Reduction cranioplasty for hydrocephalic macrocephaly: a systematic review of surgical outcomes.

OBJECTIVE: Hydrocephalic macrocephaly can result in poor psychosocial development, positioning difficulties, skin breakdown, and poor cosmesis. Although reduction cranioplasty can address these sequelae, the postoperative outcomes, complications, and mortality risk of reduction cranioplasty are not well understood given the rarity of hydrocephalic macrocephaly. Therefore, the primary objective of this systematic review was to evaluate the surgical outcomes of reduction cranioplasty for the treatment of hydrocephalic macrocephaly. METHODS: A systematic review was performed using the PubMed, Scopus, and Web of Science databases while following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Two independent reviewers screened 350 studies; 27 studies reporting surgical outcomes on reduction cranioplasty for hydrocephalic macrocephaly met inclusion criteria. Data on study design, patient demographics, operative details, and surgical outcomes were collected. RESULTS: There were 65 reduction cranioplasties among the 27 included studies. Eighteen (66.7%) studies presented level V evidence, 7 (25.9%) presented level IV evidence, and 2 (7.4%) presented level III evidence. Following reduction cranioplasty, there was improvement in postoperative head positioning in 23 (85.2%) studies, improvement in postoperative cosmesis in 22 (81.5%) studies, and improvement in global postoperative neurological functioning in 20 (74.1%) studies. The median estimated blood loss was 633 mL (range 20-2600 mL). Shunt revisions were the most common complication, reported in 9 (47.4%) of the 19 studies assessing complications. Of the 65 patients, there was a mortality rate of 6.2% (n = 4). CONCLUSIONS: The majority of the included studies reported improvement in head size, head positioning, cranial cosmesis, and global neurological functioning following reduction cranioplasty for hydrocephalic macrocephaly. However, the prevalence of lower-level evidence, risk of blood loss, complications, and mortality indicates the need for a serious discussion of surgical indication, an experienced team, and thorough perioperative planning to perform these complex surgeries.

Patient outcomes and complications following various maxillomandibular fixation techniques: A systematic review and meta-analysis.

PURPOSE: Currently, there are several methods of achieving maxillomandibular fixation (MMF), each with its unique operative considerations and subsequent patient outcomes and complications. In this study, we reviewed the literature to evaluate and compare all MMF methods. METHODS: A systematic review of all MMF types was conducted and post-operative outcome data were analyzed and compared among the different types. Conventional Erich arch bars were compared to hybrid arch bars, MMF screws, and eyelet interdental wiring. A random-effects meta-analysis was used to determine the mean differences, and 95% confidence intervals (CIs) with a statistical significance of P < 0.05. RESULTS: Among the 4234 articles identified, 24 were included, and 17 were meta-analyzed. Time to achieve MMF (-43.38 min; 95% CI, -58.20 to -28.56; P < 0.001), total operative time (-30.33 min; 95% CI, -61.05 to 0.39; P = 0.05), incidence of wire puncture injuries and glove perforations (0.11; 95% CI, 0.04 to 0.30; P < 0.001), and incidence of poor oral hygiene (0.08; 95% CI, 0.02 to 0.28; P < 0.001) were lower for alternative MMF interventions compared to those of the conventional Erich arch bars. CONCLUSIONS: Alternative MMF methods required shorter operative time to achieve MMF and demonstrated other increased efficiencies of practice such as shorter total operative time and decreased glove perforations, when compared to conventional Erich arch bars. If a patient is a candidate for MMF, the presented alternative MMF techniques should be considered depending on the clinical context and availability of institutional resources.

Postnatal myelomeningocele closure in smallest reported neonate: illustrative case.

BACKGROUND: Myelomeningocele (MMC) is the most serious form of spina bifida, a congenital defect in neural tube development. Defect closure in a patient with an extremely low birth weight presents unique challenges and risks; lower birth weight is associated with multiple organ system concerns, homeostasis is difficult, and local tissue is underdeveloped. To the authors' knowledge, the present case is the lowest reported weight (490 g) for a neonate with postnatal MMC repair. OBSERVATIONS: A preterm male with a prenatally diagnosed lumbosacral MMC and associated Chiari malformation type II was born at 23 weeks 1 day to a 29-year-old mother, gravidity 6 parity 4. The patient was medically stabilized and underwent MMC closure on day of life 5. His weight was 490 g at the time of this repair, and he did not have any surgical complications. At age 16 months, he underwent endoscopic third ventriculostomy with choroid plexus cauterization; he has not required any further hydrocephalus treatments since the last follow-up at 30 months of age. LESSONS: To the authors' knowledge, this case is the lowest birth weight ex utero MMC closure reported in the literature. Challenges of prematurity and size required appropriate preoperative stabilization, careful hemostasis and temperature regulation, and meticulous surgical technique.

