SPECIAL TOPIC

Interplast Italy: A 20-Year Plastic andReconstructive Surgery HumanitarianExperience in Developing Countries

Andrea Figus, M.D., Ph.D.,F.E.B.O.P.R.A.S.

Paolo Fioramonti, M.D.Paolo Morselli, M.D., Ph.D.,

F.E.B.O.P.R.A.S.Nicolo Scuderi, M.D.

Rome and Bologna, Italy

Background: Interplast Italy is a nongovernment, nonprofit organizationwith the aim of providing high-quality standard reconstructive procedures,contributing to local medical and nursing education, in those countrieswhere this is not available or where the local resources are inadequate to meetlocal needs. A recent debate about the real aim and the effectiveness of thiskind of health support strategy in developing countries has been raised.Methods: The authors report a 20-year experience, explaining operativestrategy, activities, and results, and contributing to the development andimprovement of the philosophy of humanitarian missions.Results: Since 1988, 47 missions and 5235 operations have been performed.A total of 2286 patients (43.7 percent) were younger than 18 years, and 2949(56.3 percent) were above that age. Congenital cleft deformity was the mostcommon diagnosis in 2415 patients (46.13 percent). Patients suffering frompostburn contractures were operated on in 1956 cases (37.36 percent). Thenumber of postburn children operated on was 922 (17.6 percent).Conclusions: Cooperation with local physicians is considered mandatory toguarantee adequate patient preselection, to organize the activity in situ, andto plan continuous effective work on a regular basis to build local capacityand facilitate sustainable models for health care. Furthermore, as localsurgeons become interested in reconstructive surgery, continuous teachingthrough a multidisciplinary approach must be paramount. The activity ofInterplast Italy contributed to building a plastic surgery service in Bang-ladesh. Combined multidisciplinary activities linked to established organi-zations such as the Interplast confederation are desirable to improve results.A link with structured organizations is needed to obtain financial resourcesto extend targets and to improve activities and outcomes. (Plast. Reconstr.Surg. 124: 1340, 2009.)

Interplast Italy is a nongovernment, nonprofitorganization founded in Bologna, Italy, in 1988with the aim of providing high-quality standard

plastic and reconstructive procedures in develop-ing countries and contributing to local medicaland nursing education. Interplast’s purpose is tooffer modern reconstructive surgical practice, ex-perience, and support in those areas of the worldwhere it is not available or where the local re-sources are inadequate to meet local needs.

In 1988, the first mission was carried out afterthe request of the bishop of Dhaka, in Bangladesh,who visited Bologna and met a child who had asurgical repair of a cleft lip and palate malforma-tion. Knowing that there were many people af-fected by this kind of pathology who did not re-ceive adequate treatment in his country, hedeveloped a cooperative program with the plasticsurgeons from Bologna that is still ongoing everyalternate year. At that time, an organization namedInterethnos was created. Since that first mission,

From Department of Plastic and Reconstructive Surgery, “LaSapienza,” University of Rome, and the Department of Plas-tic and Reconstructive Surgery, University of Bologna.Received for publication April 20, 2008; accepted December11, 2008.Copyright ©2009 by the American Society of Plastic Surgeons

DOI: 10.1097/PRS.0b013e3181b5a2ef

Disclosure: The authors have no financial inter-ests to declare in relation to the content of thisarticle.

www.PRSJournal.com1340

two to four times per year, a plastic surgery teamspends its time, effort, and resources to bring andspread reconstructive surgery in those areas wherethis is not available and the need of support andcollaboration is strong.

In September of 1991, in San Francisco, Cal-ifornia, Dr. Donald Laub, professor at StanfordUniversity, in Palo Alto, California, and founder ofInterplast Inc., USA, included Interethnos withinthe “worldwide confederation of Interplast.” Sincethat time, the name “Interplast Italy” has beenadopted. Recently, the activity of the organizationhas been enlarged due to the collaboration withvarious universities in Italy.

With the supervision of experienced academicsurgeons, it has become a truly useful instrumentfor humanitarian aims, medical education, surgi-cal training, and cultural exchange for the localpopulation and local and overseas junior doctorsin those areas where the lack of medical and sur-gical care facilities is a serious problem. Duringthese years, Bangladesh, Togo, Albania, China,Honduras, Zambia, Nepal, Kurdistan, Thailand,Northern India, Tibet, Bolivia, and Peru havebeen visited by Interplast Italy missions (Fig. 1).

