Background: Early cranioplasty after decompressive craniectomy (DC) for moderate-to-severe traumatic brain injury (TBI) improves functional recovery. However, patient candidacy is limited by persistent brain swelling, soft-tissue inflammation, and fibrotic wound remodeling. Zwitterion (ZI) hydrogels exhibit antifouling and anti-inflammatory properties that may improve the DC wound microenvironment. We hypothesize that ZI hydrogel application at the DC site attenuates TBI-associated biomarkers and improves motor recovery in rodents. Methods: Adult CD1 mice were randomized to sham, TBI, TBI/DC, or TBI/DC/ZI hydrogel (hereafter referred to as ZI hydrogel) groups to quantify serum GFAP, NfL, and UCH-L1 by ELISA at 24 hours. Adult Long Evans rats underwent the same interventions to assess ZI-dependent motor recovery using beam-walk time and limb slips normalized to baseline at days 7 and 14. Results: TBI significantly elevated serum GFAP and UCH-L1 versus sham ( P = .0014 and .0471). Both TBI/DC and ZI hydrogel normalized GFAP, NfL, and UCH-L1 to sham-comparable levels; however, only ZI hydrogel significantly reduced NfL ( P = .0256) and UCH-L1 ( P = .0200) versus TBI/DC. Beam-walk testing showed no significant post-TBI motor deterioration in ZI hydrogel rats, whereas TBI/DC rats exhibited persistent deficits in crossing time and limb slips at days 7 and 14. Conclusions: ZI hydrogel application at the time of DC reduced TBI-specific serum biomarkers and improved motor recovery in a rodent moderate-to-severe TBI model. These findings support further investigation of ZI hydrogels as adjunctive therapy to attenuate neuroinflammation and facilitate earlier, safer cranioplasty after DC.
Background: Craniofacial fellowship has become an increasingly common pathway for plastic surgery trainees, yet applicants must navigate a fragmented ecosystem spanning ASCFS, SF Match, and individual program websites. We aimed to characterize the contemporary applicant cohort, quantify the logistical and financial burden of the application process, identify modifiable system-level weaknesses, and explore motivating factors for pursuing the subspecialty. Methods: An anonymous web-based survey was administered to craniofacial fellowship applicants across the 2023 and 2024 cycles (fellowship terms 2024-2026). Twenty-seven applicants completed items covering demographics, training background, motivations, residency exposure, application behavior, costs, platform performance, and match outcomes. Descriptive statistics are reported as counts and percentages. Results: Among 27 respondents, 70% were male and 96% US-based; 81% were in or had completed a US/Canada plastic surgery residency at the time of application. Key motivators included training with a craniofacial surgeon (81%) and personal life experiences (59%). Craniofacial exposure was robust: 96% reported at least 1 cleft/craniofacial surgeon during residency and 85% a multidisciplinary clinic. Applicants applied to 4 to 33 programs and received up to 32 interviews; more than half incurred at least $2000 in application and interview costs, and 89% matched within the top third of their rank list. Although 65% rated the overall process positively, applicants reported difficulty locating applications, limited use of the official ASCFS site, and minimal contact with listed program points of contact Conclusions: The craniofacial fellowship application process is marked by high applicant motivation, robust prior exposure, and strong match success but also by substantial logistical and financial burden and a fragmented information environment. These findings informed the development of a centralized ASCFS fellowship website and Centralized Application Service (CAS) to consolidate program information, standardize submissions, and streamline interview scheduling—meaningfully reducing administrative complexity and financial burden within the fellowship application process.
Background: Although 2q13 copy number variants are frequently linked to neurodevelopmental delays, this is the first report linking them to cranial suture pathology. Case Presentation: A previously undescribed co-occurrence between a paternally inherited 2q13 multi-gene duplication and familial late-onset craniosynostosis is reported. Four siblings carrying the duplication presented with craniosynostosis, demonstrating variable phenotypic expression ranging from single-suture to multi-suture involvement. Conversely, a fifth sibling without the duplication was unaffected. Conclusion: This familial recurrence suggests the duplication may serve as a genetic susceptibility factor that disrupts postnatal cranial suture maintenance. This dynamic potentially predisposes patients to secondary fusion in the setting of altered intracranial pressure. These findings expand the phenotypic spectrum of 2q13 duplications and underscore the value of genomic evaluation in atypical craniosynostosis to guide clinical and surgical management.
