M. Tvrdek; M. Fára
Authors place of work:
Department of Plastic Surgery, 3rd Medical Faculty, Charles University, Prague, Czech Republic
Published in the journal:
ACTA CHIRURGIAE PLASTICAE, 51, 3-4, 2009, pp. 85-86
early as the end of the First World War Professor František
Burian M.D., the founder of plastic surgery in Czechoslovakia,
was the first in Europe to use his fine surgical technique and
experience to repair congenital defects, striking cosmetic
deformities and heavy postburn contractions and scars, as well as
operating on posttraumatic deformations. In this way the number of
his patients rapidly increased, with long waiting lists for
had to struggle hard in the twenties to establish a Department
of Plastic Surgery and to achieve recognition of the Speciality of
Plastic Surgery. However, as early as 1932 Plastic Surgery was
legalized in Czechoslovakia as a special branch of surgery. Thus
Czechoslovakia achieved a world-wide first in this field.
Burian was not only the first but in the early thirties the sole
pioneer of plastic surgery in Czechoslovakia. He learned from his own
experience and from visits to departments abroad where certain
methods of plastic surgery were already applied in practice. There he
acquired professional friends and subsequently exchanged professional
experience with them.
of Burian’s time and effort was devoted to cases of harelip and
cleft palate, which constituted the bulk of his interest for the rest
of his life. In his own words, this was where he experienced maximum
joy but also maximum disappointment.
achievements of Prof. Burian in the field of plastic surgery
were promoted by his artistic and creative imagination, manual skill
and theoretic approach to the applied treatment, as well as by his
deep compassion and sympathy for the mental state of patients - which
prompted him to provide to the patient with the maximum possible help
while also receiving the urgently required co-operation of the
patient during the process of treatment.
his harelip operations he first used the Thompson technique, which
was described by Davis in his monograph published in 1919. Burian was
not in favour of the use of the Hagedorn operation from 1892 (primary
raising of the height of the lip at the site of the suture with
a flap including all components of the lateral side of the lip,
which was turned round below the incised margin of the philtrum).
the twenties Lexer in the 5th
edition of his Handbuch der praktischen Chirurgie (1921) still
included the statement, printed in large type, that it is not
possible to recommend in all cases the preservation of the
premaxilla, since it is often markedly atrophic and therefore of no
value, even in a cosmetic sense, and according to Pratsch in
many cases a resection of the premaxilla does not result in
conspicuous disfiguration in the presence of a relatively good
dental articulation. By then Burian had already stated that
a resection of the premaxilla was a humiliating product of
an undignified effort to facilitate the repair of the lip, regardless
of its consequences.
bilateral complete clefts Burian performed the established osteotomy
of the vomer with a pushback of the premaxilla and a straight
suture of the skin, in a one-stage operation, without the use of
the philtrum for the construction of columella. However, he almost
succumbed to the attraction of Brophy’s method of a closure of
the maxilla with a wire; however, he abandoned the idea when he
observed subsequent frequent development of dental cysts during the
process of healing.
his own words, Burian was greatly relieved in 1923 when he learned
about the research and surgical techniques of Victor Veau. He soon
went to see Veau in person and established a lasting friendship
with him, though they often failed to agree on a number of
points. Thus Burian found it impossible to endorse Veau’s view that
a cleft is merely a non-union of parts with normal biologic
and anatomic functions. Burian was convinced that quite apart from
the non-union there was inadequate development of tissue in the
anterior pole of the upper jaw of the premaxilla, with impairment of
their growth potential.
order to prevent immediate union he began to use a mucosal flap
from the labial sulcus to bridge the cleft and to cover the anterior
pole of the palate, which remained exposed after suture. Veau did not
agree with Burian on these points, and Burian often laughingly
recalled the temperamental Frenchman, nudging him under the ribs, and
thumping him on the back during their debates. Unfortunately Veau did
not live to see that Burian was fully justified by the results of
the early thirties Burian adopted the technique of Blair and Brown
(US) aimed at a repair of deformations of the nostrils by
dedublation and excision of the crescent-shaped stricture situated
parallel to the lower margin of the ala. However, during the
subsequent cicatrisation the threshold of the nostril sunk downwards,
and therefore Burian welcomed the technique devised by Veau and
published at this time. Veau cautiously reconstructed the floor of
the nose and covered it with a mucoperiosteal palatal flap.
However, since the oral palatal flap did not cover the whole bottom
of the nasal suture in the floor of the nasal introitus and was
followed by its break-down, Burian started to complete the oral
covering with mucosal flap from the lateral segment of the lip.
Within a few years he adopted the procedure devised by Axhausen,
mainly by abandoning the use of a mucoperiosteal palatal flap
for the covering of the sutured nasal floor. Burian also stopped
using a relaxation suture drawing together the edges of the
orbicular muscle and replaced it by a neticulous suture of both
stumps of the muscle with catgut stitches.
the late thirties he also tested the Wassmund procedure. Wassmund
operated in two stages: first he reconstructed the nasal floor and
then performed suture of the lip only during the second operation. In
the forties Burian became an ardent advocate of the method devised by
Brown and McDowell, who used a small cutaneous flap connected
with the vermilion, adding the deficient substance to the lower
margin of the philtrum facing the cleft.
this led to a flattening of Cupid’s bow. In the late forties
he adopted the repair of the lip according to Tennison-Randall and
Millard, which we continue to use even today – though with one
important improvement: we detach the atypical situated muscle fibres
in both margins of cleft, bend them down and suture orbicularis
muscle in a more natural horizontal position.
the number of different methods mentioned we can see how difficult it
was to find a really satisfactory solution. Professor Burian
succeeded here, with a great deal of imagination and effort,
proving that he is without a doubt among the most worthy
research workers and scientists in facial clefts.
of Plastic Surgery
Medical Faculty Charles University, Prague
34 Prague 10