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198 images Created 10 May 2018

BRAZIL (Smile Train) – Bringing smiles deep inside Amazonia

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  • CAPTION: Plastic surgeon Dr Sá (right) and his team arrive at the airport in Manaus, ready to fly to Tabatinga, which lies on Brazil's border with Colombia and Peru. Their supplies are being loaded as the team prepares to begin their journey. LOCATION: Eduardo Gomes International Airport, Manaus, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Nelson Campos (left) and Dr Álvaro Sá (right).
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  • CAPTION: Anaesthesiologist Dr Melo ensures that the team’s supplies are checked in properly. The boxes hold medicines, medical equipment and other items needed for the operations that the team will shortly be conducting, deep inside the Amazon. They usually carry everything they might need, as the remote hospitals they visit may lack all that's needed for safe and effective surgeries. LOCATION: Eduardo Gomes International Airport, Manaus, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Dr Theomário Melo (right).
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  • CAPTION: Dr Sá and Dr Neto prepare to board the plane the government has hired for them to travel to Tabatinga. LOCATION: Eduardo Gomes International Airport, Manaus, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Dr Álvaro Sá (left) and Dr Joaquim Neto (right).
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  • CAPTION: The team of doctors arrives at Tabatinga Airport, after a flight over dense Amazonian jungle that lasted almost three hours. LOCATION: Tabatinga International Airport, Tabatinga, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Dr Joaquim Neto.
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  • CAPTION: Tabatinga is a very remote location. Doctors usually have to fly to this place, as it would take them about a week to reach here by boat from Manaus. Being located at the tristate border of Brazil, Peru and Colombia, it forms part of a busy trade route. It's also a strategic location for drug traffickers and dealers of contraband goods. LOCATION: Port of Tabatinga, Tabatinga, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: N/A.
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  • CAPTION: Helpers at the port carry the supplies out to a waiting boat. Dr Neto is in charge of logistics and co-ordination, and ensures that all the boxes are moved through efficiently. LOCATION: Port of Tabatinga, Tabatinga, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Unknown.
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  • CAPTION: With her son Kalebe in her arms, Jeane boards the same boat as the Smile Train team, bound for Benjamin Constant. Their family are from a Ribeirinho (‘river people’) village, and are not of Indian descent. It takes three hours to travel by speed boat from their village to Tabatinga, the launching point for Benjamin Constant, where Smile Train is focusing its efforts for this round of surgeries. LOCATION: Port of Tabatinga, Tabatinga, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Jeane Gomes (mother), Kalebe Rabelo (child) and Dr Joaquim Neto (right).
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  • CAPTION: Hélio is 12, and is the youngest of four siblings. He was born with a cleft lip and palate that ran all the way through to his nose. His parents had known of this condition in others, but never imagined that their son might be born with such a problem. They had previously tried surgical interventions to correct his cleft lip and palate, which proved to be unsuccessful. However, the surgery he underwent with Smile Train’s assistance has been extremely successful and he is making good progress. Here, he is seen with Victoria, who also underwent corrective surgery for her cleft palate through Smile Train. They are on their way back to the hospital via boat for a check-up. LOCATION: Rio Marañón, near Tabatinga, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Hélio Grandes (left) and Victoria Aparicio (right).
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  • CAPTION: Victoria is chirpy, cheerful and all of six years old. Tragically, she was born with both a cleft lip and palate. She had her first corrective surgery as a nine-month-old infant in São Paulo. However, owing to some complications, the palate opened again. Six months ago, she underwent her second surgery in Benjamin Constant with Smile Train’s assistance. Today, she and her mother are returning to the hospital via boat along the Rio Marañón, a branch of the Amazon, for a check-up. LOCATION: Rio Marañón, near Tabatinga, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Victoria Aparicio (left) and Veronilee Nascimento (right).
