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One hour in the Out-patient Department clinic with Mr Riaz - A bird's-eye view

Cleft Hospital, Gujrat

10am: There's hardly a free seat in the waiting room. Mothers cradled babies in their arms, fathers try to keep older children entertained and teenagers wait for their names to be called.

Rafia, in her black hijab, casts her eyes down the long list of names on the clipboard.

Along the corridor, plastic surgeon Muhammad Riax sits in the consulting room, a huge pile of patients' notes in front of him.

Nabeel Cheema, 24, graduated as a doctor just two weeks and is about to start a year-long internship at Mayo Hospital. He is here to observe.

10.03am: Chris Theopold, a cleft lip and palate surgeon from Dublin, joins Mr Riaz in the consulting room.

The man with the black scarf pulled over his face takes his seat at the side of Mr Riaz's desk. He removes the scarf to reveal signs of previous surgery on his face.

Mr Riaz explains one side of the man's face was ravaged by illness and, a year ago, he used part of the man's shoulder to rebuild the face.

The man has since put on weight and it's causing extra weight around his jaw, making it uncomfortable. 

Mr Riaz explains how he will remove some of the excess tissue to reduce the pressure on the man's jaw.

10.08am: Consultant anaesthetist Zahid Rafique enters the room to tell Mr Theopold his patient is ready for surgery and the two men leave together.

Rafia shows in the next patient, a woman with a 15-month-old baby.Mr Riaz explains the baby has a congenital weakness of one side of her face. Part of her ear is missing and the tongue is short, affecting her speech. She's booked in to be seen again.

10.15am: A teenage girl walks in the room with her parents. Part of her eyelid is missing. In the grand scheme of things, it's not the worst disfigurement at the Cleft Hospital today. But Mr Riaz understands that for the young girl in this image-conscious world, it's a big deal.

"A lot of surgeons wouldn't do it for here," he says. "It's a small operation but I can understand why she wants it doing. She feels everyone looks at it when they're talking to her. We'll just make her look the same as everyone else and that's when her confidence will grow." 

The girl, realising her operation is being scheduled, leaves with a smile on her face. 

10.18am: A father carries his baby into the room. sitting next to Mr Riaz, he removes the baby boy's happy. The boy's bladder doesn't have an anterior wall. If left like this, the baby will be incontinent, prone to urinary tract and kidney infections. He's booked in for surgery. 

10.24am: He's a 12-year-old boy who underwent surgery after a serious fall injured his face. He has a congenital problem resulting in a wide bridge of his nose and his eyelids are tight, although he has good eye movement.

Again, Mr Riaz knows some surgeons wouldn't go to the trouble of operating on the boy whose face has already had the worst of the damage repaired. But it's not about meeting minimum standards for the highly skilled plastic surgeon, it's about achieving the best for patients.

"I can make the upper lip better for him," he says. "This boy keeps coming every year and we can keep an eye on him and follow things up."

10.30am: A young girl with a mask, attached to her veil, hanging over her face,  comes into the room with her father. He asks her to detach the mask and she takes it off revealing a large port wine stain on the right side of her face. Mr Riaz tells the father it can be corrected with laser and the form is filled in.

10.33am: With the cleft lip and palate surgical system working well, the UK surgeons can afford to diversify and put their skills to good use to benefit more patients.

Mr Riaz has a rough idea of who will walk through the doors of the clinic but you sense he's always on the lookout for the more challenging patients, the ones who have been turned away time and time again because of the complexity of their cases

The next little boy is one such patient. He has a deformed nose and a depressed forehead. He came all the way from Islamabad for help last Octover and this is his second appointment.

"I like doing this because it's a bit tricker," says Mr Riaz. "You have to think of a solution that will work in this environment."

Mr Riaz asks staff to start a fasting programme with the boy with a view to him undergoing surgery on his nose later today.

10.35am:  He was born with an open face and, at 18, he's already undergone 13 operations. His palate was normal but his face is asymetrical. His nostrils are uneven and he has problems with his upper eyelids. 

A general surgeon rather than a plastic surgeon carried out most of the surgery on the boy's face and Mr Riaz is quite impressed. "He's done well," he said. Mr Riaz plans to align the boy's nostrils without leaving any scars on the boy's normal skin.

10.42am: Outside, the waiting room is packed and Mr Riaz recognises the pretty young girl in the sunshine yellow shalwar kameez as she walks through the door with her parents.

She had a cleft nose repair last March.She doesn't look like she's ever had any problems with her nose, so good is the repair But Mr Riaz knows her upper lip is still too thin.

"It's about this young girl's confidence," he said. "She doesn't stand out from anyone else now but I know I can do more for this young girl. It's taking a step further towards normality for her."

10.50am: If the last patient was striving towards perfection, the man who walks into the room after her is a far greater challenge.

Mohammed Ali is 24 now and for 23 years of his life, he was forced to live with a severe facial deformity. Not only did he have a large cleft lip and palate, his eye sockets were protruding, one eyeball had been removed and his ear was deformed. 

He is what Mr Riaz terms as "complex".

But Mr Riaz knows the young man has put himself through college to achieve a masters in management, despite his condition. It would have taken huge strength of character to drive himself so far so Mr Riaz is determined to do his best for the young man.

"Each time he comes here, he comes in the hope that we can do more for him," he said "We have to help him.

"For those 23 years, whatever failed him in his care was the system, not the availablity of things.

"You can't blame the parents, they have done their best they can to get him an education. They have done everything but it's with the people who could have helped him, no-one was interested.

"Quite often, when you see complex cases like this, no-one goes for it. It's too much like hard work.

"But someone has to take the initiative. This boy deserves it."

Mr Riaz said society had to play a part in helping Mohammed.

"We need people in power to come up with solutions to help people like him," Mr Riaz said "It's not just about offering basic treatment, we have to start thinking about better opportunities so people like him can lead as close to normal lives as they can."

11am: Dr Rafique comes into the consulting room. Mr Riaz's patient, a 12-year-old boy with frontonasal dysplasia, is on the operating theatre. it's time to go.