When alloplastic cranial implants present some complications, the classical strategy has been to remove them. Removal of the custom-made artificial skull, however, requires a second cranioplasty. We describe two representative cases of intractable scalp ulcer over the cranial prosthesis treated by vascularized calvarial flap without totally removing the implant. One patient had a previous ceramic implantation and the other a large titanium mesh, whose precedent local skin flap methods to treat the scalp ulcer were not successful. After the implant beneath the scalp ulcer was partially removed, a vascularized calvarial flap was raised. The calvarial graft of the flap was utilized to repair the implant defect and the galeal part of the flap was utilized to patch the ulcer from the reverse side. The clinical outcome is excellent. Our experience clearly demonstrated that the vascularized calvarial flap contributes to maintain a sufficient blood supply for the calvarial graft, reduces the risk of infection and provides a new tissue bed for the healing of a skin ulcer over a cranial implant for this difficult-to-treat cranial reconstruction.
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