Plastic Surgery Research Council

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Separating Craniopagus Twins: A 4 Stage Approach Using 3D Imaging Technology
Jillian E. Schreiber, MD1, Hayeem Rudy, BS2, James T. Goodrich, MD, PhD1, Oren M. Tepper, MD1.
1Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY, USA, 2Albert Einstein College of Medicine, New York, NY, USA.

Purpose: Craniopagus twins are the most rare form of conjoined twins, and successful separation poses a significant challenge to both neurosurgical and plastic surgical teams. Total craniopagus twins share a unified calvarium that houses two fused brains with shared venous sinuses. One senior author has previously separated 11 sets of craniopagus twins, and the relative advantages of our most recent approach using 3D technology will be discussed.
Methods: Two sets of total craniopagus twins were separated in 4 stages (n=4). 3D technology was used for pre-operative planning, intra-operative execution, and post-operative analysis of reconstructive outcomes. Virtual surgical planning with 3D printed jigs and guides, 3D surface analysis, and 3D printed models were used at each stage. A two-team approach with neurosurgery and plastic surgery was employed at each stage, and 3D-technology was used by each team.
Results: Two sets of total craniopagus twins were successfully separated using a 4-stage, two-team approach supplemented by 3D-technology. The neurosurgical team used 3D-printed models of the brains and vasculature to plan and perform dissection. Plastic surgery used VSP to select tissue expanders and design templates for incisions and osteotomies. 3D printed models offered intraoperative reference to safely separate the brain and its vasculature. 3D printed jigs and guides were fit on the calvarium to guide osteotomies for cranial vault reconstruction, and onto the scalp to guide soft tissue reconstruction.
Conclusions: Successful separation of total craniopagus twins relies on meticulous pre-operative planning and execution. 3D technology offers anatomic reference and surgical guidance in the multistage separation of total craniopagus twins. Separating the brain and its vasculature followed by calvarial reconstruction was improved with 3D technology.
Figure 1. Graphic from VSP prior to final surgery demonstrating total scalp surface area available after expansion and the total surface area of exposed cranium after separation (Courtesy of 3D Systems).
Figure 2. 3D ColorJet Printed model demonstrating the two brains, neurovasculature, and silicone silastic sheet (orange) that was placed to prevent adhesion formation between areas of brain tissue operated on during preceding surgeries. Green represents the areas of conjoined brain. Grey notches are to connect the two halves of the model (Courtesy of 3D Systems).


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