Revitalizing Hands: A Comprehensive Review of Anatomy and Treatment Options for Hand Rejuvenation.

Dorsal hand rejuvenation is gaining popularity as a solitary procedure and adjunct to face and neck rejuvenation treatments. As the hands age, the skin loses elasticity and becomes more translucent, the veins, joints, and tendons appear more prominent, and the bones become more noticeable. These changes are due to intrinsic and extrinsic factors. Current treatment methods include the injection of dermal fillers and autologous fat grafting. Anatomic studies to ensure the successful implementation of rejuvenation procedures identified three separate fascial layers in the dorsum, from superficial to deep. More recent re-evaluations revealed a less distinct, inseparable, sponge-like fascial layer. All authors agree that the superficial dermal layer is probably the optimal location for the injection of volumizing materials because it is free of anatomical structures. Many methods for harvesting, preparing, and injecting fat grafts to the dorsum of the hand have been described in the past three decades. Both filler and fat-graft procedures are performed on an ambulatory basis under local anesthesia. Good results with low postoperative and long-term complication rates and high patient satisfaction have been reported.

Temporal hollowing causes, classifications, and treatment options: A systematic review.

BACKGROUND: Recent developments in surgical techniques and grading schemas to treat temporal hollowing necessitate critically assessing their efficacy. This systematic review presents the currently available protocols for temporal hollowing, aimed toward improving the clinical approach, for the benefit of the surgeon and patient. METHODS: A search was conducted in PubMed, EMBASE, and Google Scholar in September 2021 using the keywords "temporal hollowing" and "temporal augmentation." Inclusion criteria were English-written articles published in peer-reviewed journals that reported an outcome relating to the cause, classification, or procedure used to prevent or correct hollowing in humans. RESULTS: Of the 413, 966 publications retrieved, 24 met the study inclusion criteria. Twenty-one publications discussed the etiology of temporal hollowing, 12 discussed a classification or grading system for temporal hollowing, and 19 discussed a procedure to prevent or correct temporal hollowing. The most commonly reported etiology for temporal hollowing was iatrogenic (63%). For classifying temporal hollowing severity, visual analogue scales (25%) were most commonly used. Mesh (26%) and autologous fat grafts (26%) were the most popular procedures used to prevent or correct temporal hollowing. DISCUSSION: We presented the spectrum of temporal hollowing grading schemas and treatment modalities currently published in the field. The use, by a majority of publications, of a grading system based on the subjective judgment of the examiner (either alone or adjunct to imaging results) suggests the need for a more standardized measurement tool. Future studies should investigate a universally applicable temporal hollowing classification system and its impact on treatment outcomes.

Massive Brain Swelling Following Reduction Cranioplasty for Secondary Turricephaly.

ABSTRACT: Cranioplasty is commonly performed to treat craniosynostosis. A rare postsurgical complication is massive brain swelling with elevated intracranial pressure. This commonly presents with mydriasis, coma, and seizures; radiologic findings include cerebral edema, parenchymal hemorrhages, and ischemic changes.The authors describe a 9-year-old boy who developed massive brain swelling following reduction cranioplasty for secondary turricephaly. His history included surgical repair of metopic-craniosynostosis at age 5.5 months, by means of an anterior cranial-vault reconstruction with fronto-orbital advancement. After presenting to our clinic with a significant turricephalic skull deformity, he underwent cranial reduction cranioplasty. On postoperative day 1, mild neurological signs associated to increased intracranial pressure were noticed. As they worsened and massive brain swelling was identified, he was treated pharmacologically. On postoperative day 13, the patient was operated for decompression.A literature review yielded 4 articles related to massive brain swelling for post-traumatic craniectomies. None described elevated intracranial pressure or massive brain swelling following cranial reduction for secondary craniosynostosis. The main dilemma regarding our patient was the necessity and timing of a second operation.The literature did not reveal relevant recommendations regarding treatment timing nor preventative measures.The authors recommend presurgical neuro-ophthalmological and imaging evaluation, for comparisons and management during the immediate and short-term follow-ups. The authors suggest that for a patient presenting with signs and symptoms of cerebral edema or high intracranial pressure following reduction-cranioplasty, pharmacological treatment should be initiated promptly, and careful drainage and eventual surgical-treatment should be considered if no improvement is shown in the subsequent days.