A recent debate about the real aim and theeffectiveness of this kind of health support strategyin the developing countries has been raised.1 Wereport a 20-year experience, explaining operativestrategy, activities, and results, contributing to thedevelopment and improvement of the philosophyof humanitarian missions in plastic and recon-structive surgery.

MATERIALS AND METHODSThe humanitarian aim of Interplast Italy mis-

sions is to provide free reconstructive surgery, to

increase and enlarge host-country medical careand educational programs, and to improve healthcare in developing countries worldwide. The ob-jectives of the organization’s activities are to:

1. Provide direct patient care and ancillary ser-vices to those areas with no other resources.

2. Provide educational training and medicalexchange.

3. Assist host-country surgeons, anesthesiolo-gists, and nurses toward medical indepen-dence.

Interplast Italy activity is based on a free vol-untary partnership of plastic surgeons, anesthesi-ologists, pediatricians, and specialized surgicaland intensive care nurses with the shared goal ofhelping, supporting, educating, and empoweringlocal communities to provide competent, safe,and available reconstructive surgical services.

Interplast Italy has no political or religiousaffiliations. As with many other humanitarian or-ganizations, it is structured with a president, sec-retary, and members. There are four committeesfor the management of medical, surgical, anes-thetic, nursing, and organizing activity for eachsingle mission. The missions themselves areplanned during the previous year at least 6 to 12months before the departure date. Before takingan active surgical role in the host country, somepoints must be considered.

First is the need for establishing contacts withthe local community to create a link with a localhospital providing basic surgical resources and se-lection of patients.

Second is the need for providing financial sup-port and surgical equipment. Due to free health-care providers and considering costs for equip-

Fig. 1. The 47 missions performed by Interplast Italy in 13 nations during the periodbetween December of 1988 and December of 2007.

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ment, Interplast Italy can perform a cleft lip andpalate reconstructive procedure for 260 euros,burn scar correction for 160 euros, and providedressings and medications for 26 euros. InterplastItaly volunteers organized a very intensive continu-ous network to provide financial support throughmeetings, charity activity, and single donations. Anannual contribution of 10,000 euros is provided bythe Italian Society of Plastic, Reconstructive, andAesthetic Surgery for Humanitarian Charity Mis-sions in Plastic Surgery.

Third is the need for contacting healthcarecompanies to obtain as much equipment as pos-sible with the lowest charges. All surgical and an-esthetic equipment, including suture material,specific drugs, and dressings, is provided by theorganization, while the local host hospital is askedto offer a sufficient number of beds and one tothree operating tables, without interfering withthe local routine hospital service. The local hostalso usually provides accommodation and trans-port. In those areas already known, local physi-cians preselect the candidates for surgery.

Two types of missions have been performedsince Interplast Italy started its activity. One is thepilot mission, which is carried out in areas wherethe local contacts are new and the local resourcesare still unknown in terms of potential growth oflocal doctors and patients’ needs. This type ofmission is usually carried out by a “micro-team”composed of two plastic surgeons, one anesthesi-ologist, and two specialized nurses. The role of thisteam is very important for planning a future ac-tivity in a new area, starting surveillance, and mon-itoring local resources and patient selection. Theother type of mission is carried out in areas wherelocal resources and patient availability are wellknown and a larger number of components (eightto 14 staff comprising two to four surgeons, two tothree anesthesiologists, three to five nurses, andone to two pediatricians) could be available toincrease the number of procedures, teaching, andpatient care (macro-team). An academic link withuniversities in Italy and the Italian Society of Plas-tic Surgeons provides at least two professors ofplastic surgery for each macro-team. A single op-erative team includes at least a senior surgeon, alocal or overseas junior surgeon, and a specializedtheater nurse. This opportunity offers excellenteducational and teaching activity for local andoverseas assistants. Lectures are given to the localdoctors on a regular basis.

