Use of local perforator flaps for closure of a thoraco-omphalopagus conjoined twin defect after separation during the COVID-19 pandemic

Abstract

Introduction Conjoined twins are a rare medical phenomenon that poses unique challenges for surgeons. Separation of conjoined twins involves multidisciplinary teamwork, complex medical management and surgical planning, and multi-stage operations and often still has a high mortality and morbidity rate. In the times of the COVID-19 pandemic, separation of conjoined twins pose even greater challenges. Aiming for the best outcome possible, while minimizing the risk of COVID transmission and ensuring the safety of the personnel, is paramount. This case report presents thoraco-omphalopagus twins who were successfully separated at 4 months of age. The preoperative planning, operative details, postoperative follow-ups, and outcomes are discussed. Methods The absence of a tissue expander and the inability to acquire it due to travel restrictions from COVID-19 further complicated the management on this patient. A Routine Polymerase Chain Reaction (PCR) swab test was performed on the patients and personnel. Standardized personnel protective equipment (PPE) was worn during ward and surgical care. After separation of the twins by cardiothoracic and pediatric surgeons, one twin underwent immediate skin closure using a double keystone perforator island flap and a lower abdominal perforator flap. Due to extensive defects, closure was delayed for the second twin. After a series of dressing changes, eventually local perforator flaps could be raised to close the defect using staged tension sutures and skin grafts for secondary defects. Results Both twins were discharged with no significant morbidity, and no personnel were exposed to COVID-19 infection during the management Conclusion Preoperative coordination and planning, multidisciplinary effort, adherence to screening protocols for COVID, and strict use of standardized PPE all contributed to the successful separation of thoraco-omphalopagus conjoined twins during the COVID-19 pandemic.

Pediatric Plastic Surgery in the COVID-19 Era

“…Two cases of this during the pandemic were described in the literature. 48,49 In the case of thoraco-omphalopagus female twins, baby 1 tested positive for COVID-19. 48 Once she stabilized and tested negative for COVID-19, the separation was performed by a multidisciplinary surgical team.…”

“…48,49 In the case of thoraco-omphalopagus female twins, baby 1 tested positive for COVID-19. 48 Once she stabilized and tested negative for COVID-19, the separation was performed by a multidisciplinary surgical team. Baby 2 underwent a double keystone perforator island flap and lower abdominal flap for soft tissue coverage.…”

“…No personnel were exposed to COVID-19 infection during these patients' managements. 48 In the second case of conjoined twins, baby A presented with COVID-19-related respiratory distress, was treated for the infection, and had surgery upon stabilization. In baby A, the central defect was covered with re-elevation of the lower limb of the right keystone perforator flap.…”

“…Microsurgery in the pediatric population is also involved in the closure of large defects, for example, as necessary in the separation of conjoined twins. Two cases of this during the pandemic were described in the literature 48,49 . In the case of thoraco-omphalopagus female twins, baby 1 tested positive for COVID-19 48 .…”

“…Both babies required wound debridements and negative pressure wound therapy changes. No personnel were exposed to COVID-19 infection during these patients' managements 48 . In the second case of conjoined twins, baby A presented with COVID-19–related respiratory distress, was treated for the infection, and had surgery upon stabilization.…”