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  • CAPTION: Kalebe is fast asleep in Jeane’s arms. Beside them is Karen, a medical student who’s accompanying the Smile Train team, and Nelson, who is providing translation support. Kalebe has an incomplete bilateral cleft of the lip and the alveolus. The doctors feel that since his palate and teeth are relatively normal, it is possible to correct his condition with just one operation. LOCATION: Rio Marañón, near Tabatinga, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Adults, from left to right: Jeane Gomes, Karen Costa and Nelson Campos; child: Kalebe Rabelo.
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  • CAPTION: Dr Neto and Mariane Goes, Smile Train's Country Director in Brazil, share a light moment as they speed along the Rio Marañón to the small town of Benjamin Constant. LOCATION: Rio Marañón, near Tabatinga, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Mariane Goes (left) and Dr Joaquim Neto (right).
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  • CAPTION: Dr Melo is careful to ensure that the anaesthesia equipment doesn't tilt over as they make the boat ride. Benjamin Constant is an impoverished town that's cut off from the outside world other than via river transport. Living conditions here can be difficult, and the local health facilities here only fairly basic infrastructure. People that live in Benjamin Constant's hinterland essentially survive on a subsistence regimen and do not have the means for travel or education. Finding a means of efficiently reaching out to patients is therefore highly important. LOCATION: Rio Marañón, near Tabatinga, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Dr Álvaro Sá (left) and Dr Theomário Melo (right).
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  • CAPTION: As the boat approaches the harbour at Benjamin Constant, a floating dentist can be seen in the river. These outposts operate like a country within a country. Brazil’s central authorities have instituted a specific department to take care of their needs. LOCATION: Paraná Benjamin Constant, Rio Javari, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: N/A.
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  • CAPTION: At Hospital Geral de Benjamin Constant, a nurse talks to a lady and her child in the local indigenous language, gathering information about the various cleft patients who've come to see the team of doctors from Manaus. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Maria Turibio (mother wearing yellow), Lilás Turibio (her baby) and Alessandra Maciel (standing).
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  • CAPTION: With translation support, Dr Neto leads an introductory session with those who’ve come for cleft check-ups and surgery and their families, as well as medical personnel at the hospital. The doctors rely on the local authorities to publicise Smile Train's work and their visit, and to get the cases in. On this occasion, 36 patients have come; aside from those who just need check-ups or are otherwise not medically fit for surgery, 12 will be operated on. The success of programme like this are very much dependent on good planning, publicity and coordination, as well as government funding for accessing remote regions. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: From left to right: Dr Álvaro Sá, Dr Joaquim Neto and unknown.
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  • CAPTION: Maria is a joyful and spirited little girl. Here, she is seen playing with her curls as she sits on her grandmother Maria’s lap while she and her mother Rosana listen carefully to the doctors who’ll soon be reviewing her cleft correction surgery, five months after her operation. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: From left to right: Rosana de Souza, Maria Souza and Maria Souza.
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  • CAPTION: Maria has brought her young baby, Lilas, in the hope that she can be operated on. Unfortunately, however, Lilas is currently unwell and does not meet the fitness criteria (for example, weighing at least five kilos) to qualify for surgery. According to Dr Sá, it can be heartbreaking to have to turn hopeful mothers like this away, but it must be done for their babies’ safety. In this case, Maria remained composed and showed that she accepted the situation. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Maria Turibio (left) and Lilás Turibio (right).
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  • CAPTION: Victoria, for the most part, has transcended her situation, as she is a very brave little girl. However, she has faced the biggest obstacles in school, where she struggles to pronounce words correctly. Her challenges in speech and pronunciation have inevitably attracted mockery and ridicule from other children. Nevertheless, Victoria tries to remain strong, and never cries, even when feeling a little sad. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Victoria Aparicio.
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  • CAPTION: Maria was born with a unilateral cleft lip that went all the way to her nose. She is Rosana's only child, and she admits that she hadn't planned on getting pregnant. Nevertheless, when she realised that she was expecting Maria, she apparently had no worries and knew that she simply had to speak with her mother about it and all would be well. In fact, her mother was overjoyed when she heard that she would be a grandparent soon. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Maria Souza.