Every mission lasts for 2 to 3 weeks, based onthe needs and resources of the local hospital. Allequipment is sent from Italy at least 2 months in

advance. Surgical sessions start on the second dayafter the arrival, after a day of patient screening,selection, and care. Usually more than 200 pa-tients, who have been previously selected by thelocal doctors, come from the entire region to un-dergo an accurate consultation with the local phy-sicians and then with the overseas reconstructiveteam. Usually, 9 to 14 operating days are plannedwithin one mission, and 50 to 250 patients un-dergo surgery after selection, according to timeand resource availability. During the first consul-tation, every patient is assessed with a clinical pho-tograph and a personal medical file. On each sur-gical table, a senior surgeon and a local and anoverseas assistant perform the surgery. A hospital-ization area with 15 to 30 beds is usually requiredfor preoperative and postoperative care. We op-erate on the most severe cases at the beginning ofthe mission to provide postoperative care our-selves. Our surgeons and anesthesiologists areavailable 24 hours a day in case of complications.We postpone the less severe cases to the last daysof our stay, as the local surgeons are then trainedto deal with possible complications and medica-tions. Two half sessions per week are entirely ded-icated to teaching and education for local medicaland nursing staff.

RESULTSSince 1988, 47 missions have been performed,

and 5235 patients have been operated on (Table 1).There were 2177 male patients (41.6 percent), and3058 female patients (58.4 percent). A total of 2286patients (43.7 percent) were younger than 18 yearsold, and 2949 (56.3 percent) were above that age.

Congenital cleft malformation was the mostcommon diagnosis in 2415 patients (46.13 per-cent of all operated patients). The subdivision is asfollows: cleft lip, 1086 (45 percent); cleft palate,387 (16 percent); and cleft lip and palate, 942 (39percent). Of all patients with clefts, 1199 (49.6percent) were children younger than 2 years old.This number represents 22.9 percent of all pa-tients operated on during these 20 years. It was notuncommon (about 20 percent of all clefts) to op-erate on cleft malformations in patients older than18 years old, which is very rare in our country.Moreover, 507 cases (21 percent) of cleft malfor-mations operated on were secondary proceduresas refinement or correction of deformities previ-ously operated on by other surgeons (Fig. 2). Onthe other hand, about 5 percent (113 patients) weresecondary procedures performed on patients oper-ated on by our team in previous missions (Fig. 3).

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Tab

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47

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9119

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9519

9619

9719

9819

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0120

0220

0320

0420

0520

0620

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Ch

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No.

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104

9510

451

9076

8210

275

7578

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527

814

416

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7�

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2741

3736

2656

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2020

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2859

5515

946

8111

855

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6358

6825

3438

3382

5537

3947

111

8011

998

7913

282

No.

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4460

5154

1325

3830

7254

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252

7755

3311

966

No.

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2532

2933

2541

2040

180

2850

1856

5212

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8539

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1221

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3181

576

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3571

7044

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413

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.

Volume 124, Number 4 • Interplast Italy

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Patients suffering from postburn contrac-tures were operated on in 1956 cases (37.36percent of all patients operated on) duringthese 20 years. The number of children under 18years old operated on after sustaining burns was922 (47.1 percent). This represents 17.6 percentof all patients operated on in all 47 missions.Other congenital or acquired deformities andtumor excisions numbered 864 (16.5 percent)

of all treated patients. Since the first mission,teaching hours have always been performed ona regular basis.

The teaching sessions have continuously in-creased within the recent missions, and since theyear 2000, about 1 to 2 hours per day are dedicatedto lectures on specific topics and interactive clin-ical case-based sessions. Furthermore, during allsurgical procedures, the most experienced sur-

Fig. 2. December of 2004, Dhaka, Bangladesh. A 9-year-old female cleft-lip patient operated on for secondaryprocedure. Preoperative and immediate postoperative views. Our little patients receive small gifts from thenurses. (Left) This girl kept hugging the kitten she had just received for the entire surgery. (Right) After thesurgery, the girl is still holding onto her gift.

Fig. 3. August of 2000, Lhasa, Tibet. An 11-year-old patient affected by severe postburn sternal-chin contracture. The patient wastreated with multistage procedures with full-thickness skin grafts in different missions (August of 2000, August of 2001, and Augustof 2002). Two years from the first surgery, he came back for a third time to treat the scars on his thorax. This case stresses theimportance of guaranteeing continuity in the missions and the significance of the cooperation with local physicians who are theones able to alert and gather the patients selected throughout the year for the 2 weeks of our stay.

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geons provide continued teaching, and 20 per-cent of the cases have been carried out by thelocal surgeons under the direct supervision of ascrubbed tutor.

We have a record of more than 20,000 clinicalpictures (Figs. 4 and 5). More than 4000 hours ofdigital recordings have been taken since the year2000, and five professional film documentarieshave been created as direct support in advertise-ments for financial recruitment.

