Asymmetric class III malocclusion: association with cranial base deformation and occult torticollis.

The etiology of Angle class III malocclusion with facial asymmetry has not been fully elucidated. To investigate the etiology, patients with asymmetric prognathism (n = 30) from a single institution were assessed for previously undiagnosed torticollis and cranial base asymmetry. Presence of torticollis was determined by measuring restricted head movement when turning the head against a wall and cranial base tilt with upward gaze. Cranial base asymmetry was evaluated by preoperative three-dimensional computed tomography scans. Thirty-one percent of patients with prognathism presented with concurrent facial asymmetry. In patients with asymmetric prognathism, cranial base tilt was present on upward gaze in all patients; mean angle between head and wall was 31 degrees greater than that in control patients, and a 22% to 36% difference in the angle was present when comparing one side with the other. Based on these findings, all patients with asymmetric prognathism were found to be affected by torticollis. By computed tomography scan, 85% of these torticollis patients showed slight anteromedial displacement of the glenoid fossa ipsilateral to torticollis, and 73% demonstrated temporal fossa shift of 4 mm or greater. The current study demonstrates a strong association between asymmetric class III malocclusion, torticollis, and cranial base asymmetry. We conclude that undiagnosed torticollis is a likely etiology for otherwise idiopathic cranial base asymmetry and that cranial base asymmetry in turn causes facial asymmetry and malocclusion. This study highlights the importance of evaluating cranial base asymmetry and torticollis in patients with class III malocclusion to allow for earlier treatment and improved outcomes.

Social networks uncovered: 10 tips every plastic surgeon should know.

Understanding online social networks is of critical importance to the plastic surgeon. With knowledge, it becomes apparent that the numerous networks available are similar in their structure, usage, and function. The key is communication between Internet media such that one maximizes exposure to patients. This article focuses on 2 social networking platforms that we feel provide the most utility to plastic surgeons. Ten tips are provided for incorporation of Facebook and Twitter into your practice.

Familiarization, reliability, and evaluation of a multiple sprint running test using self-selected recovery periods.

The aims of the present study were to investigate the process of self-selected recovery in a multiple sprint test with a view to using self-selected recovery time as a means of reliably quantifying an individual's ability to resist fatigue in this type of exercise. Twenty physically active exercise science students (means ± SD for age, height, body mass, body fat, and VO2max of the subjects were 21 ± 2 yr, 1.79 ± 0.09 m, 83.7 ± 10.8 kg, 16.6 ± 3.9%, and 52.7 ± 7.2 ml·kg·min, respectively) completed 4 trials of a 12 × 30 m multiple sprint running test under the instruction that they should allow sufficient recovery time between sprints to enable maximal sprint performance to be maintained throughout each trial. Mean recovery times across the 4 trials were 73.9 ± 24.7, 82.3 ± 23.8, 77.6 ± 19.1, and 77.5 ± 13.9 seconds, respectively, with variability across the first 3 trials considered evidence of learning effects. Test-retest reliability across trials 3 to 4 revealed a good level of reliability as evidenced by a coefficient of variation of 11.1% (95% likely range: 8.0-18.1%) and an intraclass correlation coefficient of 0.76 (95% likely range: 0.40-0.91). Despite no change in sprint performance throughout the trials, ratings of perceived exertion increased progressively and significantly (p < 0.001) from a value of 10 ± 2 after sprint 3 to 14 ± 2 after sprint 12. The correlation between relative VO2max and mean recovery time was 0.14 (95% likely range: -0.37-0.58). The results of the present study show that after the completion of 2 familiarization trials, the ability to maintain sprinting performance in a series of repeated sprints can be self-regulated by an athlete to a high degree of accuracy without the need for external timepieces.

PyroCarbon implant hemiarthroplasty for trapeziometacarpal arthritis.

The trapeziometacarpal joint is commonly affected by degenerative arthritis, presenting with pain, stiffness, and swelling at the base of the thumb. When conservative treatment fails, surgical intervention may be warranted based on clinical and radiologic staging as well as patient demand. The concept of replacing the trapeziometacarpal joint remains attractive because of the decreased pain and stiffness, prevention of thumb shortening, and earlier recovery of strength seen with implant arthroplasty. A technique of using a cementless PyroCarbon hemiarthroplasty implant that allows excellent range of motion and decreased postoperative stiffness and pain is presented, with a focus on dorsal capsular reconstruction to prevent subluxation of the implant.

