Staged custom polyetheretherketone (PEEK) cranioplasty with preliminary tissue expansion in a high-risk patient with compromised scalp: case report

Background Cranioplasty in patients with a compromised soft tissue envelope (e.g. scarred or grafted) carries a high risk of wound complications. We present a strategy to mitigate this risk in a patient with a large cranial defect and a scarred, grafted scalp. Case description A 38-year-old male presented with a large disfiguring bifrontal cranial defect following a decompressive craniectomy for trauma. His initial surgery was complicated by ischemic scalp necrosis, managed with a skin graft directly onto the dura, creating a high-risk environment for wound complications and implant exposure during direct cranioplasty. A two-stage approach was planned. First, subgaleal tissue expanders were inserted and serially inflated over three months. Second, following expander removal, a custom-designed polyetheretherketone (PEEK) implant was successfully placed. The surgical technique and outcomes are detailed. Conclusion In patients with poor scalp quality, staged soft tissue expansion is a safe and feasible method to create a robust vascularized envelope, enabling definitive and safe PEEK cranioplasty for large skull defects.