Reconstruction of a secondary scalp defect using the crane principle and a split-thickness skin graft

Abstract

Background Scalp reconstruction is a common challenge for surgeons, and there are many different treatment choices. The “crane principle” is a technique that temporarily transfers a scalp flap to the defect to deposit subcutaneous tissue. The flap is then returned to its original location, leaving behind a layer of soft tissue that is used to nourish a skin graft. Decades ago, it was commonly used for forehead scalp defects, but this useful technique has been seldom reported on in recent years due to the improvement of microsurgical techniques. Previous reports mainly used the crane principle for the primary defects, and here we present a case with its coincidental application to deal with a complication of a secondary defect. Case report We present a case of a 75-year-old female patient with a temporoparietal scalp squamous cell carcinoma (SCC). After tumor excision, the primary defect was reconstructed using a transposition flap and the donor site was covered by a split-thickness skin graft (STSG). Postoperatively, the occipital skin graft was partially lost resulting in skull bone exposure. For this secondary defect, we applied the crane principle to the previously rotated flap as a salvage procedure and skin grafting to the original tumor location covered by a viable galea fascia in 1.5 months. Both the flap and skin graft healed uneventfully. Conclusions Currently, the crane principle is a little-used technique because of the familiarity of microsurgery. Nevertheless, the concept is still useful in selected cases, especially for the management of previous flap complications.

A Rare Case of Microblading Complicated by Orbital Exenteration and Frontal Defect Reconstructed Using Crane Principle

“…2,3,7 In Millard model, an interval of 1 week was enough, but in a scalp and forehead crane technique, as in our case, one week may not be enough to supply the whole area by edge-to-edge circulation. 2,3,7 Hence, depending on the nutrient flap, it is logical to take a longer time interval in forehead cases. An interval of two weeks was sufficient concerning the safety of the flap vascularity and neovascularization process.…”

“…An interval of two weeks was sufficient concerning the safety of the flap vascularity and neovascularization process. 2,3,6…”

“…Additionally, others used this technique in the reconstruction of other sites like feet and orbits. 2,3 The temporarily transferred flap stimulates granulation tissue formation at the original site of injury, leaving behind a healthy bed for graft take later, when the flap is returned to its original location. 2,3,7 In Millard model, an interval of 1 week was enough, but in a scalp and forehead crane technique, as in our case, one week may not be enough to supply the whole area by edge-to-edge circulation.…”

“…2,3 The temporarily transferred flap stimulates granulation tissue formation at the original site of injury, leaving behind a healthy bed for graft take later, when the flap is returned to its original location. 2,3,7 In Millard model, an interval of 1 week was enough, but in a scalp and forehead crane technique, as in our case, one week may not be enough to supply the whole area by edge-to-edge circulation. 2,3,7 Hence, depending on the nutrient flap, it is logical to take a longer time interval in forehead cases.…”

Scalp reconstructive flaps

“…A dermatome is required for split-thickness grafts, which are usually harvested from the anterior thigh. A recent case series of over 100 patients noted no significant difference in graft adherence or complications between the two graft options on the scalp [19] . A bolster, which is typically cotton wrapped in petroleum gauze and sutured to surrounding tissue to apply pressure to the graft, or a wound VAC is required for approximately one week to allow for plasmatic imbibition, inosculation, and revascularization.…”