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A Surgeon's Gift



Craig Bradley is clearly used to the best: his spacious office suite is decorated with tasteful, expensive furniture and lots of wood. The walls are hung with black-and-white photographs by his wife, Anne Bradley; a square coffee table in the waiting room is covered with four neat rows of magazines--including Vogue, Architectural Digest, Chicago, Better Homes & Gardens--lined up with military precision. His own office, on two levels, comes with a huge rolltop desk, a staircase that leads to a comfortable library, and what look like ultrasuede walls. Bradley is a cosmetic surgeon; his practice is varied--breast augmentations and lipectomies, cancer reconstructions and burn repairs--and well compensated. But once a year he and a group of colleagues travel thousands of miles to operate on patients for 12 hours a day or more for no money whatsoever.

For the last four years, Bradley has spent vacation time doing operations in rural areas in the Far East. The first three years, he went with a group to the Philippines; last February, he and a group of 17 volunteers drawn mostly from Rush-Presbyterian-St. Luke's staff went to Chaiyaphum, Thailand, in the boondocks 300 miles north of Bangkok.

Tall and lanky, Bradley is boyish despite the gray invading his blond hair and the incipient bags under blue eyes. His manner seems almost enervated until he gets on a subject that interests him, which the work in Thailand emphatically does: his face lights up, his gestures become dynamic.

He denies that he "led" the group. "You can say that I'm the catalyst, the spokesman, the instigator--but there's no leader." He says he made his first trip, to the Philippines, "because a friend invited me to come along. You see that others are doing these things, but until you're offered the opportunity, you don't think about doing it. Now I can't imagine stopping. Once you're confronted with problems in society, you have to make a decision to get involved or back away. Once I became aware of the need for this kind of work, I had to do it."

When the Philippines trip didn't fit into Bradley's schedule this year, a Thai-born colleague suggested his native country as an alternative; the colleague's Thai friends became the Rush team's hosts.

"Medicine's so different there," Bradley says. "We're helping. We're able to do this thing we love to do, and there's really no hassle. It's really the purest type of feeling--there's no fee, no insurance, no malpractice--we get a chance to go there and do medicine in its purest form. We come back, and it's kind of hard to get back into the bricks and mortar of modern medical practice. I have two beautiful offices, beautiful operating rooms, and I do everything from cosmetic surgery to cancer reconstruction, and I love this kind of practice; but this is something special. Over there, there's a real freedom. There's gratitude, but even without it we would do it.

"The Thais have this gesture, called a wei"--he demonstrates, putting his hands together as if in prayer and bowing his head toward them--"and they would all do it, even when they were on their IVs. When you make the rounds and a little kid, all swollen, does that to you, tears come to your eyes. You couldn't miss it."

The team members who were surgeons spent a fair chunk of their own money in order to have that experience--they paid their own transportation and incidental costs. The other expenses--for example, supplies and nurses' costs--were paid by various foundations, including the Foundation for Children's Reconstructive Surgery and Rush-Presbyterian-St. Luke's Clarence Monroe Fund for Education in Plastic Surgery (Bradley named the fund for a plastic surgeon who frequently volunteered overseas). They also had help from a Thai institution, the Princess Mother's Medical Foundation, sponsored by the mother of the king. "She's close to 90, and she's really a saint," says Bradley. "She spends six months of the year in the provinces making sure that medical care is delivered in the small villages."

The American team worked together with the staff of the 300-bed hospital in Chaiyaphum, working exclusively to repair cleft palates and upper lips. The team from this country included six plastic surgeons and three anesthesiologists: Doctors Bradley, Robert Swartz, Anun Seetapun (the Thai connection), Shyamala K. Badrinath, David Zehring, Michael Schafer, Timothy Marten, and Rahda Sukhani, and resident Donald Jones. Rounding out the team were medical students Shaw Chen and Clark Rosen and nurses Kim Litwack, Sharon Matz, Janice Migon, Theresa Jasinowski, and Monica Linde. The 17th member was a nonmedical gofer, John Koffler, who did everything from raising money for the trip to blowing up and distributing dozens of balloons.

"In the beginning, they were watching us," says Bradley. "They wouldn't just accept us carte blanche. There were political implications: 'Do they think we're not able to do this ourselves?' Their medical personnel have excellent abilities; there just aren't enough plastic surgeons for the tremendous need." Bradley says that of the 50 plastic surgeons in Thailand, the majority live in Bangkok. "They also commit a portion of each year to do this work--but they can't ever catch up with the new ones."

Bradley reports that it's estimated there are 3,000 unrepaired cleft palates and lips in Thailand, and that one of every 700 live births there has a cleft.

"Here, in this country, no child would go unrepaired; no matter what the socioeconomic status, somebody's going to get that kid done. If the family has private insurance, private insurance takes care of it. If they don't, they can get it done by a local lip-and-palate clinic--those are supported by funding from the county, state, and federal level, and from private groups like the Shriners. There are multiple private and public organizations that find the funding.