Sociodemographic Disparities in Craniosynostosis: A Systematic Review.

OBJECTIVE: Given the consequences of delayed treatment and diagnosis of craniosynostosis, this study reviews the literature on sociodemographic risk factors and disparities associated with delayed craniosynostosis treatment. DESIGN: A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A literature search of PubMed/Medline and Embase was performed by two independent reviewers. Included studies discussed craniosynostosis health disparities. Demographic characteristics and outcomes were analyzed. SETTING: Not applicable. PATIENTS: Patients with craniosynostosis. INTERVENTIONS: Standard surgical intervention for craniosynostosis. RESULTS: Our literature search yielded 273 studies, of which 18 were included for analysis. Included studies represented data from 31 256 U.S. patients with craniosynostosis. Sixty percent of patients (n = 16 510) were White, 13.8% were Hispanic/Latino, 6.2% were Black/African American, 1.3% were Asian, 0.3% were American Indian or Alaska Native, and 0.1% were Native Hawaiian or Pacific Islander. Average age at surgery was 6.36 months for White patients, 10.63 months for Black patients, and 9.18 months for Hispanic patients. Minority racial and/or ethnic status was a risk factor for delayed presentation, and increased incidence of open surgery, complication rates, hospital charges, operative time, anesthesia duration, and hospital length of stay. Government-funded health insurance was associated with delayed intervention and increased complications. CONCLUSIONS: Minority craniosynostosis patients experience delays in intervention and increased complication rates. Our findings highlight the importance of expedited and equitable referrals, screenings, and treatment, and the need for a standardized approach to investigating longitudinal demographic and outcomes data in this population.

University of Wisconsin Guidelines for Treatment of Facial Trauma While Minimizing the Risk of COVID-19 Transmission.

BACKGROUND: The COVID-19 pandemic has forced many practices to completely change the interface between health care providers and patients. Patients presenting with facial trauma present a special risk for COVID-19 transmission, as contact with respiratory and ocular secretions is common, and so special precautions must be taken in managing them. METHODS: We created guidelines and a triage/management algorithm for patients presenting with facial trauma to decrease the risk of COVID-19 transmission. CONCLUSIONS: In this paper, we present a set of guidelines and a triage algorithm we have successfully implemented to mitigate the spread of COVID-19 while managing facial trauma. We believe that these guidelines can help other providers restructure their practices during this pandemic.

A Competency Assessment Tool for Unilateral Cleft Lip Repair.

Objective evaluation of operative performance is increasingly important in surgical training. Evaluation tools include global rating scales of performance and procedure-specific skills checklists. For unilateral cleft lip repair, the numerous techniques make universal evaluation challenging. Thus, we sought to create a unilateral cleft lip evaluation tool agnostic to specific repair technique. METHODS: Four surgeons with expertise in 3 common cleft lip repair techniques participated in a 3-round Delphi process to generate consensus evaluation points spanning all techniques. Items were categorized as marking the repair, performing the repair, and final result. Two blinded raters then scored videos of simulated cleft lip repairs using both the 21-item novel checklist and the modified Objective Structured Assessment of Technical Skills. Kappa and T values were calculated for both scales to determine level of agreement. RESULTS: Ten videos of repairs performed by novice residents through experienced craniofacial fellows were scored. Moderate (κ = 0.41-0.60) to substantial (κ = 0.61-0.80) interrater reliability was seen for the majority of questions in both the novel tool and the Objective Structured Assessment of Technical Skills. A single question in the novel tool had almost perfect agreement (κ = 0.81-1.00), 8 had moderate agreement, and 6 had substantial agreement. Poorly scoring questions were discarded from the final 18-item tool. CONCLUSIONS: Despite variations in unilateral cleft lip repair technique, common themes exist that can be used to assess performance and outcome. A universal evaluation tool has potential implications for trainee assessment, surgeon credentialing, and screening for surgical missions.

