Sharaf, Basel

Background Malpositioned orbital implants are an underappreciated source of significant postoperative morbidity, often necessitating revision surgery. Decision-making regarding practical frameworks to guide revision remains challenging and is not well standardized or characterized. Objective To analyze clinical presentations, radiographic failure patterns, multidisciplinary surgical strategies, and outcomes of patients undergoing revision surgery for malpositioned orbital implants. Methods A single-center retrospective consecutive case series was conducted of patients who underwent removal or replacement of malpositioned orbital implants. Patient demographics, presenting symptoms, radiographic findings, surgical approaches, implant management strategies, and postoperative outcomes were reviewed. Most cases were co-managed by plastic/reconstructive and oculoplastic surgeons. Descriptive statistics were used to summarize findings. Results Five of seven patients (71.4%) were female, with a median age of 60 years (range 29–78). Diplopia was the most common presenting symptom (5/7, 71.4%) along with pain or swelling (5/7, 71.4%) followed by globe malposition (3/7, 42.9%). CT demonstrated implant protrusion into orbital soft tissue in 4/7 patients (57.1%) and peri-implant inflammatory collections in 3/7 (42.9%). Out of our 7 revision cases, four patients (57.1%) underwent explantation alone, and three (42.9%) underwent secondary reconstruction with custom or semi-custom implants. At follow-up, diplopia improved or resolved in 4/5 affected patients (80%), and pain, swelling, and globe position improved in all symptomatic patients. Conclusion Malpositioned orbital implants demonstrate heterogeneous failure mechanisms that require individualized surgical management. A multidisciplinary approach can guide decision-making regarding implant removal versus revision of reconstruction, enabling safe revision surgery and favorable clinical outcomes. Additionally, virtual surgical planning and intraoperative navigation are enablers of safe and precise revision orbital surgery.

Although complications of autologous bone flap cranioplasty are well described, data on long-term bone flap survival and the comorbidities associated with secondary reconstruction are limited. This study aimed to quantify the need for secondary alloplastic cranioplasty within a standardized patient cohort. Patients who underwent delayed cranioplasty following craniectomy with banked, frozen autologous bone between 2012 and 2025 were identified and analyzed using Cox regression, spline analysis, and Kaplan–Meier survival analysis. A total of 367 patients with an average age of 39.2±19.7 years (range: 0.3–84.4 years) at the time of cranioplasty were included. A secondary cranioplasty was required in 13.6% of patients (n=50 of 367), with resorption (52%) and infection (42%) as the most common indications. In adjusted analyses, patients who underwent cranioplasty following a traumatic injury (HR: 2.37; 95% CI: 1.07–5.26; P =0.03) and patients younger than 18 years (HR: 2.99; 95% CI: 1.35–6.62; P =0.01) were more likely to require a secondary cranioplasty due to bone flap resorption. Increasing defect size was also associated with a higher risk of secondary cranioplasty due to bone flap resorption, becoming significant at roughly 95 cm² (HR: 2.54; 95% CI: 1.04–6.20; P =0.04). The estimated cumulative incidence of secondary cranioplasty was 37% at ten years after autologous reconstruction. These results indicate that although autologous bone flap cranioplasty is largely effective, select patients face a substantially higher risk of secondary cranioplasty, and alternative reconstructive options may be warranted.

Biparietal osteodystrophy, also known as bilateral parietal calvarium bone thinning, is a rare calvarial condition characterized by loss of diploic bone within the parietal region. Although historically described in anthropologic and radiologic literature, current understanding of its epidemiology, pathogenesis, clinical relevance, and management remains fragmented. This review synthesizes current evidence and highlights emerging studies on biparietal osteodystrophy. Epidemiologic reports indicate that biparietal osteodystrophy affects a broad age range but appears most frequently in older adults, with several series suggesting a slight female predominance. Prevalence is difficult to estimate due to incidental detection, though modern imaging has increased recognition of the condition. Histologically and anatomically, biparietal osteodystrophy is marked by thinning of the outer table and loss of the diploic space, with little osteoblastic or osteoclastic remodeling. Proposed pathogenic mechanisms include chronic degenerative change, impaired vascular supply to the diploë, and other theories, although no single explanation fully accounts for its complete presentation. Clinically, most patients remain asymptomatic, with complications such as calvarial fractures and traumatic brain injury being rare but highlighting the structural vulnerability associated with severe thinning. Management strategies are not standardized, and the use of anti-osteoporotic drugs and cranioplasty has been reported to offer benefit in select cases, although no treatment has been formally validated for biparietal osteodystrophy. As the understanding of biparietal osteodystrophy continues to evolve, future research is needed to clarify its natural history, identify potential etiologic pathways, and establish evidence-based management guidelines.

