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Page 4 of 14 Brawley et al. Plast Aesthet Res 2022;9:6 https://dx.doi.org/10.20517/2347-9264.2021.107

Figure 3. Secondary intention over the course of 7 months.

In scenarios of very large full-thickness scalp defects, the crane principle can be used prior to skin grafting.
This technique involves temporary locoregional flap coverage of a defect, with the return of the flap to its
original location after at least one week, allowing for appropriate granulation of the defect before additional
[21]
grafting . It was first described for the scalp by Figi and Struthers in 1955, then the term was coined by
[20]
Millard in 1969 for an abdominal flap in hand reconstruction, stating “a pedicle flap can be used as an
[22]
engineering crane to lift and transport subcutaneous tissue from one area and deposit it to another”.
Biomaterials should be considered in cases with absent periosteum or a compromised vascular bed. Integra
(Integra LifeSciences) is a dermal regeneration template composed of a superficial silicone layer and a deep
composite layer. This composite layer is comprised of bovine type I collagen and shark chondroitin-6
sulfate glycosaminoglycan . After 3-6 weeks on the scalp bed, appropriate host cell integration of the
[23]
biomatrix will have occurred, and the silicone layer is removed . It is then replaced with a split-thickness
[24]
skin graft. A systematic review of success rates on the scalp favors the fenestration of Integra .
[25]
LOCAL AND REGIONAL FLAPS
Replacing excised tissue with similar tissue is a key pillar for optimizing results aesthetically. Unfortunately,
there is no donor site that can replicate the thickness, biomechanics, and hair-bearing nature of the scalp.
This makes local and regional flaps the ideal choice for replacing small to large scalp defects when possible.

Contraindications to local flap closures include scarcity of tissue for appropriate closure, uncleared
malignancy, and other relative factors which may lead to poor wound healing, such as smoking,
anticoagulation, and prior radiation [26,27] . Irradiated tissue is associated with slow wound healing, flap
necrosis, wound dehiscence and increased local infection rates [28-30] . Rhomboid flaps have been reported to
be a successful choice in head and neck reconstruction of irradiated tissue . Preoperative assessment of
[28]
defect size and the ability of the surgeon to create a tension-free closure is pivotal when considering
locoregional flaps in previously radiated tissue . If this is not feasible, free tissue transfer of healthy,
[31]
nonradiated tissue should be favored. Advanced age of patients may be beneficial for tissue and skin laxity
aiding in the success of local flaps; however, nutritional status should be evaluated regarding poor wound
healing. Common complications of locoregional flaps include dehiscence, necrosis, hematoma, infection,
[3]
pain, alopecia, and poor cosmetic outcomes resulting in subsequent surgeries. Newman et al. reported