COMMEMORATING THE 125th ANNIVERSARY OF THE BIRTHOF PROFESSOR FRANTIŠEK BURIAN

*17. 9. 1881 †15. 10. 1965

Professor František Burian is to this day considered one of the most significant plastic surgeons not only in the Czech Republic but also internationally. He was a person with outstanding general surgical skills as well as inventiveness in introducing new surgical techniques, but he was also an artist, an expert in human psyche, a linguist and an organizer.

All of this, combined with his unusual effort and zealousness for the newly-developing field, allowed him to become immediately after the end of the 1^stWorld War the founder of plastic and reconstructive surgery not only in Czechoslovakia but also throughout the continent of Europe, establishing in this sector a high standard that was only attained in other European countries a generation later.

He was born in the Malá Strana district of Prague on September 17, 1881. He studied at the Malostranská Grammar School, where he graduated in 1900. He studied medicine at the Medical Faculty, where he graduated on April 6, 1906. From the 3^rd year of his studies he became a demonstrator in the Institute of Pathological Anatomy under Professor Hlava, where he became an assistant at the end of 1905. In this function he addressed himself particularly to experimental pathology.

At the beginning of 1908 he moved to the Surgery Department under Professor Kukula, where he became an unpaid assistant. In October 1912 he left for the Balkan War with his wife (a gynecologist) and a medical group led by Professor Tobiášek. On January 1, 1913 he was delegated Head of Surgery in the Bulgarian Army. He remained there until the end of September 1913. After his return he started a private practice as a specialized doctor of surgery; however, a year later, at the beginning of the 1^st World War, he was drafted into the army.

Initially, he established an extensive reserve hospital in a block of school buildings of the Rudolfinum, where he led the surgery department until the end of 1915. He was then attached to the 7^thArmy Corps in Timisoara, Hungary, and in 1917 he became surgery consultant of the whole 7^th Army Corps. In this function he established a plastic surgery ward, which was transferred to Prague after the end of the war and became the foundation of the Plastic Surgery Institute and Clinic.

He published more than 200 scientific papers in Czech and foreign journals and four monographs. He focused mainly on studying congenital deformities, particularly face clefts, and became an initiator of international research to prevent congenital deformities. His second main interest was the study of tissue transplantation, which triggered his interest in burns. To address both of these issues at the end of the 1950’s a research laboratory of the Czechoslovak Academy of Science was established at Burian’s clinic.

Burian’s own plastic surgery career originated in 1918 after the evacuation of Czech soldiers on an ambulance train from Timisoara to Prague. Among them were many who required other reconstructive surgery. Therefore Burian remained in an affiliation with the army and took on the leadership of the surgery department of the garrison hospital in Hradčany to assert his desire to help esthetically and functionally impaired individuals, so they could return to society and to work.

Following his vision, he started to explore the possibilities in the new field of surgery, striving to repair external shape deformities of the body to the best possible extent.

Initially he started with humble techniques of transfers and transplantation of the skin, but also bones, cartilage and tendons, which he already used as a foundation at the garrison hospital in Hradčany for the extensive reconstructions of the face and hands after war injuries.

As one of the first surgeons, he realized that a permanent result – that is, healing in the place of a transplant – can only be achieved by autotransplantation of tissues harvested from the individual undergoing the operation. Already at that time he correctly considered xenotransplants and allotransplants as suitable for only temporary coverings of the open wounds.

He soon used the knowledge he gained from operating on war veterans for surgeries of congenital deformities, which were at that time in the majority of cases outside the interest of surgeons. Virtually a generation sooner than in the majority of advanced countries of Europe and America he raised our field to a high level for the benefit of the wider community.

As early as 1932 he managed to set up an independent plastic surgery ward within the Prague Surgery Department, and in the year 1937 as a first person in the world he achieved recognition of plastic surgery as an independent surgical speciality. Soon after the end of the 2^nd World War in 1948 he achieved integration of his Institute as a Department into the Charles University along with promotion to a full professorship.

In the 1940s and 1950s he helped to establish plastic surgery institutes in Moravia and Slovakia, as well as in Poland, Bulgaria and Romania, by training qualified heads for the leading posts.

Professor Burian was not only a very talented and skilled surgeon but also a strong scientific personality. He introduced many new ingenious surgical methods and was also able to assert his organization abilities.

Thanks to his intuition dating back to his post-war Prague practice, at the beginning of 1920s he started an exact and meaningful archive with versatile documentation of patients including (at that time this was highly unusual!) photographing every patient before and after each stage of surgical treatment; he also included dental imprints and X-ray pictures. Today this archive contains about 200,000 files.

He simplified the follow-up of treatment results by establishing the double scientific card file which we use for papers to this very day.

His great merit was that he recognized at an early stage the importance of teamwork and secured the help of experts in contiguous fields, including prominent professors of Charles University. Here we can list significant names such as a founder of phoniatry Professor Seeman, the orthopedic surgeon Professor Zahradníček, the stomatologist Professor Jesenský and sexologist Professor Hynie.

