The difficult scalp and skull wound.

Scalp and skull defects can be very difficult to reconstruct. Whereas small defects may require only primary closure, skin graft, or small rotation flaps, large defects involving full-thickness scalp can be much more problematic. These large defects may require free-tissue transfer for adequate soft-tissue coverage. The calvaria also may require reconstruction. If the underlying bone is not infected, it can be left in situ and covered with well-vascularized tissue. The bone should be removed only if it is infected. Calvarial reconstruction should then be delayed for 3 to 6 months. If the tissue has been irradiated, only selected defects are appropriate for coverage with local scalp flaps because adjacent tissues may have underlying damage. With a methodic, accurate assessment of the defect, successful reconstruction can be expected.