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Successful Separation of Craniopagus
Conjoined Twins Using a Staged Approach:
An Evolution in Thought
David A. Staffenberg

Department of Plastic Surgery, Montefiore Medical Center, Center for Craniofacial Disorders, Children’s Hospital at
Montefiore, and Department of Plastic Surgery, Neurological Surgery and Pediatrics, Albert Einstein College of
Medicine of Yeshiva University, Bronx, New York, U.S.A.

James T. Goodrich

Department of Pediatric Neurosurgery, Montefiore Medical Center, Children’s Hospital at Montefiore and
Department of Neurological Surgery, Plastic Surgery and Pediatrics, Albert Einstein College of Medicine of Yeshiva
University, Bronx, New York, U.S.A.

INTRODUCTION
Conjoined twins are a rare entity that presents very special challenges to the medical and
surgical teams that care for them. The separation of craniopagus twins is an even more extreme
and rare challenge. Craniofacial surgery requires a coordinated effort between plastic surgery
and neurosurgery, and it is clear that separating craniopagus twins takes this coordination and
cooperation to a stratospheric level. As advances in medicine have taken place, the risk of
separating craniopagus twins remains daunting with survival ranging about 50%. The true
incidence of craniopagus and the outcome of separation around the world are not known
because of incomplete reporting, but frequently these cases are reported in the media as
curiosities. While outcome is affected by the extent of shared tissue, in those cases where shared
brain vasculature is included, the ultimate goal, which is to have both twins emerge from their
separation with full neurological function and a chance at leading independent and productive
lives, has remained elusive.
In March 2003, we were contacted to evaluate craniopagus conjoined male infant twins
for possible separation. In order to assess this possibility, we reviewed the literature. Briefly, this
review along with personal interviews revealed complications that included death of one or
both twins, brain exposure, meningitis, and neurological compromise. The most common
approach included a preliminary procedure to place tissue expanders under the scalp followed
by a surgical separation performed over many hours. We hypothesized that the morbidity and
mortality were primarily due to the prolonged surgery needed to separate such twins,
and inadequate time to allow for vascular adaptation. In order to minimize morbidity and
mortality, and preserve function, we designed an open-ended, multi-staged separation in order
to allow them to improve their venous collateral circulation, and recover from each stage before
progressing to the next stage. Four major stages over nine and a half months led to their
successful separation and preservation of neurological function. To our knowledge, this is the
first time an outcome like this was achieved in such a case.
A review of the pertinent literature, as well as our rationale and methodology are
discussed in this chapter.
Craniopagus twins occur in about 2% of conjoined twins. In craniopagus, the union can
occur anywhere on the cranial vault but by definition, does not involve the foramen magnum,
face, vertebrae, or skull base. The thorax and abdomen are completely separate. The junction of
the conjoined twins is rarely symmetric and can involve any part of the meninges, venous
sinuses, and the cortex. Axial and rotational orientation is variable. Each of these factors can
influence the development, distortion, deformation, and displacement of the brain, the
meninges, and the vascular system as well as the prognosis after surgical separation.

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FIGURE 1

Staffenberg and Goodrich

Craniopagus twins. Source: From Medical Modeling LLC, Golden, Colorado, U.S.A.

There are four types of conjoined twins joined at the head: (i) Craniopagus are joined only
in the calvarium (Fig. 1); (ii) Cephalopagus are joined ventrally, from the top of the head down to
the umbilicus (Fig. 2); (iii) Parapagus diprosopus are joined laterally with two faces on one head
but share only one body (Fig. 3); (iv) Rachipagus are joined dorsally along the vertebral column
(Fig. 4), occasionally involving the occiput.
The female to male ratio in craniopagus twins is about 4:1 which is similar to the ratio
for other types of conjoined twins. Other reported anomalies include congenital heart disease,
cleft lip, cleft palate, supernumerary thumbs, extrophy of the cloaca, and absence of the entire
urinary tract, bladder extrophy, absence of anus and vagina, and imperforate anus (1).