Cranioplasty Outcomes From 500 Consecutive Neuroplastic Surgery Patients.

BACKGROUND: Cranioplasty is critical to cerebral protection and restoring intracranial physiology, yet this procedure is fraught with a high risk of complications. The field of neuroplastic surgery was created to improve skull and scalp reconstruction outcomes in adult neurosurgical patients, with the hypothesis that a multidisciplinary team approach could help decrease complications. OBJECTIVE: To determine outcomes from a cohort of cranioplasty surgeries performed by a neuroplastic surgery team using a consistent surgical technique and approach. METHODS: The authors reviewed 500 consecutive adult neuroplastic surgery cranioplasties that were performed between January 2012 and September 2020. Data were abstracted from a prospectively maintained database. Univariate analysis was performed to determine association between demographic, medical, and surgical factors and odds of revision surgery. RESULTS: Patients were followed for an average of 24 months. Overall, there was a reoperation rate of 15.2% (n = 76), with the most frequent complications being infection (7.8%, n = 39), epidural hematoma (2.2%, n = 11), and wound dehiscence (1.8%, n = 9). New onset seizures occurred in 6 (1.2%) patients.Several variables were associated with increased odds of revision surgery, including lower body mass ratio, 2 or more cranial surgeries, presence of hydrocephalus shunts, scalp tissue defects, large-sized skull defect, and autologous bone flaps. importantly, implants with embedded neurotechnology were not associated with increased odds of reoperation. CONCLUSIONS: These results allow for comparison of multiple factors that impact risk of complications after cranioplasty and lay the foundation for development of a cranioplasty risk stratification scheme. Further research in neuroplastic surgery is warranted to examine how designated centers concentrating on adult neuro-cranial reconstruction and multidisciplinary collaboration may lead to improved cranioplasty outcomes and decreased risks of complications in neurosurgical patients.

Complicated wound closure following mastectomy and breast reconstruction.

Breast reconstruction incidence increased, including preventive surgery. In this context, providing women best surgical care and results is crucial, with minimum complications, such as wound dehiscence and skin flap necrosis. Tension-free closure of skin flaps is mandatory for successful healing. However, since this is not always possible, various techniques have been developed to reduce tension from wound margins, facilitate primary wound closure, and minimize and improve scarring. These techniques have not been investigated in breast surgeries. The aim of this study was to describe our experience with the Tension-Relief System in mastectomy and breast reconstructive patients, and the advantages of using this technique. The retrospective cohort consisted of 13 breasts of 11 women aged 29-74 years who underwent surgery with primary wound closure using the System, in 2019-2020 in our department. It was applied averagely 19.7 days, demonstrated effectiveness in preventing complications and as secondary treatment following complications. This enabled avoiding further and more extensive surgeries, including donor-site morbidity when needed. In mastectomy and breast reconstruction, the system minimizes complications and yields satisfactory esthetic and functional outcomes, with minimal inconvenience to the patient, and good pain control. The technique is low-cost, simple to use, and does not require special settings, surgical equipment, or particular skills.

Research Productivity among Plastic Surgeons in the State of Israel: h-index and M-quotient Assessment.

The h-index has been proven in the US and Canada to be a solid tool to assess the quality and impact of individual scientific work in the field of plastic surgery. M-quotient is an additional metric that mitigates the h-index's inherent bias toward more seasoned researchers. The objective of this study was evaluating the relationship between h-index and M-quotient and research productivity among plastic surgeons in the state of Israel. METHODS: A list of all Israeli board-certified plastic surgeons registered in the Israeli Society of Plastic and Aesthetic Surgery was obtained from the organization's website. Relevant demographic and academic factors of each surgeon were retrieved. The Scopus database was queried to determine each surgeon's h-index and M-quotient, among other bibliometric parameters. RESULTS: Our study included 173 plastic surgeons, 90% of whom were men. In total, 49.7% were working in academically affiliated hospitals; 14.4% of the surgeons had an academic rank. The mean h-index was 6.13; mean M-quotient was 0.27. Statistical analysis demonstrated a positive correlation between total number of publications (P < 0.0001), total number of citations (P < 0.0001), the surgeon's seniority (P < 0.0001), academic rank (P = 0.007), appointed as past/present plastic surgery department director (P < 0.0001), and working in an academic affiliated hospital (P < 0.025). The same parameters were found to have a positive correlation with M-quotient. CONCLUSIONS: The h-index is an effective measure to compare plastic surgeons' research productivity in Israel. M-quotient is an ancillary tool for the assessment of research productivity among plastic surgeons, with the advent of neutralizing the surgeon's seniority.