Resident Perspectives on Effective Surgical Training: Incivility, Confidence, and Mindset.

OBJECTIVE: Ample evidence exists that one's internal state (e.g., mindset, emotion) impacts one's performance. Both the military and sports organizations have focused on optimizing internal states of their service members and athletes, respectively, to improve performance and wellbeing. The internal states of surgical residents and the factors that influence their internal states have not yet been examined. Our goal is to better understand whether certain internal states are beneficial for resident operative performance, and how to optimize these during surgical training. DESIGN: A 17-question survey, containing both open-ended and multiple-choice questions, was distributed to all (n = 134) surgical residents at the University of Wisconsin. In open-ended questions, recurring themes were identified utilizing content analysis. Recurring themes stated by 25% or more of the respondents are reported. SETTING: Department of Surgery at the University of Wisconsin-Madison. PARTICIPANTS: Surgical residents at the University of Wisconsin. RESULTS: The survey response rate varied between n = 47 (35%) and n = 32 (24%), as not all respondents answered all questions. (1) Effective surgical educators were identified to demonstrate humanism and focus on teaching. (2) Nearly all residents affirmed that certain mindsets help them excel in the OR, including positive and confident mindsets. (3) Nearly all residents affirmed that faculty and senior residents influence their mindsets. (4) Constructive resident mindsets were promoted by positive faculty behaviors and personal preparation, while negative faculty behaviors were identified to stifle constructive mindsets. (5) Factors contributing to favorable OR performance included personal preparation and positive OR environments. (6) Factors contributing to poor OR performance included inadequate preparation and negative interactions with faculty. CONCLUSIONS: Residents near unanimously believe that certain mindsets help them excel, and that faculty impact their mindsets. As teachers, we must strive to better understand how to foster constructive mindsets in residents to optimize learning, performance, and wellbeing.

Human ARF Specifically Inhibits Epimorphic Regeneration in the Zebrafish Heart.

The Alternative Reading Frame (ARF) protein is a tumor suppressor encoded by the Cyclin Dependent Kinase Inhibitor 2A gene in mammals but not lower regenerative vertebrates, and has been previously implicated as a context-sensitive suppressor of regeneration in murine skeletal muscle and humanized ARF-expressing zebrafish fins. This study extends our investigation of the role of ARF in the regeneration of other solid tissues, including the zebrafish heart and the mammalian digit. Heart regeneration after cryoinjury was used to mimic massive myocardial infarction. ARF gene expression was upregulated during the cardiac regenerative process and slowed the rate of morphological recovery. ARF specifically impacts cardiomyocytes, neovascularization, and the endothelial-mesenchymal transition, while not affecting epicardial proliferation. This suggests that in the context of regeneration, ARF is specifically expressed in cells undergoing dedifferentiation. To investigate ARF as a suppressor of epimorphic regeneration in mammalian systems, we also tested whether the absence of ARF was permissive for murine digit regeneration, but found that ARF absence alone was insufficient to significantly alter digit restoration. These findings provide additional evidence that ARF suppresses epimorphic regeneration, but suggests that modulation of ARF alone is insufficient to permit regeneration.

Increasing Access to High Value Care: Preventing Complications in Common Disorders.

Most infantile hemangiomas (IHs), the most common vascular tumors of childhood, evolve without complications; however 10% to 12% require specialty referral for treatment. To emphasize the complications of late referral, we present a case of necrotizing infection within a segmental IH leading to sepsis. Early evaluation by a pediatric dermatologist could have prevented this life-threatening and disfiguring complication. We discuss how teledermatology would enable rapid triage of such critical cases in underserved areas, increasing access to high-value care and optimizing outcomes for our most vulnerable patients.

Postoperative Management of Lower Extremity Free Tissue Transfer: A Systematic Review.

