Twin toddlers on their way to healthy, active lives, thanks to two AO CMF surgeons on multidisciplinary team

Formerly conjoined toddler twin brothers today are on the road to independent, healthy, and active lives, thanks to the expertise of two AO CMF faculty members who took leading roles in a multidisciplinary team’s successful effort to separate them.

Plastic/maxillofacial surgeons and AO CMF faculty members Amir Elbarbary and Mohamed Amin were key to an Ain Shams University (Egypt) surgical team’s yearlong effort—including preparation and surgeries—that ultimately gave the Burundian twins a new lease on life. Both Elbarbary and Amin are professors at Ain Shams University in Cairo. The twins were born joined at the abdomen and pelvis and shared digestive, reproductive, and urinary system organs.

“Back when I was doing my craniofacial fellowship at the University of California, Los Angeles (UCLA), I became involved in a case of twins who were joined at the heads. That, too, was a multidisciplinary effort involving plastic surgeons, neurosurgeons, anesthetists, pediatricians, and a lot of staff,” said Elbarbary. In 2005, when he was asked to support the separation of twin girls joined at the pelvis back in Cairo, he enlisted his friend and colleague, Amin.

Very rare cases

“These cases are very, very rare and each time you encounter a case of conjoined twins and go through the very extensive planning and preparations, you become more confident,” said Elbarbary who today has been involved in seven such surgeries, six of which also involved Amin.

In the case of the Burundian twins, it was Elbarbary’s and Amin’s task to provide tissue coverage for the patients’ internal organs.

“Surgeons from other specialties do the actual separation, but kids can’t live without coverage: the muscle, subcutaneous tissues, and the skin. And it’s not just coverage. For example, if you close up a wound very tight around the abdomen, that can cause an increase in the internal abdominal pressure and might lead to a disaster called ‘compartmental syndrome.’ So, everything has to be very carefully calculated,” he said.

Amin said he and Elbarbary examined all the potential issues from a variety of perspectives and said preoperative, three-dimensional, virtual planning them to estimate the amount of tissue to be reconstructed after separation.

“We had to ask: Could these kids be operated on with safe coverage or not? Are we going to operate or not? How much tissue is missing? How many expanders do we need? Where will we put the expanders? Will there be tension from the muscle? So, placement and number of the expanders—and how to expand them—were key questions,” Amin explained, adding that each tissue expander increases the potential for complications—and there’s no “Plan B” if the expansion effort goes awry. “If that happens, you’re set back further than the starting point because you have to wait six months to a year—to make sure the tissue is stable—before attempting a revision surgery.”