The Impact of Hydrocephalus Shunt Devices on Quality of Life.

BACKGROUND: Despite advances in hydrocephalus shunt technology and improvement in hydrocephalus management, many patients have chronic disability and require multiple surgeries throughout their lifetime. There is limited data from patients' perspective regarding the impact of shunt devices on quality-of-life. METHODS: A cross-sectional survey was developed to evaluate the impact of shunt devices on patient quality-of-life. The survey was distributed via social media platforms of the Hydrocephalus Association, and patients self-selected to anonymously complete the online questionnaire. A literature review was performed to contextualize the findings from the survey. RESULTS: A total of 562 survey responses were obtained from a network encompassing 35,000 members. The mean age was 30 years old (0.5-87), and 65% identified as female. Eighty one percent underwent at least 1 shunt revision surgery, with a reported average of 10 shunt revision surgeries per patient (1-200 surgeries). Occlusion, shunt migration and infection were the leading causes for revision at 60%, 47%, and 35%, respectively. In addition, 72% of patients reported pain and discomfort from the device, and 68% expressed avoidance of certain activities due to "fear of bumping shunt." Despite numerous articles discussing shunt technology, a review of the literature indicated a paucity of studies specifically evaluating the burden of shunt devices from a patient/caregiver perspective. CONCLUSIONS: The findings from this study suggest long-term physical and psychosocial burden associated with shunt devices. Importantly, this study highlights the need for concerted efforts to develop validated tools to study patient reported outcomes as it relates to neurocranial implanted devices.

Closure of Challenging Pediatric Scalp Wounds by a Tension-Relief System.

ABSTRACT: Pediatric scalp defects may be challenging, due to their variant tension level and specific etiologies. Tissue characteristics and pre- and post-management considerations may pose difficulties to reconstruction in the pediatric patient. Primary closure is the preferred surgical technique but is not always possible. Various techniques have been described for facilitating primary wound closure, by reducing tension from the skin wound margins. The authors use a tension-relief system in some challenging scalp wounds when simple primary closure cannot be achieved. This enables primary closure without tension on the surgical margins, and may thus preclude the need for other closure techniques such as tissue-expanders, grafts, and flaps. The authors describe our use of a tension-relief system in 21 pediatric patients treated during 2017-2020, for congenital deformities, vascular malformations and other skin lesions, traumatic wounds, burn scars, and complicated surgical wounds with and without hardware exposure. A tension-relief system is a prompt, simple-to-use, safe, and low-cost surgical solution that offers several advantages over other techniques when tension-free primary intention closure is not possible. These benefits include less extensive surgery, fewer surgeries and associated anesthesia, shorter treatment period and hospitalization, better scarring, lower distress and burden to patients and their families, better pain-control, the absence of donor-site with its comorbidities, and less bleeding and risk of damaging adjacent structures. Based on our experience and the system characteristics detailed, the authors recommend using the described technique, which is convenient, accessible, and reliable, to close challenging scalp wounds in pediatric patients.

Quality of Patient-Reported Outcome Studies Utilizing the BREAST-Q: A Systematic Review.

BACKGROUND: Patient-reported outcome (PRO) studies are essential in the assessment of surgical procedures in plastic surgery. One accepted and validated questionnaire is the BREAST-Q. OBJECTIVES: The aim of this study was to assess the quality of PRO studies in plastic surgery utilizing the BREAST-Q questionnaire. METHODS: This study involved 2 steps: (1) a systematic review of 23 key criteria assessing the quality of survey research in studies utilizing the BREAST-Q that were published between 2015 and 2018; (2) a review of current guidance for survey research in journals related to plastic surgery and breast surgery which were included in the systematic review. RESULTS: Seventy-nine studies were included in the systematic review. Many key criteria were poorly reported: 51.9% of the studies did not provide a defined response rate and almost 90% did not provide a method for analysis of nonresponse error; 67.1% lacked a description of the sample's representativeness of the population of interest, and 82.3% did not present a sample size calculation. The methods used to analyze data were not described in 11.4% of the papers; in 27.8% the data analysis presented could not allow replication of the results. Of the 16 journals in the fields of plastic surgery and breast surgery for which the "instructions to authors" were reviewed, 15 (93.7%) did not provide any guidance for survey reporting. CONCLUSIONS: The majority of key criteria are underreported by authors publishing their survey research in peer-reviewed journals in the fields of plastic and breast surgery. There is an urgent need to construct well-developed reporting guidelines for survey research in plastic surgery, and particularly in breast surgery.