BACKGROUND: Free tissue transfer for lower extremity reconstruction is a safe and reliable option for a wide range of challenging wounds; however, no consensus exists regarding postoperative management. METHODS: A systematic review of postoperative management of lower extremity free tissue transfer was conducted using Medline, Cochrane Database, and Web of Science. Multicenter surveys, randomized controlled trials, cohort studies, and case series were reviewed. RESULTS: Fifteen articles investigating current protocols, flap physiology, and aggressive dangle protocols were reviewed. The following evidence-based conclusions were made: (1) Free tissue transfer to the lower extremity is unique due to altered hemodynamics and dependency during orthostasis. Free flap circulation is dependent on locally mediated responses and deprived of compensatory muscular and neurovascular mechanisms that prevent venous congestion in the normal extremity. (2) Compressive wrapping reduces venous congestion and edema and may induce ischemic conditioning, which can increase blood flow. (3) Dangle protocols vary widely in timing of initiation, frequency, and monitoring. Small volume studies examining aggressive mobilization protocols initiating early dependency have led to earlier ambulation and discharge, with no change in flap survival as compared with conservative protocols. (4) Weight bearing may begin after the completion of dangle protocol if no orthopedic injury is present. CONCLUSIONS: Early initiation of a dangle protocol does not appear to negatively impact flap survival based on this systematic review. Compressive wrapping may be a useful adjunct. Many surgeons agree that clinical monitoring is sufficient; there is no consensus on the utility of adjunct monitoring techniques. Weight bearing may begin after completion of dangle protocol with close flap monitoring, if not prevented by orthopedic restrictions. By providing additional outflow vasculature to reduce venous congestion, flow-through anastomoses may eliminate the need for a dangle protocol. Further research, including large randomized controlled trials is still needed to establish high-level evidence-based conclusions.

A Multimodal Preemptive Analgesic Protocol for Alveolar Bone Graft Surgery: Decreased Pain, Hospital Stay, and Health Care Costs.

OBJECTIVE: To evaluate postoperative pain, hospital length of stay (LOS), and associated costs of multiple perioperative analgesic strategies following alveolar bone grafting (ABG). DESIGN: Retrospective comparative cohort study. SETTING: Tertiary care pediatric hospital. PATIENTS/PARTICIPANTS: Iliac crest bone graft (ICBG) harvest techniques: "Open Harvest" (n = 22), "Trephine Only" (n = 14), or "Trephine + Pain Pump" (n = 25). INTERVENTION: The "Open Harvest" group underwent open ICBG harvest with 3-walled osteotomies. For the other 2 treatment groups, a trephine drill was used to harvest iliac crest bone with a ropivacaine infusion pump into the hip donor site ("Trephine + Pain Pump") or without ("Trephine Only"). Patients who underwent ABG with only cadaveric allograft were analyzed as a comparison group ("No Harvest"). MAIN OUTCOMES MEASURES: Outcomes were planned prior to data collection: maximum pain score, hospital LOS, and associated health care costs. RESULTS: Maximum pain scores were significantly higher in the "Open Harvest" group (7.3/10) compared to "Trephine + Pain Pump" (1.8/10; P < .0001) and "No Harvest" groups (2.8/10; P < .01). Hospital LOS decreased from 2.4 days ("Open Harvest") to 0.5 days (Trephine + Pain Pump"; P < .0001). Twelve (48%) patients from "Trephine + Pain Pump" were discharged on the day of surgery. The "Trephine + Pain Pump" saved an estimated $5336 for a unilateral ABG and $7265 for a bilateral ABG compared to "Open Harvest." CONCLUSIONS: The combined use of the trephine ICBG technique and ropivacaine infusion catheter effectively decreased pain, shortened hospital stay, and improved cost saving compared to patients who have undergone other methods of ICBG.

The Surgical Treatment of Adult Acquired Buried Penis Syndrome: A New Classification System.

BACKGROUND: Adult acquired buried penis syndrome may be associated with an inability to void, sexual dysfunction, and recurrent infection. Previously published classification systems rely on intraoperative findings, such as penile skin quality. OBJECTIVES: The purpose of this study was to evaluate outcomes after adult acquired buried penis repair and to develop a classification system based on preoperative assessment. METHODS: The authors reviewed data from patients who underwent buried penis reconstruction at a single institution. Patient history and physical examination guided the development of a classification system for surgical planning. RESULTS: Of the 27 patients included, the mean age was 56 ± 15 years and mean body mass index was 49 ± 14 kg/m2. Patients were classified into 4 groups based on examination findings: (I) buried penis due to skin deficiency, iatrogenic scarring, and/or diseased penile skin (n = 3); (II) excess abdominal skin and fat (n = 6); (III) excess skin and fat with diseased penile skin (n = 16); and (IV) type III plus severe scrotal edema (n = 2). Surgical treatment (eg, excision and grafting, mons suspension, panniculectomy, translocation of testes, and/or scrotectomy) was tailored based on classification. Complications included wound breakdown (n = 3), cellulitis (n = 4), and hematoma (n = 1). Nearly all patients (96%) reported early satisfaction and improvement in their symptoms postoperatively. CONCLUSIONS: Classifying patients with buried penis according to preoperative examination findings may guide surgical decision-making and preoperative counseling and allow for optimized aesthetics to enhance self-esteem and sexual well-being.