From doctors working on his team he required the necessary collegiate attitude, a mastery of anatomical and physiological knowledge, and respect for the patient’s psyche.

He brought new methods to surgery, such as highly thorough planning of the treatment procedures. That applies not only to the choice of appropriate time schedule for separate surgeries, alternating with the conservative treatment, but also – and of particular importance – to phased surgeries.

The majority of corrections of congenital deformities, as well as post trauma statuses, are completed in several stages, requiring the ability to use the imagination to the maximum, so we can see right from the beginning what we want and will have to do in the next stage. We should never interfere with what we achieved in the previous surgery.

Burian’s relationship with his patients was exemplary. He was able to establish the correct professional and personal contact, and to gain the patients’ confidence so they would undergo long-term and uncomfortable treatment. For example, during phased transfer of the tubulated flaps from the abdomen over the wrist to the foot the patients had to accept the prospect of spending some time tied up in a bucket. He asserted his vision: that the future of tissue defect reconstruction would be free flap transfer, transferred on neurovascular pedicle by the technique of neurovascular microsurgery.

He taught his doctors that “a plastic surgeon can never be thorough enough and that each particular surgical technique must be completed with the highest attention and accuracy. A great surgeon is someone who can perform the serious surgery as well as the smallest surgery with the same accuracy and positive result”. He instilled in them the credo that a plastic surgeon can never be fully satisfied with the result achieved and always has to be striving for better results next time.

Burian’s considerate approach to children was outstanding. His good attitude towards the treatment of congenital deformities is obvious from the initial words of his memoirs about face clefts: “The birth of a child afflicted with any deformity first and foremost impairs the whole family. The parents suffer cruel and painful disappointment. The pride of motherhood is hurt. The subconscious desire of a human to give and leave a person better than himself is not fulfilled. The cruellest are congenital deformities of the face, because these are the most obvious, and they are impossible to hide. In severe forms of cleft palates the harmony is disrupted in the area that also serves for the expression of the soul. For nine months the mother dreamed of the smile of baby she was expecting – and suddenly she sees a grinning monster mask. Afterwards, when maternal love overcomes the horror and aversion, anxiety about the future of the child stays and grows. The mother is frightened by the image that the physical and mental development of her child will be significantly held back, that the child will be ridiculed and pushed aside with aversion, that he or she will not find employment or even that the child will be excluded from society.”

At the beginning of the 1920s, when Professor Burian started to operate on congenital deformities in small children in the Jedlička Institute on Vyšehrad, he realized that preparation as well as after-treatment of pediatric patients must be provided by an experienced pediatrician. He finds such a man in the shape of Dr. Quido Mann. Dr. Quido Mann later actually arranged conditions for more severe cases that were operated at the children’s department of the Krč Hospital, where the children were also hospitalized. As a consultant, Mann established tradition of pediatricians who focused on specialized pediatric support for pediatric surgeons.

Just as Professor Burian invited permanent pediatricians into the team of plastic surgeons, he soon also invited psychologists to work with the children as well as with their parents. The involvement of more specialists led to various teams established for particular problems.

The history of Burian’s attempt to be awarded a tenured position is interesting. Between 1927 and 1929 he applied for senior lectureship three times but was rejected with the comment that medicine is a science, but plastic surgery is an art – it was even suggested with vicious spite that he should apply to the Faculty of Philosophy. The second time he was refused with the comment that plastic surgery is not a field in which he could achieve the status of senior lecturer. Therefore the third time he applied on the basis of his general surgical work, his war experience of surgical treatment of large blood vessels and penetration wounds of the heart. This work, unique for a long time, could not be denied, and therefore Burian was appointed senior lecturer in surgery on June 12, 1929. Professor Burian led his doctors to an appropriate approach to their tasks. His belief was that “Function is the goal; if function is restored, the esthetic result is good. It is therefore necessary to carefully analyze functional significance of the deformity as well as its anatomical property, superficial as well as in deeper aspects. Here we find that only with reservation can we talk about groups of plastic surgeries. The devastating force of deformity does not choose the topography of the area and is not limited by its borders”. This relation between function and shape, as emphasized by Burian at the clinic, became the impulse for useful changes of surgery techniques; for example, the transfer of the muscle fascicles in the lip and on the palate into anatomically normal position in clefts significantly improves the shape as well as functional results of the treatment.

On an international level Burian represents a significant exponent of gentle manipulation with tissues. His book “Fyziologické operování” (Physiological Surgery) from the end of the 1940s became inspiration to many surgeons, whose attention to the author’s established rules contributed to the overall improvement of surgical treatment results.