Since our activity started in Bangladesh, a newplastic and reconstructive surgery service has beencreated in Dhaka and recently renovated with fourindependent surgeons and a staff dedicated toburned patients and general plastic surgery (Fig.6). More is needed to achieve complete indepen-

dence within cleft and palate surgery. Develop-ment of this subspecialty together with the treat-ment of congenital abnormalities of externalgenitalia is now our next aim. In Tibet, a plasticsurgery service is now ongoing, as in Zambia, andindependent support from local physicians hasbeen well established. All other countries are stillfar from the target achieved in those countries.

DISCUSSIONHumanitarian missions in developing coun-

tries are often burdened with a shortage of meansand materials.2–8 A prerequisite of any mission istrying to offer in all medical procedures the sameoperating standards applied in developed coun-tries. It is essential for the entire campaign to

Fig. 4. December of 2002, Dhaka, Bangladesh. Three-year-old patient with Tessier cleft no. 8. Cor-rection with rotation and advancement cheek flaps.

Fig. 5. January of 2004, Cajamarca, Peru. A 32-year-old female patient operated on for correction of severe left unilateral cleftlip and palate.

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identify suitable local hosts and to establish a con-solidation process for fund raising. It is also nec-essary to ship, at least 2 months in advance, all therequired medical equipment, as it will be the onlyresource accessible on location. After 20 years ofexperience, Interplast Italy considers as an essen-tial priority the support of the local physicians onwhom we rely during the missions in these coun-tries. This point represents the real key for a suc-cessful mission in terms of providing patienthealth care and reaching the goal of teachingplastic and reconstructive surgery in countrieswhere this specialty is lacking.

The guidelines for our reconstructive surgicalexpeditions in developing countries are both tooperate on as many patients as possible related tothe available time set and to teach the basic sur-gical techniques to the local and overseas juniorsurgeons to give continuity to the efforts madeduring these years.

The more experienced reconstructive sur-geons should always be assisted by local surgeons,and they should be very willing to share theirknowledge and experience with them, performingdifficult operations on locally preselected patients

and also scheduling interactive lessons on thosegeneral and specific topics that local surgeons willencounter the most in their future practice. In-stead, many well-intentioned groups send surgicalexpertise to disadvantaged regions without achiev-ing the expected results. This is mainly due to lackof cooperation and does not provide proper post-surgical care with adequate teaching and educa-tion. Interplast Italy is trying to develop an actionmodel based on an old philosophy initially devel-oped for cleft care: that simple surgical interven-tion alone can produce quality outcomes.9–12

We remark that cooperation with the localphysicians is mandatory to guarantee correct pre-selection of patients for surgical treatment, to or-ganize the activity, and to plan continuous effi-cient work on a regular basis. It is very importantto start with local contacts to perform an initialassessment by sending an experienced small team(micro-team) or a “pre-trip” experienced observ-ing surgeon, and then to continue with more ex-tensive action through a wider team includinginterested and well-trained junior surgeons to givecontinuity to the activity and to enlarge the scopeof the missions.13 Furthermore, as local surgeonsin developing nations become interested in re-constructive surgery and, of course, in cleft sur-gery, teaching local surgeons through a multidis-ciplinary approach must be paramount. Patientsafety must be guaranteed at all stages.

Follow-up of the patients remains a challengeduring the humanitarian missions. Often the pa-tients come from very remote and rural parts ofthe host country, and even contact betweenthem and the local medical staff can be difficultto establish.

The major technical drawbacks of this kind ofsurgical activity still remain, with a relatively highrate of infections (�12 percent) during the earlypostoperative period and the limited rehabilita-tion program.14,15 In many countries, despite thewide use of antibiotic prophylaxis and therapy,hygiene conditions are often poor, and even ifgood antibiotic coverage is administered, it is notenough to sufficiently protect a significant per-centage of the patients.16,17

Through all of these years of humanitarianactivity, we report better results in those countrieswhere our presence is more frequent and the es-tablished cooperation with the local resources al-lows better medical action, as in Bangladesh, Ti-bet, and Zambia. Our efforts are now directedtoward improving specific subspecialties withinthese services. In the other countries, collabora-tion with the local surgeons is developing a good

Fig. 6. Interplast Italy’s last mission in Dhaka, Bangladesh, in2007. Prof. Morselli is the first on the left.