Anatomy of the supratrochlear nerve: implications for the surgical treatment of migraine headaches.

BACKGROUND: Migraine headaches have been linked to compression, irritation, or entrapment of peripheral nerves in the head and neck at muscular, fascial, and vascular sites. The frontal region is a trigger for many patients' symptoms, and the possibility for compression of the supratrochlear nerve by the corrugator muscle has been indirectly implied. To further delineate their relationship, a fresh tissue anatomical study was designed. METHODS: Dissection of the brow region was undertaken in 25 fresh cadaveric heads. The corrugator muscle was identified on both sides, and its relationship with the supratrochlear nerve was investigated. RESULTS: The supratrochlear nerve was found in all 50 hemifaces. Three potential points of compression were uncovered in this investigation: the nerve entrance into the brow through the frontal notch or foramen, the entrance of the nerve into the corrugator muscle, and the exit of the nerve from the corrugator muscle. The nerve generally bifurcates within the retro-orbicularis oculi fat pad, and these branches enter into one of four relationships with the corrugator muscle: both branches enter the muscle, one branch enters the muscle and one remains deep, both branches remain deep, and the branches further branch into ever smaller filaments that cannot be identified cranially. CONCLUSIONS: Some patients are nonresponders to migraine decompression techniques that address the supraorbital nerve. The supratrochlear nerve may be compressed in these patients. A standard corrugator resection that comes more medially within 1.8 cm of the midline may be beneficial. The morphology of the frontal notch/foramen must be examined and addressed if necessary.

Brow lift in facial rejuvenation: a systematic literature review of open versus endoscopic techniques.

BACKGROUND: Currently, there are many well-described surgical approaches to address brow aesthetics (i.e., open versus endoscopic versus combination techniques). Each technique has associated benefits and limitations. The authors' discussion in this article is intended to review current worldwide surgical approaches to brow aesthetics and to explore the following question: Are open brow lifts still pertinent in the modern era of cosmetic surgery? METHODS: A systematic review of current available literature for the dates 1992 until the present was performed using the MEDLINE, PubMed, Cochrane Central Register of Controlled Trials, and CINAWL databases. Inclusion criteria required that individual studies contain original content; provide patient outcome data, including complications; and maintain a sufficient sample size of no fewer than 20 patients. RESULTS: One hundred eighty-nine articles were reviewed from the initial keyword searches of four major databases and plastic surgery journals. Fifteen articles were included in the analysis after careful review established that the necessary criteria were met. From direct analysis of these articles, no clear evidence exists to indicate that open methods of brow surgery are inferior to endoscopic approaches. CONCLUSIONS: Brow-lift surgery has clearly evolved since the inception of endoscopic techniques in the early 1990s. However, currently there are no prospective randomized trials in the literature that compare the surgical outcomes of differing approaches. This thorough review of current worldwide English-language literature highlights the relative paucity of good comparative studies and serves as a reminder that there is still an important role for the open approach to brow aesthetic dilemmas. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Correction of hydrocephalic macrocephaly with total cranial vault remodeling and molding helmet therapy.

BACKGROUND: Hydrocephalic macrocephaly is a rare problem that may result in cranial vault instability, difficulties with posture and movement, and hindrance in neurological development. The authors studied the outcomes of hydrocephalic macrocephalic cases in which patients underwent single-stage total cranial vault remodeling and postoperative helmet therapy. METHODS: Consecutive patients with hydrocephalic macrocephaly treated at University of California, Los Angeles from 2000 to 2007 were studied (n = 8). Perioperative examinations (head circumference), lateral cranial radiographs (anteroposterior, lateral, and cranial height measurements) and three-dimensional computed tomography scans (cranial volume) were used to access cranial reduction. Developmental testing, physician evaluations (Whitaker score), and parental surveys were used. RESULTS: Improvements in mean head circumference (from 58.8 cm to 48.9 cm, or 17 percent reduction), and cranial volume measurements (from 1924 cc to 1212 cc, or 35 percent reduction) were seen in patients after the procedure. In addition, developmental testing scores improved in half, or four of eight patients. Whitaker score was 1.9 with only one case requiring revision but five needing subsequent shunts. Surveys showed a high satisfaction rate with final appearance and ease of childcare. CONCLUSION: For the rare patient with hydrocephalic macrocephaly, treatment with total cranial vault remodeling with postoperative helmet therapy may be successful, but follow-up monitoring and subsequent ventriculoperitoneal shunting may be necessary.