FIGURE 2 Cephalopagus twins. Source: From Medical Modeling
LLC, Golden, Colorado, U.S.A.

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FIGURE 3 Parapagus twins. Source: From
Medical Modeling LLC, Golden, Colorado,
U.S.A.

CLASSIFICATION
The simplest method of classification of craniopagus twins makes reference to the site of
junction: frontal, temporal, parietal, or occipital, and combinations of them. O’Connell has
suggested the use of the terms partial and total to describe the degree of junction (1). He
further describes types I, II, and III to indicate whether the twins are facing the same or opposite
directions or their axes were perpendicular to each other. Our case represents an O’Connell
type I (Fig. 1).
Winston et al. described a classification system based on the embryological origin of
the deepest shared structure: the surface ectoderm and cranium; the dura (ectomeninx);
the leptomeninges (endomeninx); and the neuroectoderm (2). Todorov et al. correlated
postoperative survival with the axial orientation of the union. He describes the acute
frontal–frontal angle was most favorable, and mortality increased as that angle increased (3).
Spencer points out that each of these systems has merit, but they fail to take into account
the anatomy of the underlying dural venous sinuses. She points out that it is the specific
anatomy of these vessels that “doom the vast majority of these infants to the wretched life of
intact conjoined twins or the significant risk of death or serious neurologic impairment
following surgical separation” (4).
The pathological configuration of the dural sinuses appears to be influenced by: (i) the site
of union; (ii) the plane of intersection, wherein the larger the plane of intersection, the greater
the probability that the sinuses and cortical surfaces are fused; and (iii) the rotation and
angulation from the frontal area. It also follows that the larger the area of confluence of the
scalps, the greater the soft tissue requirement for reconstruction.

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Staffenberg and Goodrich

FIGURE 4 Rachipagus twins. Source: From
Montefiore Medical Center, LLC, Golden,
Colorado, U.S.A.

The dural sinuses are not true veins; they do not contain valves, muscles, or fibrous walls
and are therefore very fragile. The sinuses are not movable within the surrounding tissue. The
location of the sinuses in the conjoined area may be hard to predict, and the direction of blood
flow is unpredictable. When the twins are joined vertex-to-vertex, the falx cerebri does not form
and subsequently the superior sagittal sinus cannot develop. The analog of the superior sagittal
sinus forms around the periphery of the conjoined plane in a fold of dura. This shared dural
hoop contains a venous sinus that can be either completely or partially circumferential. This
may also form a “venous lake.” Each twin will have veins draining into, or out of, this sinus.
Extracranial arteries are an important consideration when planning skin flaps but it is rare that
the intracranial arteries are involved.
Winston points out that adequate support must be provided to avoid gravitational forces
on the brains during separation surgery. The possibility of air embolism is of concern during
separation as well (2). Any external pressure on the jugular veins must be carefully avoided
since this can increase venous pressure, and subsequently bleeding and cerebral edema.
Because valves are not present in the dural sinuses, the relative position of the twins on
induction of anesthesia and surgery may cause some degree of “transfusion” from one twin to
the other. The issue of adrenal dominance is important in any kind of conjoined twinning; the
twin with adrenal suppression may require steroid supplementation preoperatively, intraoperatively, and postoperatively (5).
HISTORICAL EXPERIENCE WITH CRANIOPAGUS CONJOINED TWINS
The first attempt at separation of craniopagus recorded in the twentieth century involved
12-day-old infants with parietal union; neither survived this attempt (6). The first survival
recorded was of 14-month-old males with a large parietal union, a shared sinus in

