Mortality at older ages has fallen dramatically since 1950 in developed countries. Advances in medicine have led to an increase in the number of nonagenarians alive today. Maintaining favorable surgical mortality rates in this advanced age group can be challenging. The co-morbidities commonly present in this patient population often require innovative surgical solutions.

We report a case of recurrent skin cancer of the scalp treated with Moh's excisional therapy resulting in a 15cm. full-thickness defect with exposed calvarium. The patient's cardiologist would not permit any surgical solution using general anesthesia due to the patient's precarious heart condition.

Given the severe surgical restrictions imposed by cardiology, an old surgical approach was employed. Multiple twist drill holes were placed through the outer table to permit ingrowth of granulation tissue from the viable diploic cavity to accelerate sequestration. A reconstruction plate with multiple holes was used as a drill guide for a Hall drill. This did not require general anesthesia. Epithelialization of the resultant granulation tissue occurred with complete healing of the wound.

Plastic surgery has a rich heritage of innovation. Historical techniques, while not necessarily fashionable, still have an important role in the treatment of challenging patients.