Outcome analysis of combined lipoabdominoplasty versus conventional abdominoplasty.

BACKGROUND: Abdominoplasty and liposuction have traditionally been separate procedures. The authors performed a retrospective cohort study to evaluate the outcomes of a novel single-stage approach combining extensive lipoplasty with a modified transverse abdominoplasty. METHODS: One hundred fourteen patients were evaluated for abdominal contouring. Patients were categorized into four groups: group I (n = 20) received abdominal liposuction only, group II (n = 33) traditional W-pattern incision line abdominoplasty, group III (n = 30) modified transverse incision abdominoplasty, and group IV (n = 31) combined procedure involving widely distributed abdominal liposuction accompanied by inverted V-pattern dissection abdominoplasty. Wound complications, patient satisfaction, and revision rates were compared statistically. RESULTS: Group I (liposuction alone) experienced an overall complication rate of 5 percent; two patients were dissatisfied (10 percent) and underwent further revision with full abdominoplasties. Group II (traditional W-pattern abdominoplasty) had a complication rate of 42 percent, a dissatisfaction rate of 42 percent, and a revision rate of 39 percent. By comparison, group III (modified low transverse abdominoplasty) had a complication rate of 17 percent, a dissatisfaction rate of 37 percent, and a revision rate of 33 percent. Group IV (combined liposuction plus abdominoplasty) had significantly lower complication, dissatisfaction, and revision rates (9, 3, and 3 percent, respectively). CONCLUSIONS: Modified transverse abdominoplasty combined with extensive liposuction and limited paramedian supraumbilical dissection produced fewer complications and less dissatisfaction than did traditional abdominoplasty. This may be attributable to a reduced tension midline closure in the suprapubic region, less lateral undermining in the upper abdomen, and greater preservation of intercostal artery blood flow to the flap.

Intracranial volume and cephalic index outcomes for total calvarial reconstruction among nonsyndromic sagittal synostosis patients.

BACKGROUND: Controversy abounds as to how craniosynostosis affects intracranial volume and whether more extensive procedures achieve superior results. Intracranial volume and cephalic index were evaluated among nonsyndromic sagittal synostosis patients undergoing cranioplasty. METHODS: Twenty-four children with isolated nonsyndromic sagittal synostosis underwent a total calvarial reconstruction. Volume and cephalic index measurements were taken 1 month preoperatively, 1 month postoperatively, and at 1-year follow-up. Data obtained were compared against normative value curves, and interval shifts between curve SD ranges were noted. The absolute percentage difference between the observed intracranial volume or cephalic index and the correlated normative mean value (absolute mean percentages) was calculated for each scan. RESULTS: Preoperatively, intracranial volume for patients younger than 30 months (n = 19) was within the normal range (+/-1 SD), whereas it exceeded 1 SD in all patients older than 30 months (n = 5). Postoperatively and at follow-up, intracranial volume range was unchanged for patients younger than 30 months but was decreased to normal for 60 percent of those older than 30 months. Absolute mean volume percentage showed a small increase from preoperatively for patients younger than 12 months (p < 0.05), no change for patients aged 12 and 30 months, and decreased for patients older than 30 months (p < 0.05). Postoperatively, all patients demonstrated a normal intracranial volume growth rate. As for cephalic index, preoperatively, 92 percent of patients fell below the minimum normal values. At follow-up, 100 percent had a cephalic index in the normal range (p < 0.05). CONCLUSIONS: Nonsyndromic sagittal synostosis results in an age-dependent increased intracranial volume and decreased cephalic index. Total calvarial reconstruction (1) appears to allow for the expansile forces of the growing brain to be distributed and may relieve an underlying abnormality; (2) does not affect postoperative intracranial volume growth rate; and (3) enables normalization of cephalic index.

Reduced morbidity and improved healing with bone morphogenic protein-2 in older patients with alveolar cleft defects.