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level of independence within the plastic surgeryservice, but lack of local financial resources is af-fecting the speed of the process. More needs to bedone, and our activity is increasing in this direc-tion.

We noticed a different epidemiology of thediseases in the different world areas. Burn se-quelae are the most frequent pathology encoun-tered, followed by facial malformations.18 Chil-dren suffered from flame burns more in certainareas, such as Tibet, Bangladesh, and the north ofPeru, where fires are lit on the ground and withoutany barriers can be easily reached by these youngpatients. Scald burns in children are common inChina and Tibet due to the boiled food tradition.Women suffered burns more frequently thanmen, probably due to more time spent in thekitchen. Acid burns in women are very frequent inBangladesh due to an old custom of punishmentfor suspected adultery.19

Microsurgery, as reported by some authors,14,15

did not find a useful role in our missions. This wasbecause in the countries we visited the local med-ical staff was not sufficiently trained and the tech-nical resources were limited. At the present time,without these two fundamental elements, we feelthe standard of our activity can not be maintained.

Plastic surgeons or residents who are inter-ested in this kind of pioneering work in recon-structive surgery are recruited on the basis of strictselection and offered a unique opportunity to seea different world and to be helpful, improvingtheir knowledge and experience. Compared withother organizations, Interplast Italy recruits its vol-unteers on a basis of a psychological attitude, med-ical skills, and a teamwork mindset, supported bythe personal reference from three members of thestaff. During the past 20 years, this strict selection,however, has not affected the recruitment of newparticipants and the outcome of our surgical ac-tivity. Moreover, the humanitarian and voluntarydrive of these missions helps to transform indi-vidual efforts into a wider program multiplyingresources and results. As a junior resident statedwhen he joined our team for the first time inBangladesh, “I never worked so hard, and with thisdetermination. It was such an inspiration.”

During these years, we did not encounter anyproblems in recruiting motivated and skilled doc-tors and nurses to volunteer to operate in thesecountries. The main difficulty was in obtaining allthe necessary finances and equipment to guaran-tee a successful mission. Because we have becomemembers of the Interplast confederation,20 thishas been a definitive step forward in the constant

search for funding resources. Being a part of anestablished international organization gave uscredibility and trust, making the fundraising pro-cess easier. Another important advantage in be-longing to the Interplast confederation is the op-portunity to follow guidelines and share commonexperience. Our report is the result of a strategyin humanitarian aid that arose from this experi-ence. This link helped us to improve our actionplans, to maintain autonomy in the organizationprocess, and to develop local reconstructive sur-gery independence, reducing the risk of medicalcolonialism.

Combined multidisciplinary activities linkedto established organizations such as the Interplastconfederation are desirable to improve results. Alink with structured organizations is needed toobtain financial resources, to extend targets, andto improve activities and outcomes. Our achieve-ments are still small in comparison with the largescale of need, and other voids of aid will have tobe filled in the future.

Paolo Fioramonti, M.D.Via Cardinal Cassetta 11

00165 Rome, Italyfioramontipaolo@hotmail.com

ACKNOWLEDGMENTSThe authors thank all the volunteers who have par-

ticipated during these 20 years of Interplast Italymissions: plastic surgeons Marino Auteri, DanieleBollero, GianVittorio Campus, Carlo Cavina, CesareCavina, Alberto Chiapparelli, Luca Andrea Dessy,Stefanie Feldman, Andrea Figus, Paolo Fioramonti,Daniele Gandini, Rossella Garzani, Francesca RomanaGrippando, Giovanni Liguori, Giulia Lo Russo, Gio-vanni Micali, Andrea Morellini, Paolo Morselli, Rosa-rio Perrotta, Antonio Pistorale, Paolo Santoni Rugiu,Nicolo Scuderi, Maria Grazia Tomba, and MatteoTretti; anesthetists Tiziana Busi, Laura Ceretto Gian-none, Sabine Ivagnes, Giuseppe Lagana, Lorena Pasini,Marina Terzetta, Maurizio Turello, and Pietro Visconti;pediatricians Piero Bini, F. Garofano, and Adolfo Scala;specialized nurses Miriam Bonardo, MassimilianoCanta, Maria Convertini, Roberta Ferro, Angela Gallo,Elena Galletti, Valentina Lancellotti, Daniela Lendini,Franca Linza, Karen Mauro, Rosaria Milana, ErikaMoretti, Concetta Marrocchella, Emanuela Popoli, Gio-vanna Presepi, Armida Presiccio, Anna Maria Settem-brini, Nicoletta Silvestrini, Aneta Beata Witkowska, andTamara Zugno; and organization committee membersDaniela Boccolari, Franco Casadio, Rita Fantoni, Clau-dia Maccagnani, and Maria Renata Prevost. Moreover,the authors thank Dr. Simon Huang for his support inthe final English revision.