Separation of Craniopagus Conjoined Twins

131

a semicircular dural shelf, and a single confluence. There was massive hemorrhage when the
veins were divided. The first twin died 34 days after surgery, but the second survived with a
temporary hemiparesis but died from complications of hydrocephalus at 11 years of age (7).
The first recorded survival of both twins was in a set of seven-month-old girls with minimal
parietal union. The authors describe a thin sheet of bone across the plane of union. They shared
a 5 mm segment of the superior sagittal sinus. One twin was reported to have survived
neurologically intact in spite of massive hemorrhage, but the other suffered severe neurologic
injury. Interestingly, the neurologically impaired twin donated a kidney to her twin sister 28
years later (4,8).
It is interesting to note that efforts have been made to alter the size and angulation of the
union. Wolfowitz et al. successfully increased the angle of union between a set of frontoparietal
twins in an effort to increase the surgical exposure (9). In another case, a metal band was
placed circumferentially around the plane of junction, but had required removal when the
twins developed seizures (10). In yet another set of craniopagus conjoined twins, constriction
by a plastic ring was abandoned when the resulting ulcer became infected (11). An adjustable
pneumatic cuff was placed around another set and the bridge was decreased by 10%
and prevented subsequent growth of the conjoined area, but the five-month-old males
with a minimal occipito-parietal union died of massive hemorrhage in the operating room
(12). In a German case with extensive parietal union, a circular nylon band was used
unsuccessfully (13).
In her review on this topic, Spencer notes that the most important data to be obtained
prior to surgery concerns the location and character of the dural sinuses (4). It is clear that
division of the veins draining into the dural sinus can result in elevation of the cerebral venous
pressure and venous infarcts. In addition, such elevation in venous pressure may also result
in significant cerebral edema making reconstruction more difficult. Cardiopulmonary bypass,
hypothermia, intraluminal shunting, and circulatory arrest with division and reconstruction of
the major sinuses has led to minimal success (14).
A craniopagus was separated in stages with gradual closure of a bridging vein. To
accomplish this, a screw clamp with an exteriorized stem was used over several days to
gradually occlude a short bridging vein between superior sagittal sinuses; this method led to a
successful separation but no long-term follow-up was reported (15).
Continued advances in anesthesia techniques as well as critical care has improved the
survival of craniopagus separation. Kawamoto and Lazareff inserted tissue expanders and then
followed tissue expansion with a single-stage separation of a set of Guatamalan female
craniopagus twins. A similar technique was used by Salyer and Swift to separate a pair of
male twins from Egypt. In the latter set a rotating table was fabricated to allow the twins to be
rotated along their axis in unison. In these cases, each twin survived, but there were notable
neurologic deficits more than six months after each separation.
A set of 29-year-old Iranian women joined temporoparietally suffered fatal hemorrhage
during their attempted separation. While medical models were utilized, and the surgeons
felt that they had the advantage of many recent technological innovations, they noted that
the final bridging vein, after hours of surgery to divide the other veins, was enormously dilated
and there was significant venous engorgement. This engorgement is likely due to the venous
hypertension from the abrupt change in venous pathways.
AN EVOLUTION OF THOUGHT
A careful review of personal communications and the literature have convinced us that a
lengthy operation to ligate and divide the bridging veins in such cases leads to unavoidable
venous hypertension and circulatory compromise of the brain. Plastic surgical principles
naturally lead one to consider staged division of venous tributaries to encourage the dilatation
of venous collaterals and the resulting diversion of drainage (16).
While previous staged techniques have been attempted with mixed results, we feel that
the stages must be timed such that complete recovery is allowed to ensue prior to subsequent
stages. These breaks between surgical stages would allow for occupational and physical
therapy and nutritional support and would allow time for the desired vascular changes to

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occur. The intent of the staged approach is that it would allow the patients to be exposed
to general anesthetics for shorter periods of time, require less intravenous fluids, have less
bleeding, less cerebral edema, and require less transfusion products. Less cerebral edema
would allow for easier and more reliable soft tissue coverage at the completion of their
separation. While the skin flaps must be completely designed from the beginning of the staged
procedures, elevating the flaps for each stage would offer the delay phenomenon to the skin
flaps. Perhaps the most important benefit of the staged procedure is that it allows the bridging
veins to be divided sequentially, thereby allowing collateral venous drainage to improve. We
have hypothesized that the improved venous drainage, together with the previously discussed
advantages, would improve survival as well as the neurologic outcome. At the final stage,
during separation, improved venous drainage, and shorter surgical time prior to separation
would cause less cerebral edema, thereby making dura and scalp reconstruction less
complicated (17,18).