BACKGROUND: In older cleft patients, alveolar bone grafting may be associated with poor wound healing, graft exposure, recurrent fistula, and failure of tooth eruption. A new procedure using a resorbable collagen matrix with bone morphogenetic protein (BMP)-2 was compared with traditional iliac crest bone graft to close alveolar defects in older patients. METHODS: Skeletally mature patients with an alveolar cleft defect undergoing alveolar cleft repair were divided into either group 1 (BMP-2, experimental) or group 2 (traditional iliac graft, control) (n = 21). Bone healing was assessed with intraoral examination and NewTom scans (three-dimensional, Panorex, periapical films). Donor-site morbidity was determined with pain surveys. Overall cost and length of hospital stay were used to examine economic differences. RESULTS: Preoperative and follow-up (1 year) intraoral examinations revealed fewer complications (11 percent versus 50 percent) and better estimated bone graft take in group 1 compared with group 2. Panorex and three-dimensional computed tomographic scans showed enhanced mineralization in group 1 compared with group 2. Volumetric analysis showed group 1 had a larger percentage alveolar defect filled with new bone (95 percent) compared with group 2 (63 percent). Donor-site pain intensity and frequency were significant in group 2 but not group 1. The mean length of stay was greater for group 2 compared with group 1. In addition, the mean overall cost of the procedure was greater in group 2 ($21,800) compared with group 1 ($11,100). CONCLUSIONS: For this select group of late-presenting alveolar cleft patients, the BMP-2 procedure resulted in improved bone healing and reduced morbidity compared with traditional iliac bone grafting.

Formation of in vitro murine cleft palate by abrogation of fibroblast growth factor signaling.

BACKGROUND: A strong association between fibroblast growth factors (FGFs) and palatal anatomy suggest their role in proper palatal development. The purpose of this study was to establish whether fibroblast growth factor signaling is essential for normal palate development, improve the understanding of the biology of palatal fusion, and create a new in vitro cleft palate model. METHODS: Palatal pairs excised from embryonic day 13.5 mouse palatal shelves were divided into three equal groups (n = 18 pairs) and cultured with the nasal side down and their medial edge epithelia in close apposition. Controls received vehicle only (n = 6 pairs) or LacZ recombinant virus (n = 6 pairs). The experimental group (n = 6 pairs) received truncated FGF-R1 recombinant virus with hemagglutinin epitope tag (1 x 10(9) plaque-forming units), which abrogated signal transduction by FGF-R1, FGF-R2, and FGF-R3. Tissue sectioning and staining was used to assess palatal continuity at 96 hours and immunohistochemistry was used to localize expression of the truncated receptors. RESULTS: Both groups 1 (control, vehicle only) and 2 (LacZ) showed complete fusion of palatal shelves after 96 hours in five of six specimens and near fusion in the remaining specimen. Beta-galactosidase staining indicated effective delivery of the LacZ virus to targeted epithelial cells. None of the group 3 specimens (FGF-R1) showed histologic resolution of the medial edge epithelia seam. Immunohistochemistry for the hemagglutinin epitope tag indicated infection by the truncated FGF-R1 virus throughout the epithelium and mesenchyme of the epithelium. CONCLUSION: By abrogating signal transduction by FGF-R1, FGF-R2, and FGF-R3, the authors have demonstrated that such signaling is essential for normal mammalian palate development.

Posterior cranial fossa box expansion leads to resolution of symptomatic cerebellar ptosis following Chiari I malformation repair.

Chiari I malformation occurs when the cerebellar tonsils herniate downward through the foramen magnum into the upper cervical spinal canal. If the posterior fossa craniectomy during corrective surgery leads to excessive enlargement of the foramen magnum, the complication of cerebellar ptosis may result. To treat this difficult problem a posterior cranial fossa box expansion was devised and studied. Patients who developed symptomatic cerebellar ptosis (confirmed by MRI) following cranial vault decompression for Chiari I malformations underwent a posterior fossa box expansion (n=7). This procedure involved coverage of posterior aspect of the enlarged foramen magnum with a split-thickness calvarial bone graft box. The box reconstruction provided separation between the neck musculature, soft tissues from the neural tissue; prevention of cerebellar prolapse; and expansion of the posterior cranial vault. Patients had a mean of 12+/-1 months between initial suboccipital craniectomy and confirmation of symptomatic cerebellar ptosis. Mean age at the time of posterior fossa box reconstruction was 31+/-9 years (range of 14 to 44 years). Preoperative symptoms of headache (7/7, 100%), upper extremity numbness (5/7, 71%) or paresthesias (3/7, 43%), respiratory disturbance (2/7, 29%) and inability to walk (2/7, 29%) improved in all patients postoperatively. At more than 12 month follow-up 6/7 patients (86%) were both disease-free (MRI confirmation) and symptom-free. One out of seven patients had return of headache in a more mild form. Thus, in our patient group the posterior fossa box reconstruction led to resolution of symptomatic cerebellar ptosis following Chiari I malformation repair.