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  • CAPTION: Talking about the time when she was pregnant with Kalebe, Jeane says, “I was a bundle of emotions – happy, anxious, excited. But my pregnancy was riddled with risk, and at times it was touch and go for my baby's life”. She had some bleeding issues at this time, for example, and these worried her a lot. She first learned about the bilateral cleft lip only once she gave birth. She had had two ultrasounds during her antenatal check-ups, but the doctor couldn't see the baby's face. Having become pregnant very young, Jeane was nervous that she would not have the skills to help Kalebe cope with his condition. Soon after his birth, he began experiencing breathing and feeding issues, and lost a lot of weight, which made her very anxious. To counter this, she bottle fed him using a special mix of vitamins in the milk, as recommended by a doctor in the neighbouring town of Leticia in Colombia. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Kalebe Rabelo (left) and Jeane Gomes (right).
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  • CAPTION: Kalebe's cleft is relatively mild and easy to correct. Jeane was nevertheless concerned that she wouldn’t be able to access the services he’d need for it to be repaired. For instance, when she gave birth in Tabatinga, the doctors informed her that when Kalebe turned three months old, she would be taken with her son to Manaus; this never happened. It felt like the health services had forgotten about her and her baby. Jeane admits that she was very worried about the situation, and that she would sometimes cry all night long. Her biggest concern was that people would not accept her son; worse, that they’d make unkind remarks and joke at his expense. Her family, however, were very accepting, and made it clear to her that they were simply happy that he was healthy in all other senses. Her mother, in particular, helped her a lot in taking care of him. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Kalebe Rabelo (left) and Jeane Gomes (right).
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  • CAPTION: Jeane feared that if left unaddressed, Kalebe's appearance would lead to him feeling excluded in school and play environments. She was also concerned that he could face issues well into his adulthood, and that he could find it difficult to find a wife and have a family. She stresses, “people care a lot about appearances, and that would work against him". Jeane feared that her partner, who works as a mason, would be unable to meet the medical expenses if they have to get the operation done privately. He doesn't have regular employment, and sometimes finds he’s without work for an entire week at a time. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Kalebe Rabelo (left) and Jeane Gomes (right).
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  • CAPTION: Despite the challenges they faced, Jeane and her partner did not give up, and decided to save some money and do whatever they could on their own. Though they saved for a year and a half, however, they found it too difficult to raise sufficient funds. Luckily, Jeane learned about Smile Train through a social worker, and she and her partner have been eagerly awaiting the opportunity for Kalebe to have surgery with their support. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Kalebe Rabelo (left) and Jeane Gomes (right).
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  • CAPTION: Rosana's mother was not at all apprehensive about her daughter choosing to raise her child singlehandedly. She was confident she could play an active role as a grandparent, and that her daughter would therefore have all the help she needed with raising her child. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Maria Souza (left) and Maria Souza (right).
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  • CAPTION: When Rosana went for her ultrasound examinations, they didn't reveal that her child would be born with a cleft. As she didn't know much at all about this condition and wasn’t expecting it, she did feel overwhelmed when she first saw Maria’s face and was in tears because she felt things would be complicated now. She worried a lot about her daughter's future, though over time her sadness gave way to calm. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Maria Souza.
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  • CAPTION: When Maria was only a year away from starting school, Rosana says her biggest worry was that the other children around her would not be sensitive to her condition. She also worried that ignorant people would ostracise her. Even if they wouldn't necessarily say anything, she felt they would certainly stare at her. Further down the line, she felt that her appearance would surely affect her employment and marriage prospects. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Maria Souza (left) and Maria Souza (right).
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  • CAPTION: Armanda's mother Francineia has brought her daughter to Hospital Geral de Benjamin Constant for pre-surgery checks. Here, anaesthesiologist Dr Melo listens to the baby’s lungs to check that all is well. He is careful to ensure that he can rule out the presence of a cough or fluids in the lungs, as these will make surgery unsafe. The heart rate must also be checked and blood tests conducted to ensure that the patient is completely fit for surgery. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Armanda Guedes (baby), Francineia Guedes (mother) and Dr Theomário Melo (doctor).