Comparison of Outpatient and Inpatient Pediatric Rhinoplasty: Results From National Surgical Quality Improvement Program-Pediatric, 2012-2014.

INTRODUCTION: Outpatient management of patients undergoing elective surgical procedures has been associated with significantly decreased health care costs compared with inpatient management. This study investigates current practices in outpatient versus inpatient management of pediatric rhinoplasty patients. METHODS: A query was performed of the 2012 to 2014 National Surgical Quality Improvement Program-Pediatric data sets. Patients age 17 or younger undergoing rhinoplasty as the primary surgical procedure were included. Clinical characteristics and complications were compared among patients managed as inpatients versus outpatients using both univariate and multivariate logistic regression analyses. RESULTS: Among 938 pediatric rhinoplasty patients, 199 (21.2%) were managed as inpatients. Multivariate analysis revealed multiple variables significantly associated with an increased odds of inpatient management, including young patient age, presence of a congenital malformation, neurologic or nutritional disease, lengthy procedure time, management by a plastic surgeon compared with an otolaryngologist, and certain procedure types including cleft septorhinoplasty, secondary rhinoplasty with intermediate or major revision, and rib cartilage grafting. Complications among both inpatients and outpatients were rare, with the most common complication being readmission among 15 patients (1.6%). CONCLUSIONS: This study indicates that multiple subgroups of pediatric patients undergoing rhinoplasty procedures have a significantly increased likelihood of inpatient management without any significantly increased likelihood of a complication or need for readmission. Future efforts to manage appropriately selected children on an ambulatory basis may be safe, while improving costs and quality of care.

Variability in Minimally Invasive Surgery for Sagittal Craniosynostosis.

Minimally invasive approaches to the surgical correction of sagittal craniosynostosis are gaining favor as an alternative to open cranial vault remodeling. In this systematic review, the reviewers evaluate the variability in described surgical techniques for minimally invasive correction of sagittal craniosynostosis. Articles were selected based on predetermined inclusion and exclusion criteria from an online literature search through PubMed, EMBASE, and the Cochrane library. Extracted data included the incisions, method of dissection, osteotomies performed, and type of force therapy utilized.A total of 28 articles from 15 author groups were included in the final analysis. Of the 28 articles, 17 distinct techniques were identified. Significant variation existed in both the technique and the terminology used to describe it. Access to the cranium varied between a standard bicoronal incision (n = 2), a "lazy S" incision (n = 2), and multiple short incisions along the fused sagittal suture (n = 13). Additional variations were found in the size and design of the osteotomy, the usage (and duration, if applicable) of force therapy, and the age of the patient at the time of surgical intervention.This systematic review demonstrates that minimally invasive approaches to sagittal craniosynostosis vary widely in technique with respect to the incisions, osteotomies, and force therapy used. Additionally, the terminology employed in describing minimally invasive approaches is inconsistent across centers. This discrepancy between technique and terminology presents challenges for reporting and interpreting the increasing body of literature on this subject. We recommend standard terminology be used for future publications on minimally invasive techniques.

Pediatric Obstructive Sleep Apnea: Consensus, Controversy, and Craniofacial Considerations.

Pediatric obstructive sleep apnea, characterized by partial or complete obstruction of the upper airway during sleep, is associated with multiple adverse neurodevelopmental and cardiometabolic consequences. It is common in healthy children and occurs with a higher incidence among infants and children with craniofacial anomalies. Although soft-tissue hypertrophy is the most common cause, interplay between soft tissue and bone structure in children with craniofacial differences may also contribute to upper airway obstruction. Snoring and work of breathing are poor predictors of obstructive sleep apnea, and the gold standard for diagnosis is overnight polysomnography. Most healthy children respond favorably to adenotonsillectomy as first-line treatment, but 20 percent of children have obstructive sleep apnea refractory to adenotonsillectomy and may benefit from positive airway pressure, medical therapy, orthodontics, craniofacial surgery, or combined interventions. For children with impairment of facial skeletal growth or craniofacial anomalies, rapid maxillary expansion, midface distraction, and mandibular distraction have all been demonstrated to have therapeutic value and may significantly improve a child's respiratory status. This Special Topic article reviews current theories regarding the underlying pathophysiology of pediatric sleep apnea, summarizes standards for diagnosis and management, and discusses treatments in need of further investigation, including orthodontic and craniofacial interventions. To provide an overview of the spectrum of disease and treatment options available, a deliberately broad approach is taken that incorporates data for both healthy children and children with craniofacial anomalies.

