Fig. 2.

(A) An 82-year-old man with a history of scalp postoperative radiation treatment 10 years previously and multiple excisions of squamous cell cancers on the scalp. He had a persistent 2 year history of an open nonhealing scalp wound down to calvarial bone. Multiple biopsies showed no evidence of neoplastic recurrence and CT scan showed no evidence of osteomyelitis. Over 2 years he saw multiple physician providers and despite multiple different aggressive daily dressings and antibiotic trials, no clinical healing or granulation tissue occurred. (B) He required “jump starting” this chronic wound to get it back to the acute wound healing state by burring down the outer calvarium to the diploic layer to stimulate granulation tissue growth along with moisture retentive dressings. Other possible options for treating this wound would be a vacuum-assisted closure (VAC) device or a synthetic dermal substitute, (ex. Integra, Integra Life Sciences, Plainsboro, NJ)to stimulate granulation tissue on the bone. (C) After adequate granulation tissue formation, a split thickness skin graft successfully covered most of the open wound so that he no longer required aggressive daily dressing changes. The chronic wound was transformed into an acute healing wound.