Rare Craniofacial Diagnoses on the Craniomaxillofacial Section of the Plastic Surgery In-Service Training Exam (2007-2023)

Background: The Plastic Surgery Inservice Training Exam (PSITE) is administered annually to plastic surgery residents across the United States. The craniomaxillofacial (CMF) section of the exam is renowned among residents for featuring numerous rare pediatric craniofacial diagnoses. The aim of this study was to evaluate if rare craniofacial diagnoses are disproportionately represented on the CMF section of the PSITE. Study Design: The CMF section of PSITE from 2007 to 2023 was evaluated for rare pediatric craniofacial diagnoses. Questions were categorized based on taxonomy, answer foci, and imaging. The association between diagnosis prevalence in the literature and exam frequency was evaluated using Spearman’s correlation. Data was also collected on selected common diagnoses for comparison. Results: Of the 850 questions evaluated, 176 contained a rare craniofacial diagnosis, averaging 10.4 questions (20.0%) per CMF section. Forty-nine unique diagnoses appeared 372 times. On average, 14 unique diagnoses appeared per exam. Most diagnoses appeared as an answer choice (50.8%), of which 24.9% were the correct answer. There was a mild positive correlation between diagnosis prevalence in the literature and frequency on exams ( r = .344, P = .012). The most frequently appearing rare diagnoses on the exams were Tessier clefts, isolated cleft palate, and Treacher-Collins syndrome. On average, rare diagnoses decreased over time with an average of 24.4 appearances from 2007 to 2014 and 19.7 appearances from 2015 to 2023. Most rare craniofacial diagnoses questions required interpretation of medical information to make a diagnosis (52.8%). The answer foci of the questions were most often pathology/anatomy based (43.8%). In total 28.5% of questions included imaging. Conclusions: There is an emphasis of rare diagnoses on the CMF section of the PSITE, although with a decreased focus over time relative to more common craniofacial diagnoses.