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    Dr. Sam Jejurikar Reflections on Surgery in Bangladesh

    Dr. Sam Jejurikar: Welcome everyone to another episode of 3 Plastic Surgeons and a Microphone. As always, I am Dr. Sam Jejurikar, joined by my co-host Dr. Sam Rhee. But unlike always, we are not joined by our third co-host, Doctor Salvatore Pacella, because, unlike most times, Doctor Rhee and I are in the same location. Doctor Rhee and I just spent the past week in Bangladesh with a charitable organization, “Smile Bangladesh,” which is an organization that is near and dear to our hearts. Doctor Rhee went on the very first Smile Bangladesh mission with the founder Shahid Aziz about 16 years ago and was on the board of directors about two years into the organization’s inception. He invited me along on a trip, and I’ve been involved ever since I’m now on the board of directors. So, it’s near and dear to our hearts.

    But for those of you watching our podcast on video, you may notice that we are definitely not in Bangladesh. We are enjoying a little extended layover in a place unlike Bangladesh, Dubai, a beautiful city with a lot to offer. In fact, earlier today, Doctor Rhee and I were enjoying afternoon tea. Sam, you had afternoon tea before?

    Dr. Sam Rhee: Yeah, we just had it a couple of days ago. We were sitting in a hospital in Dhaka in, Bangladesh, in a tiny room in a hospital eating food that Bangladeshi think American people like, which was basically fried chicken, cope, and chips. Sitting with Aziz, Doctor Aziz is my dear friend, our dear friend. And to me that that’s what afternoon tea is when we travel.

    Dr. Sam Jejurikar: Yes, for our viewers who don’t know what afternoon tea is, it’s a very sophisticated British thing with little sandwiches without the crust on it. But in Bangladesh, it’s Kentucky fried chicken and tea, but they have a unique local chicken they use. So, how would you describe the local chicken in Bangladesh?

    Dr. Sam Rhee: I would say lean would be charitable.

    Dr. Sam Jejurikar: It’s all bread and very little meat, which, as a child, I would have liked a lot. But yeah, so we’re here today to talk about going to Bangladesh and what it’s like to operate there. I’ve done numerous missions to Bangladesh. So, it’s Sam, and over the years, one of the questions that always comes up from people is, why do you travel all the way across the world to help people with plastic surgery services when there are people in your own country that need help?

    Dr. Sam Rhee: It’s a good question, and I get asked that. I think the biggest thing to realize is that Bangladesh and the rest of the world are very much unlike the United States. It’s a place of unique need, and I know you know the size and scope of the issues faced by a place like Bangladesh.


    Demographics of Bangladesh

    Dr. Sam Jejurikar: So, I think from the beginning, let’s just talk about demographics. If you talk about demographics, the incidents of cleft lip and palate deformity in Bangladesh are between two to four times higher than in the United States. Now, couple that with the fact that Bangladesh is a land mass size that’s equivalent to about the state of Arkansas.

    Dr. Sam Rhee: It’s about the size of Arkansas.

    Dr. Sam Jejurikar: But the population is about half of that of the United States. If you do the math, the density of Bangladesh is about 35 times greater than that of the United States. It’s like half the population of the United States cramp into something the size of Arkansas. So, for every neighbor you might have, Sam in Bangladesh would have 35 neighbors, and so it’s incredibly dense. The other thing is, as Shahe Aziz has told us numerous times, very few plastic surgeons and oral surgeons can actually offer these services. So, it’s an abject poverty and an abject need that’s on a different magnitude than what we see in the United States.

    Dr. Sam Rhee: Yeah, the need for care for cleft patients will it’s enormous, and when you go to a place in Bangladesh, and you see the density, there’s how crowded it is, how many people. There is just a vast number of patients there. I mean, you are a drop in the bucket for sure, but the impact that you feel like you can make where in a week with these children is unlike what you could do in a place that has way more resources and abilities, such as a place called the United States.

    Dr. Sam Jejurikar: So, the way our trips are typically structured is we tend to have a team that comes from across the United States. Asmal Bangladesh is headquartered in New Jersey, but there’s a component from Dallas, which is where I’m from. There’s a component from the Northeast, which is where Doctor Rhee’s from, and on this last trip, we had a team that had 22 people. This consisted of oral surgeons and plastic surgeons who were Sam and me. Excellent nurses, an amazing anesthesia crew with 4 or 5 anesthesiologists, and an anesthesia tech. So, we had a full complement of people from across the United States. Our first, and there are a few sites now because they’ve been going to for a while to Bangladesh. A few different sites that we actually will go to, probably 5 or 6 hospitals altogether. But every time you go, you basically go to an OR that’s just an empty room.

