THE HISTORY OF CLEFT LIP OPERATIONS AT THE DEPARTMENT OF PLASTIC SURGERY IN PRAGUE

As 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 hospitalization.

Burian 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.

Professor 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.

Most 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.

The 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.

In 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).

In the twenties Lexer in the 5^th 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.

In 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.

In 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.

In 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 subsequent research.

In 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.

In 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.

Unfortunately 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.

From 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.

Address for correspondence:

M. Tvrdek, M.D.
Department of Plastic Surgery
3^rd Medical Faculty Charles University, Prague
Šrobárova 50
100 34 Prague 10
Czech Republic
E-mail: tvrdek@fnkv.cz