# A simple and aesthetically pleasing floating craniotomy: How I do it

## TL;DR

A new floating craniotomy technique is described that helps manage brain pressure while preserving the bone flap and appearance.

## Contribution

A novel floating craniotomy method using adjustable sutures for controlled decompression and cosmesis is introduced.

## Key findings

- The technique uses surgeon's knots and adjustable slip knots to loosely secure the bone flap.
- Exteriorized sutures allow for definitive securing once intracranial pressure resolves.
- The method offers controlled decompression, effective ICP management, and preserved cosmesis.

## Abstract

Decompressive craniectomy and subsequent cranioplasty are associated with significant morbidity (Kurland et al. Neurocrit Care 23:292–304, 2015). Bone flap-preserving techniques, including floating and hinged craniotomies, offer effective intracranial pressure (ICP) control (Mohan et al. Acta Neurochir (Wien) 163(5):1415–1422, 2021), although the optimal technique remains controversial, particularly in the context of traumatic brain injury where recent landmark trials have evaluated decompressive craniectomy outcomes (Patel et al. Trauma Surg Acute Care Open 10: e001784, 2025).

The bone flap is loosely secured to the cranium using surgeon's knots and adjustable slip knots, with slip knot suture ends exteriorized through the scalp. Once elevated ICP resolves, the bone flap is definitively secured by tightening the externalized sutures.

This straightforward floating craniotomy technique provides controlled decompression, effective ICP management, and preserved cosmesis.

The online version contains supplementary material available at 10.1007/s00701-026-06827-1.