CASE REVIEW
On April 21, 2002, a 29 year-old woman in the Philippines gave birth to a set of male
craniopagus twins by Ceasarian section. A level-2 ultrasound had diagnosed the condition,
and termination of the pregnancy was offered but rejected because of religious conviction. She
desired separation for them and a work-up was obtained (Fig. 5).
During intubation for radiographic studies, twin A suffered aspiration pneumonia twice
and further efforts at work-up were abandoned and transfer to the Children’s Hospital at
Montefiore was arranged. Arrangements were made to augment their nutrition, provide
pulmonary care, and intensive occupational and physical therapy at Blythedale Children’s
Hospital in Valhalla, New York. We have had a long-standing clinical relationship with
Blythedale, which is a rehabilitation center that does not provide acute care.
Upon arrival in New York, evidence of failure to thrive was present, and twin A, much
smaller than twin B, was noted to have severe hypertension. Antihypertensive medications
were prescribed. Urine output was also noted to be greater in twin A.
Craniofacial computed tomography (CT) with three-dimensional reconstruction was
obtained as well as magnetic resonance imaging/magnetic resonance venography
(MRI/MRV). Data from these studies were used to obtain diagrams and clear stereolithographic models (Medical Modeling, LLC, Golden, Colarado, U.S.A.) of the shared venous
system within the conjoined skulls (Fig. 6). In addition, a three-dimensional model of the
skin envelope was also obtained (Medical Modeling, LLC, Golden, Colarado, U.S.A.). This
model is quite useful to the plastic surgeon and a pencil can be used to design skin flaps
(Fig. 7A,B).
Scalp flaps were designed to maximize their blood supply and avoid suture lines over
the vertex of the scalp once the twins were separated. A sinusoidal pattern was designed to

FIGURE 5 Craniopagus twins referred for
separation.

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Separation of Craniopagus Conjoined Twins

FIGURE 6 Illustration showing skin envelope with shared venous sinus system
superimposed from initial computed tomography data; the lesser vessels are eliminated
for clarity. Twin A on right. Source: From
Montefiore Medical Center/Medical Modeling, LLC, Golden, Colorado, U.S.A.

accomplish this goal. While opposing pericranial flaps were considered, they were not used
because of the difficulty in incorporating this design into a multi-staged procedure.
Flaps were designed to extend toward the opposite twin’s right ear, leaving the incisions
to resemble a sinusoidal curve around the conjoined scalp. Because the twins’ interaxial angle
was slightly less than 1808 (Fig. 7), one twin would have a shorter flap. While tissue expansion
would be utilized, the twin anticipated having the larger dura defect and patch was given the
longer flap. It was crucial to identify this prior to the first stage of separation.
Craniofacial CT and MRI/MRV studies were also used to generate holograms (Voxel, Inc.,
Provo, Utah, U.S.A.). To our knowledge, this is the first time holographic images have been
used in the separation of conjoined twins (Fig. 8A,B).
If a single-staged separation of craniopagus twins were being planned, tissue expansion
could be performed on the intact scalp without previous surgery, thereby minimizing the risks
associated with tissue expansion (e.g., exposure and infection) (19). During the separation,
however, the expanders require removal, and the expanded scalp undergoes a degree of
contraction during the hours of neurosurgery required to separate the twins in a single-staged
separation. Tissue expansion during a multiple-staged separation, however, is more complicated. The need to perform tissue expansion after previous stages, with healing scars and
manipulated tissue is a challenge unique to the staged approach. In each of the stages, exposure
is provided through the previously designed flaps, and the craniotomies are kept as narrow as

(A)

(B)

FIGURE 7 Three-dimensional model fabricated from computed tomography data. (A) Anterior view; twin A on left.
(B) Posterior view; twin A on right. Source: From Montefiore Medical Center/Medical Modeling, LLC, Golden,
Colorado, U.S.A.

