Background Various methods have been described to close large meningomyelocele defects, but no technique has been proven superior to others. This study presents cases of meningomyelocele defect closure with a keystone-design perforator island flap.Methods A retrospective study was performed on 14 patients with meningomyelocele defects closed using various types of keystone flaps.Results The median age of the patients at surgery was 10.5 days (range, 1–369 days) and the average defect size was 22.5 cm2 (range, 7.1–55.0 cm2). The average operative time for defect closure was 89.6 minutes (range, 45–120 minutes). Type IV bilateral keystone flaps were used for four defects, type IV unilateral flaps for six defects, type IIA flaps for two defects, and type III flaps for two defects.Conclusions All the defects healed completely with no major complications. The keystone-design perforator island flap is a reliable, easy, and fast technique to close large meningomyelocele defects.

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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.

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Currently, there are no harmonized guidelines which govern skin banking in the Asia Pacific region. Therefore, skin banks are either unregulated or rely on their nation’s legislation or international accreditation to uphold their quality standards. A new set of skin banking guidelines was developed through a comprehensive review and collation of best international practices for the Asia Pacific Burn Association (APBA) members, from donor screening and testing, to skin recovery, processing, storage and distribution, and quality assurance. National regulatory requirements reviewed include the European directives, Australia’s Therapeutic Goods Administration and Singapore’s tissue banking standards. Further technical and quality management recommendations are referenced from the American Association of Tissue Banks (AATB), the United States Food and Drug Administration standards and guidance documents, various relevant European guides, Japanese Society of Tissue Transplantation guidelines and the Asia Pacific Association of Surgical Tissue Banking. Adapted mainly from the AATB standards, the new Asia Pacific Burn Association Guidelines for Skin Banking in Therapeutic Applications offer a comprehensive manual, addressing: governance and contracts; staff responsibilities; quality management; facilities, equipment and supplies management; donor consent and testing; and recommendations of good practices pertaining to skin recovery, processing, storage and distribution. Besides complementing current generic regulations, they provide technical specifications of major aspects unaddressed in most legislations. This inaugural set of new regional skin banking guidelines would be a start for regional members of the APBA to adopt, and will hopefully culminate in a set of standards so that, in the long run, skin allografts from this region can be of similar quality, which can simplify import process and facilitate the exchange of allografts between members.

Introduction and importance Conjoined twin is a rare congenital anomaly characterized by a fusion of certain anatomical structures. Coronavirus-19 (COVID-19) is a new emerging infectious respiratory disease affecting worldwide and potentially leads to acute respiratory distress (ARDS) in children. COVID-19 has reconstructed the healthcare system, including surgical care and decision-making. Case presentation Herein we describe a surgical separation of 2.5 months old omphalopagus conjoined twins, with one of them (Baby A) presenting COVID-19-associated respiratory distress, as well as the challenges faced during the preparation and the execution of the complex surgical procedure. Clinical discussion Baby A underwent antiviral therapy, oxygen supplementation, and ventilation in the ICU, while baby B remained stable and confirmed negative for SARS-CoV-2. The separation surgery was conducted after baby A had become clinically stable. Defect closure and reconstruction were accomplished. At one week follow-up, Baby A died of lung infection, while baby B remained well after one year. Conclusion The complexity of surgical separation requires careful planning by a multidisciplinary team. Surgical separation of conjoined twins during the pandemic era has not been reported much in the literature, more reports are required to provide further insight.

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