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  • CAPTION: Anaesthesiologist Dr Melo checks Armanda’s paperwork to make sure it is complete in every respect. This small girl has some rare and extremely complex deformities with her nose and hand, in addition to her complete (and rather wide) bilateral cleft lip and palate. The doctors suggest that this is probably due to a genetic condition. As it would be difficult to perform surgery on both the nose and lip at the same time, they say they would prefer to conduct multiple surgeries over time. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Armanda Guedes (baby), Francineia Guedes (mother) and Dr Theomário Melo (doctor).
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  • CAPTION: Smile Train-supported surgeon Dr Sá speaks with Jeane as part of his efforts to evaluate Kalebe's health and readiness for surgery. Jeane says that when she saw Dr Sá and the other doctors climbing onto the boat with them, bound for Benjamin Constant, she felt extremely happy that the day had finally come and began to well up. At that precise moment, she felt her worries disappear. Jeane is very happy to be with Kalebe at the hospital now, and feels reassured that her son is in good hands. Although she does feel a bit nervous, she is confident that the doctors will perform the operation skilfully. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: From left to right: Dr Álvaro Sá, Jeane Gomes and Kalebe Rabelo.
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  • CAPTION: After the evaluation is complete, Dr Melo entertains Kalebe by making a toy out of an inflated glove. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: From left to right: Jeane Gomes, Kalebe Rabelo, Alessandra Maciel and Dr Theomário Melo.
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  • CAPTION: Armanda's is not a common condition, even among cleft cases. There appear to be multiple issues, as can happen with genetic syndromes. Experts in genetics would ideally need to be brought in before associated deformities with her nose and hand can be tackled in a holistic manner. Even considering the facial aspects alone, her very wide bilateral cleft and duplicated nostril on the left side will likely need multiple surgeries. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Armanda Guedes (left) and Francineia Guedes (right).
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  • CAPTION: Nurse Latorre talks to Armanda and her mother, as they wait for the little girl’s turn to come in the operating theatre. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: From left to right: Guanssyrla Latorre, Armanda Guedes and Francineia Guedes.
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  • CAPTION: Now that her daughter has been taken for surgery, Francineia remains hopeful as she silently prays outside the operating theatre. She looks forward to some good news coming soon, which she will convey via mobile home to those waiting anxiously back home. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Francineia Guedes.
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  • CAPTION: The hospital’s dentist, Dr Mesquita, holds Armanda in her arms as the team make their final preparations for surgery. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Armanda Guedes (left) and Thassyla Mesquita (right).
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  • CAPTION: The hospital’s dentist, Dr Mesquita, holds Armanda in her arms as the team make their final preparations for surgery. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Thassyla Mesquita (left) and Armanda Guedes (right).
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  • CAPTION: The hospital’s dentist, Dr Mesquita, holds Armanda in her arms as the team make their final preparations for surgery. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: From left to right: Dr Álvaro Sá, Armanda Guedes and Thássyla Mesquita.
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  • CAPTION: Dr Melo and his team try to anaesthetise Armanda by administering an inhalant to her. Babies can be very fidgety, and will typically move around so much that it’s hard for doctors to locate a vein. Hence, inhalants are used to sedate them before the anaesthesia is administered. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Adults, from left to right: Dr Theomário Melo, Francisco Jumbato and Marcos Braga; baby: Armanda Guedes.
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  • CAPTION: Armanda is now nearly completely anaesthetised. Here, Dr Melo is administering oxygen to her. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Dr Theomário Melo (doctor) and Armanda Guedes (baby).
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  • CAPTION: While they wait for the anaesthesia process to be completed, team members examine the deformity in Armanda’s left hand. She has only her thumb and two fingers on this hand. It is likely that she has been affected by a genetic syndrome. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Adults, from left to right: Dr Theomário Melo, Dr Joaquim Neto and Marcos Braga; baby: Armanda Guedes.
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  • CAPTION: The doctors also examine Armanda’s nostril duplication, and it appears that she has a nostril within a nostril. After checking that her airway is fully open and she is fully anaesthetised, they try to locate a vein to administer an injection. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Armanda Guedes.
