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Our interdisciplinary craniofacial team in North Austin are experienced in the care of all forms of craniosynostosis (kray-nee-o-sin-os-TOE-sis). We recognize how scary it can be when your doctor refers your baby to us for assessment of a different head shape. Our craniofacial surgeon and pediatric neurosurgeon will meet with you the same day to evaluate your child and provide all the information you need to help decide the best treatment. Not every head shape difference will need surgery and we can help identify when this is the case. If your child does need surgical treatment for their head shape difference, our entire hospital team will work together to achieve a safe and high quality result with the least stress and discomfort for your family and your baby.

Infant with bilateral coronal craniosynostosis before treatment
Sutures are flexible joints often called growth lines that hold the major bones of the skull together while also allowing the bones to move and enlarge evenly as the brain grows. The sutures allow an infant’s head to mold in shape when being born through the birth canal. They also allow the baby’s growing brain to grow in all directions after birth.
Craniosynostosis is when one or more of the sutures in an infants' skull close and become bone earlier than normal. The name comes from “cranio” meaning skull bones and “synostosis” meaning fused or together.
The fastest growth period of an infant’s brain is the first year when an infant’s head size becomes 60 percent of its adult size, which is why toddlers’ heads look big compared to their bodies. The sutures are not needed forever, and some close earlier, such as the metopic suture down the middle of the forehead that usually closes between two to eight months of age. Others, like the coronal sutures on the side of the forehead, do not close fully until adulthood.
In craniosynostosis, a cranial suture closes either while the baby is in the uterus, or in more rare cases, in the first years of life. When a suture closes early, the brain cannot use that suture to expand in a certain direction and instead uses other cranial sutures to continue to grow in a different direction so that the brain does not come under pressure. This change in brain growth creates different head shapes based on the suture that is closed. In the most common suture fusion, sagittal synostosis, the brain can grow from front to back, but not from side to side, so an elongated or “boat-shaped” head can result.
There are major suture fusion patterns (Sagittal, Metopic, Coronal, or Lambdoid) and more rare “minor” suture fusions (such as Spheno-frontal or Squamosal). Your surgeons at Texas Children’s Hospital North Austin Campus are trained to identify the head shape associated with each type of craniosynostosis and to make sure the head shape is not due to a condition that does not need surgery, such as “Deformational Plagiocephaly.”
Craniosynostosis is a rare condition that only occurs once in every 1,000 to 2,000 births. Researchers are continuing to try to find out exactly what causes craniosynostosis. One thing known is that it is not caused by what a mother takes or does during pregnancy. Research is ongoing to develop medicines that could prevent craniosynostosis from happening during the pregnancy, but at this time surgery is the only accepted treatment.
Most cases of craniosynostosis occur in a family that has never had anyone else with the condition. In other cases, a family may have a history of one suture closing early in other family members. When a baby with craniosynostosis is born into a family, it does not mean that future children will have the same condition. Our genetics team can help describe the chances of craniosynostosis in future pregnancies with you.
Most children with craniosynostosis have only one fused suture (single suture craniosynostosis) and are otherwise healthy at birth. Other children may have more than one suture fused multiple suture craniosynostosis and our team will be looking for other associated things that may need to be treated, such as Chiari Malformation, hand anomalies, or difficult airway challenges. In many cases of multiple suture craniosynostosis, we can identify a mutation or change in the infant’s DNA that can help us better diagnose syndromes that caused the craniosynostosis. Examples of syndromic craniosynostoses are Crouzon, Apert, Pfeiffer, Saethre-Chotzen, and Muenke syndromes. Children with these syndromes have other medical conditions besides craniosynostosis and we will involve whichever sub-specialist on our team can best treat these conditions.
Because craniosynostosis is such a rare condition, most families have never heard of this diagnosis before their child is born with it. At Texas Children’s Hospital North Austin Campus, our craniofacial surgeons and neurosurgeons are all fellowship-trained in pediatric cranial surgery and have a national reputation for excellence. We have performed careful outcome studies of the surgical techniques we use to make sure they are as safe and have the best results as possible.
