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

BACKGROUND: 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). METHODS: 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. CONCLUSION: This straightforward floating craniotomy technique provides controlled decompression, effective ICP management, and preserved cosmesis.