Sisters' ultimate test (separating adult twins conjoined at the head “Please pray for us”)

An international team of doctors in Singapore will soon attempt the unprecedented surgical feat of separating adult twins conjoined at the head, Mark Baker reports.

Laleh Bijani shares a simple ambition with the twin sister with whom she has spent every moment of her life. "We would like to see our faces without the mirror," she laughs. Ladan Bijani smiles and nods in agreement: "Yes, we want to see each other - face to face."

Early next month the Iranian sisters will know whether their lifelong dream has been realised or whether their quest to live normal, separate lives is to end in tragedy.

"When we first opened our eyes to see the light we wanted to be separated," Ladan says. "We are now almost 30 years old. That is enough."

A team of 12 leading international doctors has begun gathering in Singapore to attempt an unprecedented surgical feat - the separation of adult twins conjoined at the head. Success will earn them a place in medical history and the eternal gratitude of two young women. Failure will fan a rising chorus of disapproval from other leading doctors who see a dangerous and unnecessary surgical adventure.

Laleh and Ladan were born in the Iranian city of Shiraz with separate bodies, faces and brains but sharing a single cranial cavity and a joined superior saggital sinus - the main vein that drains blood from the brain. In a marathon 48-hour operation at Singapore's Raffles Hospital, the surgeons plan to separate the women's skulls, reconstruct the blood supply systems to their brains and close the opened cavities with muscle and skin grafted from their backs.

The surgery is fraught with danger, as the head of the team, the consultant neurosurgeon, Keith Goh, says. "It's hard to put numbers on it, but if you look at all the historical data I think the figure that's been quoted is that four out of five sets of twins either die or have severe disabilities after surgery," he says. "Certainly the results in the 1990s and this decade have been better, but if you look back over 50 years, those are the unsettling figures."

But the sisters, who have spent more than six months in Singapore undergoing exhaustive preparatory tests and psychological appraisal, are determined to go ahead despite having the dangers spelled out in stark detail.

Laleh and Ladan arrived in Singapore last November after searching for years for surgeons willing to attempt to separate them. They made contact with Goh and his colleague, Professor Walter Tan, after learning of their success two years ago in separating Nepalese babies Ganga and Jamuna, who were also born joined at the head.

"We are very excited to be having this surgery and we hope the surgery will be successful. We feel happy, excited and a little bit nervous," Ladan said on Wednesday night when the sisters met journalists for the first time since the Singapore team confirmed they would go ahead with the operation. "We believe God will help us. We don't feel anxious or afraid ... We don't have any fear about the surgery, but we know that any surgery has high risks."

Confident, intelligent and vivacious, the two women, both law graduates from Tehran University, have become increasingly desperate to be separated, not only because of the obvious frustrations and discomforts of their daily lives but also because of their diverging interests and ambitions.

"We love each other and we have enjoyed our lives together but now we want to live separately," Ladan says. "After the surgery we want to have different careers. I want to continue my career as a lawyer, but my sister wants to be a journalist like you. We have a lot of dreams."

Says Laleh: "We are individual persons. We have different ideas about our lives. We are opposites."

Unlike Ladan, Laleh likes puzzles, computer games and animals. Unlike Laleh, Ladan enjoys cooking, news programs and teaching herself computer programming. "I'm talking to you, but Laleh is so quiet and shy," she says. Ladan's favourite colours are blue and grey; Laleh prefers white and red.

The decision to go ahead with the operation has sparked controversy in international medical circles with many specialists opposed to a move that may lead to the death of one or both of the otherwise healthy young women. Neurosurgery on adults is considered far more dangerous than with infants as the developing brains of children have an ability to reorganise and adapt damaged functions.

The operation will involve a team of surgeons drawn from Europe, the United States and Asia who, like Raffles Hospital, are donating their services.

Goh says separating the twins' brains will be relatively straightforward as they are "just lying side by side" with no fusion of tissue. But he says the first of two serious surgical challenges will be in separating the superior saggital sinus - the principal blood-draining vein - where it joins near the base of the women's skull. In attempting to resolve that issue, a choice will be made that could distinctly favour the survival chances of one twin over the other.

"One of them will get it. The other one will have to either bank on the alternate channels we call the collateral veins taking over the drainage or we'll have to form some sort of veinous bypass graft and re-create that vein," says Goh.

The second critical issue will be closing a gap the size of a bread and butter plate on the side of each twin's head after separation. It is expected to take plastic surgeons 12 hours to build covering layers of grafted skin and muscle. If that succeeds, later surgery will implant permanent protective plates.

The women deny local media speculation that they have a secret pact on who should live if surgeons can only save one. "It depends on God," says Ladan. "We don't think about who will be saved and who will die; we don't like to think about that."

Asked what they will say to each other before they are led into the operating theatre, she jokingly replies: "We had a good life when we were joined, and thank you very much." But as they walked arm-in-arm from their press conference, there was a more sombre mood. "Please, everyone, pray for us," said Laleh.

The Mind and the Brain was published this year, or late last at the earliest. It suggests that if that surgery was to be attempted, the girls had a much better shot when they were children.

But even so, brain plasticity is such that recovery can be hoped (and worked) for. The book indicates that the "phantom pain" phenomenon experienced by amputees is caused by the activity of the portion of the brain previously dedicated to the now-lost limb effectively getting bored and looking for signals somewhere else nearby. When it finds them, the patient's sensation is associated with the brain site getting stimulation from a "foreign" region. IOW that part of the brain tries to find something useful to do, and "phantom pain" is confusing consequence.

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