Background: Sexual dimorphism in the facial skeleton is fundamental to aesthetics and gender perception. This study employs AI-assisted three-dimensional (3D) imaging to analyze morphological differences between males and females in the upper, mid, and lower facial regions. Methods: A retrospective analysis was conducted on 280 high-resolution craniofacial CT scans (147 females, 133 males) of adults aged 20 years and older. AI-assisted segmentation and modeling were performed using Materialise Mimics and 3-Matic software. The facial skeleton was divided into upper, mid, and lower regions for detailed morphometric evaluation. Statistical shape modeling (SSM) and heatmaps were used to visualize surface projection differences across age groups. Statistical comparisons were conducted to assess gender-based variation. Results: Significant sexual dimorphism was observed across all facial regions. In the upper face, males had greater interorbital width, frontotemporal brow width, inter-medial canthi distance, and more prominent frontal bossing. In the midface, males exhibited increased width, depth, and vertical height, with the most pronounced differences occurring in middle age. The lower face showed larger mandibular dimensions in males, including bigonial width, ramus height, and a sharper mental angle, while females had a more rounded chin and smoother mandibular contour. Heatmaps confirmed greater surface projection in male skeletons, particularly in the gonial and midfacial regions, with dimorphism decreasing with age. Conclusion: This represents the first large-sample CT study utilizing AI to comprehensively quantify facial skeletal dimorphism. Findings support the importance of gender-specific planning in facial reconstructive and aesthetic procedures.

BACKGROUND AND OBJECTIVES: External ventricular drain (EVD) placement is the most commonly performed bedside emergent neurosurgical procedure. However, catheter misplacement occurs in approximately 25% of cases, potentially resulting in neurological injury or the need for repositioning, highlighting the need for safer and more accurate placement techniques. This review aims to (1) summarize technological innovations developed to enhance the accuracy and safety of bedside EVD placement, (2) evaluate their reported benefits and limitations, and (3) identify key barriers to their clinical implementation in critical care settings. METHODS: We conducted a systematic review of PubMed, Embase, and Scopus combining terms related to EVD placement and assistive technologies. All the studies evaluated EVD placement using simulations, phantoms, cadavers, and patient procedures conducted at the bedside and in the operating room. RESULTS: We identified 3898 records, and 76 studies met the inclusion criteria. Of these, 30 studies compared stereotactic systems, ultrasound guidance, frameless neuronavigation, and augmented or mixed reality technologies to the freehand technique. These studies consistently reported improved accuracy with advanced systems although complication rates and procedural times were variably reported. An additional 35 and 12 studies evaluated nonimmersive and immersive technologies, respectively, in noncomparative settings. Most of these demonstrated high first-pass success and mean tip deviations under 3 mm. Variability in the definitions of accuracy and procedural metrics limited data synthesis, but the overall findings suggest a promising trajectory for technology-assisted EVD placement. CONCLUSION: Assistive technologies for EVD placement show potential to improve accuracy and safety over the freehand technique. These early successes signal potential to improve bedside neurosurgical care. Realizing this promise will require future studies to standardize accuracy metrics, report time, and safety outcomes consistently and validate performance in real-world critical care settings.