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  • CAPTION: At this point, the team’s alarm bells start to ring and it becomes clear that it will not be possible for Armanda to undergo surgery. Although there is supposed to be a period of starving before a cleft operation, it’s now clear that she was fed before the procedure, leading her to vomit when anaesthetised. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Adults: Francisco Jumbato (left) and Dr Theomário Melo (right); baby: Armanda Guedes.
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  • CAPTION: Dr Melo appears very concerned as he examines Armanda as she continues to vomit. He has turned her onto her side, so that she won't aspirate and choke on what she is ejecting. The team would ignore this situation at their peril, as it could be lethal. Fortunately, Dr Melo is a very competent anaesthesiologist, and handles the situation with utmost professionalism. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Adults, from left to right: Dr Theomário Melo, Siloé and Marcos Braga; baby: Armanda Guedes.
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  • CAPTION: Armanda is now out of harm’s way and recovering in the arms of nurse Siloé. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: From left to right: Dr Theomário Melo, Siloé and Armanda Guedes.
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  • CAPTION: As Nurse Siloé gently reviving Armanda from the effects of anaesthesia, Dr Melo checks her pulse to verify that all is well. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Baby: Armanda Guedes; adults: Dr Theomário Melo (left) and Siloé (right).
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  • CAPTION: Jeane admits to having been nervous when handing Kalebe over to the nurse, pre-surgery. While she was delighted that the time had come, she was also feeling apprehensive that there might be risks involved. She shares that she didn't talk to any of the other patients or families while she waited, though she did feel confident as she saw other patients being brought out of the operating theatre after successful completion of similar surgeries. Here, Dr Melo is beginning to intubate Kalebe, as a nurse stands by to assist. In order to intubate a patient, his or her breathing must be paused. Though this can be difficult with some patients, the process goes smoothly here. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Adults: Marcos Braga (left) and Dr Theomário Melo (right); child: Kalebe Rabelo.
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  • CAPTION: Dr Melo applies a protective cream to Kalebe’s eyes. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Adults: Dr Theomário Melo (left) and Dr Álvaro Sá (right); child: Kalebe Rabelo.
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  • CAPTION: Dr Sá takes a photograph of Kalebe before the surgery begins. This ‘before’ picture will be sent to Smile Train for their records. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Adults: Marcos Braga (left) and Dr Álvaro Sá (right); child: Kalebe Rabelo.
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  • CAPTION: After ensuring that Kalebe is fully anaesthetised, Dr Melo checks the position of the tube that goes to his lungs. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Dr Theomário Melo (doctor) and Kalebe Rabelo (child).
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  • CAPTION: Surgery is about to begin, and the scrub nurse and circulating nurse stand ready to assist Dr Melo and Dr Sá  with whatever they need. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Dr Theomário Melo (doctor) and Kalebe Rabelo (child).
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  • CAPTION: Little Kalebe is deep in sleep, completely unaware of all that is going on. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Kalebe Rabelo.
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  • CAPTION: Dr Melo makes sure that records are kept of all the necessary details of the surgery. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Dr Theomário Melo.
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  • CAPTION: Povidone-iodine solution, an anti-bacterial agent, is applied to Kalebe's skin to prevent any infections during the operation. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Dr Álvaro Sá (doctor) and Kalebe Rabelo (child).
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  • CAPTION: All but the area of Kalebe’s face that will be operated on is now covered. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Kalebe Rabelo.
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  • CAPTION: Dr Sá carefully makes various markings that will guide him during the operation. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Kalebe Rabelo.
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  • CAPTION: Adrenaline is injected into Kalebe's lip in order to prevent excessive bleeding. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Kalebe Rabelo.
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  • CAPTION: Dr Sá starts to make incisions in Kalebe's lip. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Kalebe Rabelo.
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  • CAPTION: He then proceeds to remove tissue from the area between his incisions. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Kalebe Rabelo.
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  • CAPTION: Dr Sá dissects Kelebe’s muscle, paving the way for reconstructive surgery. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Kalebe Rabelo.