Delayed closure of the hard palate leads to speech problems and deleterious maxillary growth.

BACKGROUND: Hard palate cleft closure has been associated with maxillary hypoplasia. The Schweckendiek procedure offers delayed hard palate closure to avoid early subperiosteal dissection and palatal scarring. This study sought to compare single-stage versus delayed hard palate closure for speech outcome and maxillary growth. METHODS: A retrospective outcome study was performed of unilateral cleft lip and palate patients with either delayed hard palate repair with a pinned-retained speech prosthesis (Schweckendiek repair) (group 1, delayed hard palate repair, 1978 to 1983) or single-stage cleft palate repair (group 2, single-stage repair, 1983 to 1988). Patients with complete records to maturity at the University of Pittsburgh Cleft Palate Craniofacial Center (n = 82, two equal groups of 41 patients) were studied. Comparative data were collected from multidisciplinary evaluations, perceptual speech scores, speech tests, and cephalometric analysis. RESULTS: Single-stage cleft palate repair had a lower fistulization rate (11 percent) compared with delayed hard palate repair (58 percent). It also had better speech outcomes compared with delayed hard palate repair: mean speech score, 3.1 versus 7.8; final speech score, 0.9 versus 2.9; velopharyngeal incompetency, 21 percent versus 66 percent; failed video fluoroscopy or nasoendoscopy, 18 percent versus 52 percent; and need for secondary speech procedure, 20 percent versus 63 percent. Single-stage repair showed less maxillary growth disturbance, with class III malocclusion, 31 percent versus 66 percent; cephalometric SNA, 78.2 versus 74.8; need for Le Fort I advancement, 24 percent versus 42 percent; and amount of maxillary advancement required, 6 mm versus 9 mm. CONCLUSION: The delayed cleft palate repair led to worse speech outcomes; thus, the authors' center abandoned this technique in favor of single-stage repair. In addition, their data showed that the delayed cleft palate repair led to deleterious maxillary growth.

Cranial suture response to stress: expression patterns of Noggin and Runx2.

BACKGROUND: Current theory on normal cranial suture fusion entrusts the dura with the regulatory role. Studies suggest that the dura responds to stress with changes in gene expression. Noggin (bone morphogenetic protein inhibitor) expression is decreased in normal (rat and mouse) cranial suture fusion, but its role in craniosynostosis and the response to stress has not been studied. METHODS: Posterior frontal (fusing) and sagittal (patent) rat cranial sutures were held static, oscillated, or distracted for 10 days in an organ culture microdistraction device beginning at 5 days of age (n = 30 sutures, or 10 sutures per group). The percentage of fusion equaled the score received for bony closure. Noggin, Runx2, and alkaline phosphatase expression was localized by immunohistochemistry for all groups. RESULTS: Both the posterior frontal and sagittal sutures demonstrated a significant (p < 0.05) increase in fusion percentage with oscillation relative to the static control. Noggin was not expressed in the fusing posterior frontal suture but was expressed in the normally patent sagittal suture. Conversely, Runx2 was expressed in the posterior frontal suture but not in the sagittal suture. However, when a mechanical stress was applied, both the posterior frontal and sagittal sutures expressed Runx2 but not Noggin, as in the static fusing suture. CONCLUSIONS: The application of mechanical stress to cranial sutures results in fusion of both the posterior frontal suture and the normally patent sagittal suture. Runx2 is expressed but Noggin is not expressed. Thus, mechanical stress influences sutural fusion and may play a role in craniosynostosis.

Craniofrontonasal dysplasia: a surgical treatment algorithm.

