Manikandan was born to plantation workers Selvan and Ramata of the Marasar community in Parambikulam, Palakkad district, Kerala. A gap in the bones of his skull had never closed. Through it, non-functioning brain tissue and fluid filled a sac that hung from his nose like a pendulum, about the size of a fist. The mass pushed the bone of his right eye outward, blocked part of his vision, and warped the midface. He did not go to school. Other children mocked him. His four siblings were healthy. The swelling had been there since birth and had only grown.

Encephalocele of this anterior type is uncommon — on the order of one in several thousand births worldwide, more often seen in parts of Asia than in the West. The tissue in the sac is usually gliotic and useless. The danger is leak, infection, and the hole in the skull base that never seals itself.

In 2017 a team of about ten to twelve surgeons at Amrita Institute of Medical Sciences in Kochi spent eleven hours on him. Kerala government schemes paid the bill; the family could not. Led by plastic and reconstructive surgeon Dr. Subramania Iyer, with craniofacial colleagues including Dr. Suhas Udayakumaran and Dr. Pramod Subhash, they opened the skull, separated living brain from the dangling sac, excised the mass, rebuilt the bony defect, moved the orbits back into line, and remodelled the nose. Iyer called the challenges “huge.” The hospital said the boy recovered and was ready for discharge, able at last to start school and mix with other children. His father thanked the team for a life that would no longer be lived indoors.

That is the documented ending from July 2017: a face without a pendulum, a state that paid, a child who said he wanted friends. Craniofacial encephalocele surgery does not rewind thirteen years of isolation. It closes a skull that should have closed in the womb. For one boy from a tea estate, that was enough to walk out of the ward looking like himself.

Sources: Amrita Vishwa Vidyapeetham / Amrita Institute of Medical Sciences press note (July 2017); Hindustan Times; Deccan Chronicle; Amritapuri report quoting Dr. Subramania Iyer and Selvan.