Is Time a Factor in Quality of Life Improvement Following Breast Reduction?

BACKGROUND: Macromastia (breast hypertrophy) has a significant influence on patients' quality of life (QoL), and surgical treatment therefore offers clear medical benefits.Rapid improvements in musculoskeletal complaints are being reported long before final aesthetic results are traditionally evaluated. OBJECTIVES: The aim of this study was to use the RAND Health Status Survey, in modified validated Short Form 36 (SF-36), to analyze patient QoL after breast reduction, and examine whether QoL changes as a function of postoperative time. METHODS: This cross-sectional study included 50 consecutive selected female patients who underwent breast reduction surgery by the same technique performed by a single surgeon between January 2016 and December 2019. Changes in QoL were reported based on a modified SF-36 survey, with scores standardized according to the mean of the general population. Time intervals between the operations and surveys were recorded. RESULTS: The patients were divided into 3 categories according to time since their operation (<3 months, 3-12 months, and >12 months), and assessed pre- and postoperatively. The mean [standard deviation] weight of breast tissue removed was 479.97 [159.38] g per breast. Mean follow-up time was 15.02 [14.3] months. All patients were satisfied with the shape of their new breasts and none reported to have suffered major complications postoperatively. For all 3 groups, patients' scores in the SF-36 survey post- compared with preoperation indicated improvement unrelated to time elapsed since operation. CONCLUSIONS: Breast reduction improves symptoms and well-being, unrelated to amount of tissue removed or to time elapsed postsurgery. This improvement is rapid and may lead to better coverage from medical insurance providers.

Translucent Customized Cranial Implants Made of Clear Polymethylmethacrylate: An Early Outcome Analysis of 55 Consecutive Cranioplasty Cases.

BACKGROUND: Large skull reconstruction, with the use of customized cranial implants, restores cerebral protection, physiologic homeostasis, and one's preoperative appearance. Cranial implants may be composed of either bone or a myriad of alloplastic biomaterials. Recently, patient-specific cranial implants have been fabricated using clear polymethylmethacrylate (PMMA), a visually transparent and sonolucent variant of standard opaque PMMA. Given the new enhanced diagnostic and therapeutic applications of clear PMMA, we present here a study evaluating all outcomes and complications in a consecutive patient series. METHODS: A single-surgeon, retrospective, 3-year study was conducted on all consecutive patients undergoing large cranioplasty with clear PMMA implants (2016-2019). Patients who received clear PMMA implants with embedded neurotechnologies were excluded due to confounding variables. All outcomes were analyzed in detail and compared with previous studies utilizing similar alloplastic implant materials. RESULTS: Fifty-five patients underwent cranioplasty with customized clear PMMA implants. Twenty-one (38%) were performed using a single-stage cranioplasty method (ie, craniectomy and cranioplasty performed during the same operation utilizing a prefabricated, oversized design and labor-intense, manual modification), whereas the remaining 34 (62%) underwent a standard, 2-stage reconstruction (craniectomy with a delayed surgery for cranioplasty and minimal-to-no implant modification necessary). The mean cranial defect size was 101.8 cm. The mean follow-up time was 9 months (range, 1.5-39). Major complications requiring additional surgery occurred in 7 patients (13%) consisting of 2 (4%) cerebrospinal fluid leaks, 2 (4%) epidural hematomas, and 3 (4%) infections. In addition, 3 patients developed self-limiting or nonoperative complications including 2 (4%) with new onset seizures and 1 (2%) with delayed scalp healing. CONCLUSIONS: This is the first reported consecutive case series of cranioplasty reconstruction using customized clear PMMA implants, demonstrating excellent results with regard to ease of use, safety, and complication rates well below published rates when compared with other alloplastic materials. Clear PMMA also provides additional benefits, such as visual transparency and sonolucency, which is material specific and unavailable with autologous bone. Although these early results are promising, further studies with multicenter investigations are well justified to evaluate long-term outcomes.