BACKGROUND: Craniofrontonasal dysplasia is a rare, familial X-linked syndrome with coronal synostosis (brachycephaly or plagiocephaly), hypertelorbitism (frequently asymmetric), and extracranial anomalies. Details of the timing and technique of the craniofacial correction have not been well described. The largest series of patients with craniofrontonasal dysplasia treated at a single institution was used for review. METHODS: A review of patients at the University of California, Los Angeles Craniofacial Clinic with the diagnosis of craniofrontonasal dysplasia was performed (n = 21). Data included office, hospital, and operative records; photographs; lateral cephalograms; and three-dimensional computed tomographic scans. Based on surgical outcomes, a treatment algorithm was created. RESULTS: Fourteen patients were female, seven were male, and five had a family history of craniofrontonasal dysplasia (24 percent). Eight patients had unilateral coronal synostosis (plagiocephaly) and 13 had bilateral coronal synostosis (brachycephaly). Eleven patients had asymmetric hypertelorbitism and 10 had symmetric hypertelorbitism. Patients also had cleft lip-cleft palate (10 percent), ear deformities (19 percent), strabismus or esotropia (81 percent), dry frizzy hair (100 percent), syndactyly (14 percent), and nail (100 percent) or other anomalies. After fronto-orbital advancement, no patients had increased intracranial pressure problems or difficulty related to resynostosis. After hypertelorbitism correction, three patients relapsed. Because of this, correction in later patients was delayed until after eruption of permanent maxillary incisors. The mean anterior interorbital distance was reduced in patients from 184 percent to 98 percent of sex-matched controls. CONCLUSIONS: The phenotypic expression of craniofrontonasal dysplasia is described to recognize patients early. A treatment algorithm for craniofrontonasal dysplasia based on timing and technique is offered to decrease the need for revision and improve outcomes.

Autologous fat transfer national consensus survey: trends in techniques for harvest, preparation, and application, and perception of short- and long-term results.

BACKGROUND: Despite a perceived interest in autologous fat transfer, there is no consensus as to the best technique or the level of success. The purpose of the present study was to determine the national trends in techniques for harvest, preparation, and application of autologous fat, as well as the success perceived by practitioners. METHODS: Comprehensive surveys were sent to 650 randomly selected members of the American Society for Aesthetic Plastic Surgery. The survey was aimed at determining whether autologous fat transfer is a commonly performed procedure and, if so, the specific methods involved and the subjective perception of short- and long-term results. RESULTS: The results of the national consensus survey from 508 surgeons (78 percent return rate) showed the following: (1) autologous fat transfer is a relatively common procedure (57 percent perform >10 annually), but few perform it in high volume (only 23 percent perform >30 annually); (2) techniques for harvest, preparation, and injection rarely deviate from methods discussed in the literature (microcannula, 54 percent; centrifugation, 75 percent; injection in nasolabial fold > lips > nasojugal folds); (3) most physicians believe that at least some graft survival is clinically evident (93 percent); and (4) patients are pleased with the short-term results (good to excellent, 84 percent), despite a lower rate of long-term patient satisfaction (fair to good, 80 percent). CONCLUSION: Currently, plastic surgeons across the country report a uniformity of autologous fat grafting techniques with acceptable patient satisfaction.

Repair of alveolar cleft defects: reduced morbidity with bone marrow stem cells in a resorbable matrix.

Harvest of the autogenous iliac crest bone graft for an alveolar cleft defect (the gold standard) may cause short- and long-term pain and sensory disturbances. To determine if a tissue engineering technique with similar bone healing results offered decreased morbidity, we compared techniques for postoperative donor site pain. Traditional iliac crest bone graft had more donor site complications compared with both tissue engineering and minimally invasive iliac crest bone graft. With donor site pain, traditional had the most patients with pain and tissue engineering had the least patients with pain at all time points. The mean pain score, including both intensity and pain frequency, was greatest at all time points in traditional and least at all time points in tissue engineering. Closure of alveolar cleft defects with a resorbable collagen sponge and bone marrow stem cells resulted in reduced donor site morbidity and decreased donor site pain intensity and frequency.

Caution in treating transsphenoidal encephalocele with concomitant moyamoya disease.

A basal encephalocele is a rare congenital malformation involving a cranial bone defect and cystic-like herniation through the defect. Moyamoya is a rare cerebrovascular disease of unclear etiology involving occlusion of the distal internal carotids and formation of collateral vascular networks. Both diseases have been correlated with optic disc anomalies, hypopituitarism, and midfacial defects. We present a case of a 2-year-old boy with a midline facial cleft who underwent surgical correction of a basal encephalocele. His moyamoya disease may have contributed to a vascular complication. There is growing evidence indicating an overlap in disease profiles for these two rare diseases. In addition, molecular evidence indicates elevated levels of fibroblast growth factor and transforming growth factor in both diseases, suggesting common molecular pathways.