Management of large full thickness cranial defects presents a challenging reconstructive problem. Cranioplasty with soft tissue coverage is usually required. The risk of failure is inversely related to dependability and durability of soft tissue coverage and presence of infection.

We present our twelve consecutive skull reconstruction patients over thirty five months. There were nine males and three females ranging in age between 39 and 85. Seven problems were due to invasive and locally recurrent cutaneous carcinoma extirpations; two were local sarcoma recurrences; one had recurrent wound problems after cranioplasty, and two had non-healing full thickness calvarial osteoradionecrosis. A total of thirteen free flaps were performed. Cranioplasty was necessary in ten cases.

There were two flap related complications requiring re-exploration. Three patients had wound dehiscence requiring re-advancement of the flaps. One patient developed infection necessitating removal of cranioplasty material. One patient with a sarcoma recurrence opted for paliatve care. Another sarcoma recurrence patient underwent reconstruction with a second anterorlateral thigh free flap and the third patient with wound breakdown healed following advancement of his flap.

In conclusion, full thickness scalp defects involving soft tissue and bone can be successfully managed with immediate reconstruction utilizing both alloplastic cranioplasty and free tissue transfer.