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(A)

Staffenberg and Goodrich

(B)

FIGURE 8 (A) Hologram from computed tomography data on left and magnetic resonance venography data on right
(these can be overlayed). Twin A is at the top. (B) Holograms projected in front of viewbox. Source: From Montefiore
Medical Center/Voxel, Inc., Provo, Utah, U.S.A.

possible along the conjoined perimeter. Originally, tissue expansion was planned for each stage,
replacing the expanders at each surgery with a larger size. We felt that gradually increasing the
size of the expanders would be needed, as the healing scars grew longer with each stage.
Multiple dental caries were noted on examination. These represented possible sources of
bacteremia, and multiple extractions were performed under general anesthesia. Anesthesiologists were, from that point forward, dedicated to the continued care of each specific twin
throughout their various stages. Our dedicated craniofacial surgery scrub technicians and
circulating nurses made the same commitment.
Stage 1
On October 20, 2003 stage 1 was performed. Intraoperative navigation was utilized (Stryker).
The conjoined twins were positioned supine and the forehead was opened along the planned
incision line exposing the shared frontal bone. A frontal craniotomy was performed and dura
was divided adjacent to the line of fusion on the side of twin B. A circumferential “shelf” of
dura was seen. This shelf was the dura enveloping the circumferential sinus, which would
ultimately be left with twin A. Brains were seen to be separate. A large anterior bridging vein
in twin B was divided at this stage (Fig. 9). A silastic sheet was placed between the brains to
avoid adhesions. Dura was closed, and the craniotomy was closed with titanium miniplates.
We typically use resorbable fixation in our pediatric craniofacial work, but because hardware
would need to be removed during the final separation, titanium hardware was applied. 100 cc
tissue expanders (Inamed, Santa Barbara, California) were then placed adjacent to the
craniotomy and the scalp was closed in layers.
Subgaleal fluid leaked from the suturelines 10 days postoperatively and worsening fevers
led to removal of the tissue expanders. Otherwise, recovery was uncomplicated.
Stage 2
On November 24, 2003, the twins returned to the operating room for the second stage. The skin
incision was lengthened toward the left ear of twin A and further to the occipital area, allowing
for the second craniotomy to be performed. Bridging veins were temporarily clamped on twin
B’s side of the circumferential sinus. No sign of cortical edema was observed so these veins

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FIGURE 9 Note orientation and large bridging vein that was ligated (clipped) and divided, leaving the circumferential
venous sinus with twin A on left. Source: From Montefiore Medical Center/Medical Modeling, LLC, Golden, Colorado, U.S.A.

were ligated and divided (Fig. 10). The previously placed silastic sheet was replaced. Closure
was performed similarly after placement of new tissue expanders. The tissue expanders were
again removed 14 days later for similar reasons as the prior stage. At this point, we felt that
tissue expansion should be performed separate from the craniotomies because the usual
cerebrospinal fluid leaks into the surgical site.
Stage 3
New CT scan and MRI/MRV were obtained and on February 20, 2004 the third stage of their
vascular separation was performed. CT and MRI/MRV studies were repeated between stages
to confirm the development of the needed venous collaterals (Fig. 11). From the first procedure,
timing between stages was subjectively judged with regard to their progress in physical
therapy as well as their soft tissue healing. No predetermined schedule was utilized.

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FIGURE 10 Note orientation and bridging veins that were ligated (clipped) and divided, leaving the circumferential
venous sinus with twin A on left. Source: From Montefiore Medical Center/Medical Modeling, LLC, Golden, Colorado,
U.S.A.

