Deep in a forest in Ancient Greece, a young man by the name of Orchis stumbled upon a festival in honor of the god Dionysius. It was a wild celebration filled with drinking and dancing. Young Orchis was drawn to the party and decided to join in. After a few hours and a few too many goblets of wine, he tried to rape a Dionysian priestess. Upon witnessing this violation, his fellow revelers tore him to pieces. The next morning, his father gathered together the pieces of his dead son, but he could not resurrect him. As he fell to his knees, Orchis’ father prayed to his gods for aid in bringing his son back to life. The Greek gods wanted to help, but they could not just restore Orchis. He needed to be punished for what he had done. So, instead of bringing Orchis back to life as a man, they transformed him into a slender flower—what we now call an orchid.
Cartersville, West Virginia
My patient was almost six months old. Bright blue eyes. Curly, platinum-blonde hair. Cute pink fingers. Her name was Britney Ann Cooper. She was a perfect twelve-pound baby girl—except for the angry, open gash that trailed from her nose to her mouth. For most children, the palate fuses together before birth, but for one in every 700, it does not.
Britney’s mother was distraught. Her friends kept saying that God had given Britney a cleft palate for a reason. They kept telling her that she was being punished by God for her sins. They said that if she tried to change Britney, God would strike her baby dead.
I disagreed. “Nobody’s dying in my operating room today. Not if I can help it.
Britney’s mom said, “Is she gonna be okay?”
“Yep. I promise. Never lost one yet. Trust me. Gimme an hour, and she’ll be good as new.”
Britney’s mom had no insurance. She was unmarried, seventeen years old, and on welfare. I was standing next to her in a makeshift OR in the back of a free clinic in a single-wide trailer. Sweat dripped down into my eyes. It was 97 degrees, and there was no air conditioning. This part of West Virginia is as poor as some cities in Third World countries.
“Okay. Fine. Whatever. Just do it, but I can’t watch,” Britney’s mom said through tears before turning to run out of the trailer.
A nurse anesthetist stuck an endotracheal tube down Britney’s throat. One slip on her part and my skills would be lost on a dead baby. I tried to focus on the task at hand. I turned to the circulator nurse as she wiped my forehead. “Hey, if it’s too easy, it’s no fun—right?”
My patient rested on a gynecology examining table, the only table the free clinic had for surgery. The leg stirrups had been removed, but the attaching mounts stuck up so far from the table that it kept me at arms distance away from my tiny patient.
I stared though my magnifying loupes and traced the length of the cleft. It opened at the floor of the nostril and down through the upper lip and back over the palate, dividing it all the way through to the uvula. I paused before lifting the scalpel.
If I had been in my air-conditioned cosmetic surgery office in North Carolina, I would have repaired the lip then and the palate the following year. Closing the lip early is essential to containing the mouth, so the baby can suck and feed on a nipple. Without the lip repair, the baby will become extremely malnourished. The palate closure is necessary for proper speech development, which doesn’t begin until eighteen months. But, since we were in a rural area and I wouldn’t be back next year, I had to do it all then.
I took a marking pencil and quickly outlined the cuts on the upper lip, with rotation advancement of the two halves of the upper lip and a tiny Z-plasty on the vermillion border. With my thumb and index finger squeezing the labial artery—the primary blood supply of the lip—I made the lip incisions, discarding only the thin rim of tissue that blocked the repair. I heard Britney gurgle and took her pulse. It was slow, which meant she wasn’t getting the oxygen she needed. I ordered the anesthetist to take out the endotracheal tube and put it back in again.
The cautery machine was an antique. I hadn’t used one of these old ones since med school, and I was worried about excessive burning. To be safe, I touched the individual bleeders with a small 25-gauge hypodermic needle.
I took the smallest suture material available, 4-0 gut, for the muscle repair. I preferred much smaller sutures, but none were available. Three of the stitches aligned the lip exactly.
Twenty minutes and four forehead wipes later, I was almost done. Just the palate left to stitch up, but it was the most complicated part of the procedure. I felt sweat about to drip in the wound and turned quickly for another brow wipe. My back was killing me, but I adjusted my posture and put the pain out of my mind.
Just suture the palate. With some fine silk, 5-0, which was perfect for a mucosal repair, I placed five fine sutures in mattress fashion, to turn the lining of the palate outward.
I stepped back to admire my work. Damn! The vermillion borders of the lip didn’t match; the left side was lower than the right.
The baby started gurgling and coughing. Crap! The nurse anesthetist had disappeared to prep another patient, and I was on my own. It wasn’t safe for Baby Britney to be out so long. I had to do this fast and finish up. I breathed in deeply and tried again. I made a 5-0 silk stitch and placed each side exactly in the vermillion border. I slowly tied the stitch and pulled.
Again, I stepped back and looked at my patient. The two sides slid into precise alignment as God had intended them. Perfect!