We recognize that every child and every family is different, and therefore we tailor the treatment options to your baby’s specific needs. We offer four surgical techniques for the treatment of craniosynostosis: open cranial vault remodeling, endoscopic-assisted strip craniectomy with helmet molding, spring-assisted cranial expansion, and cranial expansion with distraction osteogenesis. Based on our experience and outcome studies, we will discuss which of these treatments is right for your baby, based on their age, suture fused and other considerations.
We recognize that surgery is not the only treatment you child may need. We have the full range of medical specialties your family may need in treating craniosynostosis, including genetic counselling, pre-natal counselling, child life support, physiotherapy, ophthalmology, among others. Although we see many of our patients soon after they are born, we are also experienced in treating older patients who either previously have not been diagnosed or have had previous surgeries but are looking for a second opinion or continued care.
Although head shape is one of the first things we examine in diagnosing craniosynostosis, there are other things we look at during your visit. In some cases, a ridge or bump-line can be felt along the fused suture. Other things that can give us more information is ear position, which can be pulled towards the fused suture, or how level is the skull base at the back of the neck, such as in lambdoid synostosis. In metopic synostosis the eyes are commonly closer together, and in one sided fusion of the coronal suture (unilateral coronal synostosis), the eye on the affected side is raised, whereas in spheno-frontal fusion it is lowered. We also examine your baby’s face, hands and feet for possible signs of syndromic craniosynostosis.
Besides a physical examination, we may recommend other tests. In some cases where it is unclear whether head shape is caused by suture fusion, we order an ultrasound to examine the suture to see if it is open. In other cases, and before we perform any surgery, we recommend a CT scan of your baby’s head. We follow a CT scan protocol that uses the lowest dose of radiation that still lets us examine the sutures and brain. We perform CT scans before surgeries because we have seen cases that have a diagnosis of craniosynostosis after clinical examination, but the CT scan shows all sutures are open and therefore surgery is not needed.
If your child is older when they come to us to test for craniosynostosis, we can check for symptoms that may be associated with craniosynostosis such as headaches and developmental challenges. Unlike babies with single suture craniosynostosis, older children may have pressure on the brain (increased intracranial pressure). In older children, a special eye examination (dilated fundoscopy or optical coherence tomography (OCT)) can check the nerve at the back of the eye to see if pressure exists.
The main goal in treating craniosynostosis is to allow your child’s brain to grow without pressure from the bones of the skull. Currently this is only possible through surgery. The surgeries do not create new sutures, but instead release the bones of the skull in ways that allow the brain to continue to grow and expand. In some procedures such as endoscopic assisted craniectomy, the growth of the brain after surgery expands the released skull bones to create the new head shape with the use of a molding helmet. In other procedures such as posterior vault distraction osteogenesis, or spring cranioplasty, a small device is placed at the time of surgery and used to expand the skull. In open cranial vault remodeling, the new skull shape and size is achieved by the end of the surgery by repositioning the bones and holding them in their new position using resorbable plates and screws that go away by themselves similar to the material in some dissolving stitches.
All our surgeries are performed by a fellowship-trained pediatric neurosurgeon and pediatric craniofacial plastic surgeon who use their specific skills for the best outcome. In general, the neurosurgeon focuses on carefully separating or removing bone from the covering of the brain, while the craniofacial surgeon focuses on the skin scar, reshaping the bone, or placing any devices or plates that are needed. Both surgeons will assess your child before any surgery is planned, and both will follow your child after surgery.
We will recommend the timing of surgery based on your child’s age, which sutures are involved and which surgical treatment we decide is best for them. Our focus is always on what is best for your child’s specific needs.
In single suture craniosynostosis, only one surgery is usually needed to treat the condition. In very rare cases a second cranial expansion is needed if the skull bone stops allowing the brain to expand the way it wants. In cases of multiple suture craniosynostosis, two surgeries may be needed – one on the back of the head in the first months of life, and one on the front, closer to one year old. Syndromic craniosynostosis, such as in Crouzon, Apert or Pfeiffer syndromes, usually requires a series of very carefully timed surgeries over the first decade of a child’s life.