The twins were placed in prone position and the incision was lengthened along its predesigned path and an occipital craniotomy was performed. Vessels were addressed in similar
fashion and closure was performed (Fig. 12).
Tissue expanders were placed eight weeks prior to their expected separation surgery.
Expanders were placed over each left ear, through separate incisions behind the ears, in areas
that were not previously operated upon. Subcutaneous ports were placed behind the earlobes,
and expansion was begun three weeks after placement.
Stage 4
Final separation surgery was performed on August 4, 2004, nine and a half months after the
first stage. Placement of the tissue expanders above the ears allowed them to remain in place
while the separation was performed. Continued circumferential dissection and division of the
remaining dura and veins allowed their separation in a controlled fashion. In spite of abundant

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FIGURE 11 Increased quality of venous collaterals; twin B on right. Source: From Montefiore Medical Center/Medical
Modeling, LLC, Golden, Colorado, U.S.A.

preoperative imaging, a shared posterior temporal lobe was encountered and divided
according to its vascular pattern (Fig. 13).
Once the twins were separated, the operating tables were rotated approximately 308 to
allow teams to work side-by-side. This rotation was felt to require the least amount of
movement in the operating room, (tables pivoted on their pedestals and anesthesia teams
did not need to move) and was therefore felt to be the safest maneuver. Durasisw (Cook Biotech,
West Lafayette, Indiana, U.S.A.) was used to replace missing dura, tissue expanders were
removed and scalp flaps closed. Twin B underwent completely primary closure over the large
dural graft, while Allodermw (LifeCell, Branchburg, New Jersy, U.S.A.) was placed over the
native dura over the right ear of twin A.
Through all stages of surgery, the twins shared 4175 cc of packed red blood cells. No
drains or primary shunts were used during the final separation, nor were they required
subsequently. The twins were lightly sedated until their extubation of postoperative day 3 for
twin B and postoperative day 4 for twin A. Prophylactic phenobarbital was used for each
procedure. Twin A’s antihypertensive medications were discontinued one week after surgery.
Neither twin has developed hydrocephalus. Wounds have healed without cerebrospinal fluid
leak (Fig. 14). In twin A, split thickness skin grafts were placed over the Alloderm three months
after separation.
At the time of this writing, 32 months after separation, both twins are neurologically
intact, interactive and playful; they currently feed themselves. Each twin walks without the aid
of walkers. Since their separation they required tonsillectomy and adenoidectomy, as well as
myringotomies for chronic otitis media. They have each developed speech and continue to gain
the developmental milestones that were delayed by the nature of their conjoined status.
As healing progresses, additional scalp flap advancement, with or without tissue
expansion, will provide complete scalp coverage in twin A; calvarial vault reconstruction
will follow in each twin (Figs. 14–16). We are delaying reconstruction in order to allow them as
much time as possible in school, therapy, and as a family. Fourteen months after separation, a
three-bedroom home in the community was made available to the twins and their mother. The
twins commute daily by school bus to therapy and school. There are no detectable neurologic
deficits according to our neurology colleagues.

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FIGURE 12 Note orientation and bridging veins that were ligated (clipped) and divided, leaving the circumferential
venous sinus with twin A on left. Source: From Montefiore Medical Center/Medical Modeling, LLC, Golden, Colorado,
U.S.A.

DISCUSSION
Craniopagus is a very rare entity. While advances in anesthesia and critical care management have been significant, survival from separation surgery remains about 50% over
the past decades. Among the surviving twins however, neurological injury has been
common in reported cases of O’Connell type I twins. To our knowledge, no such twins
have been able to go on to lead independent, productive lives as a separated pair. After
being asked to evaluate such a pair of infants for separation, our thoughts have undergone
an evolution from the more commonly performed single-staged separation. In reviewing the
available literature, it became clear that dividing the shared veins in a single stage was a
likely source of brain injury. Furthermore, our experience in craniofacial surgery indicates
that patients, especially infants and children, recover more easily when procedures are done
expeditiously.

