Conjoined Twin Separation and Reconstruction: An Anatomical Classification System, Techniques, and Outcomes at a Tertiary Pediatric Care Center
Brody W King1, Kala T Pham1, Erica Xue1
1From the Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine.
Background:
Conjoined twin separation is highly complex. Existing taxonomies describe morphology but not the extent of sharing across regions-a key determinant of feasibility, planning, and outcomes. The authors introduce the Texas Children's Hospital classification system and report their institutional experience, supplemented by a structured literature review.
Methods:
The authors conducted a retrospective review of conjoined twins (2014 to 2024). The Texas Children's Hospital system assigns 1 point per domain (eg, skin/soft tissue, deep viscera, major vascular, central neurological, and bone) within 4 regions (eg, cranium, thorax, abdomen, and pelvis); region scores yield a composite fusion score. Two reviewers scored cases. The authors described outcomes and compared composite fusion scores between separated and nonseparated twins. A PubMed review identified cases with anatomical detail for scoring.
Results:
Seventeen cases were identified; 12 of 17 (70.6%) were viable at birth, and 4 of 12 (33.3%; 4 of 17, 23.5% overall) underwent elective separation. Tissue expansion preceded separation in 3 of 4 pairs (75%); hepatic artery embolization was performed in 1 of 4 (25%). Device complications occurred in 2 of 3 tissue expansion pairs; sternal hardware complications occurred in 2 of 3 plated patients. Infection and seroma each occurred in 2 of 8 patients (25%). Three of 8 patients (37.5%) required tracheostomy and 3 (37.5%), gastrostomy. All separated twins survived (follow-up 9 to 117 months). Composite fusion score was lower in separated versus nonseparated twins in both institutional (mean [SD], 5.2 [2.8] versus 9.3 [3.2]; P = 0.041) and literature cohorts (4.7 [1.9] versus 7.1 [1.8]; P = 0.010).
Conclusions:
The Texas Children's Hospital classification offers an adjunctive, anatomy-based framework capturing the burden of shared structures and is associated with separation feasibility. Although not predictive, it provides a common language to align teams, structure operative strategy, and support counseling.
