Unveiling the “Kebab” technique: A case report on a two-stage reconstruction method for repeated complex cranioplasty

RATIONALE: Cranioplasty after decompressive craniectomy provides brain protection and improves cerebral hemodynamics. However, recurrent infection and sinking skin flap syndrome after cranioplasty remain cumbersome complications that require a well-planned reconstruction strategy. PATIENT CONCERNS: A 74-year-old man presented with traumatic subdural hematoma and underwent decompressive craniectomy. Cranioplasty using an original bone flap, bone cement with wires, and a titanium mesh were complicated and resulted in recalcitrant infection and sinking skin flap syndrome. DIAGNOSES: Recurrent infection and sinking skin flap syndrome post-cranioplasty. INTERVENTIONS: We designed a two-stage “kebab” reconstruction technique using a combination of free latissimus dorsi myocutaneous flap and delayed non-vascularized free rib graft. A well-vascularized musculocutaneous flap can obliterate dead space in skull defects and reduce bacterial inoculation in deep infections. Subsequently, delayed rib grafts act as the scaffold to expand the sunken scalp flap. OUTCOMES: At the 3-year follow-up, the patient showed improvement in headache, without evidence of surgical site infection. LESSONS: The novel “kebab” technique using a combination of a free myocutaneous flap and delayed rib graft can eliminate bacterial growth in infected calvarial defects, reverse sinking skin flap syndrome, and minimize potential donor-site morbidity, and is therefore suitable for patients who require multiple cranioplasties and are unable to withstand major reconstructions.