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Reconstruction of a Secondary Scalp Defect Using the Crane Principle And Lu et al. BMC Surg (2021) 21:41 https://doi.org/10.1186/s12893-021-01056-y CASE REPORT Open Access Reconstruction of a secondary scalp defect using the crane principle and a split-thickness skin graft Yi Lu1, Ke‑Chung Chang2, Che‑Ning Chang1 and Dun‑Hao Chang1,2,3,4* Abstract Background: Scalp reconstruction is a common challenge for surgeons, and there are many diferent treatment choices. The “crane principle” is a technique that temporarily transfers a scalp fap to the defect to deposit subcutane‑ ous tissue. The fap 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 sel‑ dom 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 carci‑ noma (SCC). After tumor excision, the primary defect was reconstructed using a transposition fap 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 fap as a salvage procedure and skin grafting to the original tumor location covered by a viable galea fascia in 1.5 months. Both the fap and skin graft healed uneventfully. Conclusions: Currently, the crane principle is a little‑used technique because of the familiarity of microsurgery. Nev‑ ertheless, the concept is still useful in selected cases, especially for the management of previous fap complications. Keywords: Crane principle, Scalp reconstruction, Local scalp fap Background to provide immediate blood supply and coverage, and Scalp defects result from several etiologies, such as the eventual deposition of a layer of soft tissue, which is trauma, infection, neoplasm ablation or congenital later used to nourish a skin graft and the scalp fap is later deformities. Since scalp defects may be partial or full- returned to its original location. In 1969, this method was thickness, diferent surgical methodologies and recon- named the "crane principle" by Millard [2]. As for scalp struction approaches are considered that involved reconstruction, the crane principle takes advantage of multiple dimensions, such as the type of defect, patient the fve-layer structure of the scalp and is a relatively sim- characteristics, and surgeon preference [1]. In 1955, Figi ple procedure to utilize [3], especially in the era before and Struthers were the frst to report on the temporary microsurgery. use of a scalp fap placed over an exposed skull defect Here we present a case of a 75-year-old female patient with a temporoparietal scalp squamous cell carcinoma *Correspondence: [email protected] (SCC). After wide excision of the skin cancer along with 1 School of Medicine, National Yang‑Ming University, Taipei, Taiwan the underlying pericranium, the primary defect with Full list of author information is available at the end of the article skull exposure was reconstructed by transposition fap © The Author(s) 2021. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creat iveco mmons .org/licen ses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creat iveco mmons .org/publi cdoma in/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Lu et al. BMC Surg (2021) 21:41 Page 2 of 5 and split-thickness skin graft (STSG) on the pericranium scan showed no lymphadenopathy in the preauricular, of the fap donor site. Unfortunately, the patient experi- postauricular, or cervical regions, but the tumor invaded enced a postoperative complication with skin graft loss deeply, which just abutted the pericranium. Wide exci- and bone exposure. For this secondary defect, we uti- sion with a 1.5 cm margin was performed and the dissec- lized the crane principle to rotate the previously placed tion plane was deep and directly under the pericranium fap and leave a layer of soft tissue as a salvage procedure layer, which left a 7 cm × 7 cm defect with bare bone and skin grafting to the original tumor location. Ulti- exposure (Fig. 1b). Te defect was reconstructed using a mately the fap and skin graft healed well and they both cephalically-based transposition fap that was harvested were in stable condition in the following 6 months. Tis from the occipital area. Te fap donor site, with an intact case report was approved by the Research Ethics Review pericranium, was resurfaced with meshed STSG and Committee of Far Eastern Memorial Hospital (FEMH, fxed with a tie over bolster dressing (Fig. 1c). Te fnal New Taipei City). pathology report revealed moderately diferentiated, pT3 SCC without lymphovascular or perineural invasion, and Case report both the peripheral and deep margins were free from A 75-year-old woman presented a 4 cm × 4 cm protrud- tumor invasion. ing ulcerative skin lesion on the right temporoparietal During the follow-up period, a partial loss of the STSG scalp (Fig. 1a). She had a history of lobectomy for lung occurred on the center of fap donor site. After conserva- adenocarcinoma 10 years ago and was in stable condi- tive wound care for 45 days, the wound was revealed tion. After a biopsy, the lesion was proven to be SCC. to be a skin and soft tissue defect with bare bone expo- Physical examination and computed tomography (CT) sure (Fig. 1d). After discussions with the patient and her Fig. 1 a A 75‑year‑old woman with a 4 4 cm squamous cell carcinoma on the right temporoparietal scalp. b Wide excision with 1.5 cm margin × was performed and deep to the scalp bone. c The defect was reconstructed with transposition fap, and the donor site was covered with meshed STSG. d Partial skin graft loss was noted after tie over bolster removal Lu et al. BMC Surg (2021) 21:41 Page 3 of 5 family, a decision was made to rotate the previous fap Hence, radical excision followed by reconstruction has back with the galea and a layer a soft tissue left in situ and become the standard treatment to scalp SCC [6]. In our then the skin graft was performed on the original tumor patient, the preoperative CT scan showed deep invasion location, so called as the “crane principle”. of the tumor without skull bone involvement. Terefore, During the surgery, we injected 1:200,000 epinephrine based on the “non-touch” policy, we excised the tumor into the subcutaneous layer and the fap was elevated subperiosteally. Te fnal pathological fndings also con- with a sharp dissection between the subcutis and galea. frmed the adequacy of the excision margins. (Fig. 2a) After debridement of the occipital wound, the Tere are many surgical techniques for scalp recon- fap was rotated to cover the wound. (Fig. 2b) A thick struction, including primary closure, skin grafting, local layer of well-vascularized soft tissue was left in the tem- faps, regional faps, free tissue transfer, and tissue expan- poroparietal region, and the wound was covered by STSG sion [7]. Several factors should be taken into consid- harvested from the adjacent scalp (Fig. 2c). eration regarding the selection of the technique, such as Te fap and skin graft healed well at postoperative defect thickness, size, location, the status of pericranium 2 weeks. (Fig. 2d) Tere was no tumor recurrence at both and calvarial defects, prior surgical procedures and the the 3-month and 6-month follow-up. medical and functional status of the patient [8]. In our case, the patient was of older age and had Discussion restricted lung function due to the previous lobectomy. SCC is a malignant and invasive neoplasm, which can Given these factors, after well discussion and consent, potentially present with distant metastases. Overall, we chose to use a transposition fap with skin grafting for 3–8% of SCCs are located on the scalp [4]. In this particu- her scalp reconstruction rather than other more compli- lar location, SCC is clinically characterized with a greater cated and time-consuming techniques. Te reason why tendency toward ulceration. Studies report that there is we selected the occipital scalp as the donor site was to a relatively higher probability of chronic, non-healing hide the alopecia area on the rear of her head. However, occurrence of ulcers compared to other skin locations [5]. the donor site wound ended up with subsequent graft Fig. 2 a Bone exposure at occipital wound was noted at 1.5 months post tumor resection. b The fap was rotated back to cover the occipital bone exposed wound.
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