Orbital fractures are among the most common forms of craniofacial trauma and present significant diagnostic and therapeutic challenges because of the orbit’s complex anatomy and the potential for long-term functional and aesthetic sequelae. This review synthesizes current evidence regarding the evaluation, imaging, management, and complications of orbital fractures, with emphasis on evolving treatment paradigms and ongoing areas of controversy. A PubMed ® literature review was conducted using search terms related to orbital fracture anatomy, physical examination, imaging, conservative management, surgical intervention, antibiotics, and complications, with emphasis placed on contemporary studies. Clinical assessment remains central to management, particularly evaluation of visual acuity, globe position, ocular motility, diplopia, and infraorbital sensation, while high-resolution computed tomography continues to represent the diagnostic gold standard for characterization of fracture morphology, soft tissue herniation, and muscle entrapment. Current evidence increasingly supports selective rather than routine operative intervention, emphasizing functional deficits such as persistent diplopia, clinically significant enophthalmos, extraocular muscle entrapment, and vision-threatening complications over fracture size alone. Urgent repair remains indicated in cases of oculocardiac reflex, orbital compartment syndrome, or pediatric trapdoor fractures. Advances in transconjunctival approaches, image-guided navigation, biomaterials, and patient-specific implants have improved reconstructive precision and reduced postoperative morbidity, although controversy persists regarding operative timing, implant selection, and the routine use of prophylactic antibiotics for fractures communicating with the paranasal sinuses. Postoperative complications, including diplopia, infraorbital nerve dysfunction, retrobulbar hematoma, eyelid malposition, enophthalmos, and implant-related morbidity, continue to influence clinical outcomes despite advances in care. Overall, contemporary management increasingly favors an individualized, multidisciplinary, and evidence-based approach tailored to patient symptoms and functional outcomes, while future prospective studies with standardized outcome measures are needed to clarify unresolved management questions and establish more consistent treatment algorithms for orbital trauma.
Background: We present a case of an 8-year-old female presenting with chronic headaches and elevated intracranial pressure (ICP) secondary to craniocerebral disproportion (CCD), in the absence of classic craniosynostosis. Although medical management, including acetazolamide and multiple lumbar punctures, provided temporary relief, imaging consistently revealed signs of restricted intracranial volume. Case presentation: The patient underwent posterior vault distraction osteogenesis (PVDO) to increase intracranial volume. The procedure involved a biparieto-occipital craniotomy and placement of distractors, ultimately achieving a 30 mm expansion. Although she experienced recurrent distractor-site infections, these were successfully managed with local wound care and antibiotics, ultimately resolving completely. Outcome: Following PVDO and hardware removal, the patient experienced a significant symptomatic improvement. Estimated intracranial volume, calculated using the ellipsoid approximation method, increased from 1387 cm 3 preoperatively to 1627 cm 3 postoperatively, representing a 17.3% increase. Imaging confirmed interval healing of the cranial vault, ventricular expansion, and increased overall intracranial volume. Conclusion: This case suggests that PVDO may represent a viable treatment option for chronic headaches caused by CCD in the absence of overt craniosynostosis. While limited to a single patient, this report adds to a growing body of literature supporting the consideration of calvarial volume expansion in select patients with atypical presentations of elevated ICP. It also emphasizes the importance of multidisciplinary collaboration for accurate diagnosis, surgical planning, and long-term follow-up.
The scope of craniomaxillofacial surgery has expanded dramatically over the past century, driven less by incremental progress than by episodic paradigm shifts and the interdisciplinary collaboration that made them possible. From the reconstructive efforts of Gillies in the early 20th century to the craniofacial revolutions of Tessier and McCarthy, the field has continuously redefined its boundaries. This paper examines the historical development, philosophical underpinnings, and contemporary opportunities for scope expansion in craniomaxillofacial surgery. Through analysis of training models, emerging technologies, and institutional strategy, we propose a framework for the next paradigm shift in craniofacial and maxillofacial surgery; 1 integrating virtual surgical planning, biologic reconstruction, and systems-based leadership. Expanding the scope of practice in craniomaxillofacial surgery will not happen passively. It requires claiming complex cases, measuring outcomes that matter to patients, and training surgeons who lead multidisciplinary teams rather than defer to them. The future of craniomaxillofacial surgery depends on our willingness to redefine its borders rather than simply defend them.