    You got OR tables and some anesthesia machines you can use, but we have to bring all of our own equipment. You got to bring the anesthesia gauze. You got to bring the surgical instruments. The suture material. The gauze. Everything. We have to bring all that. And so, on the one hand, part of the team is working on getting everything set up. The part is screening patients. Screening patients is a real sort of interesting phenomenon. Sam, like how would you describe screening data to our listeners?

    Dr. Sam Rhee: Well, after all these trips, we’ve gotten incredibly efficient about it. I love our team. We made this year’s screening go by well, but as you know, hundreds of families are showing up from radiant, far distances. Because they have advertised a dance that there is a team coming from the United States to help specific types of patients, and these families are literally crowding around this hospital to be evaluated.

    Dr. Sam Jejurikar: Yeah, I mean to even talk about it more. Imagine sitting at a table with you, maybe a local physician and anesthesiologist, and 10s and 10s up to 100 people crammed into a room. You’re basically surrounded on all sides by people who want to be seen. There’s a language barrier. You’re reliant upon other people to translate for you. You might have some labs, but, in my impression, and tell me if you agree with this, Sam, the level of deformity of what we see there was unlike what we see in the United States, and a lot of these kids have just so many other congenital problems.


    Bangladesh Citizens Unfortunate Cleft Deformities 

    Dr. Sam Rhee: Yeah. I’ve worked as a craniofacial surgeon in a previous life and I’ve never seen the range and rarity of some of these craniofacial and cleft deformities. These are things that typically you might only see in a textbook, and you might see these routinely in a screening way. And you literally have no information about these patients other than what these families can give you, and they can pretty much give you no information. So, you’re trying to diagnose these pretty complex conditions in the space of 5 minutes, maybe, because you have so many patients to see. Anesthesia is trying to determine if they’re healthy enough or if it’s safe enough to have them withstand surgery. It’s a little stressful to try to figure out what it is that you can do for these patients when you know these are the kind of issues that, if you were in the United States, we would literally spend months teeing them up in order to take care of them properly.

    Dr. Sam Jejurikar: And I think you get different types of patients you see. Rarely do you see a young child with a relatively straightforward cleft lip or cleft palate? No other problems. Those are the ones that we feel really amazing about being able to help because we know we can take care of them in a safe manner. And the first rule of the Hippocratic oath is that all Doctor Steak is the first to do no harm, and we know we can do these cases safely. Another category, though, can be somewhat heartbreaking. These are either the patients that clearly have medical problems that would require significant workup that we’re just unable to deliver in these situations. More medical problems that are just beyond our scope. Sam, tell me about the young woman that we saw together at our table.

    Dr. Sam Rhee: This was a heartbreaker. She was such a beautiful young woman. She had a large vascular malformation, which is basically a large collection of blood vessels that she was born with. Look like a big spongy grape-like collection on her lower lip. It was basically filled with blood vessels, and you might see in the United States these types of ginangiomas or vascular malformations. Sometimes they call them stork bites. They’re little small ones often you might see in a child, and they usually might regress and get smaller on their own. But this poor girl, she might, maybe she was about 6. It covered her entire lip, and it extended all the way along her jawline, almost back to her years, and it was really difficult to tell her in a family no.


    Managing Celft Deformities in the United States

    Dr. Sam Jejurikar: Yeah, and how would you manage that in the United States if you saw that?

    Dr. Sam Rhee: Well, we would get vascular imaging, we would see the extent to which the blood vessels that were feeding this benign tumor, this massive blood vessel where they led. We would work with interventional radiology specialists, who would then block those blood vessels and embolize them basically. And then once we reduce the blood supply or cut off the blood supply to these masses, then we can safely surgically remove them without the risk of severe blood loss.

    Dr. Sam Jejurikar: Right; we would have blood products available, too, because the risk of bleeding is quite high. Meanwhile, in Bangladesh, we don’t really even have working basic cautery devices like we would have in any OR, like a breast augmentation or an upper eyelid lift. We don’t even have that in our operating rooms there. And then you have the family really wanting us to do this operation. They dress this young woman up in her finest clothing for screening day. She was wearing a tiara and pearls, and even the local surgeons were trying to get us to do something. Because they don’t really quite understand or want someone else to try to help this young woman. So, say know on screening day can be heartbreaking.

