Out of the Box: The Magical Force of Having Your Back Against the Wall
“Get that cut down, in, now, or this patient will die, and it will be your fault.” 
The story of Gloria Hernandez is a wonderful example of the use of Hippocratic medicine – perfecting yourself in skill and knowledge [“S&K”]and then applying it for the benefit of the other. The psychic income derived is not expected and is not a reason for doing the work; it is not a strict exchange of compensation for goods or services provided.
On the other hand, Gloria Hernandez is a routine, “run in the mill” case in plastic and reconstructive surgery. Once you know the S&K and begin to apply it to the other people they tend to come out of the woodwork and a full slate of GH-type cases fill your schedule when you do an international humanitarian interchange. And of course, as Srivastava says, education is the most important thing. Yes! – education – and then research stems from that. What is the cause of this malady? It seems that in these GH cases everyone in contact benefits and it seems that the most fundamental part of these operations is the real benefit to society as a whole, is not service – case by case – but discovered what the basic molecular cause, the basic genetic problem, how to solve, and how society should manage the cleft lip and palate. The educational component is important also because it begins the multiplier effect [ME] and if you teach one you heal many. 
Nevertheless, the real basic interaction is a social interchange, meaning that you on one hand take . This is not colonialism or even neo-colonialism. These are not done in the modality of a parachute trip, rather the initial trip is the first of a 20 year relationship. The GH case is perfect for the development of an international long-lasting interchange working according to the design principles as in the field of physiatry and in international . The miracle seems to work with one person with another person, one surgeon with another surgeon, one country with another country. We should think once more about using the short-term multidisciplinary humanitarian trip as a weapon of foreign policy. 
Gloria Hernandez was a 19-year-old girl with a unilateral wide cleft lip and a normal cleft palate in Mexicali, Baja California, Mexico. She lived 614 miles from my office at Stanford Hospital. We were working at a clinic 1.7 miles south of the barricade fence separating my country, with its skill and knowledge in cleft lip and palate repair, from Mexico, considered a developing country at the time.
The clinic nurse was Lisa Villa, of Mexican descent, born in Los Angeles and a Stanford nurse from our plastic surgery clinic there. Our research papers were blank and I was filling them out for this patient. Paternal age: 41 years (not so advanced as to be suspicious for etiology of cleft). No heavy exposure of family to agricultural chemicals. Father worked at plastics plant, was exposed to many different smelling chemicals. Mother was housewife, pregnancy not unusual, no extended nausea. Patient born in hospital. Mother did not take supplementary vitamins nor B6 or B12. Patient’s speech was good and she had a normal attitude, not overly burdened with the deformity, but she was somewhat shy. Good general health. No upper respiratory infection. Usual childhood diseases. We scheduled her for surgery on the next day. Instructed her about washing face, scrubbing teeth, eating nothing at all after midnight “or she would die.” She was to be the second case of the day.
Murray Walker was the anesthesiologist. Richard Siegel was the intake resident, but did not scrub on the case. Monitors from the local medical community were there, closely looking over our shoulders to see if we knew what the hell we were doing. Induction of anesthesia was perfect. Mouth gag was in. Gauze was placed in the throat to prevent aspiration of blood. Head was positioned well. The OR light was working, as was the electrocautery. Suction was in good order. A Mexican physician was assisting, as well as our resident, Bob Buchholz.
This repair was probably the third cleft lip repair of my career. It was done with the Millard rotation advancement flap technique, which I had heard explained in detail by Millard on several occasions. The evening conferences at Stanford and plastic surgery at a faculty member’s home every week, and the rounds and weekly grand rounds at Stanford had also helped prepare me. And I had read Millard’s book, had memorized where the lines were cut, and had reviewed the concept that the important aspects were first, repair of the muscle, then repair of the mucosa and periosteum, and then perfect alignment of the skin. Attention should be paid to the nose repair, and work on the nose should be accomplished at the time of surgery. The entire idea was that the muscle that surrounds the mouth is not in a complete circle in the case of cleft lip. When the muscle contracts, as in smiling, the cleft is accentuated and pulled apart. But when the repair is made with the muscle, when the muscle contracts as in smiling, the muscle pulls the defect area together and assists the scar healing and furthermore exerts a constant orthodontic force on the malpositioned teeth. I was careful to make the incisions in the lines which I had memorized and written in my sleep and on scrap paper on many occasions. I was armed for bear, I thought, having gained confidence by the Stanford powerhouse teaching techniques.