Background: Endoscopic repair of craniosynostosis has emerged as a common surgical option due to its minimally invasive nature and safety profile. However, its indications related to patient age necessitate early diagnosis and referral, potentially exacerbating access disparities among socioeconomically and racially marginalized populations. To evaluate demographic, socioeconomic, and hospital-related factors influencing the utilization of endoscopic versus open craniosynostosis repair in a national inpatient cohort. Methods: A retrospective analysis was conducted using the National Inpatient Sample (2018-2021). Patients undergoing craniosynostosis repair were categorized by surgical approach (endoscopic vs open). Demographic, socioeconomic, and hospital characteristics were compared using chi-square tests and binary logistic regression. Results: From a sample of 1099 patients, 183 (16.6%) underwent endoscopic repair. Endoscopic patients were significantly more likely to be under 1-year-old, White, privately insured, and from high-income zip codes ( P < .001 for all). Endoscopic procedures were more frequently performed at private, not-for-profit hospitals ( P = .029), and less frequently at government, nonfederal hospitals (adjusted P = .048). Disparities persisted in a subgroup analysis of patients under 1 year. Conclusion: Significant racial, socioeconomic, and institutional disparities exist in access to endoscopic craniosynostosis repair in the United States. These disparities persist even among clinically eligible patients, suggesting systemic barriers in early diagnosis and referral. Efforts to expand equitable access must address both social determinants and structural healthcare inequities to ensure timely, optimal care for all patients.
Background: Microtia, a congenital difference of the external ear, requires complex, specialized care. Access to care and the influencing factors for microtia reconstruction have not been comprehensively evaluated. This study uses the PHIS database to assess how age, race, and socioeconomic factors (Child Opportunity Index [COI]) influence access for microtia reconstruction, regardless of surgical approach, in the United States. Methods: A PHIS database query was conducted from 2016 to 2024. Patients with a diagnosis of microtia and related procedures were identified. Key variables, including age, race, gender, COI, and payor type, were statistically analyzed. Results: Only index procedures for both autologous and alloplastic-based reconstruction were evaluated, and the final sample size consisted of 1,072 procedures. The average age at surgery was 10.5 years, with most procedures performed in late childhood and the majority of patients identifying as Hispanic and publicly insured. Among microtia patients with complex chronic conditions, females were significantly older at surgery than males. Among publicly insured patients, White patients had surgery earlier than their non-White peers, a trend that was opposite in privately insured patients. Patients who underwent alloplastic-based reconstruction were, on average, younger than those who underwent autologous-based reconstruction. Conclusion: Timing of index microtia reconstruction and reconstructive approach varied across patient subgroups, highlighting potential differences in access to care and treatment patterns in this population. Future studies should determine whether these differences are associated with downstream clinical or psychosocial outcomes.
Purpose: We present a patient with an optic nerve infarct after a recent medial orbital wall fracture. The suspected mechanism was a transient orbital compartment syndrome or localized air bubble in the orbital apex, as the patient presented with pain in the affected eye, with sneezing as a potential trigger. Observations: A 66-year-old male presented to the outpatient ophthalmology clinic with persistent left eye pain and swelling. Four days prior, a fall led him to the emergency department (ED), where computed tomography (CT) showed a left medial orbital wall fracture. Initial visual acuity was 20/20 and 20/40. Intraocular pressure (IOP) was 9 and 22 mmHg in the right and left eyes respectively. There was mild limitation of left eye supraduction and infraduction. Repeat CT demonstrated orbital emphysema, and he was given a methylprednisolone dose pack and strict sinus precautions. Fifteen hours after the clinic visit, nearly 5 days after his fall, he presented to the ED with left eye pain and with no light perception (NLP) in the left eye, an IOP of 26, non-reactive pupil with a left afferent pupillary defect, and near complete ophthalmoplegia. He reported sneezing multiple times overnight. He received IV steroids and underwent emergent lateral canthotomy with superior and inferior cantholysis of the left eye, after which IOP was 19 in that eye. He remained NLP, and Magnetic Resonance (MR) imaging demonstrated an ischemic infarct within the optic nerve. Conclusions and importance: While rare, vision loss can occur as a complication of orbital emphysema (OE). Providers may consider recommending patients check their vision after any Valsalva inducing event. Possible interventions for OE, if vision-threatening, include emergent cantholysis and needle decompression.
