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Separation of Craniopagus Conjoined Twins With a Staged Approach

Staffenberg, David A. MD, DSci,*; Goodrich, James T. MD, PhD,

Journal of Craniofacial Surgery: November 2012 - Volume 23 - Issue 7 - p S62–S68
doi: 10.1097/SCS.0b013e318262d3f7
Original Articles

The separation of craniopagus conjoined twins is a very rare and complex challenge. As with many rare challenges, it presents initially as a deceptively simple problem requiring only the most basic clinical techniques. As in many reconstructive problems, this paradigm mandates that the neurosurgical team performs the separation with the plastic surgeons providing closure at the end of the separation. Historically, these approaches have included, as with the separation of many other types of conjoined twins, the use of tissue expansion before separation followed by separation surgery. In the best hands, at the most capable medical centers, the mortality reported in the literature for the past 50 years is greater than 50%. Craniofacial surgery frequently demands a coordinated effort between plastic surgery and neurosurgery and many other specializations; separating craniopagus twins takes this coordination to a stratospheric level. It is, however, this coordination that is of paramount importance. Success clearly requires an understanding of the complex interrelationship between the “separation” and the “reconstruction” and that decisions made for 1 aspect of the surgery will have a profound impact on another aspect of the surgery. The impact can be disastrous or, if planned well, can be advantageous.

We were contacted to evaluate craniopagus conjoined male infant twins for separation. Radiographic studies suggested that the brains were separate, and their medical team suggested that they were “fit for separation.” We reviewed the literature and reviewed our colleagues’ experiences with similar cases around the world. It became clear that whether separation had been unsuccessful or successful, a variety of issues accompanied surgery as follows: (1) massive intraoperative hemorrhage, (2) cerebral edema, (3) venous infarcts, (4) swelling of flaps, and (5) dehiscence of repairs with cerebrospinal fluid (CSF) leak, meningitis, or brain exposure. Although the initial plan was to separate the twins in the same fashion as in previous cases (ie, single-stage separation surgery preceded by tissue expansion of the scalp), it was clear that this approach increases cerebral venous pressure during the separation component of surgery and therefore set up a cascade of events favoring failure rather than success. Wishing to favor success, we elected to design an open-ended multistaged separation to improve venous collateral circulation. We believe that this would improve venous drainage, prevent increased venous pressure, diminish cerebral edema, and favor the integrity of the dura and flap repair that would in turn lessen the risk of CSF leak. The stages would also allow the twins to recover from each stage before progressing to the next stage while continuing to receive nutritional support and physical therapy. Four major stages for 9 ½ months led to their successful separation. There has been no CSF leak or meningitis. To our knowledge, this technique has since been applied to 2 other sets of craniopagus with similar outcomes.

A review of the pertinent literature, our rationale, and methodology are discussed in this article.

From the *Department of Pediatric Surgery, Institute of Reconstructive Plastic Surgery, New York University Langone Medical Center, New York; and †Pediatric Neurologic Surgery, Montefiore Medical Center, Bronx, New York.

Received May 31, 2012.

Accepted for publication May 31, 2012.

Address correspondence and reprint requests to David A. Staffenberg, MD, DSci, Institute of Reconstructive Plastic Surgery, 307 E 33rd St, New York, NY 10016; E-mail:

Philanthropic support provided by the following: Children’s Hospital at Montefiore, Montefiore Medical Center (Bronx, NY), Blythedale Children’s Hospital (Valhalla, NY), Medical Modeling, LLC (Golden, CO), Voxel Inc (Provo, UT), Hill-Rom (Batesville, IN), Inamed (Santa Barbara, CA), Children’s Chance Inc (Waterbury, CT), Knightsbridge International (West Hills, CA), Philippine Airlines Foundation (Manila, Philippines), and Hanger Prosthetics and Orthotics (Farmingdale, NY).

The authors report no conflicts of interest.

© 2012 Mutaz B. Habal, MD