Craniosynostosis needing surgery on the back of the skull (sagittal and lambdoid craniosynostosis) are usually performed before six months of age but can be done at older ages if needed. Surgeries on the forehead for single suture craniosynostosis are usually done closer to one year of age. For syndromic craniosynostosis the forehead surgery results are better closer to two years of age. A surgery on the back of the skull at four to eight months of age, such as posterior cranial vault remodeling or posterior vault distraction osteogenesis, may be needed to create enough space for the brain until the forehead surgery.
The age of surgery can also be determined by the technique that is best for your child. Open cranial vault remodeling is best from four to eight months of age for the back of the head, and nine to 13 months for the front. Endoscopic-assisted strip craniectomy with helmet molding and spring-assisted cranial expansion need to be done before four months of age. Posterior cranial expansion with distraction osteogenesis can be done at any age but is often performed at four to eight months of age.
Our team is well-aware that having an infant or child who needs craniosynostosis surgery will be a very stressful event for your family. Although we have years of experience treating this condition, we never forget that this is your first time. We have strict treatment protocols in our hospital to make sure every detail of care is done safely and with quality before, during and after surgery.
Before the surgery your child will be evaluated in our Craniofacial Destination Program clinic by a craniofacial plastic surgeon and a pediatric neurosurgeon and meet the other members of the craniofacial team. If a diagnosis of craniosynostosis is confirmed, we will discuss the surgical techniques that would be best for your child and determine a timing for surgery. During this first visit, we may recommend taking a blood sample for tests that are needed to prepare for surgery and possibly during surgery.
Approximately one month before surgery, we will arrange a surgery preparation visit for you to meet the anesthesiology team in the Pediatric Anesthesia Screening Service or PASS clinic. Your child will also have their final blood work taken. If a CT scan has not yet been done to absolutely confirm the diagnosis, it will be done at this visit. We will make sure all your questions have been answered. One to two days before the surgery you will receive a call to remind you what to do before the hospital admission and what time and where to come on the day of surgery.
On the day of admission, you will see your surgeons, anesthesiologist, and the nursing team who will be in the room. The surgeons will come out to talk with you personally after the surgery while your child awakes from the surgery and is taken to the Pediatric Intensive Care Unit. We do a careful checklist procedure between the surgery team and PICU team for a safe hand-over of your child’s care plan. After that, you will be able to see and remain with your child in the PICU. There is a daybed in the ICU room if you decide to stay in the room overnight. After single suture craniosynostosis surgery, a child stays in the PICU for only one night. After multiple suture craniosynostosis surgery, the stay may be for two of three nights.
After the ICU, your child will be taken to a regular hospital room where they will stay for a few more days. Total time in hospital depends on the age of your child and what procedure was performed. In most cases, time in hospital ranges from 3 to 5 days.
We will prepare you and your family as your discharge from hospital approaches. You will know how to contact us with any questions and how to care for your child at home. Many parents can feel nervous when getting ready for discharge, but once they get home the say that it was easier than they had thought.
After getting home, your child will start to return to their usual activities. During the first week they will usually need more of your time to calm them when they are fussy and give them a small amount of pain medicine if they need it. In the second week they usually return to most of their usual play activities inside the home but may still have a change in their sleep routines. By the third week, pain medicine is no longer needed and normal sleep routines return. Baths and showers can start as soon as you return home, but swimming in outside water such as pools should wait until all dissolving stitches dissolve in around 4 to 6 weeks. Older children who have craniosynostosis surgery need to wait 6 to 8 weeks before returning to sports.
For follow-up after craniosynostosis surgery we will offer you either a telemedicine or an in-person clinic visit 3 to 4 weeks after surgery. During this visit we simply want to make sure that your child has returned to their usual activities and to answer any questions you have. Since recovery is so quick after that first visit, the next scheduled clinic visit will often be one year after surgery.
If your child had endoscopic assisted craniectomy with helmet molding, we will work with your helmet molding team and see you before a second helmet is needed. If your child had spring-assisted cranial expansion or cranial expansion with distraction osteogenesis we will schedule the day surgery procedure to remove the devices, which will take place approximately five months after surgery. If your child had open cranial vault remodeling, the resorbable plates and screws used to hold the bones during healing may temporarily swell nine months after surgery. The swelling occurs as the plates are dissolving and only lasts a few weeks and does not cause any discomfort.