A Treatment Algorithm for Patients Presenting with Sagittal Craniosynostosis after the Age of 1 Year.

BACKGROUND: Sagittal craniosynostosis typically presents shortly after birth, with a scaphocephalic head shape, and is addressed surgically for functional and aesthetic concerns. This study highlights the authors' experience with a challenging patient population: those with phenotypically mild, missed, and late-developing sagittal craniosynostosis. METHODS: A prospective cohort study was conducted for all cases of sagittal craniosynostosis presenting to the authors' institution between July of 2013 and December of 2015. Patients older than 1 year with isolated sagittal craniosynostosis were included. All children were evaluated by craniofacial surgery, neurosurgery, and ophthalmology departments. All patients had dilated fundus examinations and visual evoked potentials. RESULTS: Fifty-two patients met inclusion criteria. Only nine patients have been treated surgically (17.3 percent). Two patients underwent operative correction for obvious scaphocephaly. Four patients who presented with concerning ophthalmologic evaluations and another patient with classic intracranial hypertension-related headaches underwent cranial vault expansion. Eight patients presented with inconclusive ophthalmologic evaluations. These patients were admitted for intracranial pressure monitoring, of which two were found to have elevated levels (25 percent) and underwent operative intervention. Thirty-seven other patients presented with isolated sagittal craniosynostosis in the setting of overall normocephaly without any signs concerning for intracranial hypertension. These patients continue to undergo serial evaluation. CONCLUSIONS: The authors describe their treatment protocol for a large series of patients presenting with the delayed diagnosis of sagittal craniosynostosis. Based on the early experience of the authors' center with this protocol, the risk of intracranial hypertension appears to be low in this population. The majority of patients to date have been managed nonsurgically without invasive monitoring. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Human Satellite Cell Transplantation and Regeneration from Diverse Skeletal Muscles.

Identification of human satellite cells that fulfill muscle stem cell criteria is an unmet need in regenerative medicine. This hurdle limits understanding how closely muscle stem cell properties are conserved among mice and humans and hampers translational efforts in muscle regeneration. Here, we report that PAX7 satellite cells exist at a consistent frequency of 2-4 cells/mm of fiber in muscles of the human trunk, limbs, and head. Xenotransplantation into mice of 50-70 fiber-associated, or 1,000-5,000 FACS-enriched CD56(+)/CD29(+) human satellite cells led to stable engraftment and formation of human-derived myofibers. Human cells with characteristic PAX7, CD56, and CD29 expression patterns populated the satellite cell niche beneath the basal lamina on the periphery of regenerated fibers. After additional injury, transplanted satellite cells robustly regenerated to form hundreds of human-derived fibers. Together, these findings conclusively delineate a source of bona-fide endogenous human muscle stem cells that will aid development of clinical applications.

Regenerative strategies for craniofacial disorders.

Craniofacial disorders present markedly complicated problems in reconstruction because of the complex interactions of the multiple, simultaneously affected tissues. Regenerative medicine holds promise for new strategies to improve treatment of these disorders. This review addresses current areas of unmet need in craniofacial reconstruction and emphasizes how craniofacial tissues differ from their analogs elsewhere in the body. We present a problem-based approach to illustrate current treatment strategies for various craniofacial disorders, to highlight areas of need, and to suggest regenerative strategies for craniofacial bone, fat, muscle, nerve, and skin. For some tissues, current approaches offer excellent reconstructive solutions using autologous tissue or prosthetic materials. Thus, new "regenerative" approaches would need to offer major advantages in order to be adopted. In other tissues, the unmet need is great, and we suggest the greatest regenerative need is for muscle, skin, and nerve. The advent of composite facial tissue transplantation and the development of regenerative medicine are each likely to add important new paradigms to our treatment of craniofacial disorders.