    Dr. Sam Rhee: It was the worst, especially this particular girl. As I said, she was dressed up. She was so cute. She had these little pearls on her tiara. She was wearing this gorgeous little pink dress because these families often really dress up these kids because they want them to look good. They want us to do these surgeries. And the families don’t really understand the reasons why we can’t do surgery on a particular child. All they know is they traveled such a long day is they know their daughter needs help. They look around, and they see this child being helped, and they say yes to this other child. But for some reason that they can’t understand, we’re saying no, and you know screening day is over, they’re still standing out there, they’re begging. Probably one of the tougher times when we’re dealing with this type of situation.

    Dr. Sam Jejurikar: Yeah, it’s situations like that. Luckily or not the norm, but they are heartbreaking for sure. So that day is over. We set up the OR and then Shahid Aziz, who we’ve had on a previous podcast. If you’re interested in learning more about him and the organization, check out that one. But he then compiles his master’s schedule. And we take in this particular case; we had four operating tables going simultaneously. We had an oral maxillofacial surgeon from Houston, Jose Marchetta, who works at Ben Todd Trauma Center. We had Shahid Aziz at another table. We had me on a table. We had Sam at a table, and then we had John Wallace, an oral surgeon from Dallas, at another table. You may have noticed that it’s five and we had four tables.

    So, we have some rotation going on and some relief. But that means we have four anesthesiologists, and all this is happening in just sometimes one or two opening rooms that we’re doing this. There was a lot of activity. Lots of cases are going on at the same time. Lots of residents in Oil Maxwell Facial Surgery from across the country. So, it’s an amazing experience for these residents because they get to see just the full breadth of cleft lip and palate surgery literally in the span of just a few days.

    Dr. Sam Rhee: I mean, you got to realize these are exceptionally skilled people who come on these mission trips. Shout out to the anesthesia fighters Doctor Mike Reeves from Colorado. Doctor Chris Chin from Dartmouth, Doctor Neha Patel, and Xena Hussain.

    Dr. Sam Jejurikar: Yeah.

    Dr. Sam Rhee: Yeah. Mina Hussein. These guys, listen, doing pediatric anesthesia is challenging under any circumstance. It’s easier, easier, and take care of a 150- or 100-pound person, but when you’re going with literally four, like a 2-month-old, four-child kid or a 6-pound kid who’s malnourished, has a lot of chronic issues. Bangladesh is a really difficult place to grow up and live. These are very unhealthy children, and for them to be able to manage what we do surgically on them, get them through the surgeries, get them to recover, get them to be pain-free and comfortable during this. It’s a feat that blows my mind every time I see them do it. We have sort of a simple part of it where we’re just doing what we normally do. But for them, these are exceptionally different and difficult patients since it is.

    Dr. Sam Jejurikar: I always have a hard time putting this next thing into words, but I’m never fully comfortable when I’m in Bangladesh. I’m not just talking about personal comforts. But that’s certainly factoring into it, but even in the operating room setting, just all aspects of life, I don’t feel that comfortable when I’m married. So, do you feel that way?

    Dr. Sam Rhee: It’s a challenge, listen; you’re taking us; we live in the United States. It is comfort, everything we do is comfortable, and yet then you come here.

    Dr. Sam Jejurikar: Here, this is very comfortable.


    Challenges of Surgery in Bangladesh

    Dr. Sam Rhee: Okay, this is very comfortable. Goodbye. But you go to Bangladesh, and you go to some; we actually were in Dhaka at this time, which was marginally better, or we’ve been in places. From the minute you step to put into the country where we stay, there are living conditions or, let’s just say, multiple orders of magnitude different. You’re dealing with potential health issues. Dengue fever was an issue that we were concerned about at this time. Generally, when we go out into the Hinterlands and out into the rural areas. Malaria Prophylaxes are a must. Just the hospital conditions under which you have to sort of navigate and be creative about in terms of. I mean, these are not OR tables some of these things. I mean, this time, it was pretty good, but we operate on wood tables like literal wood tables.

    Dr. Sam Jejurikar: We’ve had operating room lights go out.

    Dr. Sam Rhee: Yeah.

    Dr. Sam Jejurikar: And I remember doing a cleft pallet with just my headlights and the ambient light of a laptop to try to be light. So yeah, the operating now, I will say that it seems like things are getting better in Bangladesh. There’s more like it was still not the United States, but on this most recent trip, we actually had real OR lights for the first time on any trip. So, it is getting better, but yeah, I mean, Sam and I shared a hotel room. In a tiny little hotel room with we were on these narrow little beds where our beds were basically touching each other. We had a view of where the apartment next door to ours was about three feet away from our window.

    Dr. Sam Rhee: It’s at the tank crumbling structure.

