Spring-Assisted Surgery-A Surgeon's Manual for the Manufacture and Utilization of Springs in Craniofacial Surgery
Abstract
BACKGROUND AND PURPOSE: Spring-assisted surgery has been used for the treatment of craniofacial deformities since its 1997 inception in Sweden by Dr Lauritzen (Scand J Plast Reconstr Surg Hand Surg 1998;32:331-338). Initial applications have focused on the treatment of patients with single-suture craniosynostosis. Recently, indications and applications have expanded to include patients with syndromic craniosynostosis, multiple-suture synostosis, and midface hypoplasia. The advancement of spring-assisted surgery in this country has been hindered by the need for patient-specific spring fabrication because few surgeons understand how to make the springs for each application. We will review our spring design and treatment algorithms to facilitate wider use of this innovative treatment modality. METHODS: This is a retrospective institutional review board-approved analysis of the spring design for our first 90 cases of spring-assisted surgery used to treat sagittal synostosis at the North Carolina Center for Cleft and Craniofacial Deformities. Outcome analysis was done to generate a treatment algorithm based on diagnosis, patient age, spring design, number of springs, spring force and expansion, and clinical outcome. RESULTS: Ninety children with sagittal craniosynostosis (64 males, 26 females) were treated during an 8-year period (2001-2009) with spring-assisted surgery. Mean age at treatment was 4.4 months and mean age at spring removal was 8.8 months. Mean number of springs used was 2 (range, 1-3). Mean spring force used in sagittal synostosis was 5.5-9.5 (range) for the anterior spring and 5.5-9.5 (range) for the posterior spring with a mean posttreatment expansion of 6.65 cm. Analysis of the results shows that spring force and expansion required for optimal correction is dependent on the age at surgery, type of the deformity, and severity of the deformity. Specifically, the younger the child, the weaker the spring needed for surgical correction. General principles for spring application for scaphocephaly include (1) the longer the anterior posterior dimension of the skull deformity, the more likely a third spring is necessary; (2) the narrower the posterior occiput, the stronger the posterior spring required; and (3) if a postcoronal band is seen in the calvarium, a stronger anterior spring is needed. CONCLUSIONS: Long-term experience with spring-assisted surgery has facilitated the development of standardized, reproducible techniques allowing spring design modifications to optimize clinical outcome.
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Use of springs to treat prematurely fused sagittal suture allows two-dimensional expansion of the skull.
“The use of springs to treat prematurely fused sagittal suture, especially in cases where families refuse helmet therapy or the child is too old for it, allows two-dimensional expansion of the skull and has been shown to be a successful addition and minimally invasive alternative [51, 64].”
From Developments in diagnostic and surgical techniques in children with sagittal suture craniosynostosis: a systematic review spanning the last 30 years (2025) · cites this paper as [64]
Use of springs to treat prematurely fused sagittal suture is a successful addition and minimally invasive alternative, especially when families refuse helmet therapy or the child is too old for it.
“The use of springs to treat prematurely fused sagittal suture, especially in cases where families refuse helmet therapy or the child is too old for it, allows two-dimensional expansion of the skull and has been shown to be a successful addition and minimally invasive alternative [51, 64].”
From Developments in diagnostic and surgical techniques in children with sagittal suture craniosynostosis: a systematic review spanning the last 30 years (2025) · cites this paper as [64]
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BackgroundAssessment of spring cranioplasty biomechanics in sagittal craniosynostosis patients
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MethodA Systematic Approach to Predicting Spring Force for Sagittal Craniosynostosis Surgery
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“5 cm between the inner aspects of the footplates.(13) Two omega-shaped springs are made via the wire bender and custom bent to fit each child’s cranial contour.”
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“If a custom-made spring is utilized, there is a learning curve for determining and executing the appropriate modifications to the springs (Pyle et al., 2009).”
MethodSelf-citationLatest trends in minimally invasive synostosis surgery
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“[14] The advantage for institutions using springs is that the age limit can be increased because the skull growth is driven by the device.”
