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New York City, NY, December 14, 2004 -- Carl and Clarence Aguirre, the formerly conjoined Filipino twins who were successfully separated at The Children’s Hospital at Montefiore (CHAM) four months ago, will on Wednesday begin a series of skin grafts and reconstructive surgeries to replace areas of missing scalp and skull, according to the boys’ doctors at CHAM.
The surgeries, one on each boy, will be “the first gentle steps forward in the reconstructive process that will likely go on throughout the spring of 2005 and beyond," said David A. Staffenberg, MD, chief, Plastic Surgery, CHAM. The surgeries will involve minor skin graft procedures on two areas on the top of Carl’s head (one the size of a nickel and the other the size of a dime) and on a larger area above Clarence’s right ear.
The boys’ overall current medical conditions were described by their lead pediatrician, Robert Marion, MD, director of the Center for Congenital Disorders, CHAM, as “a miracle, considering that a little over a year ago they were both severely malnourished, had highly abnormal blood pressures and were conjoined at their brains." While the boys have minor medical issues, specifically acid reflux and sleep apnea, they will be examined by pediatric specialists at CHAM, including an expert on swallowing, gastroenterologists, a pediatric nutritionist, pediatric sleep experts and others. While they are under sedation Wednesday, a pediatric gastroenterologist, using an endoscope, will determine if a weak muscle between each boy’s esophagus and throat is the cause of the acid reflux problem. If so, the boys’ muscles could be tightened in a standard procedure for this condition.
"Since August, the boys have undergone intensive physical, occupational and speech therapy and are making remarkable progress," said Dr. Marion.
"The rehabilitation process and stabilization have been key to the boys overall recovery," said James T. Goodrich, MD, the boys’ chief neurosurgeon. Following the separation surgery in August, for example, the boys’ neck muscles and leg muscles were weak because they were forced to stay on their backs their entire lives because of their condition. Today, the two-and-a-half year olds can both sit up without support and stand (Carl) or kneel (Clarence) with support. Carl is saying single words and conducting “imitative play,” such as feeding a doll. Clarence can point to body parts and identify them.
Dr. Marion said that both twins have gained weight steadily over the past year: Clarence weighed 11 lbs. 12 oz. in September 2003, and now weighs 20 lbs., 11 oz.; Carl went from 14 lbs. 5 oz. to 23 lbs., 13 oz. "Carl has for the first time crossed over to a “normal” weight range for children his age," Dr. Marion said. "Both boys are clearly speech delayed, but can articulate individual words and have learned sign language."
"We have to realize that there is no ‘standard’ for speech development for conjoined twins who have been separated at the head. This has never been done before,” he said.
Staging The Reconstructive Process
In Wednesday's operations, each boy will undergo a temporary skin graft procedure to replace bald areas on their scalps. Skin will be taken from high up on the boys' hips or thighs and then grafted onto the bald areas of their scalps. These skin grafts are temporary. The boys will eventually undergo tissue expansion of their existing “scalp flaps” (which have hair) and these stretched portions of the scalp will be advanced gradually until both boys have a complete head of hair.
After these scalp procedures are completed, Dr. Staffenberg will then proceed to reconstruct the boys’ skulls. He intends to use each boy’s own bone as grafting material. Preferably he will use bone from their foreheads to avoid scarring elsewhere on the body. "We do this as a sequence from completing their scalps and then doing bone reconstruction because the boys’ skull bones need adequate blood supply on both sides (from the brain’s dura mater on the inside, and scalp on the outside) in order to heal," said Dr. Staffenberg.
“We don’t know how many stages and operations there will be as we move forward,” said Dr. Staffenberg. “We will continue with the same philosophy that resulted in a successful separation – after each procedure, we will assess where we are and how Clarence and Carl are doing and then proceed to the next stage.”
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