Background: Cranioplasty is a commonly performed reconstructive procedure to restore cranial integrity in patients with acquired skull defects after strokes, traumatic brain injury, and tumors, among other diagnoses. Given the procedure's high complication rate and extensive perioperative planning, patient education is critical for informed decision-making. The American Medical Association (AMA) recommends that online patient education materials (OPEMs) be written at a sixth grade reading level to ensure equitable access to health information. Despite this, OPEMs for surgical interventions frequently exceed these recommendations. This study characterizes the readability and availability of English and Spanish-language OPEMs for cranioplasty.Methods: The top 20 English ("cranioplasty") and Spanish ("craneoplastia") OPEMs from Google searches were analyzed. English OPEMs were assessed using Flesch Reading Ease (FRE), Fry Graph (FG), Simple Measure of Gobbledygook (SMOG), and Gunning Fog Index (GFI). Spanish OPEMs were analyzed using Fern & aacute;ndez-Huerta Reading Ease (FHRE), Gilliam-Pe & ntilde;a-Mountain Grade Level (GPM), Spanish Orthographic Length (SOL), and & Iacute;ndice de Legibilidad de Flesch-Szigriszt (INFLESZ).Results: No OPEMs met the recommended sixth grade reading level. Among Spanish OPEMs, 55% (11) were written at the high school level and 45% (9) at a college level. Conversely, 35% (7) of English OPEMs were written at the high school level and 65% (13) at the college level. When adapted analog indices were compared across languages, Spanish OPEMs were on average easier to read than English OPEMs. No US healthcare institutions had Spanish OPEMs for cranioplasty and Spanish OPEMs were underrepresented among first-page search results (50%) relative to English OPEMs (70%).Conclusions: OPEMs for cranioplasty are written above recommended readability levels in both English and Spanish. Despite the United States' large Spanish speaking patient population, no U.S. healthcare institutions currently have Spanish OPEMs for cranioplasty.
Background: Scalp-Ear-Nipple syndrome (SEN), or Finlay-Marks syndrome, is an exceedingly rare congenital disorder characterized by scalp aplasia, auricular malformations, and nipple hypoplasia or absence. Fewer than 100 cases have been described, and phenotypic variability complicates diagnosis and management. Case Presentation: Two male neonates presented with large aplasia cutis congenita (ACC) defects and variable phenotypic features. The first patient, born at 37 weeks, exhibited the classic triad of occipital ACC, bilateral cupped ears, and athelia, along with PDA and left upper eyelid coloboma. Genetic testing identified a pathogenic KCTD1 mutation and a 47, XXY karyotype consistent with Klinefelter syndrome. The second patient, born at term, had an isolated midline scalp defect with distal limb anomalies including hallux hypoplasia and nail dysplasia. Genetic testing for Adams-Oliver syndrome and SEN-associated genes was negative. Both patients underwent staged reconstructive strategies using biologic allografts and Integra Dermal Regeneration Template to promote epithelialization and soft tissue coverage. Reconstruction was coordinated through a multidisciplinary craniofacial team. Patients showed progressive epithelialization and calvarial regeneration with normal neurodevelopment, and stable wound healing with age-appropriate neurologic development throughout follow-up. Conclusion: This case series highlights phenotypic variability in SEN syndrome, including a novel co-occurrence with Klinefelter syndrome. Early recognition, genetic evaluation, and staged reconstruction are essential to optimize outcomes in patients with syndromic ACC.
Purpose: The neo-bandeau is a single-segment modification of traditional fronto-orbital advancement (FOA) intended to simplify reconstruction of the frontal bone and superior orbits while potentially improving contour and reducing temporal hollowing. We describe our operative approach and report early clinical outcomes from a single-center case series. Methods: Following Institutional Review Board approval, a retrospective review was performed of patients treated for craniosynostosis at a tertiary academic center from database inception through April 2025. Patients were included if they underwent open anterior cranial vault reconstruction using a neo-bandeau FOA technique. Demographics, diagnosis, operative details (estimated blood loss, transfusion, operative duration), hospital course (ICU stay, length of stay), complications, and short-term follow-up outcomes were extracted from the medical record. Results: Four patients underwent neo-bandeau FOA: 3 with metopic craniosynostosis and 1 syndromic patient with combined sagittal and metopic craniosynostosis. Estimated blood loss ranged from 75 to 500 mL. Three patients received intraoperative red blood cell transfusion, and 2 received postoperative packed red blood cells on postoperative night 1. Operative duration ranged from 3 hours 26 minutes to 4 hours 8 minutes. All patients were managed postoperatively in the pediatric ICU (1-2 days) and then transferred to the surgical floor. Total hospital length of stay ranged from 3 to 6 days. There were no intraoperative complications, no perioperative surgical complications documented during the index admission, and no adverse events reported at follow-up (range: 4 months to 1.5 years). Representative pre- and postoperative imaging demonstrated improved frontal and supraorbital contour. Conclusions: In this small single-center series, neo-bandeau FOA was feasible and reproducible, with early outcomes suggesting an acceptable safety profile and encouraging short-term esthetic results. Larger studies with longer follow-up are needed to define long-term cranial growth, contour stability, and rates of secondary deformities compared with traditional FOA.
