As Amanda Stapleton, MD, prepared for a delicate surgery on 8-month-old Julian Pennington, she wanted to take advantage of every available resource.
Julian was born with a dermoid cyst on his nose that extended inside the nasal passage toward his brain. Knowing she was in for a tricky procedure, Dr. Stapleton contacted UPMC’s 3D Printing Program to create a 3D model of Julian’s skull.
“In pediatrics, the anatomy is so small, and the area that we’re working at can sometimes be hard to visualize,” says Dr. Stapleton, a pediatric otolaryngologist and endoscopic sinus and skull base surgeon at UPMC Children’s Hospital of Pittsburgh. “Especially when you’re dealing with a baby, and you’re talking about millimeters of tissue that you have to go find.”
Dr. Stapleton and a pediatric neurosurgeon used the model to plan Julian’s surgery. In March 2024, they successfully removed the mass from the exterior and interior of Julian’s nose.
“For us, (3D printing) has really been a huge adjuvant to our pediatric skull base practice,” Dr. Stapleton says. “We are dealing with small noses, small heads, working in tight spaces. And to be able to explain to a family what their child’s about to go through — having a 3D model has revolutionized how parents view us.”
A Rare Condition
Before Julian’s birth, his parents learned he had a congenital heart condition that would require surgery soon after birth.
“The second half of the pregnancy was tainted a little bit because of it, just because you’re so worried,” says Sarah Pennington, Julian’s mother. “It was very scary having your child go through that.”
When Julian was born in July 2023, he had “a little dent on his nose,” Sarah says.
Doctors told Sarah and her husband, Ivan, that the dent was likely from trauma during birth. However, over the next few months, what was initially a small dent became a rapidly growing mass on his nose.
Julian’s pediatrician referred the couple to an ear, nose, and throat doctor in October 2023. Julian underwent a magnetic resonance imaging (MRI) exam, but the images were unclear.
In January 2024, Julian underwent open heart surgery at UPMC Children’s for his congenital heart condition. Later that month, Ivan and Sarah visited Dr. Stapleton at UPMC Children’s to see if she could evaluate the growth on Julian’s nose.
“It was starting to cover maybe half to three-quarters of the top of his nose,” Dr. Stapleton says. “It seemed to be growing more rapidly, meaning the family had noticed it almost doubling in size over a short period of time. And so, they were anxious to get treatment for it.”
Dr. Stapleton ordered another MRI and a computed tomography (CT) scan. This time, the imaging showed that the growth on Julian’s nose extended inside his nasal passage toward his brain.
Dr. Stapleton suspected Julian had either a dermoid cyst or a glioma in his nasal passage. Dermoid cysts are rare, congenital, fluid-filled growths, while gliomas are a rare type of congenital tumor.
Although both dermoid cysts and gliomas are noncancerous, the growth’s location meant it could cause future complications. Julian needed surgery to remove it.
“We didn’t know if it was a glioma or a cyst, and (Dr. Stapleton) said she wouldn’t know until she did (the surgery),” Ivan says. “But they could see a pinhole behind the bridge of his nose, so they did know that it was coming out of the skull.”
Additionally, because the growth was on Julian’s nose, there was a cosmetic concern.
“I felt like he’d been through so much at that point,” Sarah says. “An open-heart surgery for anyone is just so huge. And then it’s just another thing to tack on to what he was already going through.
“So, I was just worried about him developmentally, I guess. Like, is he going to hit his milestones on time? Is he going to have any developmental delays?”
Creating a Model
Because of Julian’s open-heart surgery, the family had to wait a couple of months before he could undergo another procedure.
Before the March 2024 procedure, Dr. Stapleton contacted the 3D Printing Program at UPMC. The program, which has been around since 2016, creates virtual 3D models and prints physical 3D printing models for surgical planning.
Dr. Stapleton and the 3D printing lab partnered on a research project that showed 3D models were effective in surgical planning and educating patients about procedures.
“I’ve had a really great working relationship with the 3D printing team,” Dr. Stapleton says. “We’ve done a lot of cases over the years together.”
Dr. Stapleton asked the 3D Printing Program to create a model of Julian’s skull with the growth inside his nasal passage.