    Dr. Sam Jejurikar: We could see right into there, and it was a very nice lady who would look right back at us, and she would be doing laundry and cooking her dinner all sort of in this tiny little space right across from us. We basically ate curry or rice and daal, which is like a vegetable sort of curry, for every meal. Breakfast, lunch, and dinner are the same meals.

    Dr. Sam Rhee: I think the more I travel and the more we’re experienced with this, but you focus on the very basics, and the basics are what can you eat safely? How do you make sure your GI tract is working properly, and how can you not get sick on any of these trips? I think that we pretty, I mean as opposed to other trips, pretty much escaped unscathed this time around.

    Dr. Sam Jejurikar: Yeah, I mean, I definitely have my tricks that go completely against what I do at home. I only eat highly processed food. And I don’t drink water unless I’m sure it’s come from a bottle, and I’ve seen the bottle because Sam and I are both important by that in the past for sure.

    Dr. Sam Rhee: I think the odors and the smells are always interesting when you’re traveling around in and out of the country, particularly so when you’re in Bangladesh.

    Dr. Sam Jejurikar: Yeah.

    Dr. Sam Rhee: And here’s what it does every time I travel here to Bangladesh. It does remind me, yes, the minute I step foot in the country. This is Bangladesh. I can smell it. It’s, and most of the time, it’s quite a variety that is not what you would normally count to in the United States.

    Dr. Sam Jejurikar: So, our complaining aside.

    Dr. Sam Rhee: It was that complaining I was trying to be good about.

    Dr. Sam Jejurikar: Yeah. Oh, I brought it on. So, I’m not signaling you up by any stretch. I think this trip is one of the best things that we both do. The profound gratitude that I have comes out of this trip. Whether it’s for everything I have in my life. Whether it’s for the bonds that I form with people from another culture or another country who don’t speak the same language yet show such unmistakable gratitude and just are so overjoyed that people will come from all across the world to help them. The bonds that I form with these people so quickly are probably the most fulfilling thing that I have done in my life. I mean, do you feel that way too?


    Why Surgery for Bangladeshi Citizens Matter

    Dr. Sam Rhee: And as doctors, and listen, let’s face it, we do aesthetic surgery as our job at this point. We impact patients’ lives for the better. We want patients to be happy after we help them, but this kind of helping on this level is profoundly different. When you think about a child that grows up in Bangladesh, children that would be shunned, ostracized, never made part of a normal society, and when you should actually change their life, their entire course of their life with a 2-hour surgery at an age…

    Dr. Sam Jejurikar: Or even a 1-hour.

    Dr. Sam Rhee: Or some of them 1 hour.

    Dr. Sam Jejurikar: Yeah.

    Dr. Sam Rhee: You’re a faster, a better surgeon than I. It might take me 2. But you’re right. It’s just when you think about what, when I think about those people, that I feel like I can make such a dramatic impact, it brings ruling, and it brings contrast to everything else I do. I enjoy what I do every day at work. I appreciate it even more when I come to a place like Bangladesh and I can help with these petitions. It’s overwhelming. It’s profoundly overwhelming, and I am always left with such a sense of gratitude and joy that we have the skills to be able to do this. And, in a week, and literally a week of our lives every year, this is the first year in a while that I’ve been able to do it. But over the years, it’s kept me grounded, and it’s made me a better person pretty much in every way.

    Dr. Sam Jejurikar: Here that I couldn’t agree more. I can’t wait to go back next year, but I can’t wait to go home. Can’t wait to see my family. Can’t wait to work at Dallas Plastic Surgery Institute, where everything is efficient, and I don’t have to worry about where the equipment is coming from.

    Dr. Sam Rhee: No more surgical, little surgical temper tantrums when you’re in the operating room, and they don’t have the right music playing for you.

    Dr. Sam Jejurikar: Yeah, I mean, it just makes me feel so grateful for everything. Both the trip and what I have in my own life.

    Dr. Sam Rhee: I want to thank all the people in Bangladesh. I would like to thank Smile Bangladesh and its founder Doctor Aziz. I would like to thank our team. This was, as Sam said, the biggest team, 22 people. Fantastic. These were all amazing surgeons and anesthesia. Adrian and Caitlin were amazing in recovery. I will not know about my life for at least a week after I get back.

    Dr. Sam Jejurikar: So, hopefully, you have a little bit of insight into what Bangladesh is like for us. We’ve thought we would talk about this while it’s fresh in our heads. If you would like to learn more or would like to help in any way, the website is “” There’s a donate section on there as well. Every little bit you can donate helps the organization and helps us take care of more children. So, thank you for watching, and until we see you again, take care.




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