Background/objective: The paucity of normative angular nasal and labio-oral anthropometric data on indigenous sub-Saharan Africans hinders the esthetic effectiveness of reconstructive/plastic surgery on their faces. This data void also negatively affects their facial biometrics, information retrieval, forensics, dentistry, and beauty analysis. This study contributes to filling this gap by generating normative values for the nasal and labio-oral angles in young adult autochthonic Africans living in Ghana. Methods: One hundred and five volunteers (54 males and 51 females) were conveniently sampled from students at our institution. Seven nasal and labio-oral angles, namely; the Nasofrontal, Nasal tip, Nasolabial, Labiomental, Alar slope, Mandibular Frankfurt plane, and Mentocervical were measured by direct anthropometric (angle meter) and indirect anthropometric (Photogrammetry) methods. Data were assessed for sexual dimorphism using Student’s t -test. Scatter plots with Correlation Analyses were used to determine the association between the direct and indirect datasets. Results: Comparison between direct and indirect methods showed no significant differences for most angles, except for the Mandibular-Frankfurt plane angle (MFA; P = .037) and Mentocervical angle (MCA; P = .013). Regarding sexual dimorphism, the Nasofrontal angle (NFA) was significantly greater in females than in males ( P < .001). Indirect measurements of each of the 7 nasal and labio-oral angles strongly correlated positively with their corresponding direct measurements. Conclusion: This study provides baseline normative data on nasal and labio-oral angles in young Indigenous Ghanaians. Apart from the Nasofrontal angle, which exhibited significant sexual dimorphism (females > males), 6 other angles did not significantly differ between sexes. Our results indicate that the indirect photogrammetric method correlates strongly with direct measurements for selected angles, and it may serve as a useful alternative when standardized photographs are available. However, caution is advised for MFA and MCA where methodological differences were observed.
Background: Microtia is a congenital defect of the external ear, ranging from structural auricular deficiency to anotia, and is frequently associated with hearing impairment. Its prevalence varies geographically, with notably higher rates reported in high-altitude regions of Ecuador. However, clinical, and anatomical comparisons between isolated and familial microtia in Ecuador remain limited. Objective: To analyze the demographic, clinical, and anatomical characteristics of Ecuadorian patients with microtia, emphasizing differences between isolated and familial cases. Methods: A cross-sectional observational study was conducted in 2024, including 146 patients with confirmed microtia. Patients were classified as isolated or familial according to family history. Demographic, clinical, anatomical, and audiological variables were collected. Minor auricular findings, including auricular nodules, preauricular sinus, Darwin tubercle, and prominent ear, were recorded separately as associated anatomical observations and were not considered diagnostic criteria or severity indicators. Data were analyzed using descriptive statistics, chi-square, and Mann-Whitney tests, and multivariate logistic regression. Results: Median age was 10 years (IQR 8-14), with no significant age differences between groups. Isolated microtia was more frequent in males than familial microtia (72.32% vs 52.94%; P = .034). Familial cases showed more Grade 1 right-ear microtia (26.7% vs 11%; P = .003), whereas isolated cases more commonly presented Grade 3 microtia. Left auricular nodules, or mamelons, were significantly associated with isolated microtia ( P = .024; OR = 8.07; 95% CI: 1.05-62.24). Conclusion: Isolated and familial microtia showed distinct demographic and anatomical patterns. Auricular nodules were associated with isolated microtia but should be interpreted as associated anatomical findings, not diagnostic or severity markers.
Purpose: Authorship plays a crucial role in academic medicine. It significantly impacts residency placement for students, especially in competitive specialties like plastic surgery. Despite the existing guidelines, widespread ethical concerns remain unsettled. This study aimed to explore the understanding, perceptions, and attitudes of authorship practices among medical students interested in plastic surgery to evaluate the need for more comprehensive analysis and to generate hypothesis-driven insights to enhance research integrity. Design: An IRB-approved, anonymous 29-question survey was distributed to medical students interested in plastic surgery to explore their understanding, perceptions, and attitudes in authorship practices. Results: A total of 46 students met inclusion criteria. Although 82.6% reported awareness of authorship criteria, only 21.7% reported receiving any formal training. Misconceptions were common, as many students endorsed non-qualifying contributions as sufficient for authorship. Perceived unethical authorship practices, including ghost and honorary authorship, were reported by 32.6% and 52.2% of respondents, respectively. These were often reported to be driven by seniority, institutional norms, and publication pressure. More than a third of respondents reported experiencing unfair authorship orders. Over a quarter had experienced disputes, yet few were aware of or utilized institutional resources. Conclusion: Medical students interested in plastic surgery report frequent challenges related to authorship in research. These findings likely reflect a combination of misunderstandings of authorship criteria and true deviations from established standards, both of which have important implications for ethics education, mentorship, and institutional policies. As a preliminary analysis, these results support the need for further large-scale investigation to validate findings.
