Introduction: The primary task of reconstructive surgeons is to provide a healthy and stable cover to the exposed brains of the craniopagus twins after separation with minimal wound related complications. For the successful cover of both the open calvaria, the available skin is invariably less than what is required.
Our case: The 2 years old craniopagus twins had a type III total vertical variant with an oblique line of fusion of their brains and shared a single common circular sinus. In the 1st Stage, partial venous and parenchymal disconnection was done with simultaneous insertion of two tissue expanders in the occipital regions of both the twins. Stage 2 – Twin 1 developed cardiomegaly and deteriorating cardiac functions which lead to an emergency separation surgery with inadequately expanded skin at hand. Local partially expanded flaps were used to cover critical areas in twin 1 whereas bilateral trapezius myocutaneous flaps were used to cover the critical areas in occipital region of twin 2. Both twins required prolonged maximum inotrope support in the post-operative period that started showing on the flaps. After multiple sessions of serial debridement, skin allografts, regular dressings and skin isografts, wounds of both the twins were completely healed in 3 months’ time and both the twins were discharged 6 months after the separation surgery.
Conclusion: Successful Craniopagus separation is considered an insurmountable task because it requires a well-orchestrated and coordinated effort between various teams. Regular communication among various teams is the key to success. One of the most important factors determining the initial skin incisions is the proposed final circumferential craniotomy line that is planned by the neurosurgery team.