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  • CAPTION: When performing corrective surgery for clefts, surgeons should be extremely careful to ensure that their patients will leave with no more than minimal facial scars, post-surgery. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Kalebe Rabelo.
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  • CAPTION: Dr Sá is now well into the suturing process. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Kalebe Rabelo.
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  • CAPTION: Finishing touches are made to the suturing. Good sutures will help to minimise scarring. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Kalebe Rabelo.
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  • CAPTION: Kalebe’s surgery nears completion. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Kalebe Rabelo.
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  • CAPTION: Dr Sá makes his finishing touches, completing his repair of Kalebe’s cleft. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Dr Álvaro Sá (doctor) and Kalebe Rabelo (child).
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  • CAPTION: Kalebe is taken to meet his mother by the circulating nurse. Though he appears tearful, this is more from the confusion he’s experiencing as he wakes from the effects of anaesthesia. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Adults: Dr Theomário Melo (left) and Siloé (right); child: Kalebe Rabelo.
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  • CAPTION: Jeane gently receives Kalebe from Dr Melo, onto her lap. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Dr Theomário Melo (doctor), Jeane Gomes (mother) and Kalebe Rabelo (child).
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  • CAPTION: Jeane carefully observes the surgery area and the sutures that have been sewn into her son’s lip. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Kalebe Rabelo (left) and Jeane Gomes (right).
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  • CAPTION: As she admires her son's face, Jeane smiles to herself. She is clearly delighted with the results. Kalebe will now spend about an hour with her here in the recovery room. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Kalebe Rabelo (left) and Jeane Gomes (right).
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  • CAPTION: Christiane and her father Dozario have travelled to the hospital at Benjamin Constant from a small village called São Domingo Dois, around four hours away by boat. After arriving in nearby Tabatinga, they stayed at the Casa de Saúde Indígena (CASAI), a centre for the welfare of Amazonian Indians run by the government, and this provided them with food and assistance prior to their trip to the hospital. At the hospital, too, all meals are provided. The family was originally part of the nomadic Ticuna tribe, but has now settled into village living. They stay in an Indian reservation, where theirs is one of around 80 households. Dozario farms and sells plantains and manioc to make a living, and if transport had not been paid for then it would have been very challenging to raise the 200 Reals (US$ 70) necessary for such a journey. Their fellow villagers had never met someone with a cleft lip or cleft palate before they encountered Christiane, and her family certainly notice how people react to her. Aside from the disfigurement, Christiane's condition has left her with a lot of pain and discomfort. She often gets ear infections, which result in an oozing yellow discharge. She also finds eating difficult, and even suffers great discomfort with breathing at night. Now that she’s come for surgery, she is looking forward to eating and breathing without pain and to an end to her ear infections; the fact that she will soon be able to talk such that she is intelligible to everyone fills her and her father with hope. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: From left to right: Chrístiane Mariano, Dozario Mariano and unknown.
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  • CAPTION: Reuny is from the Ticuna tribe of indigenous Amazonians, and the second youngest in a family of eight children. He is also his father's favourite son, in addition to being his namesake. The two have come to Hospital Geral de Benjamin Constant, a four-hour journey by boat from their tiny village, for an operation to repair Reuny Jr.’s unilateral complete cleft lip. The cleft is big, going all the way to his nose and also affecting his palate. When he was born, his father was really taken aback by his deformity. Yet he says he didn’t panic or worry too much. He quietly told himself that he would do everything in his power to help him get a correction. When other children would ask what was wrong with their son, Reuny Sr. and his wife would tell them, “God has decreed that he will be born this way, so we must take care of him”. This explanation always worked. The village they live in is predominantly Catholic, and all the villagers - including the local priest - have thankfully been very supportive of Reuny's condition. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Reuny Felix Sr. (left) and Reuny Felix Jr. (right).