OBJECTIVE Achieving submillimetric accuracy in stereotactic neurosurgery remains critical for safely targeting deep brain structures. Current workflows rely on intraoperative CT to register stereotactic frames to preoperative imaging, but this introduces additional radiation exposure, cost, and workflow complexity. Three-dimensional surface scanning (3DSS) potentially offers a fast radiation-free alternative capable of capturing detailed craniofacial anatomy and frame geometry. Therefore, the aim of this cadaveric study was to evaluate the feasibility, accuracy, and navigational compatibility of integrating 3DSS into stereotactic workflows as a potential replacement for intraoperative CT. METHODS A human cadaveric head was imaged with both thin-slice CT and structured-light 3DSS after mounting stereotactic frame components. CT, 3DSS, and computer-aided design (CAD) models were registered using a multistep point cloud alignment pipeline involving the fast point feature histogram, the random sample consensus method, and the iterative closest point algorithm. Accuracy was assessed using surface deviation error, root mean square error (RMSE), and fiducial registration error within a commercial neuronavigation platform. RESULTS Fusion of the 3D facial scan with CT provided a mean surface deviation error of approximately 0.4 mm. Registration of the 3DSS-derived N-bar localizer to its CAD reference model produced a frame alignment RMSE of 1.3 mm. Within the navigation system, the 3DSS-based workflow achieved a mean fiducial registration error of 0.14 mm (range 0.02–0.20 mm), outperforming the conventional CT-based method (mean error 0.20 mm, range 0.09–0.40 mm). CONCLUSIONS The 3DSS-based method enabled precise submillimetric stereotactic registration without the need for intraoperative CT, reducing radiation exposure and operative complexity. This workflow is fully compatible with existing navigation systems and could serve as a practical radiation-free alternative in stereotactic neurosurgery. Future work will focus on automating frame detection, incorporating artificial intelligence–driven fusion methods, and validating this approach in live surgical settings.

Summary: Umbilical piercings are popular among young individuals for aesthetic body enhancement. However, umbilical piercings can lead to complications such as infections, hypertrophic scarring, and epithelialized tracts that require surgical intervention. This case report presents a novel, minimally invasive technique using a lacrimal probe and iris scissors under local anesthesia to excise the epithelialized piercing tracts. A 23-year-old patient underwent the procedure, resulting in minimal scarring and high satisfaction at an 11-month follow-up. Compared with the existing methods, this approach ensures complete tract removal while preserving the natural umbilical contour. Given the limited literature, this technique offers an effective solution with excellent cosmetic outcomes.

Summary: Anatomy is a critical component of surgical training; however, traditional resources—such as Netter’s Surgical Anatomy , Gray’s Anatomy , and anatomy applications—often fall short in delivering surgically relevant, 3-dimensional (3D) perspectives of facial anatomy. Although cadaveric dissection remains a valuable teaching tool, its accessibility is limited by cost, ethical concerns, and the lack of structured curricula, making it less feasible for ongoing surgical education. To address these limitations, this article introduced a novel educational approach that integrates 3D photogrammetry and virtual reality technology into the surgical anatomy curriculum for craniofacial and aesthetic surgery. Six fresh cadaveric specimens were meticulously dissected by a plastic surgeon to illustrate the intricate layered anatomy of the face and neck. At each stage of the dissection, a photogrammetry technique was used to capture 360-degree images using 5 digital single-lens reflex cameras alongside a 3D handheld camera. This approach not only ensured high-quality imaging but also facilitated the creation of detailed, lifelike virtual 3D models, enhancing the understanding of facial and neck anatomy within a surgical context. Additionally, we present some technical refinements of the 3D volume renderings to capture precise anatomical details during our dissections. Preliminary results from the use of this technology in anatomy courses and workshops indicated trainee engagement, a clearer grasp of the spatial anatomical relationships, and greater confidence in applying this knowledge to hands-on surgical procedures.

Background/Objectives Auricular reconstruction poses significant surgical challenges in congenital and post-traumatic cases. Porous polyethylene (PPE) implants have emerged as a biocompatible alternative to the traditional autologous rib cartilage frames, offering less morbidity and a potentially stable framework. Here, we summarize the current evidence of the use of PPE auricular implants. Methods: A literature search was performed in accordance with PRISMA guidelines across several databases. Studies reporting outcomes of PPE implants in auricular reconstruction were included. Data were extracted on patient characteristics, operative details, and complication rates, along with any required interventions to address complications. Complications were classified as minor or major based on their management strategy. Results: Of 544 screened studies, 14 studies representing 1036 patients were included. PPE implant use was generally linked with favorable esthetic outcomes and high patient satisfaction (80%). Study-to-study variation in complication rates was notable, with some complication rates as high as 44% in the early 1990s. By the early 2000s, advancements in surgical methods—particularly the use of temporoparietal fascia (TPF) flaps and other flaps for optimal soft tissue coverage—had markedly reduced complication rates, with recent studies reporting rates as low as 7%. Implant exposure (6.7%) and implant fractures (ranging from 1.6% to 3.2%) were the most frequently reported problems. Conclusions: PPE auricular implants, despite decades of availability, have faced limited global adoption due to concerns over complications and longevity. Advances in surgical techniques have significantly reduced complication rates (<7%), making PPE implants a viable early intervention with favorable esthetics and negligible donor-site morbidity.