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LOS ANGELES – One-year-old Guatemalan twins joined at the head were separated in a 22-hour operation that ended early Tuesday, but one of the girls underwent nearly five more hours of surgery to remove blood that built up in her brain. 

Maria Teresa Quiej Alvarez developed a hematoma related to surgery and was brought back into an operating room at the University of California, Los Angeles Medical Center at 9:17 a.m. Surgery began an hour later and ended at midafternoon. 

Maria Teresa was returned to the pediatic intensive care unit, where she was listed in critical but stable condition. Her sister, Maria de Jesus, also was in critical but stable condition as she recovered from the separation surgery. 

Maria Teresa’s bleeding was not an unexpected development, Dr. Michael Karpf, the medical center director, told a news conference after her second surgery began. 

“This is very complicated surgery and until we get past several days it will be life threatening for both of them. We are minute to minute, hour to hour, day by day. We just can’t get ahead of ourselves,” Karpf said. 

Doctors initially described Maria Teresa’s bleeding as being on the surface of the brain. After the surgery the hospital released a statement saying there was a buildup of blood in her brain. 

There was no word from the parents, Wenceslao Quiej Lopez and Alba Leticia Alvarez. The mother spent eight days in labor at home in the town of Santo Domingo, Suchitepequez, before delivering the twins in a hospital by C-section. 

“Despite the complication involving Maria Teresa, we feel that the outlook for both twins is positive,” said Dr. Jorge Lazareff, lead neurosurgeon. 

In Guatemala, Juliana Hernandez, the twins’ 85-year-old great-grandmother, told local media that she wished she could hold the girls. 

“I haven’t seen them in a long time. I’ve just seen the papers and TV images of them, but at this moment I would love to have them here and hug them,” Hernandez said. 

The twins’ relatives live in the village of Belen, about 125 miles south of Guatemala City. The 500 residents went to Mass Monday night to pray for the girls, local reporter Fredy Rodas told The Associated Press. 

“We prayed a lot asking God to guide the doctors’ hands during the surgery,” said the twins’ grandmother, Loyda de Jesus Lopez. 

The risky separation surgery took 22 hours to complete. 

“A big cheer went up in the operating room — they were really excited when the separation happened,” Karpf said of the 50 or more people who assisted in the operation. 

The surgery began at 8 a.m. Monday and was completed at 5:40 a.m. Tuesday. Actual separation occurred about 1 a.m. 

Doctors still do not know how well the two survived the surgery, Karpf said. 

“When the surgeons went into this, they had hopes both would come out functional — very functional,” Karpf said. “We won’t know for sure where things stand for a few more days.” 

The girls, born in rural Guatemala, were attached at the top of the skull and faced opposite directions. While the two shared bone and blood vessels, they had separate brains. Cases like theirs occur in fewer than one in 2.5 million live births. 

The riskiest part of the surgery was the separation of the veins that connected the girls’ heads. 

Surgeons at UCLA’s Mattel Children’s Hospital had to separate the individual blood vessels the two shared and decide which belonged to each child. Rerouting the flow of blood to and from the brain of each child put both at risk for stroke, said UCLA neurosurgeon Dr. Itzhak Fried. 

That was followed by plastic surgery to extend the scalp of each child to cover the portion of exposed brain where they had been attached. 

Dr. Henry Kawamoto Jr., a plastic and reconstructive surgeon at UCLA, likened the procedure to the stretching of a peel over the exposed half of an orange that has been cut in two. 

“There’s just not much orange peel to do that,” Kawamoto said in a recent interview. 

The two still face follow-up surgeries to reconstruct their skulls, Kawamoto said. Surgeons will peel off sections of their skulls, using excess boney material to patch the holes left as a result of the separation surgery, he said. 

Physicians around the world have performed cranial separations only five times in the past decade. Not all twins have survived. 

Healing the Children, a nonprofit group, arranged to bring the sisters from Guatemala to Los Angeles for the $1.5 million operation. The UCLA doctors donated their services but hospitalization costs remained to be covered. 

The girls’ parents gave them kisses before the operation began, said UCLA spokeswoman Roxanne Moster. 

“The girls were smiling a lot and were very playful,” she said.