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REFERENCES1. Zbar RI, Rai SM, Dingman DL. Establishing cleft malformation

surgery in developing nations: A model for the new millennium.Plast Reconstr Surg. 2000;106:886–889; discussion 890–891.

2. Nicolai JP, Grieb N, Van Twisk R, Krause-Bergmann A. In-terplast in India: Review of 14 years. Ann Chir Plast Esthet.2004;49:291–293.

3. Marshall DR. The achievements of Interplast. Aust N Z J Surg.1994;64:19–21.

4. Zeeman RJ. Interplast program in Peshawar, Pakistan. PlastReconstr Surg. 1993;92:1202.

5. Sloan ES. Interplast: Nursing practice in developing nations.Today’s OR Nurse 1990;12 (5): 4–8.

6. Olson S. Interplast in Ecuador–-1984: Bridging the gap. CanOper Room Nurs J. 1985;3:26–31.

7. Gaynor E. Interplast: Caring for children worldwide. J HospSupply Process Distrib. 1984;2:48–50.

8. Samuels SI, Wyner J, Brodsky JB, Laub DR. Interplast: Asuccessful model for anaesthesia and plastic surgery in de-veloping countries. JAMA. 1984;252:3152–3155.

9. Zbar RI, Otake LR, Miller MJ, Persing JA, Dingman DL.Web-based medicine as a means to establish centers of sur-gical excellence in the developing world. Plast Reconstr Surg.2001;108:460–465.

10. Zbar RI, Rai SM, Ghimire P. Repair of congenital nasalanomalies involving redundancy of structures. Cleft PalateCraniofac J. 2003;40:214–217.

11. Erdmann D, Schierle H, Sauerbier M, Germann G, LemperleG. [Reconstruction of severe facial defects due to noma.]Chirurg 1998;69:1257–1262.

12. Lampe H, Wolters M, Lemperle G, et al. A three-year aidprogram for plastic surgery in Peshawar (Pakistan): Ongoingmanagement of severely injured patients of the Afghanistanwar: 1,528 large operations, 5,171 smaller interventions,15,932 patients examined. Langenbecks Arch Chir. 1993;378:353–357.

13. Baudet J, Martin D, Pelissier P, Etcheberry TG, Casoli V.[Humanitarian plastic surgery missions: Actions and reflec-tions.] Ann Chir Plast Esthet. 1999;44:72–76.

14. Giessler GA, Fieger A, Cornelius CP, Schmidt AB. Microsur-gical reconstruction of noma-related facial defects withfolded free flaps: An overview of 31 cases. Ann Plast Surg.2005;55:132–138.

15. Giessler GA, Schmidt AB. Noma: Experiences with a micro-vascular approach under West African conditions. Plast Re-constr Surg. 2003;112:947–954; discussion 955–956.

16. Lee ST. New treatment and research strategies for the im-provement of care of cleft lip and palate patients in the newmillennium. Ann Acad Med Singapore 1999;28:760–767.

17. Zilliox R, Borsche A, Braye F. [Burn sequelae in developingcountries.] Ann Chir Plast Esthet. 1999;44:56–63.

18. Lau YS. An insight into burns in a developing country: A SriLankan experience. Public Health 2006;120:958–965.

19. Walker SP, Wachs TD, Meeks Gardner J, et al. Child devel-opment: Risk factors for adverse outcomes in developingcountries. Lancet 2007;369:145–157.

20. Baran CN, Tiftikcioglu YO. Physicians for Peace and Inter-plast Turkiye: Combined humanitarian surgical activities andconferences. Plast Reconstr Surg. 2007;119:1077–1190.

PRS Mission StatementThe goal of Plastic and Reconstructive Surgery� is to inform readers about significant developments in all areasrelated to reconstructive and cosmetic surgery. Significant papers on any aspect of plastic surgery—originalclinical or laboratory research, operative procedures, comprehensive reviews, cosmetic surgery—as well asselected ideas and innovations, letters, case reports, and announcements of educational courses, meetings,and symposia are invited for publication.

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