“She asked for a clear model of the bony anatomy with a colored mass,” says Elliott Hammersley, lead biomedical engineer, UPMC 3D Printing Program. “And she wanted to be able to split (the model) sagittally, or right down the middle of the nose, into two pieces so that she could take it apart and kind of see the track that the tumor was in.”
Using the high-definition imaging of Julian’s skull, Elliott created a virtual 3D model for Dr. Stapleton’s approval. Board-certified radiologist Barton Branstetter, MD, also reviewed the virtual model to ensure the accuracy of the anatomy.
After Dr. Stapleton and the radiologist approved the virtual model, Elliott used a 3D printer to create the physical model of Julian’s skull.
“It was split down the middle, and you can see the path of the mass and where it goes up into the skull base,” Elliott says.
A Successful Surgery
Elliott delivered the 3D model to Dr. Stapleton about a week before Julian’s procedure. She and her co-surgeon, a pediatric neurosurgeon, reviewed the model to plan Julian’s surgery.
“This model was particularly helpful because I think we underestimated the amount of intracranial extension, meaning how much was going inside toward the brain,” Dr. Stapleton says.
“It helped us realize that we needed to reach all the way to the region of the anterior skull base to get a complete resection. And because he’s so small, it’s really important that we don’t leave anything behind because that’s when things can come back.”
The external growth on Julian’s nose had become inflamed and had continued to grow. A couple of weeks before surgery, it burst.
“It got bulbous, at a point,” Ivan says. “It got so big that it did eventually burst, but it wasn’t the actual growth itself. His nose got smaller, but it didn’t go away completely after it burst.”
Dr. Stapleton and her co-surgeon still had to surgically remove the mass from Julian’s nasal passage and address the exterior as well. Before the surgery, Dr. Stapleton used the 3D model to explain the procedure to Sarah and Ivan.
“It definitely gave me some more perspective,” Sarah says. “I knew it was serious, but then seeing the tail that it had, it just made me wonder how it got there, where it came from, how serious it really was. And if it does come out, does that mean anything? Will he be OK?”
Dr. Stapleton says she believes 3D models are very useful in explaining surgeries to families.
“When they can open it and fold it and turn it, it really helps them understand what their child’s about to go through surgically as well as understanding the post-op care,” she says.
Julian’s surgery took place on March 21, 2024. Dr. Stapleton and her co-surgeon successfully removed the mass in a delicate eight-hour procedure. Afterward, they confirmed that the mass was a dermoid cyst.
“I have this picture of him on the same day of surgery. Like hours later, he’s sitting up in bed, smiling,” Sarah says. “It was crazy to me. He must have felt pretty good. That made me happy.”
A Healthy Child
A year after surgery, Julian is healthy. Although he has a small scar on the top of his nose, it’s grown less apparent with time.
“You would barely know that he had surgery just based on his septum,” Sarah says. “It’s really just the top of his nose where it had burst.”
Dr. Stapleton says Julian’s case is an example of the value of the 3D Printing Program at UPMC.
“The 3D lab is really great,” she says. “Anytime that it’s patient-related care, they take care of it.”
The 3D Printing Program created about 600 models in 2024, its busiest year to date. Elliott says it’s rewarding to help patients like Julian.
“I think it’s why we do it every day,” he says. “Specifically for me, working with (UPMC) Children’s patients is extra rewarding because a lot of times, the reason that they’re in the hospital is totally out of their control, and it’s also scary. So, anything we can do to make that less scary and a better experience makes us all feel pretty good.”
In addition to Julian, Sarah and Ivan have a 3-year-old named Isaiah. The couple are expecting a third boy in the spring of 2025. Sarah says she’s thankful for the care Julian received.
“We felt like Julian was in really good care while we were there,” she says. “He had very knowledgeable doctors. At times, it felt like you were kind of in the presence of a superhero. Like, they’re doing such great things for your kid. You can’t believe they even know how to do any of it.
”So, we were just really grateful. We’re so lucky and fortunate that we even live close enough to a place that could do that.”
Learn more about 3D Printing at UPMC.