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FIGURE 13 Note orientation and bridging veins that were ligated (clipped) and divided, leaving the circumferential
venous sinus with twin A on left. Source: From Montefiore Medical Center/Medical Modeling, LLC, Golden, Colorado,
U.S.A.

While the literature does include cases that have been separated in stages, these stages
have been relatively close together and morbidity and mortality still appeared to be
unchanged. We became convinced that a carefully planned multiple-staged separation
could allow for the desired outcome if the patients were allowed appropriate recovery time
between stages. After each stage we would not be able to predict the amount of time needed
for recovery, but our team was committed to close observation and an open-ended schedule
for the stages.
While the preservation of neurologic function became our prime goal, the difficulties of
such a staged separation became clear. Tissue expansion has higher morbidity when
performed at the same time as a craniotomy; vascular clips are needed on the edges of the
dura, which then compromise a watertight closure leading to increased amounts of fluid
around the tissue expanders. The limited area around the heads makes it difficult to place the
expanders in a site where they are not exposed to this fluid and the resulting risk of infection
and exposure. Because of our experience, we feel that expansion should be done as an isolated

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FIGURE 14

Staffenberg and Goodrich

Twin B postoperative day 14; he managed to remove his entire head dressing.

procedure prior to the final stage. Additional issues may arise as the soft tissue envelope is
repeatedly elevated leading to some trauma, but this may be countered by a delay
phenomenon as the flaps are elevated and returned to their original position, only to be
used at a later stage.
The potential advantages of separation surgery in multiple stages include less exposure
to general anesthesia, less bleeding, less intravenous fluids, less transfusion requirement, less
cerebral edema, and less fatigue in the surgical team. The venous drainage between twins
can be analogous to automobile traffic in New York City. During a single-staged separation, all
of the bridging veins are ligated and divided during the course of surgery. This may be
likened to closing off all the cross-streets in midtown at the same time, which would surely
lead to “gridlock,” and traffic would come to a stop. The circulatory equivalent in the brain is
a frightful thought. However, if those same cross-streets were closed off gradually, drivers
would learn to use alternate routes to get to their destination; existing roadways could be
used and New York City would not need to build new roads. Surgically, we are encouraging
the existing venous system in each brain to dilate gradually in order to handle the needed
increase in flow.
In 2006, we consulted on another craniopagus in order to plan a similar staged separation
in Europe. With the experience gained during our first staged separation of craniopagus, this
second separation was successfully achieved in four major stages performed over a six-month
period. The degree of involvement and specific anatomy was similar to the case reviewed.
Again, both twins survived without neurological compromise (20).
For plastic surgeons, this concept and our experience with this separation, is particularly
gratifying as we are constantly concerned about manipulating living tissue in order to maintain
or improve function.

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FIGURE 15

Twin A on postoperative day 14.

FIGURE 16

The separated twins on postoperative day 25; twin A on left. Source: From Montefiore Medical Center.

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Staffenberg and Goodrich

ACKNOWLEDGMENTS
All parties involved in the staged separation have donated their care.
Philanthropic support was provided by:
&
&
&
&
&
&
&
&
&
&

The Children’s Hospital at Montefiore, Montefiore Medical Center (Bronx, New York, U.S.A.)
Blythedale Children’s Hospital (Valhalla, New York, U.S.A.)
Medical Modeling, LLC (Golden, Colorado, U.S.A.)
Voxel, Inc. (Provo, Utah, U.S.A.)
Hill-Rom (Batesville, Indiana, U.S.A.)
Inamed (Santa Barbara, California, U.S.A.)
Children’s Chance, Inc. (Waterbury, Connecticut, U.S.A.)
Knightsbridge International (West Hills, California., U.S.A.)
Philippine Airlines Foundation (Manila, Philippines)
Hanger Prosthetics and Orthotics (Farmingdale, New York, U.S.A.)

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