International organizations have performed palatoplasties in low- and middle-income countries for decades, often working with local providers. Few studies report long-term outcomes, especially for palatal fistulas. A fistula after palatoplasty may affect speech, socialization, and nutrition. Fistula rates on surgical missions have not been compared with rates at U.S. craniofacial centers nor have the rates of the visiting and local surgeons working on missions been compared. Fistula rates for two Ecuadorian cohorts were compared with fistula rates for a craniofacial center in the United States. In Ecuador, North American surgeons repaired one cohort (n = 46) and Ecuadorians the other (n = 82) during 2000 through 2005. Ecuadorian patients were evaluated during 2007 and 2008. The center's clinical database (n = 189) provided U.S. cohort data. On missions, the fistula rates were 57 percent (95 percent CI, 46 to 68 percent) for Ecuadorian surgeons and 54 percent (95 percent CI, 39 to 69 percent) for North American surgeons. The rate was 2.6 percent (95 percent CI, 0.8 to 6.0 percent) at the U.S. craniofacial center. There was no difference between the two Ecuadorian cohorts' rates (p = 0.75), but they were significantly higher than those of the U.S. cohort (p < 0.001). Having a cleft lip together with cleft palate was associated with fistula formation, whereas surgeon nationality and older age at surgery were not. The fistula rate on Ecuadorian missions, regardless of the surgeon's nationality, was significantly higher than in the United States. Further investigation into the causes of this higher fistula rate in this population is needed. Therapeutic, III.

A significant need is met by volunteer groups who provide free reconstructive plastic surgery for underserved children in developing countries. However, at present there are no consistent guidelines for volunteer groups in plastic surgery seeking to provide high-quality and safe care. With these quality and safety standards in mind, in 2006, the Volunteers in Plastic Surgery Committee of the American Society of Plastic Surgeons/Plastic Surgery Educational Foundation undertook a project to develop a detailed set of guidelines for volunteer groups from developed countries seeking to provide plastic surgery services to children in developing countries. To make the guidelines include both surgical and anesthetic needs, they were developed in conjunction with the Society for Pediatric Anesthesia. Guidelines for the delivery of plastic surgery care by volunteer groups to developing countries have been reviewed and approved by the boards of both organizations (the American Society of Plastic Surgeons/Plastic Surgery Educational Foundation and the Society for Pediatric Anesthesia). These include guidelines for the initial site visit, site and patient selection, staff and equipment that should be available, and procedures that can be safely performed based on the site and available facilities. Guidelines for assessment of outcomes, dealing with adverse outcomes, and quality improvement are also provided. Any plastic surgery group undertaking an international mission trip should be able to go to one source to find a detailed discussion of the perceived needs in providing high-quality, safe care for children. The present document was created to satisfy this need.

Background The assessment of the economic burden of surgical disease is integral to determining allocation of resources for health globally. We estimate the economic gain realised over an 11-year period resulting from a vertical surgical programme addressing cleft lip (CL) and cleft palate (CP). Methods The database from a large non-governmental organisation (Smile Train) over an 11-year period was analysed. Incidence-based disability-adjusted life years (DALYs) averted through the programme were calculated, discounted 3%, using disability weights from the Global Burden of Disease (GBD) study and an effectiveness factor for each surgical intervention. The effectiveness factor allowed for the lack of 100% resolution of the disability from the operation. We used the value of lost welfare approach, based on the concept of the value of a statistical life (VSL), to assess the economic gain associated with each operation. Using income elasticities (IEs) tailored to the income level of each country, a country-specific VSL was calculated and the VSL-year (VSLY) was determined. The VSLY is the economic value of a DALY, and the DALYs averted were converted to economic gain per patient and aggregated to give a total value and an average per patient. Sensitivity analyses were performed based on the variations of IE applied for each country. Results Each CL operation averted 2.2 DALYs on average and each CP operation 3.3. Total averted DALYs were 1 325 678 (CP 686 577 and CL 639 102). The economic benefit from the programme was between US$7.9 and US$20.7 billion. Per patient, the average benefit was between US$16 133 and US$42 351. Expense per DALY averted was estimated to be $149. Conclusions Addressing basic surgical needs in developing countries provides a massive economic boost through improved health. Expansion of surgical capacity in the developing world is of significant economic and health value and should be a priority in global health efforts.

Natural disasters significantly contribute to human death and suffering. Moreover, they exacerbate pre-existing health inequalities by imposing an additional burden on the most vulnerable populations. Robust local health systems can greatly mitigate this burden by absorbing the extraordinary patient volume and case complexity immediately after a disaster. This resilience is largely determined by the predisaster local surgical capacity, with trauma, neurosurgical, obstetrical and anaesthesia care of particular importance. Nevertheless, the disaster management and global surgery communities have not coordinated the development of surgical systems in low/middle-income countries (LMIC) with disaster resilience in mind. Herein, we argue that an appropriate peridisaster response requires coordinated surgical and disaster policy, as only local surgical systems can provide adequate disaster care in LMICs. We highlight three opportunities to help guide this policy collaboration. First, the Lancet Commission on Global Surgery and the Sendai Framework for Disaster Risk Reduction set forth independent roadmaps for global surgical care and disaster risk reduction; however, ultimately both advocate for health system strengthening in LMICs. Second, the integration of surgical and disaster planning is necessary. Disaster risk reduction plans could recognise the role of surgical systems in disaster preparedness more explicitly and pre-emptively identify deficiencies in surgical systems. Based on these insights, National Surgical, Obstetric, and Anesthesia Plans, in turn, can better address deficiencies in systems and ensure increased disaster resilience. Lastly, the recent momentum for national surgical planning in LMICs represents a political window for the integration of surgical policy and disaster risk reduction strategies.