Burian’s work contacts and frequently very friendly informal contacts with foreign surgeons, who were enthusiastic for the developing field of plastic surgery, were hugely significant for the development of our field. As early as 1923 he met the Frenchman Victor Veau, who at that time published as a first scientist the research of cleft lip and palate. They became good friends and their sometimes even very controversial opinions about this problem increased Burian’s interest to the point that clefts became his lifelong uppermost priority. Even at that time Burian demonstrated his ability to recreate a realistic insight into the possibilities of development of particular tissues in congenital deformities. His opposition to Veau’s theory, describing the cleft lip, jaw and palate as a simple separation while there is also an inadequate development with hypoplasia, was soon universally accepted.

This theory about hypoplasia by cleft deformed tissues, confirmed by experience, led Burian to the introduction of a pedicled mucosal flap, generally known as “Burian’s flap”, which was inserted between the poles of jaw segments and filling the hypoplastic edges of the jaw. He filled the hypoplastic edges with a skin flap from the outside of the lip, like Tennison and Millard.

Burian found the same hypoplasia status on the cleft palate, and therefore in 1924 he introduced filling of the rear part of the palate by a pharyngeal flap with lower-based pedicle according to Rosenthal. After he met the Italian Professor Sanvenero-Rosellini he took on his method with upper-based pedicle, and this method remains today a routine component of primary reconstruction of short palates.

Burian, with his publications and active presentation on all pre-war congresses and other meetings of plastic surgeons, quickly gained a reputation not only as a pioneer in the field but also as the originator of significant new surgical techniques in all areas of what was then a young field, and as the author of significant monographs (for example “Chirurgie rozštěpů” [Surgery of Clefts] or “Atlas plastické chirurgie” [Atlas of Plastic Surgery]). Therefore the Prague Department became not only a target for visits of many later significant plastic surgeons but also a teaching workplace of surgeons from the whole world. Repeated visits from the founder of the English plastic surgery, Professor Gillies and many others important English and American plastic surgeons (for example Professor Pickerell, Dr. Pick, Professor Lewin, Professor Hogan and others) proved Burian’s importance in the world. One indication of Burian’s high standing was the fact that Professor John Marquise Converse, later the eminent representative of the American plastic surgery, considered Burian his teacher. He studied in Prague for long time in 1937 and repeatedly visited Burian in Prague after the war.

Burian was often invited abroad to lecture as a guest speaker, and at these occasions he was awarded various honours.

From the beginning of 1960s, when travelling abroad was easier, Burian was able to use his connections with heads of significant plastic surgery and burn workplaces for professional and language benefits of his young doctors at the clinic by sending them for internships to Sweden, Scotland and Texas.

Burian found a good friend in the official founder of the American plastic surgery, Dr. Jaques W. Maliniac. He considered Burian’s surgical and research contribution unique, and at the same time he also highlighted Burian’s organization of the Czechoslovak plastic surgery. Maliniac devoted his opening speech at the annual meeting of the American Society of Plastic and Reconstructive Surgery in December 1949 in Hollywood, Florida, which was published in Plastic and Reconstructive Surgery to this theme. He stated that Czechoslovakia can be proud of a perfectly organized “plastic set-up”. He described the whole history of Burian’s efforts, list of surgeries completed every year, work on prevention and research.

With admiration he mentioned that: “Burian never missed out scientific aspects of his surgical activities. He documented thoroughly his work with his own drawings in clinical records and by photographs from all stages of treatment, by dental imprints, X-rays and detailed scientific registry.” He concluded as follows: “Somewhere between anarchistic ’laissez-faire‘ in France and Italy and the state-controlled services in Czechoslovakia and in Britain we should here in the USA strive to find a middle road that connects benevolence of a sound organization and planned distribution with the present rapid initiative and other inventions of our own medical system.”

The fact that the reputation which Burian enjoyed during his lifetime still persists was proved by the invitation to a presentation at the American Congress of Plastic Surgery in Washington in 1992. The presentation “Tradition of cleft treatment in Prague” was in honour of J. Maliniac and it was lectured in the presence of J. Maliniac’s widow.

The Academician Burian always stressed that the work of a plastic surgeon must not be limited to surgery. It must focus on a proper post surgery rehabilitation of a patient. He or she must not be afraid to go to a laboratory and a dissecting room with the goal of gaining motivation for clinical work. He or she should learn to hand down enthusiasm for the cooperation with other medical fields for the purpose of creating effective multidisciplinary therapeutic team. This applies to the complex therapy of congenital deformities as well as the treatment of injuries, tumours, burns and presently also neurovascular microsurgery.

In 1957 Burian created a scientific base for clinical activity after he was elected academician by establishing an excellently equipped Laboratory of Congenital Deformities with genetic, teratology, electrophysiology and immunology workplaces and extensive orthodontic department, and a Center for Research into Tissue Transplantation at the extensive burn department that he built in 1951 adjoining the former Borůvka convalescent hospital in Legerova Street, Prague.

Thereupon after his death in 1965 the academician Burian left a legacy which fully, according to his intentions, allowed us to strive for advancement in the treatment development and for complex care of our patients.

Prof. M. Fára, MD., DSc.

Assoc. Prof. M. Tvrdek, MD.

Charles University

Department of Plastic Surgery

Šrobárova 50

Prague 10