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  • CAPTION: As they wait to be called for surgery, Reuny Sr. looks down adoringly at his little boy. From the very beginning, he knew that living with the cleft would not be an acceptable option, as it would affect his speech and language skills as well as he ability to eat. He was also concerned that going to school with a cleft would make social adjustment difficult. He felt it likely that he’d find himself excluded from activities, and that kids would make jokes at his expense, or else refuse to communicate with him. In the future, it could also affect his prospects for marriage. The condition has certainly made nutrition a challenge. When he tries to drink anything, it comes out through his nose, choking him and leaving him  gasping for air. When he was a baby, his mother struggled hard to breastfeed him, and he was constantly weak because he could not consume all that he needed. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Reuny Felix Sr. (left) and Reuny Felix Jr. (right).
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  • CAPTION: Karen, a medical student from Manaus, asks Reuny Sr. a few questions in order to complete his son’s pre-surgery form. He is delighted to be here today, as it has been a long journey to get to this point. Earlier, when he initially approached his nearest government health centre for information on State entitlements, he was told that since he was employed, he and his family could not claim anything at all. Yet even travelling there took much of his resources, as his village is remote and the only means of transport is via costly boats. He then tried to save money in order to pay for the surgery on his own, but found it pretty much impossible to come close to what he needed. He was very disappointed at this situation, but felt sure that God was preparing an alternative for him. Soon enough, a nurse from Hospital Geral de Benjamin Constant called him about the doctors visiting with Smile Train’s support, and told him that they’d send a boat to his village to enable them to come; she also assured him that they’d get whatever food they needed while there, too. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: From left to right: Karen Costa, Reuny Felix Sr. and Reuny Felix Jr..
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  • CAPTION: A nurse administers medicine to Reuny intravenously, as he waits to be called for surgery. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: From left to right: Izaque Bastos, Reuny Felix Sr. and Reuny Felix Jr..
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  • CAPTION: Though Francineia is disappointed, she seems resigned to the fact that her daughter cannot receive surgery on this occasion. Here, Armanda is being administered vapour-based medication to help her recover from any aspiration of her vomit. Her oxygen level is also being checked at this time. Dr Sá says that it’s really unfortunate that he was unable to perform surgery on her today. Thankfully, there will be another opportunity when the team returns to the area in four months’ time. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: José dos Santos (left), Francineia Guedes (mother) and Armanda Guedes (baby).
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  • CAPTION: As they wait at the hospital for transportation back to the Amazonian Indian reservation in which they live, Maria nurses baby Lilas even as she sleeps. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Maria Turibio (mother) and Lilás Turibio (baby).
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  • CAPTION: Reuny Jr. has been given a sedative as the time of his surgery nears. As his father holds him in his arms and takes his last look at the unprepared cleft, Dr Neto stands by to take him to the operating theatre. Reuny Sr. says he’s happy that the doctors here have shared a lot of useful information about what they are doing and what can be expected. He assures that he is not really anxious at all, and adds that he is certain that once the operation is done, his son will feel completely fine. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: From left to right: Reuny Felix Sr., Reuny Felix Jr. and Dr Joaquim Neto.
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  • CAPTION: Dr Neto receives Reuny Jr. from his father with a big smile. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: From left to right: Dr Joaquim Neto, Reuny Felix Jr. and Reuny Felix Sr..
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  • CAPTION: Crizângela proudly watches over her young son, Ildren, as she awaits her move during a game of naughts and crosses. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Crizângela dos Santos (left) and Ildren dos Santos (right).
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  • CAPTION: Dr Neto (right) serves as this group’s team leader. He has been actively involved with humanitarian medical missions for a long time now, and ensures that logistics for these trips are managed well. He also shares valuable insights on procedures with relatives and older patients, and assists with operations. In the background, Dr Melo can be seen taking notes on the medication being administered, as well as other details such as the start time of the surgery. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: From left to right: Dr Theomário Melo, Dr Álvaro Sá and Dr Joaquim Neto.
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  • CAPTION: Dr Sá marks up Reuny’s lip in accordance with the Millard Procedure, which he has chosen to follow for this repair. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Reuny Felix Jr..
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  • CAPTION: Local anaesthetic and adrenaline are now administered to the patient. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Dr Álvaro Sá.
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  • CAPTION: Dr Sá proudly flies the flag for Smile Train, wearing branded scrubs as he works. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Dr Joaquim Neto (left) and Dr Álvaro Sá (right).