"In Thailand, it's particularly important to repair clefts because those kids are usually social outcasts, shunned because of their appearance. But it's not just a matter of aesthetics--they can't speak. Most of our patients were little kids, but we had a lot of teens with unrepaired clefts who'd never learned to speak normally. There was one woman who was 60 years old, with a wide-open cleft on her face."

A cleft lip is a fissure that runs all the way through the lip from the base of the nose. It is sometimes accompanied by a cleft palate. A complete unilateral cleft palate is a single fissure that goes through the arch that holds the teeth and through the hard and soft palates. Often the nasal cavity then opens into the mouth. A complete bilateral cleft palate means two fissures, so that there's a segment between the two clefts. It's more difficult to reconstruct because there is insufficient tissue to cover the gaps.

Cleft palates and lips can mean a vast array of problems. To start with the physical: food particles can get stuck in the passages above the mouth, leading to infection that often travels up into the ears. "With an open cleft palate," says Dr. Peter Randall in a handbook for cosmetic surgeons, Plastic Surgery, "it is virtually impossible in some patients to be completely free from tenacious mucus or even mucopurulent material in the nasopharynx." A related difficulty is that some patients may not be entirely clear of infection for the repair operation.

There are also speech problems, and the combination of physical appearance and speech difficulties often leads to social and psychological problems, particularly in cultures where it's not considered rude to point and stare.

The surgery to repair clefts is common in this country because clefts are common: according to Randy McNally, senior plastic surgeon at Rush-Presbyterian-St. Luke's, the rate is 1 in 1,200 among blacks, 1 in 800 among whites, and still higher among Orientals.

The palate is just one area of several that Bradley calls "formation centers," where fetuses often develop defects; heart disease and extra fingers are other common defects in newborns. "We just happen to be focused on palates," he says. Some of the causes may be environmental--there are links to maternal viral infections in the first three months of pregnancy, says retired surgeon Clarence Monroe. Bradley suggests that some may be caused by poor maternal nutrition during the formation of the palate and lip structures. "There are no specific environmental causes," says Bradley. "There's no specific etiology." Some causes may be, as McNally says, "weakly genetic. You take the Philippines--their genetic pool is real heavy on clefts.

"Having a cleft palate is not a major threat to your life, but it makes a major difference in speech and the quality of life. Speech is a part of our humanness--without that ability, you don't have an even start in life. But if it's repaired in time, you can overcome the handicap." He points out that a former cleft-palate patient won the Illinois high school debate competition a couple of years ago.

Most repairs are made before speech begins, usually at 12 to 18 months. These days, only unusually wide clefts can't be corrected with surgery; about 1 in 100 sufferers has to have a lifetime prosthesis to cover the cleft, McNally says. "It's like the difference between false teeth and your own teeth. Children never handle prostheses very well, and I suppose that in the third world they're not very available." Children also outgrow their prostheses with the same appalling regularity that they outgrow everything else; new ones must be frequently obtained.

A cleft lip can also be single-sided or double-sided; to repair a double-sided cleft is more involved. McNally says, "To artistically restore the anatomy is our goal. The edges of each of the tissue layers used to cover the gap have to be freshened--made raw--cut away and pieced together properly. To repair a palate, the edges are freshened; incisions are made out from the midline of the palate. That's repeated for each of the layers."

In lip surgery, three layers are involved: mucous membrane, muscle, and skin. "In a unilateral, the parts are usually there, but in very deformed position; in a bilateral, there are parts missing, and we have to try to compensate," explains Bradley. "The muscles are brought across the defect, and the skin rotated, as flaps, into a position that brings them down and across . . . In palate repair, the critical part is to try to get the muscle repaired to achieve speech."

The patient is put first on a liquid, then a soft diet for three to four weeks following surgery. McNally says that children have to have arm restraints so that they don't put their thumbs--or anything else--in their mouths and push through the repair.

McNally has not participated in any overseas trips, with the exception of a one-week stint in Vietnam during the war, but he admires and advocates this kind of work. "It's educational for the people who participate on both sides of it--both the American medical personnel and the people who participate in the medical aspects at the other end, in the interchange of the surgical techniques. Obviously, it's a very charitable thing to do.

"I coached Craig Bradley through his first cleft-lip operation, and I saw his wondrous enthusiasm then. I saw the rebirth of it when he returned from this most recent venture."

McNally knows that some people resent these third-world efforts--they feel that charity should begin at home and that the surgeons should be helping needy Americans. "But with all the hospitals and social agencies in this country, no little kid would ever get into kindergarten with a cleft lip. Somebody would find him and help him."

The number of countries receptive to these medical missionaries is limited. As McNally says, "There has to be goodwill, at least in a political sense, in this kind of endeavor."

Clarence Monroe was a pioneering medical missionary: starting in 1963, he put in five lengthy sessions overseas. He became a practicing plastic surgeon in 1936--he's now 84--and worked in Chicago until his retirement in 1974. Bradley, who studied under Monroe during his residency, credits him with inspiring younger generations with the urge to work in the less developed nations. "He was a mentor in some way," Bradley says, "for almost all of us who went to Thailand."

