On Wednesday 30 January 2013, at a press conference attended by media from around the world, Dr Dave Rosser, Medical Director at University Hospitals Birmingham NHS Foundation Trust (UHB), gave details of the surgery which Malala Yousufzai is scheduled to undergo within the next 10 days.

Stefan Edmondson, the Trust’s Principal Maxillofacial Prosthetist, was also there to provide details of the cranial reconstruction technique.

The surgery

• Titanium cranioplasty: repairing the missing area of skull with a titanium plate that has been moulded to accurately replicate the skull
• Cochlear implant: fitting a small, complex electronic device that provides a sense of sound to someone who is profoundly deaf or severely hard of hearing

Malala was shot at point blank range. The bullet hit her left brow and instead of penetrating her skull it travelled underneath the skin, the whole length of the side of her head and into her shoulder.

The shock wave shattered the thinnest bone of the skull and the soft tissues at the base of her jaw/neck were damaged. The bullet and its fracture lines also destroyed her eardrum and the bones for hearing. She has no hearing in her left ear (her right ear remains normal). However, the nerve of hearing is intact.

The procedure

• The titanium cranioplasty procedure is carried out first and will take between one and two hours. The head will be shaved at the wound location and the flap of skin covering it will be prepared and draped back
• This will expose the dura – the tough fibrous membrane covering the brain
• The 0.6mm metal plate that has been moulded from a 3D model created through CT imaging from Malala’s own skull will then be put in place. It is secured to the skull with screws placed in 2mm counter-sunk holes
• The flap of skin is then draped back over the plate and stitched into place
• The cochlear surgeon then takes over from the neurosurgeon. The surgeon will locate the cochlea and identify the structures of the inner ear. An incision will be made in the round window membrane and the implant is fed through it
• A small well will be drilled in the skull behind the titanium plate to allow the electronics to be implanted
• This part of the surgery will take approximately 90 minutes

The medical team

• Consultant neurosurgeon
• Ear, nose and throat (ENT) consultant Neurotologist
• Consultant anaesthetist
• Burns and plastics consultant surgeon
• Anaesthetic Operating department practitioner
• Scrub/recovery nurse
• Scrub nurse
• Nursing auxiliary
• Healthcare assistant

Video and 3D animation

Part 1 illustrates the making of the plate. The scans and 3D images are taken from Malala’s medical records and show her skull and the area of damage.

The part-skull model and titanium plate shown by Mr Edmondson at his desk are also Malala’s. This plate is the one that will be fitted during surgery.

The footage demonstrating how the plate is created (the wax contouring; plate pressing and grinding) feature other patients’ working models and plates.

Part 2 shows the 3D image created from Malala’s CT scans when she was first admitted to Queen Elizabeth Hospital Birmingham (QEHB). The tracheostomy tube that enabled her to breathe through her neck is visible. The animation shows the damage to her skull.

Part 3 shows how the titanium plate and cochlear implant are fitted. The red line drawn diagonally down the skull shows the approximate journey of the bullet.