At 10 months old, Fulton Kramer is a gorgeous baby. He grabs his chubby little toes and giggles at his mom while his watchful 2-year-old sister hovers nearby.

It’s hard to notice the scar under his sandy-blond hair flanked by four tiny bumps on his scalp. They're fading reminders of a remarkable surgery performed by experts at UPMC Children’s Hospital of Pittsburgh.

The UPMC Children’s Cleft-Craniofacial Center began doing spring-assisted cranioplasty surgery in 2014, when Jesse Goldstein, MD, a plastic surgeon, joined the staff. Since then, he’s done close to 40 of the surgeries in place of the classic — and more invasive — cranial vault surgery.

Call the UPMC Children’s Cleft-Craniofacial Center at 412-692-8650 to learn more.

Born with a Skull Abnormality

Humans are born with five major bones in the skull. The bones — held together by six seams, or sutures — help the brain expand quickly during the first few years of life. This is when most skull growth occurs.

The sutures don't fully fuse until about the age of 20. But sometimes they fuse too early, causing craniosynostosis.

Craniosynostosis stops the bones from growing apart and causes the brain to press the skull out into an awkward shape. Left untreated, it can put pressure on the brain and lead to delayed development, chronic headaches, and blindness.

“Craniosynostosis is the most common condition you’ve never heard of,” says Dr. Goldstein. “It occurs in about one in 2,000 births. It can also occur after birth.”

Fulton was born on Sept. 17, 2018, with a fused sagittal suture — the most common skull abnormality. It makes up about half of all craniosynostosis cases, Dr. Goldstein says.

Traits of this skull abnormality include a:

• Long, skinny head shape with a narrow back and side.
• Rounded, bulging forehead.

Doctors can detect severe forms of craniosynostosis before birth. But often they don't detect the condition until birth, because the changes can be subtle at first.

Fulton’s pediatrician was the first to notice the odd shape of his head when he was born. Fulton's parents, Nadia and Daniel Kramer of Steubenville, Ohio, could barely detect it.

“Fulton's doctor came to see us in the hospital when he was born. She noticed an irregularity with his skull and told us to keep an eye on it,” says Mrs. Kramer.

Healthy Growth with a Spring Assist

At Fulton’s 2-month check-up, she referred the family to the Cleft-Craniofacial Center at UPMC Children’s. Doctors determined that Fulton was a candidate for spring-assisted cranioplasty.

“We were in shock. We had never heard of this condition,” Mrs. Kramer adds.

Any type of surgery — especially one near the brain — can be scary for parents. Spring-assisted cranioplasty is much less invasive than cranial vault surgery to fix craniosynostosis.

“Spring-assisted cranioplasty is a tremendous leap forward in the quality of care we can provide,” says Dr. Goldstein. “It lets us offer better treatment with less risk and discomfort, which resonates with all we try to do at UPMC Children’s. The other treatment is cranial vault surgery, which is more complex. It requires a blood transfusion, five days in the hospital — including the ICU, and lots of stress and hardship for the family.”

During cranial vault, doctors make an incision across the head from ear to ear. Then they remove the bones from the skull, reshape them, and put them back in place.

“Although patients do great with this open technique, we can achieve comparable results with a much smaller operation. That is what draws patients to springs,” Dr. Goldstein adds.

Joseph Losee, MD, chief, Division of Pediatric Plastic Surgery, and director, Cleft-Craniofacial Center, says:

“Our craniofacial team has routinely treated children with craniosynostosis for decades. But Dr. Goldstein has helped bring us ‘into the future’ with advanced, cutting-edge technologies to help treat these complex problems. He's also leading the way with innovations and applied research from the computer lab to the bedside.”

The best time to perform spring-assisted cranioplasty is between 3 and 6 months of age, preferably around 4 months old. Doctors scheduled Fulton’s first surgery on Jan. 17, 2019.

“When Dr. Goldstein laid out the timeline, the thought of my baby going in for surgery and how soon overwhelmed me. But the more I heard about spring-assisted cranioplasty, I felt relieved there was a less-invasive option to cranial vault,” Mrs. Kramer says.

Less Invasive, Instant Results

Spring-assisted cranioplasty requires the combined skills of a children's neurosurgeon and plastic surgeon.

During Fulton’s 90-minute surgery, Ian Pollack, MD, chief, Pediatric Neurosurgery, made a small cut in the scalp right above the sagittal suture. He removed a thin strip of the fused bone, about the width of an adult finger.

Dr. Goldstein then placed two parallel springs into the newly opened suture and secured them.

Fulton only needed one overnight stay at the hospital to recover.

The tiny springs slowly push the narrowed skull bones apart over four to eight weeks. But the results are visible right away.

“When we put the springs in, you can see them starting to work right there on the operating table,” Dr. Goldstein says.

That first post-op glimpse of their baby reassured Fulton’s parents that they made the right choice allowing the surgery.

“We were very relieved when he came out of surgery. He hadn’t started swelling yet, so we could already see his forehead going back into place,” says Mr. Kramer.

Doctors removed Fulton’s springs in a second, 30-minute outpatient surgery on May 13. Since the removal surgery is less complex, Fulton could go home the same day.

Planning for a Full Future

Fulton’s follow-up care at the Cleft-Craniofacial Center includes regular visits with Drs. Goldstein and Pollack. He also sees an ophthalmologist and psychologist through age 12 when his head stops growing.

“The clinic team is awesome. They arrange it so that we have all the appointments on the same day. It makes a huge difference, especially since home is more than an hour’s drive from UPMC Children’s,” says Mrs. Kramer.

Fulton may not be thinking beyond his favorite toy and his big sister, Sophia. But the adults couldn't be more pleased with the outlook for his future.

Call the UPMC Children’s Cleft-Craniofacial Center at 412-692-8650 to learn more.

Plastic Surgery Resources

Read more about plastic surgery resources from UPMC Children's Hospital Department of Plastic Surgery.