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  • CAPTION: Dr Sá now prepares the Reuny’s lip muscle by disconnecting it from its anomalous insertions. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Dr Álvaro Sá (left) and Reuny Felix Jr. (right).
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  • CAPTION: Dr Neto is deft in handing Dr Sá whatever he needs to conduct the operation in a very efficient manner. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: From left to right: Francisco Jumbato, Dr Álvaro Sá and Dr Joaquim Neto.
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  • CAPTION: The initial ‘destructive’ part of the operation is now nearly finished, and ‘reconstruction’ will now happen through the sewing of sutures. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Reuny Felix Jr..
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  • CAPTION: By sewing the sutures, the doctors repair the muscle. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Reuny Felix Jr..
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  • CAPTION: Dr Sá focuses intently on placing the sutures just right, as this will ensure the minimum of scarring. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Dr Álvaro Sá (doctor) and Reuny Felix Jr. (child).
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  • CAPTION: As the final stitches are made, Reuny's surgery is nearing completion. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Reuny Felix Jr..
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  • CAPTION: While Dr Melo prepares to revive the patient, Dr Neto takes a final look at what he and his teammates have achieved. Meanwhile, Karen takes a photograph for submission to Smile Train. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Adults, from left to right: Dr Theomário Melo, Dr Joaquim Neto and Karen Costa; child: Reuny Felix Jr..
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  • CAPTION: The last of the equipment is now removed, and Reuny will soon be awake again. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Reuny Felix Jr..
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  • CAPTION: Reuny is now slightly awake, as the anaesthesia is wearing off. It’s normal for the body to shake around about now, which is why the nurse is holding him down to protect him from an accidental injury or fall. Dr Melo can be seen administering painkillers. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Adults, from left to right: Siloé, Francisco Jumbato and Dr Theomário Melo; child: Reuny Felix Jr.
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  • CAPTION: Reuny is carried to the recovery room by Nurse Jumbato, affectionately known as ‘Chico’, one of the most competent nurses at the hospital. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: From left to right: Siloé, Reuny Felix Jr. and Francisco Jumbato.
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  • CAPTION: Reuny is reunited with his father. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Reuny Felix Jr. (child), Reuny Felix Sr. (father) and Francisco Jumbato (nurse).
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  • CAPTION: Reuny tries to deal with the sense of disorientation following the surgery, as his adoring father does his best to comfort him. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Reuny Felix Sr. (father) and Reuny Felix Jr. (son).
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  • CAPTION: Reuny Sr. is so proud of his son, and very satisfied with the surgery. He feels overwhelmed, joyous and peaceful, all at the same time. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Reuny Felix Sr. (father) and Reuny Felix Jr. (son).
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  • CAPTION: Reuny Sr. looks down at his son with tenderness. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Reuny Felix Sr. (father) and Reuny Felix Jr. (son).
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  • CAPTION: Reuny Sr. takes his son in his arms to calm and comfort him. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Reuny Felix Sr. (father) and Reuny Felix Jr. (son).
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  • CAPTION: Reuny Sr. takes his son in his arms to calm and comfort him. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Reuny Felix Sr. (father) and Reuny Felix Jr. (son).
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  • CAPTION: As he begins to calm down, Reuny Jr. feels safe in his father's arms. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Reuny Felix Sr. (father) and Reuny Felix Jr. (son).
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  • CAPTION: Reuny is a little tearful. Cleft repair procedures are generally not too painful, though one can feel a little uncomfortable immediately following surgery. Any pain wears off very quickly. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Reuny Felix Sr. (father) and Reuny Felix Jr. (son).
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  • CAPTION: Reuny Sr. sits cheek to cheek with his son, and whispers affectionately into his ear. LOCATION: Hospital Geral de Benjamin Constant, Rua 13 de Maio, 1496, Benjamin Constant, Amazonas, Brazil. INDIVIDUAL(S) PHOTOGRAPHED: Reuny Felix Sr. (father) and Reuny Felix Jr. (son).
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