Monroe went to Haiti, Liberia, and Honduras, and to Korea twice. Usually he went for a month at a time, operating and teaching local surgeons plastic-surgery techniques. "It's a very specialized field," he says. "There are lots of people in the third world who have this kind of deformity, and nobody around to repair it."

Foreign colleagues have benefited from Monroe's practical experience--he once tracked down a spate of postoperative infections, for example, to a faulty sterilizing device. He has also helped his foreign colleagues learn to be problem solvers. He's worked both on problems common in this country, like cleft palates, and on problems unknown to us: in Korea, he made eyebrows for leprosy patients. "People who have leprosy often lose their eyebrows, and the other people in those areas where leprosy is common know that, so someone who's lost his eyebrows is usually driven out of the village." Even when the disease is treated and the patient is no longer leprous, the eyebrows don't come back--and neither can the outcasts. "I made eyebrows for this one fellow," says Monroe, "and the others let him come back because of it. That felt very good."

Monroe is a firm believer in sharing knowledge and supports Bradley's trips: "If you want to know my one criticism, and I told Craig this, it's that a fairly large group of them went, and I wonder if they were able to teach any Thai surgeons how to do the job. That, in my opinion, is how you leave part of yourself overseas--by teaching others how to replicate what you've done. Of course, things may have been more primitive there. I know they had to take their own equipment. But my feeling is that we do our best if we share our knowledge with them.

"If you do this a few times, and you do it in different places, you certainly bring home a new appreciation of how people in third-world countries live and how they cope with their problems. They have a lot to teach you as well."

On the bus ride from Bangkok, the team was presented with information on each patient: the definition of the problem, data on blood work done, even preoperative photos that had been assembled by the well-organized Thai medical community. Every night at the hospital, a crowd of children--with their whole families camped out on their beds--gathered in the ward for the next day's surgery. Every day, from 7 AM to 10:30 PM, the Americans operated; their Thai nurses worked even longer hours, preparing for and cleaning up after the surgery. The American nurses assisted the surgeries.

"We thought we could comfortably get 25 kids done in a day, but they had a lot more than that lined up for us, and we couldn't send them back without operating on them," says Bradley. Some of the children had problems that required neurosurgery before plastic surgery could be done. These patients needed to be treated in Bangkok, and arrangements were made for them to be operated on there. A total of 178 people, mostly children between the ages of 9 and 12, were operated on in five days in Chaiyaphum.

"I think the most we did was 45 kids in one day. That's seven or nine kids per doctor in a day. It took between one and three hours per operation. We did one case after another, with literally moments between cases--there was not even time to go to the bathroom. It's one of those things that you just do--you paced yourself, you found the energy. Could you do it for a month? No. Could you do it for five days? Yes. We weren't exhausted--we were tired, but you can do it for a week."

Conditions were not exactly primitive, but they weren't luxurious. There were frequent power brownouts--the team wore mining headlights and nurses held flashlights. The heat was sticky, there was no air-conditioning, and even the fans barely moved during brownouts. The Americans were proud that they got all the operable patients done.

It won them the respect of the Thai staff, who turned over five of their six operating rooms, worked with the Americans, and threw a party for them at the end of the killer week. Bradley says, "It wasn't Americans doing something for them--it was Americans and Thais working together to do something special. It was an incredible connection." Bradley regrets not being able to do his own follow-up but says the Thai doctors have a good system for that. "And we'll see some of the kids who had too much to do in one visit again next year."

Although the team plans to return in 1990, "and go wherever the princess mother's foundation wants us to go," Bradley does not do pro bono work in this country. The entire subject is a hot button; his whole demeanor changes at the question, and his voice rises: "I used to--and then the government got involved, telling me I had to do this or that, and telling me how much I could charge. It's price fixing. I do this work because I want to." Here, too, there's the ever-present specter of malpractice. And he feels that there's much less need for no- or low-charge work in the United States than in the third world.

"It's interesting to compare our lives here and there--the luxury we work in here, the kind of cases we do. Here we may be doing a face-lift or an augmentation mammoplasty--but Americans today are at a place where we can make these choices. It's not one and the same, but I've seen so many people over my medical career where changing their nose or changing their breast size was as important to them, and as gratifying to me, as this.

"Lots of other doctors are doing third-world work. Ophthalmologists were among the first, treating cataracts. It's a way of paying back for the talents we've been given--a way of paying back to humanity for the gifts we've been given.

"We're very, very fortunate, so to share it in a country where there aren't as many doctors is very important."

The team made a shaky home video to document the trip. After the footage showing boxes being packed for the trip, the gathering at O'Hare, and the tourist attractions in Bangkok, there are haunting images of the children: a baby with a single upper tooth visible through a cleft in her lip; another baby, his head shaved except for a round spot in front, being rocked in a homemade hammock, his expression made grotesque by his malformed lip. A bench full of preteens look shyly at the camera scanning their misshapen faces. A small boy with an IV hooked into his arm trudges down the hall, makes a wei to his doctor, and climbs trustingly onto the operating table.

Art accompanying story in printed newspaper (not available in this archive): photos/Bruce Powell.

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