before they can have relatively normal lives. Regions in which  regular bloody conflicts occur, have almost non existent smile services because most expat plastic surgeons do not dare venture into places where even angels fear to tread. This is the sad reality of volatile regions where medical teams are often at risk .
The Smile Train  charity is the best legacy for cleft children in any country that needs this service ,but bottlenecks in these troubled and often corrupt places make it very difficult for children to have that second chance at life. That is one of the reasons why available smile services cannot function normally in high risk zones.
Despite all the killings and massacres in this country, we have cleared a huge number of 1336 Smile Train operations in a little over 320 days ,but the number does not mean that all these children are now normal.Each cleft child may need anything between 2 to 4 corrective procedures which means that the wait list for surgery in this group alone is over two thousand surgeries.
A cleft child usually has a cleft lip, a cleft palate,a deformed nose,maladjustments, speech defects and cleft alveolus.
1001 Arabian Smiles is one of the world's greatest smile miracles, because the Smile Train made this happen despite the overwhelming odds against an expat plastic surgeon,when it was launched in January 2010 by Ashish Sabharwal of the Smile Train and some of us.The charity programme was immediately blocked by some corrupt medical doctors and several high ranking officers.

 Thankfully,all the cleft children were saved by many good leaders in the nation .The  highest authorities in the country intervened quickly, and the charity was allowed to work across the entire nation. As a result,poor patients now have easy access to the services ,during more peaceful times.