A complete smile

Syahrini lived with a cleft lip for the first five years of her life, until doctors from Singapore helped fix her smile.

One in five hundred Asians are born with a cleft lip, a congenital condition caused by abnormally aligned facial muscles that appear as a break in the upper lip. Five-year-old Syahrini, from the Indonesian coastal village of Tinombo, was one of them.

In September I travelled with the Republic of Singapore Navy to Tinombo, where they brought medical and dental care, including minor surgeries, to residents of the village.

According to a 2010 Wikipedia article – also the most current source of demographic indicators for the village – Tinombo has a population of about 34,500.

Most people work as farmers or fishermen, according to health officials I spoke to, and support families of about four children on approximately 500,000 to a million Indonesian Rupiah (SGD50-100) per month.

When most of the income goes to meeting the families basic needs, there isn’t much left to spare for medical conditions that are not life threatening. Syahrini’s father Mr Syahrun tells me, through a translator, that he has never sought medical treatment for her condition before. She can eat and speak – perhaps not as clearly or as much as her two older siblings who do not have the same condition – but well enough to get by.

I first meet father and daughter in the morning, at the newly opened Raja Tombolotutu hospital in Tinombo. I use the phrase newly opened loosely – a large part of the roof, just after the main entrance, is unfinished and patched up by wooden boards. At other parts of the hospital, black stains accompany leaking ceilings.

But for today, it houses a host of Singaporean and Indonesian doctors, brought to Tinombo on a socio-civic mission led by the Indonesian Navy (TNI AL).

The Singaporean doctors, many of whom are NSmen, are plastic or general surgeons back home, each accomplished in their own field and here as part of their annual reservist training. They screen each patient to ensure that they are fit and suitable for surgery – that babies are old enough, that conditions can be treated safely with the equipment and facilities we have brought.

All patients are screened to make sure they are fit and suitable for surgery before they are taken to landing ship tank RSS Endeavour.

Plastic and reconstructive surgeon MAJ (Dr) (NS) Matthew Yeo screens Syahrini for surgery and finds her suitable. We will do the surgery today, okay? He asks her father. Mr Shayhrun nods his consent.

Syahrini and five other patients are transported, by bus to the pier and then by fast craft, to landing ship tank RSS Endeavour, which is a distance away from shore where the waters are deep enough. The crew tried to anchor the ship, but the anchor wouldn’t stay put in the rocky seabed. They are forced to keep it moving, the navigation team on the bridge and the engineers below decks, keeping it turning around the same spot for three days so the ship could function as a mobile hospital for day surgeries.

Surgeries are performed on landing ship tank RSS Endeavour, which is a distance away from the village of Tinombo. The crew operates fast craft throughout the day to ferry patients back and forth.

On the ship, surgeries are carried out in three areas – the briefing room which can be converted into an operating theatre, the medical centre, and two rapidly deployable maritime containers, which house a makeshift operating theatre and intensive care unit located on the ship’s flight deck. The latter, built with overlapping layers like a matchbox, can be expanded into three times its original size for surgeries. Now it is being used for the first time.

Mr Syahrun comforts his daughter, when she cries before the surgery begins.

While waiting for surgery Syahrini is calm as I interview her father, even though all of the day’s experiences have been new to her. But she cries when her father carries her to the operating table, clad in scrubs. Lying down, her feet do not extend past half the table. Tiny fingers cling to tired hands, worn from a lifetime of cocoa farming.

Then anesthesiologist LTC (Dr) (NS) Ho Kok Yuen puts in an intravenous drip, and Syahrini quietens.

She takes a while to go under, because the mask delivering the general anesthetic (GA) is too small, and the doctors cannot get a good seal.

“In Singapore if you’re five you’re probably about 20kg, but she is only 13kg,” says LTC (Dr) (NS) Chong Si Jack, who will perform the surgery.

Dr Chong marks out how he will reorientate Syahrini’s oral muscles.

Over the next hour or so he re-orientates her abnormally inserted oral muscles and corrects her nose position by narrowing the base and sharpening the tip. It will facilitate swallowing and speech, and improve her confidence. “She won’t look perfect, but from far you can’t tell,” says Dr Chong.

The whole surgery takes just over an hour, and when Dr Chong is done he is happy with the result.

When the surgery is over he is pleased. “This gives her a complete smile. A smile is very important – sometimes it gets you out of trouble,” he says.

Syahrini wakes up in tears as the GA wears off, but the effect on her appearance is immediate. Her upper lip is unbroken, and her left nostril, originally flattened, has been corrected. She will not smile until the pain and shock has worn off.  But for now her father does as he soothes the crying child, one hand stroking her chest and the other clutching a plastic bag of the clothes she first wore to hospital in the morning. He is still smiling when Syahrini and the other patients board the fast craft to be taken back to shore, and I wish I knew what he was thinking, or that I understood Bahasa Indonesia well enough to ask.

A fast craft returns the patients to shore before sundown.

In a week the stitches on Syahrini’s upper lip can come off, the sutures inside her mouth will melt away, and she can return to school, with a complete smile.

An abridged version of this article was published in the 3/15 issue of Navy News. All opinions expressed in the article are my own and do not necessarily reflect the official views of the Navy or Ministry of Defence.