Investigation of a Valve-Agnostic Cranial Implant for Adult Hydrocephalus Patients Requiring Ventriculoperitoneal Shunting.

INTRODUCTION: Currently, the most effective treatment strategy for adults with hydrocephalus involves cerebrospinal fluid diversion by means of a shunt system, most commonly ventriculoperitoneal shunts (VPS). Ventriculoperitoneal shunting is associated with high complication and/or revision rates, in part due to the high-profile programmable valve designs. Thus, the valve-agnostic cranial implant (VACI) was designed and investigated as a safe and effective method of reducing the valve's high profile and is currently undergoing clinical trials. As such, the objective of this study was to collate preliminary, multi-institutional data of early outcomes using a VACI approach for patients requiring VPS by way of an Institutional Review Board approved registry. METHODS: A total of 25 adult patients across 4 institutions and 6 surgeons underwent VACI placement for VPS based on preoperative evaluation and perceived benefit. Patient demographics, operative details, and preliminary outcomes are presented here. RESULTS: Valve-agnostic cranial implant placement via a limited size craniectomy at time of shunt revision was performed with no adverse events. Over an average follow-up period of 1 year (394 ±â€Š178 days), 92% of patients experienced no major shunt-related or scalp-related complications. There were 2 cases with a major complication requiring reoperation: 1 shunt tubing extrusion and 1 case of meningitis. The most frequent postsurgical intervention seen in this study was related to adjustment of drainage: a non-invasively performed valve reprogramming after initial shunt placement when proper flow rate is being established. Of the 8 cases of drainage adjustment, all but 1 (88%) were receiving a VPS for the first time, with the exception undergoing a fourth shunt revision. All instances of improper flow were treated non-surgically and remediated effectively via shunt reprogramming in clinic. Removal of the VACI was not indicated in any treatment course. In this way, all complications as they relate to the shunt valve were minor and required nonsurgical intervention, and no complications reported were directly or indirectly caused by using the VACI. CONCLUSION: Preliminary findings from this multicenter trial suggest promising outcomes with a low complication rate for patients with hydrocephalus undergoing VACI placement during VPS. Ongoing research will continue to provide a more robust clinical picture of VACI in hydrocephalus management as more data becomes available.

"POMELO PROJECT" - a simple and low cost simulator for harvesting skin graft by plastic surgery residents.

BACKGROUND: Harvesting partial thickness skin grafts is an important technical skill the training plastic surgeon is required to hone. Historically accomplished via manual dermatome (Humby's knife) or the modern day electric dermatome. OBJECTIVE: Presenting a means of practicing the use of Humby's knife for novice surgeons. METHODS: 15 plastic surgeons comprising 8 seniors and 7 residents, in a single tertiary center participated. Each utilised a Humby knife to harvest 4 skin grafts from a Pomelo. The graft areas were measured via computerised image processing, comparing measures of graft harvest consistency across groups of surgeons. RESULTS: In the resident surgeon group, the average relative difference between exact graft area and encompassing area was 0.45, as compared with 0.15 in the Senior surgeon group, indicating a greater degree of inconsistency in graft harvest. Comparisons across groups yielded significant differences per each of the 4 grafts harvested (p <=0.005). LIMITATIONS: single center and small cohort (inherent to the sparsity of plastic surgeons), marginal statistical evidence. CONCLUSIONS: Citrus Maxima (Pomelo) is a useful substrate to instruct and practice the use of Humby knife effectively, allowing novice surgeons to practice the manual manoeuvres required therefore as well as increase confidence in its subsequent operative use.

Algorithm for Temple Reconstruction With Consideration of Anatomic and Defect Characteristics.

The temple is an intriguing region of the face with unique anatomic features, such as the temporal hairline, concave contour, and close proximity to vital structures like the frontal branch of the facial nerve. However, cancerous skin lesions can plague this sun-exposed region and, when excised, it can result in large and significant defects. Reconstruction in this area is a formidable challenge for surgeons, as it requires comprehensive knowledge of temple morphology and the use of creative techniques in order to minimize disruption of surrounding functional and aesthetic structures. In this study, we describe our experience with temple reconstruction in patients of varying defect size and depth. Based on these defect characteristics, anatomic and aesthetic principles of the temple, we propose a surgical algorithm for temple reconstruction to aid surgeons in achieving optimal results.

Is Being Left Handed an Advantage toward a Plastic Surgery Residency?