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Self-citationCraniometric Analysis of Endoscopic Suturectomy for Bilateral Coronal Craniosynostosis
Rottgers, S. A., Syed, H. R., Jodeh, D. S., Jeelani, Y., Yang, E., Meara, J. G., & Proctor, M. R. (2018) · Plastic & Reconstructive Surgery · doi:10.1097/prs.0000000000005118 · Cited by 14 · see citing works
Objective classification system for sagittal craniosynostosis based on suture segmentation
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“Despite these favorable results, lack of operative standardization in spring biomechanics employed by SMC imparts variability to reporting of surgical outcomes and may foster hesitancy in technique adoption.(14) The biomechanical forces and interaction between the skull and springs to expand the cranium in SMC remain…”
BackgroundJeelani, O., Borghi, A., Rodríguez-Flórez, N., Bozkurt, S., Dunaway, D. J., & Schievano, S. (2020) · Journal of Craniofacial Surgery · doi:10.1097/scs.0000000000006865 · Cited by 8 · see citing works
“This process was further standardized in some centers with the use of a custom designed wire bender which created a 1-inch bend diameter.(28) A lack of standardization among these earlier studies makes translation and comparative analyses across Units more difficult.”
MethodThe removal of cranial springs used in the treatment of scaphocephaly: A minimal access approach
Rtshiladze, M. A., Roy, A.-A., Goltsman, D., Hunt, J. A., Reddy, R., & Gianoutsos, M. P. (2019) · Journal of Cranio-Maxillofacial Surgery · doi:10.1016/j.jcms.2019.04.001 · Cited by 8 · see citing works
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“Despite inclusion of spring parameters such as spring force and length, this study does not account for other springs properties including material type, spring diameter, or coil number, which may also impact outcomes following SMC [25, 26].”
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Skull Base Cephalometric Changes in Cranial Expansion by Springs
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“Indications, number, and strength of springs, as well as location of spring placement, have been determined.(9) The aim of this study was to evaluate the changes produced in the skull base through cephalometric measurement after the experimental use of springs in the sagittal and parasagittal regions in experimental a…”
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“The use of springs to treat prematurely fused sagittal suture, especially in cases where families refuse helmet therapy or the child is too old for it, allows two-dimensional expansion of the skull and has been shown to be a successful addition and minimally invasive alternative [51, 64].”
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“6,7 Since correction is determined principally by the rate of brain growth, these MI procedures are age-limited and can only be offered to infants diagnosed in early infancy.”
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Spring-Assisted Cranioplasty in Multisuture Craniosynostosis: Initial Experience From Thailand
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Spring Cranioplasty for the Fused Sagittal Suture
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- Authors
- Pyle, J., Glazier, S., Couture, D., Sanger, C., Gordon, S., & David, L.
- Affiliations
- Wake Forest University Health Sciences (US)
- Medical University of South Carolina (US)
- Corresponding author
- Pyle, Jeremy
- Gordon, Stan
- David, Lisa
- ORCID
- David, Lisa
- Venue
- Journal of Craniofacial Surgery
- Published
- 2009-11
- Volume
- 20
- Issue
- 6
- Pages
- 1962-1968
- ISSN
- 1049-2275 (ISSN-L)
- OpenAlex
- W2093440441
- Cited by
- 39
- References
- 20
- Citations by year
- 2026: 4 · 2025: 3 · 2024: 2 · 2023: 1 · 2022: 2 · 2021: 1 · 2020: 6 · 2019: 1 · 2018: 3 · 2017: 4 · 2016: 3 · 2015: 2 · 2014: 2 · 2013: 1 · 2012: 3
- FWCI
- 0.78
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Journal of Craniofacial Surgery (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Life Sciences › Biochemistry, Genetics and Molecular Biology › Genetics › Craniofacial Disorders and Treatments
- Health Sciences › Dentistry › Orthodontics › Orthodontics and Dentofacial Orthopedics
- Health Sciences › Medicine › Surgery › Reconstructive Facial Surgery Techniques
- Keywords
- craniosynostosis, sagittal synostosis, spring design, spring force, cranial expansion, scaphocephaly, syndromic craniosynostosis, midface hypoplasia, treatment algorithm, pediatric craniofacial surgery, age at surgery, postoperative outcomes
- MeSH terms
- Cranial Sutures, Craniosynostoses, Craniotomy, Equipment Design, Female, Humans, Infant, Male, Retrospective Studies, Stress, Mechanical, Plastic Surgery Procedures, Prostheses and Implants
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