June 27, 2002 Doctors at UCLA's Mattel Children's Hospital completed a skin expansion procedure at 3:30 p.m. on June 24 on Maria Teresa and Maria de Jesus Quiej-Alvarez, 11-month-old twins joined at the skull. UCLA plastic surgeons implanted balloons under the babies' scalps to stretch the skin enough to cover their heads after their separation surgery next month.
"This was almost a dress rehearsal for the twins' longer surgeries next month," explained UCLA plastic and reconstructive surgeon Dr. Henry Kawamoto Jr., who conducted the 75-minute skin expansion procedure. "The time was well spent discussing what we'll need to do next time and the type of supplies we'll require in the operating room."
Both twins responded well to the anesthesia and surgery. Surgeons encountered a minor problem, however, when inserting one of the four expander balloons.
"The skin in one spot was very thin, and the scalp tore slightly in the groove between their heads," said Kawamoto. "We stitched the wound together, but we will not be able to expand the scalp there until the skin heals."
Surgeons inflated the three remaining balloons with saline solution. Still, UCLA will postpone the separation surgery until the torn tissue heals and is able to be stretched. Doctors do not know how long the delay will be. Because the twins will remain in the hospital, however, Kawamoto will be able to monitor the babies on a daily basis.
Prepping the babies for surgery lasted two hours. After anesthesia, the doctors faced the dilemma of how to best position the twins to gain access to their heads for surgery. After much discussion, the doctors rested one twin on her back, facing up, and the other twin on her abdomen, her face cradled in an open cushion shaped like a donut.
After shaving the infants' hair, the doctors used an ultrasound wand on the girls' heads to detect major blood vessels. These were inked in red on their scalp so surgeons would know where to avoid performing the incision. "Overall, everything went exactly as it should have," said Dr. Barbara Van De Wiele, chief anesthesiologist on the case. "We're very pleased."
UCLA plastic surgeons made a tiny incision on one side of the babies' heads, between their ears. In the small groove separating the twins' heads, Kawamoto threaded two eight-inch long silicone balloons around each girl's head, creating a bulging halo effect under their scalps. The end of the balloon runs into a slender hose with a self-sealing valve. Twice a day, doctors will inject saline solution into the valve.
Tissue expansion enables the body to "grow" extra skin for use in reconstructing almost any part of the body. Surgeons prefer to use tissue expansion to reconstruct parts of the scalp, where hair growth makes it difficult to replace lost tissue with skin from elsewhere on the body. Even after stretching, skin from the scalp retains its ability to generate natural hair growth. In addition, the skin is less likely to die because it remains connected to the scalp's own blood and nerve supply.
The Quiej-Alvarez twins were born in a small hospital in Guatemala on July 25, 2001. The hospital called the Guatemalan Pediatric Foundation, which contacted Healing the Children, a nonprofit group that finds medical care for children in underdeveloped countries. The organization approached UCLA pediatric neurosurgeon Dr. Jorge Lazareff, one of their volunteer physicians, for aid in accepting the twins' cases. Lazareff and Kawamoto are leading the team of UCLA physicians, nurses and medical staff who will treat the twins. The twins arrived in Los Angeles with their mother, Leticia Alba Alvarez, on June 7.
Craniopagus twins — those who are fused at the tops of their heads — are one of the rarest types of conjoined twins. An estimated two percent of conjoined twins are craniopagus.
In addition to Lazareff and Kawamoto — who are donating their services — a team of more than 50 UCLA physicians, nurses, residents and staff will ultimately be involved in the twins' cases. Mattel Children's Hospital expects the babies' care to cost upwards of $1.5 million. To recover some of these expenses, the hospital has established a fund called Twins Care at UCLA. Checks payable to UCLA Foundation may be mailed to UCLA Medical Sciences Development, 10945 Le Conte Ave., Ste. 3132, Los Angeles, CA 90095.
Healing the Children is also accepting donations on behalf of the twins at Box 221478, Newhall, CA 91322. See http://www.healingchildren.org for more details.
For pictures and more information about the twins and their UCLA medical team, please see http://www.healthcare.ucla.edu.
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