Left hand dominance is a minority trait historically regarded as disadvantageous for surgeons. Contemporary scientific literature and folklore have shed new light on left handedness as a "boutique trait" and possible marker of gifted and exceptional individuals. Our subjective impression that left handedness is prevalent in the unique field of plastic surgery raised questions regarding the scope and possible causality of this phenomenon. METHODS: One hundred eleven medical doctors in our medical center filled out a 13-item questionnaire regarding hand dominance, medical speciality, and various creative outlets or hobbies. RESULTS: Sixty-four percent of the participating plastic surgeons were left handed (significantly higher than the approximate 12% of the general population; P = 0.007). Many of the left-handed doctors admitted to practicing musical instruments and various arts, crafts, and other hobbies. CONCLUSIONS: Plastic surgery is a unique profession requiring astute minds capable of creative and "outside-the-box" thinking; traits we have learned in recent decades may be particularly keen in left-handed individuals, perhaps suggest a causal relationship to the conglomeration of a majority of left-handed plastic surgeons.

Risk of Complications in Primary Versus Revision-Type Cranioplasty.

INTRODUCTION: Cranioplasty (CP) is a multifaceted procedure in a heterogenous patient population, with a high risk for complication. However, no previous large-scale studies have compared outcomes in primary (ie, first attempt) CP versus revision CP (ie, following previous attempts). The authors, therefore, analyzed long-term outcomes of 506 consecutive primary and revision CPs, performed by a single surgeon. METHODS: All CPs performed between 2012 and 2019 were analyzed under IRB protocol approval. Surgeries were categorized as either primary (no previous CP; n = 279) or revision CP (at least one previous CP; n = 227). Complications were defined as either major or minor. Subgroup analyses investigated whether or not CP complication risk directly correlated with the number of previous neuro-cranial surgeries and/or CP attempts. RESULTS: The primary CP group experienced a major complication rate of 9% (26/279). In comparison, the revision CP group demonstrated a major complication rate of 32% (73/227). For the revision CP group, the rate of major complications rose with each additional surgery, from 4% (1 prior surgery) to 17% (2 prior surgeries) to 39% (3-4 prior surgeries) to 47% (≥5 prior surgeries). CONCLUSION: In a review of 506 consecutive cases, patients undergoing revision CP had a 3-fold increase in incidence of major complications, as compared to those undergoing primary CP. These results provide critical insight into overall CP risk stratification and may guide preoperative risk-benefit discussions. Furthermore, these findings may support a center-of-excellence care model, particularly for those patients with a history of previous neuro-cranial surgeries and/or CP attempts.

First-In-Human Experience With Integration of Wireless Intracranial Pressure Monitoring Device Within a Customized Cranial Implant.

BACKGROUND: Decompressive craniectomy is a lifesaving treatment for intractable intracranial hypertension. For patients who survive, a second surgery for cranial reconstruction (cranioplasty) is required. The effect of cranioplasty on intracranial pressure (ICP) is unknown. OBJECTIVE: To integrate the recently Food and Drug Administration-approved, fully implantable, noninvasive ICP sensor within a customized cranial implant (CCI) for postoperative monitoring in patients at high risk for intracranial hypertension. METHODS: A 16-yr-old female presented for cranioplasty 4-mo after decompressive hemicraniectomy for craniocerebral gunshot wound. Given the persistent transcranial herniation with concomitant subdural hygroma, there was concern for intracranial hypertension following cranioplasty. Thus, cranial reconstruction was performed utilizing a CCI with an integrated wireless ICP sensor, and noninvasive postoperative monitoring was performed. RESULTS: Intermittent ICP measurements were obtained twice daily using a wireless, handheld monitor. The ICP ranged from 2 to 10 mmHg in the supine position and from -5 to 4 mmHg in the sitting position. Interestingly, an average of 7 mmHg difference was consistently noted between the sitting and supine measurements. CONCLUSION: This first-in-human experience demonstrates several notable findings, including (1) newfound safety and efficacy of integrating a wireless ICP sensor within a CCI for perioperative neuromonitoring; (2) proven restoration of normal ICP postcranioplasty despite severe preoperative transcranial herniation; and (3) proven restoration of postural ICP adaptations following cranioplasty. To the best of our knowledge, this is the first case demonstrating these intriguing findings with the potential to fundamentally alter the paradigm of cranial reconstruction.