As we worked, I explained the technique to the wide-eyed watching community doctors, describing to them the reasons for the various maneuvers, as they were not fully trained plastic surgeons. Everything went well. I had repaired the muscle well, pulled it together with a few 3-0 chromics and mostly 4-0 chromics. I repaired the periosteum where needed, elevating it and repairing with 4-0 chromic. The mucosa was repaired. After trimming, the skin was repaired with 6-0 nylon. The nose needed a little readjustment, which we did by loosening the cartilage and allowing it to be pulled so that it would continue to grow, although she was already nineteen. The muscle would help by providing an orthognathic force after repair, getting the teeth into better alignment.
The patient awoke from anesthesia and was discharged the next day. There was no bleeding to speak of, and the wound was cleansed nicely by myself and my residents with hydrogen peroxide. Dr. Xochimitl, future ophthalmologist and intern on social service from the medical school in Mexicali, was present for postoperative care. She reported no problems. We saw the patient again on three occasions -6 weeks and 6months and 6 years after surgery. Of course we memorialized with photography. We found out that after a three-year interval she had rehabilitated. She had gone to stenography school, learned a trade, had had a job since the surgery, and already had three children. This was a wonderful case and I was so happy. This outcome was partly due to Stanford having a great training program.
Three years later I submitted her picture as one of my prize cases to show the American Board of Plastic Surgery what my work was, for their judgment as to whether I should receive certification as a plastic surgeon in the United States of America. I was certified. In fact, I came in number two in the country. Dave Dibbell was number three. A surgeon from Green Bay, Wisconsin was number one.
This case was a fantastic example of the power of changing the body, which improves the self-image and the body image, improves the life, and makes the patient productive in society. Furthermore, the patient made the surgeon’s life more productive. She helped me pass the boards! And I was grateful to her and I wondered whether the favor was equivalent, surgeon to patient and patient to surgeon. My thanks to her!
This case of Gloria Hernandez was performed on my second trip to Mexicali for surgery, and only the fourth time I had visited for the purpose of mitigating the disparity of medical services between the developed area of Stanford University, with its knowledge and skill in plastic surgery, and a developing country. Of course, the secondary purpose was to find some human pathology by which to train the residents and, I suppose, myself as well. We were working in Hospital Civil, a structure that looked somewhat like a house. It was actually a 28-bed white wooden structure, with a jail in the rear portion of the building. We stayed at the home of Phil Collins, a stand-up comedian and insurance agent from Chicago, Illinois, who had ratted on the mob and was under FBI protection. He was working for LAMP, the Latin American Mission Program, as the executive director in that city.
That night Murray Walker, the anesthesiologist, had slept on the pool table for lack of a bed. Siegel and I slept on cots near a window toward the dusty road. There was traffic and headlights all night. We awoke at about 4:30 a.m., as on every subsequent day of each of our forty-five trips to Mexicali, to the accompaniment of dogs and roosters. I still remember that first morning. We ate at a table between the pool table and the ping pong table. Breakfast consisted of machaca with salsa made by Cruz, Phil’s wife. Proper machaca originated in the state of Sonora and consisted of burro meat (now usually beef or pork), boiled well, then fried in grease with cilantro and spices. She made it with eggs and it was one of the most wonderful dishes I’ve ever had, then or since.
We went to the hospital and the group immediately took action. Even though I was the undisputed leader and director and had an answer for every problem that came up, I was quiet that day. Everyone knew their role and everything happened as it should. We got the patients in, nothing unexpected had happened during the night, anesthesia went easily, the oxygen tanks and other equipment worked well, and the first case was uneventful.
Through working together, this was a good start to the program. We had Mexican medical college professional approval, and governmental approval which we had obtained through the wife of the governor of the state of Baja California. We had full support of the Rotary Club, and the Rotary Club president, a prominent urologist. We had transportation by private plane. We were able to be at work two-and-a-half hours after early departure from the Reed-Hillview airport or from the San Jose airport. This was a fantastic thing. I’ll never forget flying down in the morning as the sun rose over the clouds. I would watch the horizon and follow our route on the aeronautical map. I’ll never forget the wonderful surgery, the recovery room,the mariachi band at night, a drop of tequila, the excessive dancing—the happiness of it all!
 Dr. Murray Walker, anesthesiologist, ca. June 1964, Stanford University Operating Room #2
 Charles Horton. Physicians for Peace motto.
 LAUB DR. Globalization of Craniofacial Plastic Surgery: Foreign Mission Programs for Cleft Lip and Palate. Journal of Craniofacial Surgery. 26;4, June 2015 (1029)